Palace Rehabilitation And Care Center, The

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility did not ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to a.) follow appropriate hand hygiene practices for 1 of 2 nurses who administered medications to 3 of 6 residents (Resident #42, Resident #50, and Resident #59) during the medication pass, and b.) properly store a nebulizer mask leaving the mask exposed to air on a bed table for 1 of 1 resident (Resident #143) reviewed for respiratory care. This deficient practice was evidenced by the following:1.) On 2/18/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 exit a resident's room and return to the medication cart. The surveyor explained to the LPN that the surveyor would be observing the medication pass and the LPN informed the surveyor that she was going to prepare Resident #59's medications. At that time, without performing hand hygiene, the LPN dispensed five medications into a medicine cup and then administered them to Resident #59. When the LPN returned to the medication cart, she did not perform hand hygiene.
At 8:22 AM, LPN #1 moved her medication cart to Resident #50's room and without performing hand hygiene, the LPN dispensed five medications, removed an incorrect medication from the medicine cup and destroyed it, and then administered the remaining medications to Resident #50. When the LPN returned to the medication cart, she did not perform hand hygiene.
At 8:30 AM, LPN #1 moved her medication cart to Resident #42's room and without performing hand hygiene, the LPN dispensed six medications into a medicine cup and then administered them to Resident #42. When the LPN returned to the medication cart, she did not perform hand hygiene.
On 2/18/26 at 8:37 AM, the surveyor interviewed LPN #1 who stated hand hygiene should be performed before and after administering medications to prevent the spread of germs. When asked about her hand hygiene during the medication pass, LPN #1 acknowledged that she did not perform hand hygiene during the medication pass observation.
On 2/18/26 at 8:48 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that during the medication pass, nurses should use hand sanitizer between each resident to prevent the spread of germs.
On 2/18/26 at 9:17 AM the surveyor interviewed the Director of Nursing (DON) who stated the nurses should perform hand hygiene before dispensing medications and after administering medications by either washing their hands with soap and water or using hand sanitizer for infection control purposes.
On 2/18/26 at 10:25 AM, the surveyor informed the DON of LPN #1's lack of hand hygiene during the medication pass observation and the DON stated LPN #1 should have used the hand sanitizer that was available on her medication cart.
A review of the facility's Administering Medications policy, dated July 2025, included, Staff shall follow established facility infection control procedures (e.g., handwashing.) for the administration of medications, as applicable.
A review of the facility's Handwashing/Hand Hygiene policy, dated July 2025, included, In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations:
a. Before and after direct contact with residents;.
d. Before preparing or handling medications;.

2.) On 2/17/26 at 11:15 AM, Surveyor #2 observed Resident #143 seated in his/her wheelchair in his/her bedroom, waiting to go to therapy. A nebulizer mask was left on the bedside table, exposed to air.
The surveyor reviewed the medical record for Resident #143.
According to the admission Record, the resident had diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD) (long-term lung disease that makes it difficult to breathe).
A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 1/15/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.
A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 1/8/26 that the resident was at risk for respiratory impairment. Interventions included, but were not limited to: administering medications and treatments as ordered per physician orders.
A review of the Order Summary Report (OSR), dated as of 2/19/26, included the following physician orders (PO):
A PO, dated 9/22/25, for Albuterol Sulfate Nebulization Solution (2.5 milligrams (mg)/3 milliliters (mL) 0.083%, 3mL inhale orally via nebulizer every 6 hours as needed for COPD.
A PO, dated 12/3/25, for Budesonide inhalation Suspension (0.5 mg/2mL), 2 mL inhale orally two times a day for COPD.
A PO, dated 12/3/25, for Ipratropium-Albuterol Inhalation Solution 0.5 -2.5 (3) mg/3 mL inhale orally three times a day for COPD.
During an interview with the surveyor on 2/18/26 at 12:25 PM, the Registered Nurse/Unit Manager #2 (RN/UM #2) stated that Resident #143's nebulizer mask should not have been left on a bedside table exposed to air and should have been placed in a plastic bag after use for infection control purposes.
During an interview with the surveyor on 2/18/26 at 12:30 PM, the Licensed Practical Nurse #1 (LPN #1) stated that Resident #143's nebulizer mask should not have been left at bedside after use and should be placed in a plastic bag to prevent exposure to germs.
A review of the facility's Oxygen Therapy policy, dated July 2025, revealed that When not in use, the nasal cannula or oxygen mask will be placed in a plastic bag. The plastic bag will be labeled with the resident's name and dated. The plastic bag will be changed when the cannula/mask and humidifier bottle are changed weekly.

NJAC 8:39-19.4(a)(1)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI).This deficient practice was identified for 11 of 11 residents (Resident #1, #8, #55, #65, #73, #108, #110, #142, #156, #159 and #171) reviewed for PNA and was evidenced by: On 2/17/26 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of 2/17/26. A review of the facility's PNA Quarterly Statement from 10/1/25 to 12/31/25 revealed 11 residents had balances that ranged from $1877.71 to $2316.28. A review of the facility's Trial Balance as of 2/17/25 revealed the 11 residents still had pending balances that ranged from $1,800.25 to $1,800.71. On 2/18/26 at 10:44 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that the PNA statements were provided quarterly to the residents and/or resident's representatives who were also provided ways to spend down the balances. She further stated the PNA Quarterly Statements included the name of the resident or representative who received the statement. At that time, the surveyor requested all the documentation that the DSS stated she did for the 11 residents. On 2/18/26 at 11:16 AM, the DSS provided emails and other pertinent facility documents that included clothing purchases from October 2025 and prepaid funeral arrangements from 2022 and 2023. A further review of the email dated 1/27/26, for Resident #65, reflected the Office of Public Guardianship (OPG) reached out and requested the PNA balance to be spent down for Medicaid purposes. On 2/19/26 at 10:48 AM, during a follow up interview, the DSS explained ways the facility spent down PNA balances such as buying clothing or prepaying funeral arrangements. She further stated she discussed with the residents and/or the representative on ways to spend down their PNA balances. When asked if a written notification was provided when the PNA balances were approaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI, the DSS stated that she did not document it in the resident's chart, but she went over the statements quarterly and if the balance was approaching $2000.00, then she purchased items to spend down the balance. On 2/19/26 at 1:18 PM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (LNHA) who stated that the DSS would sit with the residents to spend down their PNA balance. He further stated he was unsure if there was a written notification but would look. There was no evidence of a written notification when approaching the limit that could jeopardize the 11 residents' eligibility for Medicaid or SSI prior to surveyor inquiry. On 2/20/26 at 9:38 AM, the DSS stated in the presence of the Regional LNHA and the survey team that they reviewed the regulations and that they ensured the residents were not going over the $2000.00 maximum for Medicaid. At that time, the Regional LNHA acknowledged that they should have provided a written notification of approaching the limit. When ask was there was a specific amount at which the resident should be notified, the Regional LNHA stated they did not have a specific amount but that if it was approaching $2000.00, there should be a written notification. The DSS stated after surveyor inquiry she reached out to each resident and the OPG of their PNA balance and the need for it to be spent down. On 2/20/26 at 9:48 AM, the surveyor interviewed the LNHA who stated the DSS notified the families on how to spend the PNA balance down when they were nearing $2,000.00. The LNHA stated it was important to inform the residents they were approaching $2000.00 because they could be cut from Medicaid. A review of the facility's Personal Needs Allowance policy, revised July 2025, did not include a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI. A review of the regulations the facility provided NJ Admin Code 10: 166-1.16 - Utilization of resident's income for cost of care in the Nursing Facility (NF) and for PNA, included: 1. If the NF is handling the PNA, the facility shall closely monitor the PNA account and inform the beneficiary and/or his or her representative when the amount comes within $200.00 of the resource eligibility cap. NJAC 8:39-9.5

Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 2/18/26 at 10:30 AM, five of five alert and oriented residents (#32, #40, #86, #89, and #104), said they were not aware of the location of the State Survey results, that the facility had not spoken to them about the results, and that they were interested in reading the reports. On 2/19/26 at 11:55 AM, the surveyor toured the A-Wing Unit to locate the State Survey results, but the State Survey Book was not readily accessible. When the surveyor asked Unit Manager/Registered Nurse (UM/RN #2 and other floor staff where the State Survey results could be found, they had difficulty locating the State Survey Book. When found, the surveyor reviewed the State Survey book, but the most recent survey results were not current and were dated 6/5/23. On 2/19/26 at 12:04 PM, the surveyor toured the B-Wing Unit, but the State Survey Book was not readily accessible. When located by UM/RN #1, the surveyor reviewed the survey book and found the most recent survey results were not current and were dated 6/5/23. On 2/19/26 at 12:12 PM, the surveyor toured the C-Wing Unit. The UM/LPN #1 and her staff were unable to locate the State Survey book. During the survey, there were no signs posted to direct the residents to the location of the State Survey results. In addition, the State Survey results book in the front lobby was not readily accessible to residents due to the locked door that required a four-digit code to enter between the lobby and residents' units. During an interview with the surveyor on 2/24/26 at 11:27 AM, the LNHA was informed that the State Survey results were behind the nurse's station and not readily accessible by the residents without having to ask staff. The surveyor also explained that only two (2) out of the three (3) units had Survey Result Books and that they were not current. The facility provided a policy, Resident Rights, with a revision date of July 2025, that included the statement, Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the residents' right to: F. Examine survey results. NJAC 8:39-9.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe and homelike environment by providing adequate lighting. This deficient practice was identified on 1 of 3 nursing units (C-Wing) toured and was evidenced by the following: On 2/17/26 at 10:51 AM, on initial tour of the facility, the surveyor entered room [ROOM NUMBER], located on the C Wing. The surveyor observed Resident #87 sitting on the side of the bed and the resident told the surveyor that the bathroom light did not work. The surveyor entered the bathroom and there was no cover on a ceiling light. When the surveyor turned the light switch on, the light did not turn on. The resident was in a semiprivate room, and both residents used the bathroom independently. Resident #87 utilized a rolling walker to ambulate. The resident told the surveyor that maintenance was aware of the problem and had not fixed it yet. The surveyor asked how long the light did not work and the resident stated, Maybe two weeks. On 2/18/26 at 11:10 AM, the surveyor observed the Resident #87 in bed in his/her room. The resident told the surveyor that the light was not fixed, and It's pretty hard going to the bathroom at night. On 2/18/26 at 11:15 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 regarding the maintenance process. She told the surveyor there was a maintenance log that the staff write in and maintenance checked the log, I think every day, but don't quote me. The surveyor then interviewed Unit Manager/Licensed Practical Nurse (UM/LPN) #1 regarding the process for repairs from maintenance. She told the surveyor there was a logbook any staff could write in any issue, and maintenance checked the book daily and they also communicated through an app on the phone if they needed them right away. On 2/18/26 at 11:28 AM, the surveyor reviewed the maintenance book. On 2/9/26 there was an entry for room [ROOM NUMBER], Resident #87's room number. It was documented as bathroom light out. The column in the book where maintenance would sign when the issue was repaired was blank. On 2/18/2026 at 12:48 PM, the surveyor interviewed the Maintenance Technician (MT) regarding the process for repairs in residents' rooms. The MT stated every unit had a book they wrote in their issues, and he checked the book in the morning. When the repairs were done, he then signed the book. He told the surveyor he checked the book three (3) more times each day. The surveyor asked about the 2/9/26 request for the bathroom light to be fixed and he stated the facility was waiting on an order. The surveyor asked what the plan was until the order arrived as the resident was in the dark at night and he stated the plan was to get another light in the meantime. The surveyor explained it had been nine (9) days since the light stopped working, and the MT had no response. The surveyor requested to see the order for the new light, but the MT did not provide one to the surveyor. On 2/20/26 at 10:56 AM, the surveyor requested a policy for homelike environment from the Licensed Nursing Home Administrator (LNHA). The LNHA stated the facility did not have one. On 2/24/26 at 11:00 AM, the surveyor asked the Regional LNHA for a copy of the invoice for the light ordered on 2/9/26, but the facility was unable to provide one. NJAC 8:39-31.2 (e)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation and failed to implement policies and procedures related to pre-employment screening. Specifically, the facility did not complete required license verifications, reference checks, or criminal background checks prior to the start of employment. This deficient practice was identified in 10 of 55 employee files reviewed (Employees #1 through #10). The deficient practice was evidenced by the following:On 2/17/2026 10:10 AM, the surveyor requested that the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional DON and the Regional LNHA provide personnel files for all employees hired since the last annual recertification survey 10/29/24, regardless of current employment status. The requested documentation included the department of hire, date of hire, license verification, reference checks, criminal background checks, and pre-employment medical documentation, including physical examinations and two-step Mantoux test results.On 2/20/26 at 9:15 AM, the surveyors began reviewing the personnel files of 55 newly hired employees. Of the personnel files reviewed, there was no evidence that license verifications, reference checks, or criminal background checks were completed prior to the start of employment for 10 of the employee files. The review of the personnel files of all newly hired employees revealed the following: Employee # 1, a Certified Nursing Assistant (CNA) with date of hire (DOH) of 11/3/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 2, a CNA with DOH 9/8/25. There was no evidence that a reference check or a certification verification was completed prior to the start of employment.Employee # 3, a CNA with DOH 11/24/24. There was no evidence that a reference check was completed prior to the start of employment.Employee # 4, a Registered Nurse (RN) with DOH 8/11/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 5, a LNHA with DOH 6/1/25. There was no evidence that a license verification was completed prior to the start of employment.Employee # 6, a CNA with DOH 10/20/25. There was no evidence that a certification verification was completed prior to the start of employment.Employee # 7, an RN with DOH 10/6/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 8, a CNA with DOH 3/24/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 9, a Smoke Aide with DOH 1/25/25. There was no evidence that a background check was completed prior to the start of employment.Employee # 10, a Housekeeper with DOH 1/7/25. There was no evidence that a background check was completed prior to the start of employment. On 2/20/26 at 1:00 PM, the surveyor interviewed the Director of Human Resources (DHR) in the presence of the DON and LNHA, who stated she had been employed for one (1) week and was still in training. The LNHA stated that the onboarding process included a completion of an employment application and verification of references, vaccination records, applicable licenses, and a criminal background check prior to orientation. The LNHA further stated that it was important that all documentation must be completed prior to the employee working on the floor to ensure staff are physically fit and properly credentialed. A review of the facility's Residents/Patient rights-Abuse, Neglect, Mistreatment, or Misappropriation of Resident/Patient's Property policy, revised July 2025, revealed that the facility will be thorough in the investigation of past histories of individuals hired, This will be done through: a. inquiry of State Aide Registry, b. inquiry of licensing authorities, when appropriate and c. references will be checked. NJAC 8:39-9.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to ensure an accurate assessment of a resident with a history of falls in the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 5 residents (Resident #79) reviewed for accidents and was evidenced by the following:On 2/17/26 at 10:48 AM, the surveyor observed Resident #79 in bed with eyes closed. The surveyor observed a fall mat on the right side of the bed and the left side of the bed was against the wall. On 2/17/26 at 11:16 AM, the surveyor walked past Resident #79's room and observed a Certified Nursing Assistant (CNA) sitting in a chair in the doorway. The surveyor asked if the CNA was there to observe the resident because of a fall history and she stated yes. A review of the admission Record revealed the resident was admitted to the facility with medical diagnoses which included, but were not limited to, dementia, chronic kidney disease, abnormal gait and mobility, and falls. A review of the quarterly MDS, dated [DATE], indicated Resident #79 had a Brief Interview of Mental Status (BIMS) of 00 of 15, meaning the resident had severe cognitive impairment. Review of section J1800 of the MDS for any falls since admission to facility was documented as zero, meaning the resident had no falls since admission to facility. A review of Resident #79's incidents and accidents showed that Resident #79 had falls on 4/5/25, 4/18/25, 5/2/25, 11/12/25, 12/20/25, and 1/8/26. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus for falls initiated on 4/5/25. Review of the interventions revealed that the care plan was revised following each fall with new interventions related to fall prevention. On 2/20/26 at 10:25 AM, the surveyor interviewed the Minimum Data Set Coordinator (MDSC) regarding Resident #79's MDS. The surveyor asked how the MDSC was updated if residents had falls. The MDSC stated that falls would be a quarter look back, meaning the number of falls which happened in the previous three months would be added to the quarterly MDS being completed. The surveyor asked how she would be made aware if a resident were to have a fall and she stated, in the morning meeting, or I would look at the risk assessment. The surveyor had the MDSC review the Electronic Medical Record (EMR) for Resident #79 and the MDSC stated she did not know how she missed it. The surveyor asked if any falls should be on the 12/24/25 quarterly MDS and she stated, Yes. The facility did not have an MDS policy to provide to the surveyor. NJAC 8:39-11.1

Based on observation, interview, and review of pertinent facility documents it was determined the facility failed to revise an Individual Comprehensive Care Plan (ICCP) for a resident no longer receiving tube feedings. This deficient practice was identified in 1 of 1 resident (Resident #164) reviewed for tube feeding and was evidenced by the following: On 2/17/26 at 10:10 AM, Resident #164 was observed in bed in his/her room. The resident was not receiving any tube feeding at the time of the observation and there was no feeding pump in the room. A review of the admission Record revealed Resident #164 had diagnoses which included, but were not limited to, bipolar disorder, gastrostomy tube (feeding tube), dementia, anxiety, and failure to thrive. A review of the Physician Order Summary Report showed an order for regular diet, regular texture, thin consistency and super cereal at breakfast. The order was dated 12/1/25 and remained active. There was also an order for Ensure Plus (oral liquid supplement shake) three times a day given by mouth, ordered on 12/1/25 and remained an active order. Further order review showed an order to cleanse feeding tube site daily with soap and water and cover with a drain sponge, an active order dated 12/2/25. The surveyor did not locate any orders for tube feeding formula. A review of the ICCP showed a focus for the need for a feeding tube and resident refuses feedings at times. The care plan was initiated on 5/15/23 with a revision date of 10/22/24. Interventions included, but were not limited to, administer tube feeding formula, hydration, and flushes per orders, and encourage compliance with tube feedings, hydrations, and flushes as ordered. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/7/25, revealed the resident had a Brief Interview of Mental Status of 4 of 15, meaning the resident had severe cognitive impairment. Review of Section K for nutritional status was marked as yes for having a feeding tube, and yes for receiving a therapeutic diet. On 2/20/26 at 9:56 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN) #1 of C Wing regarding care plans. The UM/LPN#1 told the surveyor that when any type of care focus was resolved, such as a completed tube feeding, the care plan would be revised to include a resolved under that specific focus. UM/LPN#1 stated that the Nursing Supervisor, Minimum Data Set Coordinator (MDSC), and nursing staff were all responsible for care plans but the UM/LPN #1 and the MDSC were the most responsible to ensure they were completed. A review of the facility's Interdisciplinary Care Planning Protocol policy, undated, included, that nursing provides overview of medical and nursing care regimes and problems established by the team with resident/family input must be specific and individualized. The policy did not address care plan revisions. NJAC 8:30-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility did not ensure the daily nurse staffing report was updated and posted each day in a location accessible to the public. This deficient practice was evidenced by the following: On 2/17/26 at 8:56 AM, upon initial entrance to the facility, while the survey team was in the lobby awaiting facility administration, the surveyor observed the posted daily staffing sheet located in the lobby was dated 2/5/26. During an interview with the surveyor on 2/20/26 at 12:50 PM, the Staff Coordinator (SC) stated that staffing information was required to be updated to reflect any changes and posted daily in the facility lobby in a location accessible to the public. During an interview with the surveyor on 2/20/26 at 1:10 PM, the Licensed Nursing Home Administrator (LNHA) stated that the daily staffing sheet was required to be updated to reflect any changes and was to be posted each day in the facility lobby in a location accessible to the public. When asked by the surveyor to provide the facility's staffing policy, the LNHA stated that the facility followed the state staffing regulations and did not maintain a separate written staffing policy. The facility was unable to provide a written policy regarding daily staffing postings. NJAC 8:39-41.2 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate medication dispensing and administration for 1 of 6 residents (Resident #50) observed during the medication pass. This deficient practice was evidenced by the following:On 2/18/26 at 8:22 AM, the surveyor observed Licensed Practical Nurse (LPN #1) dispense five medications for Resident #50. As the LPN pulled the medications from the medication cart, she handed them to the surveyor. The LPN handed the surveyor an over-the-counter (OTC) pill bottle of calcium citrate 200 milligrams (mg) and then the LPN dispensed one pill from the bottle into the medication cup. When the LPN finished dispensing the medications, she locked the medication cart and turned on the privacy screen on the monitor. Before the LPN entered the resident's room, the surveyor asked the LPN to review the resident's medications. The LPN verified the resident had the following physician's order: calcium citrate-vitamin D 315-5 milligrams (mg)-micrograms (mcg) give one table by mouth one time a day. At that time, the LPN acknowledged that she dispensed the incorrect calcium citrate medication and used a drug buster to destroy the medication. She looked in the medication cart for the correct medication but was unable to locate it. The LPN then asked Licensed Practical Nurse/Unit Manager (LPN/UM) #2 to find the correct medication in the facility's OTC supply. On 2/18/26 at 8:37 AM, the surveyor interviewed LPN #1 who stated the process for medication administration included reading the physician's order and checking the medication against the order. The LPN explained this process was important to prevent medication errors. When asked about the calcium citrate-vitamin D order, the LPN stated she only read the part of the order that said, calcium citrate. The surveyor reviewed the medical record for Resident #50. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, dementia and disorders of bone density and structure. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 11/18/25, included the resident had a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. A review of the Order Summary Report, as of 2/18/26, included the following physician's order (PO):A PO, dated 5/31/23, for calcium citrate-vitamin D oral tablet 315-5 mg-mcg, give one tablet by mouth one time a day for supplement. On 2/18/26 at 8:48 AM, the surveyor interviewed LPN/UM #2 who stated that during medication pass, the nurses should check the physician's order against the medication to ensure the right medication is given. The LPN/UM further stated that if the nurse could not find the correct medication, she should notify the physician. When asked about the calcium citrate-vitamin D, the LPN/UM stated she was unable to locate the medication in the facility's OTC supply and would notify the physician. On 2/18/26 at 9:17 AM, the surveyor interviewed the Director of Nursing (DON) who stated that during medication pass, the nurses should read the physician's order and then check the medication against the order three times to make sure the medication was correct and to prevent a medication error. On 2/18/26 at 10:25 AM, during a follow-up interview, the surveyor informed the DON of the above medication error. The DON acknowledged that LPN #1 should have read the physician's order thoroughly before dispensing or administering the medication. A review of the facility's Administering Medications policy, dated 7/2025, included, Medications must be administered in accordance with the physician's orders, and, The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. NJAC 8:39-27.1(a)NJAC 8:39 - 29.2(d)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1of 1 resident (Resident #143).On 2/17/26 at 11:15 AM, the surveyor observed Resident #143 seated in his/her wheelchair in their bedroom, waiting to go to therapy. A nebulizer medication vial was noted on the bedside table. The resident stated that he/she administered their own breathing treatments after the nurses leave the medication for him/her. The surveyor reviewed the medical record for Resident #143. A review of the admission Record, indicated the resident was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) (long-term lung disease that makes it hard to breathe). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 1/15/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 1/8/26 indicating that Resident #143 was at risk for respiratory impairment. Interventions included, administering medications and treatments as ordered per physician orders. A review of the Order Summary Report (OSR), dated as of 2/19/26, included the following physician orders (PO): A PO, dated 9/22/25, for Albuterol Sulfate Nebulization Solution (2.5 milligrams (mg)/3 milliliters (mL) 0.083%, 3mL inhale orally via nebulizer every 6 hours as needed for COPD. A PO, dated 12/3/25, for Budesonide inhalation Suspension (0.5 mg/2mL), 2 mL inhale orally two times a day for COPD. A PO, dated 12/3/25, for Ipratropium-Albuterol Inhalation Solution 0.5 -2.5 (3) mg/3 mL inhale orally three times a day for COPD. During an interview with the surveyor on 2/18/26 at 12:25 PM, the Registered Nurse/Unit Manager #2 (RN/UM #2) stated that Resident #143's nebulizer medication vial should not have been left on the bedside table, the resident did not have a care plan to self-administer medications, and for safety reasons. During an interview with the surveyor on 2/18/26 at 12:30 PM, the Licensed Practical Nurse #1 (LPN #1) stated that she usually leaves Resident #143's nebulizer medication vials at the bedside, and the resident places the medication into his/her nebulizer mask and turns on the nebulizer machine. The LPN #1 stated that she returns in approximately 10 to 15 minutes to ensure the resident has completed the nebulizer treatment. She further stated that if the resident was not care planned to self-administer medications, the medication should not be left at the bedside, and she should administer the medication to ensure the breathing treatment was completed for the safety of the resident. A review of the facility's Storage of Medications policy dated July 2025, included, The nursing staff be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. A review of the facility's Medication Administration policy dated July 2025, included, Licensed nursing professionals will administer medications according to times of administration determined by the facility. NJAC 8:39-29.2(d)

Based on observations, interview, and review of pertinent facility documentation it was determined that the facility failed to follow the planned written menu for 2 of 2 meals observed. This deficient practice was evidenced by the following:On 2/19/26 at 11:10 AM, the surveyor entered the kitchen during lunch preparation. The menu for lunch was crispy baked chicken, macaroni and cheese, and roasted zucchini. The surveyor observed a vegetable mix cooking on the stove top which had cauliflower, carrots, and zucchini. It was simmering in a stainless-steel pan with water on the stove top. At that time, the surveyor interviewed a [NAME] who stated the lunch was chicken and the alternate lunch was glazed ham. During the observation the [NAME] was cleaning chicken thighs. The surveyor asked about the menu process for resident choices and the [NAME] stated that the Food Service Director (FSD) hanged the menus on the units an hour before lunch was served and residents could choose the main meal, the alternate, or the always available options. On 2/19/26 at 12:33 PM, the surveyor went into the kitchen with the FSD. The tray line temperatures were checked by FSD in the presence of the surveyor. During the observation, the surveyor observed the chicken being placed in a deep fryer. The surveyor asked the [NAME] if all the chicken was fried or if baked chicken was an option, and he stated that all the chicken was fried. On 2/20/26 at 10:41 AM, the surveyor reviewed the breakfast menu for the day. The menu provided to the surveyor and the menu posted on the A, B, and C wing indicated the residents would receive orange juice, farina, egg and spinach frittata, apple cinnamon muffin, whole milk and coffee. At that time, the surveyor interviewed a Certified Nursing Assistant (CNA) on C wing regarding what was served on the breakfast trays. She said scrambled eggs, bacon, English muffin, and coffee. The surveyor then interviewed an unsampled resident on C wing who stated they received scrambled eggs, bacon, English muffin and coffee and milk. The surveyor then interviewed a CNA on B wing who stated all the residents' received eggs, bacon, English muffin, and coffee. The surveyor then interviewed an unsampled resident on A Wing who stated breakfast included scrambled eggs, bacon, English muffin, and coffee. On 2/20/26 at 11:54 AM, the surveyor interviewed the Regional Dietician (RD) regarding menus. The surveyor asked why it was important for a facility to follow the menu for residents. The RD replied, Because when menus are developed a nutrient analysis is done, and if you are changing menu, it may not meet the nutritional needs of the residents. On 2/24/26 at 11:50 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA), who stated that the facility found a fault in the kitchen that caused incorrect meals/menus. The surveyor asked why following a planned menu was important for the facility and he stated that it was important due to meeting the residents' preferences and to ensure nutritional value was being met. The facility did not provide any documentation on meal substitutions or menu changes. NJAC 8:39-17.4 (a) 3

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to maintain kitchen and equipment areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA) During the kitchen tour the surveyor observed the following: 1.The surveyor took a white paper town to wipe down the white plastic ice guard in the ice machine which guided the ice into the large bin. When the surveyor looked at the paper towel it was left with red and brown substance. When the surveyor visualized the white plastic guard in the ice machine, the red and brown substance was noted on the white guard. The surveyor reviewed the ice machine cleaning log which showed the ice machine was cleaned weekly and the last cleaning was 2/9/26. The surveyor asked the RLNHA if weekly cleaning was sufficient based on what was seen and he stated, No. 2.A large bin of rice with the scoop laying inside of the rice (large clear scoop with attached handle). The surveyor asked the FSD if the scoop should be stored within the product and the FSD stated no. 3.The lid of a large flour bin had a large amount of black and brown substance smeared on the top. The surveyor asked the RLNHA if the container appeared clean and he stated no. 4.A seven pound can of cranberry sauce with a large dent in dry storage area. 5. A can opener blade, when lifted from the hold, had a large amount of black debris. 6.During tray line temperature checks, the surveyor observed, in the water of the steam table, a large amount of rectangular shaped pasta and yellow brown sediment on the bottom of the water holder and floating in the water. Pasta was not being served on the day of observation. The FSD immediately said We have to empty that. A policy regarding kitchen cleanliness was not provided by the FSD when requested. NJAC 8:39-17.2 (g)

Based on observation and interview it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of debris and failed to cover 2 of the 4 dumpsters. This was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA). During the kitchen tour, the surveyor, in the presence of the FSD and the RLNHA, observed four outside dumpsters located behind the kitchen. Two of the four dumpsters had open lids. Surrounding the front of the four dumpsters were multiple cardboard boxes on the ground. To the right of the dumpsters there was a fence with a grassy area extending down the back of the building. The surveyor observed multiple debris including papers and paper cups scattered on the ground. The surveyor interviewed both the RLNHA and the FSD who told the surveyor it was both the dietary staff and the housekeeping staff who were responsible for ensuring the area was kept clean. No policy regarding the outside dumpster area was provided to the surveyor. NJAC 8:39-19.7 (b), 31.5 (a)

Based on interview and review of facility documentation, it was determined that the facility failed to provide immediate access to records and requested information necessary to conduct the survey.The deficient practice was evidenced by the following: On 2/17/26 at 10:10 AM, during the entrance conference, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), the Regional LNHA, and the Regional DON, was informed that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification on 10/29/24. Also at that time, the Survey Team Coordinator requested the LNHA to complete the AAS-11 (Daily Nursing Staff Report used to track actual hours worked by shift) and AAS-12 (Facility Census and Care Evaluation used to track resident acuity and specialized clinical needs) for the facility staffing and return them via email by 2/18/26.1.) On 2/19/26 at 1:15 PM, the survey team started reviewing the personnel portion of the employee files but there was no evidence of the medical files. At that time, the Director of Social Services (DSS) stated that the Infection Preventionist (IP) kept the health files and confirmed the survey team only received the personnel portion of the employee files. On 2/20/26 the survey team reviewed the 55 employee personnel files and medical files. On 2/20/26 at 1:16 PM, the survey team reviewed the employee files with the LNHA and the DON which revealed that there were new hire records missing reference checks, background checks, license verification, and had incomplete health physicals. 2.) On 2/18/26 at 4:32 PM, the survey team received the AAS-11 and AAS-12 forms via email. A review of the AAS-11 and AAS-12 forms completed by the Staffing Coordinator (SC), and signed by the DON, revealed inconsistent numbers on the forms. The Survey Team Coordinator returned the forms to the LNHA for correction. On 2/19/26 at 2:23 PM, the LNHA returned the forms with corrections that still contained data-entry errors. On 2/19/26 at 4:11 PM, the SC emailed the forms with corrections that again contained inconsistent numbers on the forms. On 2/20/26 at 9:20 AM, the surveyor met with the LNHA, the DON, and the SC to identify continued findings of inconsistent data entry. The SC appeared to correct the data on her computer in the presence of the surveyor and emailed the final forms at 11:36 AM, which were determined to be inaccurate again. On 2/20/26 at 11:36 AM, the SC returned the forms, and the DON signed the forms, but the daily census was missing on the forms. On 2/20/26 at 1:20 PM, the LNHA sent the forms to the survey team for the last time for Department of Health review. On 2/24/26 at 10:20 AM, the surveyor interviewed the LNHA who stated she was responsible for everything and the overall function of the facility. A review of the Administrator's Job Description, included, the primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities.6. Represent the facility in dealings with outside agencies .9. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed.10. Delegate a responsible staff member to act in your behalf when absent from facility. Personnel Function 8. Assure that appropriate documentation is filed in the employee's personnel record in accordance with current regulations. N.J.A.C. 8:39-9.2(a)

Based on observations and interviews it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) and the Medical Director's (MD) licenses were visibly displayed. This deficient practice was evidenced by the following:On 2/20/26 at 12:15 PM, two surveyors toured the facility and there was no evidence that the current MD (MD #1) or the LNHA's licenses were visibly displayed. During the tour, the two surveyors observed in the facility's copier room a copy of MD #2's license on the bulletin board. On 2/20/26 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that MD #2 was the previous Medical Director and MD #1 was the current Medical Director. At that time, the Regional DON, the Director of Social Services (DSS), and the DON, with the surveyor, looked in the main hallway and they stated that the license was previously visibly posted. They all confirmed it was not currently posted and would have to see where it went. The DSS stated that one of the bulletin boards fell and they put it somewhere. The DSS further stated, we just have to find it. On 2/20/26 at 12:38 PM, the surveyor interviewed the LNHA who stated the DON had a copy of the MD's license in her office and that she personally kept hers. The LNHA confirmed the MD and her license were not currently visibly posted and that it should be posted in the main hallway. She then stated the licenses were previously posted but she was not sure what happened. On 2/20/26 at 12:56 PM, the LNHA stated the MD's license was posted visibly in the main hallway after surveyor inquiry. On 2/24/26 at 10:20 AM, the LNHA showed the surveyor her license was now posted visibly in the main hallway. She stated that the bulletin with the licenses in the main hall was taken down to put up a new time clock that needed to be connected through the wall. She stated the time clock was completed about three weeks ago. The LNHA acknowledged the MD and the LNHA's licenses should have been visible to the public prior to surveyor inquiry. No additional documents were provided. NJAC 8:39 - 5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 185087
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 1 of 3 nursing units (C-Wing).
Hot water temperatures obtained on 3/29/25, in both residents' rooms and in the resident shower room on the C-Wing nursing unit, registered between 137.1 degrees Fahrenheit (F) and 138.4 degrees F. Interviews with the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD) revealed that hot water temperatures should be maintained between 95 and 110 degrees F to prevent residents from being burned. The RLNHA and the MD stated that the C-Wing nursing unit had a separate boiler that provided hot water to all those residents which included cognitively impaired residents.
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 (IJ) situation.
The IJ began on 3/29/25 at 1:30 PM, when the survey team identified water temperatures on the C-Wing nursing unit in excess of 130 degrees F. The facility's Administration was notified of the IJ on 3/29/25 at 3:16 PM. The facility submitted an acceptable Removal Plan (RP) on 3/29/25. The surveyor verified the implementation of the RP during the continuation of the on-site survey on 3/31/25.
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 3/29/25 at 10:20 AM, the surveyor interviewed the Social Worker (SW), who stated that the facility had a fire yesterday (3/28/25) that started at approximately 10:30 AM, that affected the laundry room, A-wing's dining room, and Resident room [ROOM NUMBER]. The SW stated that utilities were shut off including the facility's boilers, but all utilities had been restored and the facility was fully functioning.
On 3/29/25 at 11:25 AM, the surveyor interviewed the RLNHA, who stated that the facility had a fire yesterday, and the Fire Marshal (FM) and Local Health Department (LHD) cleared the facility so the residents returned to their room and the utilities were restored. The RLNHA confirmed that there was hot water throughout the building.
On 3/29/25 at 12:15 PM, the surveyor conducted a telephone interview with the FM, who stated that the facility had an accidental fire to their outside laundry dryer vents. The FM reported that before he left the facility last night, he had checked the boiler and the facility had hot water.
On 3/29/25 at 1:18 PM, the surveyor (Surveyor #1) and the Director of Dietary (DD), in the presence of Surveyor #2 and the RLNHA, calibrated two thin probed thermometers using an ice bath. The surveyor and DD checked the hot water temperatures throughout the kitchen. Then the surveyor asked the DD if the RLNHA could use his calibrated thermometer to check water temperatures throughout the building. The DD confirmed and provided the RLNHA with his thermometer. At that time, the surveyor asked the RLNHA at what temperature should the hot water be at, and the RLNHA stated between 95 and 110 degrees F to prevent burns.
On 3/29/25 at 1:20 PM, Surveyor #1 and the RLNHA were both obtaining a water temperature from Resident room [ROOM NUMBER]'s sink, and halfway through obtaining the temperature, the RLNHA stopped. The surveyor obtained a water temperature of 105 degrees F, and the RLNHA acknowledged it as the temperature. The surveyor then instructed the RLNHA that moving forward, they wanted them to both obtain the water temperature, and the RLNHA stated that he would go with the temperature that the surveyor obtained because the surveyor was better at obtaining the water temperature.
On 3/29/25 from 1:30 PM through 1:41 PM, the surveyors and the RLNHA obtained hot water temperatures on the C-Wing nursing unit and the following occurred:
At 1:30 PM, Surveyor #1 obtained a water temperature of 138.3 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, Surveyor #1 and the RLNHA felt the hot water and they both agreed the water was hot. The RLNHA stated it was scalding and confirmed a resident could get burned.
At 1:31 PM, Resident #1 informed the surveyor that the hot water got really hot that they could make tea with it. Surveyor #1 asked if it would steep it, and Resident #1 confirmed yes. Surveyor #1 then asked how long this was occurring for, and Resident #1 stated they were not saying nothing.
A review of Resident #1's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/30/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated a fully intact cognition.
At 1:33 PM, the RLNHA informed the surveyors that he called the maintenance staff and instructed them to turn the boiler down. The RLNHA stated that the C-Wing nursing unit had a separate boiler from the other two nursing units. Surveyor #1 asked if any resident had ever been burned from the facility's hot water, and the RLNHA stated no.
At 1:34 PM, Surveyor #1 obtained a water temperature of 137.1 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, the RLNHA acknowledged the temperature, and he confirmed that the unit had cognitively impaired residents residing on it.
At 1:35 PM, Surveyor #2 obtained a water temperature of 138.4 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, the RLNHA acknowledged the temperature.
At 1:37 PM, Surveyor #1 obtained a water temperature of 137.7 degrees F in the C-Wing Shower Room. The RLNHA acknowledged the temperature, and he confirmed that was the only shower room on the nursing unit.
At 1:39 PM, Resident #2 informed the surveyor that they were able to make instant noodle soup using their sink. The surveyor asked if the water softened the noodles, and the resident confirmed yes.
A review of Resident #2's most recent quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition.
At 1:41 PM, Surveyor #2 obtained a water temperature of 138.4 degrees F from the sink at the Nurse's Station. The RLNHA acknowledged the temperature, and he stated that staff were instructed to turn the boiler down.
On 3/29/25 at 1:42 PM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that the facility's water was usually not too hot, and she stated no residents had complained.
On 3/29/25 at 1:44 PM, the surveyor interviewed the Maintenance Staff (MS #1), who stated that water temperatures were obtained daily throughout the facility by the MD.
On 3/29/25 at 1:45 PM, the surveyors accompanied by MS #1 and the RLNHA observed C-Wing's boiler room. The surveyors observed the boiler system for C-Wing was a residential unit with no gauge to show the water temperature. The boiler had a dial that could be set to low, medium, or high. The dial was currently set to high.
On 3/29/25 at 1:47 PM, the surveyor interviewed the Registered Nurse (RN #1), who stated that residents did not complain about the hot water.
On 3/29/25 at 1:48 PM, the MD provided the surveyor with water temperature logs for February 2025 and March 2025. The logs had sustained water damage from the fire and the ink had bled in places. However, there were no markings in the boxes for the C-Wing water temperature from 3/18/25 through the present date, and there was no indication that any ink had bled through from water damage, the boxes were paper colored. The surveyor then showed the log to the RLNHA and asked if it looked like there was anything written in those boxes that might have bled, and the RLHNA responded, that is what my MD is saying. The log also did not specify where in C-Wing the water temperatures were obtained from. At that time, the RLNHA stated that the facility had been checking water temperatures in every resident room since last night on a separate log, and the surveyor requested a copy of it and the facility's water policy.
On 3/29/25 at 1:55 PM, the surveyors observed the boiler room in A-Wing that contained all the facility's state inspection certificates. The MD stated one of those certificates was for C-Wing's boiler that was inspected on 10/10/24, but he was unsure which one. The MD stated that C-Wing's boiler was an eighty gallon tank that serviced only C-Wing. The MD stated that the maintenance staff checked water temperatures daily, and that none of his staff had adjusted the boiler to make the temperature hotter; the boiler maintained the same setting. The MD stated that the facility had never had high water temperatures. The surveyor informed the MD that both surveyors in the presence of the RLNHA obtained high water temperatures over 130 degrees F. The MD denied the findings. The surveyor asked what the temperature should be, and the MD stated between 95 and 110 degrees F.
On 3/29/25 at 2:04 PM, the RLNHA stated that the facility did not have a water policy and the facility followed the regulations. At that time, the RLNHA provided the surveyor with a copy of the water temperature logs for all three nursing units from 3/28/25 at 8:00 PM, until 3/29/25 at 12:00 AM. The highest temperature recorded was 109 degrees F in Resident room [ROOM NUMBER].
On 3/29/25 at 2:15 PM, the SW provided the surveyor with a list of forty-eight residents who resided on C-Wing. Out of those residents, the SW indicated that twenty-two of the residents were cognitively impaired. At that time, the surveyor requested the RLNHA to ask the MD to meet the surveyors in C-Wing to obtain water temperatures. The RLNHA stated the MD was already there.
On 3/29/25 at 2:17 PM, the surveyor, in the presence of the MD, obtained a water temperature of 122 degrees F from the C-Wing Shower Room. The MD did not want to use his thermometer in hand to obtain a temperature, and he stated that the surveyor's temperature was sufficient. The surveyor then obtained a water temperature of 121 degrees F from Resident room [ROOM NUMBER]'s sink. The MD stated that no one had touched the boiler yet to bring the temperature down, and he was waiting for us. The surveyor then questioned the RLNHA about informing the surveyors that the facility staff had lowered the boiler temperature when they first obtained high readings, and the RLNHA stated he thought they did.
An Acceptable Removal plan was received on 3/29/25, which indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; on 3/29/25 at 3:30 PM, the MD lowered the hot water temperature on the boiler, water temperatures were obtained throughout every residents' room in the facility, the facility initiated water temperatures to be taken every two hours for three days, all residents on C-Wing were assessed for skin damage, the facility conducted a resident council meeting to discuss safe water temperatures with the residents, and the Director of Nursing/designee initiated a house-wide staff in-service on safe water temperatures, the process of taking water temperatures, and any staff not in-serviced would be prior to their next shift.
During the verification of the Removal Plan on 3/31/25 at 11:10 AM, Resident #3 informed the surveyor that the water could be hotter now, and they understood why the temperature needed to be cooler. Resident #3 reported that they were able to (prior to the IJ) make hot chocolate or tea using the water from their sink, but now they could not since the temperature was lowered. The surveyor asked how long the resident had been able to make hot beverages using their sink water, and Resident #3 stated the whole time they resided in the facility.
A review of Resident #3's most recent comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition.
The surveyor verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/31/25.
NJAC 8:39-31.7(h)

Based on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices for donning (putting on) appropriate Personal Protective Equipment (PPE) prior to providing care to a resident who was on Enhanced Barrier Precautions (EBP) for 1 of 1 resident (Resident #138) reviewed for pressure ulcers.
This deficient practice was evidenced by the following:
On 10/24/24 at 10:26 AM, the surveyor reviewed the electronic medical record for Resident #138.
A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: pressure-induced deep tissue damage of right ankle and pressure-induced ulcer of left heel unstageable.
A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/18/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had multiple pressure ulcers that were not present upon the resident's admission to the facility.
A review of the individualized comprehensive care plan (ICCP) included a focus area, initiated 08/19/24, that the resident was on EBP during high contact resident care activities related to skin alterations. Interventions included that staff must wear a gown and gloves during wound care and that staff should don PPE before care.
A review of the Order Summary Report (OSR), dated as of 10/25/24, included the following physician's orders (PO):
A PO, dated 08/19/24, for Enhanced Barrier Precautions (EBP) adherence during high contact resident care activities. Must wear gown and gloves during: . wound care. DON/DOFF and cleanse hands before and after care.
On 10/24/24 at 12:14 PM, the surveyor observed Resident #138's doorway which revealed a small pink flower next to the resident's name. There was no other indication that the resident was on EBP and there was no PPE supply bin outside the resident's room.
On 10/25/24 at 11:07 AM, the surveyor observed a wound care treatment performed by Registered Nurse (RN#2). RN#2 reviewed the treatment order, washed her hands, gathered the treatment supplies, and entered Resident #138's room without donning PPE. The RN then donned gloves, removed the old wound dressing from the resident's left heel, removed her gloves, washed her hands, donned new gloves, and applied the treatment to the resident's left heel. The RN did not don a gown when she performed the wound care treatment.
On 10/25/24 at 11:46 AM, immediately after the wound treatment observation, the surveyor interviewed RN #2 who stated residents with wounds were on EBP and that staff must wear PPE which consisted of a gown and gloves when providing wound care. The RN further stated the flower next to the resident's name at the doorway indicated the resident was on EBP, but that Resident #138 should have had a PPE supply bin outside of the room, which was why the RN did not remember to don PPE prior to entering the room. The RN explained that it was important to wear the correct PPE for residents on EBP to protect the resident and staff from any pathogens.
On 10/25/24 at 11:39 AM, the surveyor interviewed the Director of Nursing (DON) who stated that residents with wounds were on EBP and that staff must wear PPE which consisted of a gown and gloves when providing wound care. The DON further stated that a flower next to the resident's name at the doorway indicated the resident was on EBP and that there should be a PPE supply bin outside the resident's room. The DON explained that PPE should be donned at the door prior to entering the room to protect the resident. At that time, the surveyor informed the DON of the wound care treatment performed by RN #2 and the DON confirmed that RN #2 should have worn a gown during the wound care treatment.
A review of the facility's Enhanced Barrier Precautions (EBP) policy, dated 4/1/24, included, EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing.
NJAC 8:39-19.4(a); 27.1(a)

COMPLAINT #: NJ172102
Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to report an alleged violation of misappropriation of resident property to the New Jersey Department of Health (NJDOH).
This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following:
1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it.
A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain).
A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/19/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired.
A review of the resident's electronic medical record (EMR) revealed the resident had the following physician's orders:
-Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions. -Start Date: 12/12/23 -End Date: 6/16/24
-Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Start Date: 12/12/23 -End Date: 02/21/24
A review of the resident's Individual Patient's Controlled Drug Record for February 2024 revealed the following:
A sheet with the date range of 1/23/224 - 2/5/24:
2/1/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
2/2/24: 2 Percocet tablets were signed out at 3 PM
2/3/24: 2 Percocet tablets were signed out at 7 AM, 12 PM, 4 PM, 8 PM
2/4/24: 2 Percocet tablets were signed out at 8 PM
2/5/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
An additional sheet with the date range of 2/4/24 - 2/23/24:
2/4/24: 2 Percocet tablets were signed out at 8 PM
2/5/24: 2 Percocet tablets were signed out at 12 AM
2/6/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
2/7/24: 2 Percocet tablets were signed out at 12:30 AM, 4 PM, 11 PM
2/13/24: 2 Percocet tablets were signed out at 12:30 PM
2/14/24: 2 Percocet tablets were signed out at 9 AM
2/15/24: 2 Percocet tablets were signed out at 8 PM
2/16/24: 2 Percocet tablets were signed out at 9 AM, 8 PM
2/17/24: 2 Percocet tablets were signed out at 5 PM
2/18/24: 2 Percocet tablets were signed out at 11 AM, 5 PM
2/19/24: 1 Percocet tablet was signed out at 8 AM
2/19/24: 2 Percocet tablets were signed out at 5 PM
2/20/24: 2 Percocet tablets were signed out at 4 PM
A review of the Medication Administration Record (MAR) for February 2024 revealed the resident was prescribed:
Percocet Oral Tablet 5-325 MG (Oxycodone w/Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions -Order Date- 12/12/2023 -D/C Date- 06/16/2024
Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Order Date- 12/12/2023 -D/C Date- 02/21/2024
A further review of the February 2024 MAR for the corresponding dates revealed the following:
2/1/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/2/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/3/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 7 AM, 12 PM, 4 PM, 8 PM.
2/4/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM
2/5/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/6/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/7/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/13/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/14/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/15/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM.
2/16/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 9 AM, 8 PM
2/17/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 5 PM.
2/18/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/19/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/20/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 4 PM
A review of the progress notes for the above corresponding dates did not include any additional documentation regarding Percocet administration for the aforementioned dates and times.
2.) Resident #365 was not at the facility during the survey. A closed record review for Resident #365 was completed.
A review of the admission Record (an admission summary), revealed the resident had diagnoses which included, but were not limited to; opioid dependence, spinal stenosis (the narrowing of one or more spaces within your spinal canal), and fracture of the right tibia.
A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/13/23, which revealed the resident had a Brief Interview for Menal Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.
A review of the resident's electronic medical record (EMR) revealed the resident had the following physician's orders:
-Oxycodone HCl Oral Tablet 20 milligram (mg) (Oxycodone HCl) Give 20 mg by mouth every four (4) hours as needed for (severe pain 8-10) -Start Date: 11/13/23 -End Date: 12/26/23
A review of the resident's Individual Patient's Controlled Drug Record for December 2023 revealed the following:
A sheet with the date range of 11/23/23 - 12/3/23:
12/1/23: 1 Oxycodone 20 mg signed out at 1:45 AM
12/2/23: 1 Oxycodone 20 mg signed out at 12 AM
An additional sheet with the date range of 12/4/23 - 12/12/23:
12/11/23: 1 Oxycodone 20 mg signed out at 2:46 PM
A review of the Medication Administration Record (MAR) for December 2023 revealed the resident was prescribed:
Oxycodone HCl Oral Tablet 20 MG (Oxycodone HCl) Give 20 mg by mouth every 4 hours as needed for (severe pain 8-10) -Order Date- 11/13/2023 -D/C Date- 12/26/2023
A further review of the December 2023 MAR for the corresponding dates revealed the following:
12/1/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 1:45 AM
12/2/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 12 AM.
12/11/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 2:46 PM.
A review of the Progress Notes for the above corresponding dates did not include any additional documentation regarding Oxycodone administration.
The facility provided the surveyor with an Investigation Summary for three staff: Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. Under the Investigation Findings of each of the summaries, the following was noted: .Upon investigation, interviews and statements, alleged drug diversion was unsubstantiated . The investigation for LPN #1 also included an Employee Suspension Notice which revealed, [LPN #1] is being suspended pending investigation while facility investigates possible drug diversion. There was no evidence provided to the surveyor that the facility notified the NJDOH of the investigation related to a possible drug diversion.
On 10/28/24 at 1:24 PM, during an interview with the surveyor that included Regional Director of Nursing (RDON) #1, RDON #2, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Administrator (RLNHA), the surveyor asked if the concerns of the alleged drug diversion as referenced in the three Investigation Summaries had been reported to the NJDOH. RDON #1 stated, No, because we immediately ruled out the drug diversion issue through interviews with residents who all expressed relief of pain. We were also under the impression that the ombudsman had already informed the state.
The surveyor reviewed the facility's undated Incident/Occurence Investigation Procedure. Under the Policy Statement section the policy revealed, .3. All allegations of misappropriation of residents' property will be investigated . Further review of the policy did not reveal that the facility was to contact the NJDOH to report an alleged violation of misappropriation of resident property, per the regulation.
NJAC 8:39-9.4
NJAC 8:39-27.1(a)
NJAC 8:39-29.7(c)

COMPLAINT #: NJ172102
Based on observations, interviews, records review, and review of other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents (Resident #58) reviewed for personal property.
This deficient practice was evidenced by the following:
On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it.
A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain).
A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 7/19/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired.
A review of the electronic medical record (EMR) revealed the resident had the following physician's orders:
-Percocet Oral Tablet 5-325 milligrams (mg) (Oxycodone w/ Acetaminophen) Give two (2) tablets by mouth every four (4) hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Start Date: 12/12/23 -End Date: 02/21/24
A review of the Individual Patient's Controlled Drug Record for February 2024 revealed the following:
A sheet with the date range of 1/23/224 - 2/5/24:
2/4/24: 2 Percocet tablets were signed out at 8 PM
The Destroyed/Wasted Medication Doses section of the form was blank.
An additional sheet with the date range of 2/4/24 - 2/23/24:
2/4/24: 2 Percocet tablets were signed out at 8 PM
The Destroyed/Wasted Medication Doses section of the form was blank.
A review of the Medication Administration Record (MAR) for February 2024 revealed the resident was prescribed:
Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Order Date- 12/12/2023 -D/C Date- 02/21/2024
A further review of the February 2024 MAR for the corresponding dates revealed the following:
2/4/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM
A review of the Progress Notes for the above corresponding dates did not include any additional documentation regarding Percocet administration for the aforementioned date and time.
The facility provided the surveyor with an Investigation Summary for three staff: Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. Under the Investigation Findings of each of the summaries, the following was noted: .Upon investigation, interviews and statements alleged drug diversion was unsubstantiated . The investigation for LPN #1 also included an Employee Suspension Notice which revealed that, [LPN #1] is being suspended pending investigation while facility investigates possible drug diversion.
On 10/28/24 at 2:54 P.M., the surveyor interviewed the [NAME] President of Clinical Services (VPCS) #1, in the presence of Regional Director of Nursing (RDON) #2. The VPCS stated, The 2/4/24 duplicate dose at 8 PM was not investigated because it was not brought to our attention.
The surveyor reviewed the facility's undated Incident/Occurence Investigation Procedure. Under the Policy Statement section the policy revealed, .3. All allegations of misappropriation of residents' property will be investigated . The Procedure section further revealed, .Nursing or Social Services will conduct their initial investigation and review all pertinent documentation related to the event within 24 hours .
NJAC 8:39-9.4
NJAC 8:39-27.1(a)
NJAC 8:39-29.7(c)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's care plan with related goals and interventions each time the resident violated the facility's smoking policy.
This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for smoking and was evidenced by the following:
Refer to F689
During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hung loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity.
A review of Resident #72's admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to: tobacco use, nicotine dependence, unspecified, uncomplicated, hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction (stroke) affecting unspecified side.
A review of Resident #72's comprehensive Minimum Data Set (MDS), an assessments tool, dated 9/30/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident's cognition was moderately impaired. Further review of the MDS, under section J1300, indicated the resident was identified with current tobacco use.
A review of Resident #72's individualized comprehensive care plan (ICCP) revealed an entry that was dated 12/27/21, with a revision date of 10/11/24, that indicated the resident was a smoker and used tobacco frequently and was not compliant with the smoking facility rules and policies. The goal indicated that the resident would safely continue to smoke without any issues (date initiated was 3/17/22, with a revision dated of 10/14/24). The interventions included, but were not limited to: Discussed where the smoking areas in the facility were, review contract annually, smoking assessment as needed, and, on 10/15/24, a care plan revision revealed that the SW (Social Worker) re-reviewed the smoking contract with resident.
A review of Resident #72's Comprehensive Smoking Assessment, dated 9/27/24, revealed the following: The resident had cognitive loss, a dexterity problem, used the right hand for smoking, had a history of CVA (cerebral vascular attack, also known as a stroke), neurological disorder or chronic illness with residual altered sensation, and altered reflexes. Further review of the assessment, under Section E. Safety, indicated that the resident did not require adaptive equipment such as smoking apron (protective shield used to protect the clothing) or a cigarette holder. The assessment specified that the resident's cigarettes and lighters were in safe keeping.
On 10/24/24 at 11:48 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair. The resident stated that he/she smoked at 11 AM, 2 PM, 4 PM, and 6 PM daily. The resident stated that the staff held their cigarettes and lighter. The resident's clothing was intact with no evidence of burn holes.
On 10/25/24 at 11:15 AM, the surveyor observed Resident #72 in the smoking area in his/her wheelchair. The resident wore a scarf around his/her neck as a make shift sling to support his/her left upper extremity over their hooded sweatshirt. Smoking Aide (SA) #1 provided the resident with a cigarette and lit it for the resident.
At that time, the surveyor noted that Resident #72 had a Band Aid on his/her right thumb. The resident held a cigarette in his/hand and the ash was very long. As the resident passed by SA #1 in his/her wheelchair while smoking, the ash fell down into his/her scarf and the front of the resident's hoody. The resident quickly patted the area around their scarf and hoody. The surveyor observed that the resident had a burn hole on the lower right portion of their hooded sweatshirt. When questioned about the hole, the resident stated, The hole was already there. Resident #72 then proceeded to pass his/her lit cigarette to Resident #137 in front of SA #1, and Resident #137 used the cigarette as a light source to light his/her cigarette rather than having SA #1 light it with the facility lighter. When the surveyor asked SA #1 if it were permissible for residents to share their cigarettes to light one another's cigarettes, SA #1 proceeded to reprimand the residents. When the surveyor asked SA #1 if she were required to intervene and offer direction to Resident #72 to flick the ash off of their cigarette before it became too long and fell onto his/her clothing, and SA #1 stated, I think he/she needs an apron. The surveyor then observed Resident #72 who had smoked the cigarette all of the way down to the filter, and the resident rolled the tip of the cigarette between their fingers. When the surveyor asked the resident how he/she extinguished the cigarette and where the cigarette butt was, the resident reached into the cup holder on their wheelchair that held a carton of juice. The surveyor then noted that the resident had placed the cigarette butt on the ground.
At that time, Smoke Aide (SA) #2 was present and had helped to search for the resident's cigarette butt. SA #2 reached into the back of the resident's wheel chair and pulled out a cigarette. SA #2 stated that Resident #72 had a name brand cigarette in the back pocket of their wheelchair. SA #2 explained that the facility made their own generic cigarettes and did not provide residents with brand name cigarettes. SA #2 further stated, The resident was suspended last week because they found cigarettes and a lighter in the back of [his/her] chair. SA #2 stated that the resident put the cigarette on the ground when it was supposed to have been put in an ashtray. SA #2 stated, No one should have a light, but us. SA #2 further stated, All [he/she] had to do was ask us for a light. SA #2 stated, a cigarette was a personal item and should not be shared due to germs, and it was still a fire at the end of the day. SA #2 further stated, We try to keep all hazards to a minimum.
On 10/25/24 at 11:40 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the Social Worker handled everything that had to do with smoking in the courtyard and informed staff when a smoking violation occurred.
On 10/25/24 at 11:57 AM, the surveyor interviewed the Social Worker (SW) who stated that two weeks ago, Resident #72 was found with a cigarette and lighter in their possession coming outside to the courtyard and we immediately grabbed him/her and suspended the resident for two smoke breaks. She stated, I try to be lenient. The SW stated that the resident then tried to come after staff and was then suspended for one day. There was no documented evidence within the resident's electronic health record or ICCP that detailed the events described by the SW.
On 10/25/24 at 1:39 PM, the surveyor requested all investigations related to Resident #72's smoking and was provided with a copy of an untitled document, dated 9/18/24, which indicated that it was Resident #72's first violation of Smoking and indicated that the resident's smoking privileges were suspended for one week. Further review of the document revealed that the resident's smoking privileges were stopped on 9/18/24 and resumed on 9/22/24. The document indicated that the resident refused to sign receipt. The facility also provided the surveyor with two smoking policies that were signed by the resident that were dated 4/19/23 and 5/3/24, and a notice that a Smoker's Meeting was held on 4/1/24.
On 10/28/24 at 11:19 AM, the Regional Licensed Nursing Home Administrator (RLNHA) and the SW provided the surveyor with a timeline of events for Resident #72, dated 10/25/24. A review of the timeline revealed that the following:
1. On 7/6, Resident was observed placing a name brand cigarette in his/her pocket. The residents room was searched and nothing was found.
2. On 7/12, found with lighter in his/her socks. Denied event.
3. On 8/23, had cigarettes behind his/her wheelchair.
4. On 9/18/24, was observed grabbing cigarette from the table. Denied event. First violation.
5. 10/6, observed trying to get cigarette from the ashtray. Got into altercation with another resident in the courtyard. Denied incident. Second violation.
6. 10/25, observed by surveyor with cigarette in the back of his/her wheelchair. Denied incident. Third violation.
There was no documented evidence that Resident #72's ICCP was updated when the resident demonstrated noncompliance with the facility smoking policy on 7/6, 7/12, 8/23, and 9/18/24.
On 10/28/24 at 11:43 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that whoever found Resident #72 to be noncompliant with the facility smoking policy was responsible to update the resident's care plan.
On 10/28/24 at 11:58 AM, the surveyor interviewed the MDS Coordinator (MDSC) who stated that it was a group effort at the facility to update resident care plans. The MDSC stated that the care plan should be updated however many times the resident had a violation in the smoking policy.
On 10/28/24 at 1:47 PM, the surveyor interviewed the Regional Director of Nursing (RDON) in the presence of the survey team. The RDON stated that Resident #72's care plan was required to be updated after each smoking infraction. The RDON further stated that the care plan should clearly illustrate what staff needed to look for.
On 10/29/24 at 9:39 AM, the surveyor interviewed the SW, in the presence of the survey team. The SW stated that the facility did not create an incident report for a resident harboring a lighter, just the smoking contract. The SW further stated that the care plan should have been updated after each occurrence.
A review of the facility's Interdisciplinary Care Planning Protocol policy, undated, revealed the following:
.Interdisciplinary Care Planning:
Social Services provides overview of social history and needs
Nursing provides overview of medical and nursing care regimes. Nursing provides input especially related to ADL (activities of daily living), skin, weights, and safety needs .
.Problems established by the team with the resident/family input must be specific and individualized.
NJAC 8:39-11.2 (e) 2

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide adequate supervision during resident smoking sessions and consistently follow and implement the facility smoking policy to ensure the safety of all residents at the facility for 2 of 5 residents (Resident #72 and Resident #137) reviewed for smoking.
This deficient practice was evidenced by the following:
During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hanging loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity.
A review of Resident #72's admission Record, an admission summary, revealed that the resident had diagnoses that included, but were not limited to: tobacco use, nicotine dependence, unspecified, uncomplicated, hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction (stroke) affecting unspecified side.
A review of Resident #72's comprehensive Minimum Data Set (MDS), an assessments tool, dated 9/30/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident was moderately cognitively impaired. Further review of the MDS, under section J1300, indicated that the resident was identified with current tobacco use.
A review of Resident #72's individualized comprehensive care plan entry, dated 12/27/21, with revision on 10/11/24, revealed the resident was a smoker and used tobacco frequently and was not compliant with the smoking facility rules and policies. The goal indicated that the resident would safely continue to smoke without any issues (date initiated was 3/17/22, with a revision dated of 10/14/24). The interventions included, but were not limited to: Discussed where the smoking areas in the facility were, review contract annually, smoking assessment as needed, and, on 10/15/24, a care plan revision revealed that SW (Social Worker) re-reviewed the smoking contract with resident.
A review of Resident #72's Comprehensive Smoking Assessment, dated 9/27/24, revealed the following: The resident had cognitive loss, a dexterity problem, used the right hand for smoking, had a history of CVA (cerebral vascular attack, also known as stroke), neurological disorder or chronic illness with residual altered sensation, and altered reflexes. Further review of the assessment, under Section E. Safety, indicated that the resident did not require adaptive equipment such as smoking apron (protective shield used to protect the clothing) or a cigarette holder. The assessment specified that the resident's cigarettes and lighters were in safe keeping
On 10/24/24 at 11:48 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair. The resident stated that he/she smoked at 11 AM, 2 PM, 4 PM and 6 PM daily. The resident stated that the staff held their cigarettes and lighter. The resident's clothing was intact with no evidence of burn holes.
On 10/25/24 at 11:15 AM, the surveyor observed Resident #72 in the smoking area in his/her wheelchair. The resident wore a scarf around his/neck as a make shift sling to support his/her left upper extremity over their hooded sweatshirt. Smoking Aide (SA) #1 provided the resident with a cigarette and lit it for the resident.
At that time, the surveyor interviewed Smoking Aide (SA) #1 who stated that she worked at the facility for one month. When the surveyor asked SA #1 to describe the process for the identification of residents who required smoking aprons, smoking holders, or smoking assistance she stated, They told me who smokes. She stated that the aides put smoke aprons on the residents and brought them down to smoke. When the surveyor asked SA #1 if she had a list of smokers with their level of smoking assistance identified to ensure compliance, and she stated there was no list. SA #1 stated that she knew who smoked which type of cigarettes. SA #1 further stated that the aides communicated any change in the resident's status. The surveyor pointed out to SA #1 that there were numerous cigarette butts on the ground in her direct vicinity. SA #1 stated, We have ashtrays. The residents know not to put their cigarettes out on the ground and we remind them.
At that time, the surveyor noted that Resident #72 had a Band Aid on his/her right thumb. The resident held a cigarette in his/hand and the ash was very long. As the resident passed by SA #1 in his/her wheelchair while smoking, the ash fell down into his/her scarf and the front of the resident's hooded sweatshirt. The resident quickly patted the area around their scarf and the front of the hooded sweatshirt. The surveyor observed that the resident had a burn hole on the lower right portion of their hooded sweatshirt. When questioned about the hole, the resident stated, The hole was already there. Resident #72 then proceeded to pass his/her lit cigarette to Resident #137 in front of SA #1, and Resident #137 used the cigarette as a light source to light his/her cigarette rather than having SA #1 light it with the facility lighter, as required. When the surveyor asked SA #1 if it were permissible for residents to share their cigarettes to light one another's cigarettes, SA #1 proceeded to reprimand the residents. When the surveyor asked SA #1 if she were required to intervene and offer direction to Resident #72 to flick the ash off of their cigarette before it became to long and fell onto his/her clothing, and she stated, I think [he/she] needs an apron. The surveyor then observed the Resident #72 who had smoked the cigarette all of the way down to the filter, and the resident rolled the tip of the cigarette between their fingers. When the surveyor asked the resident how he extinguished the cigarette and where the cigarette butt was, the resident reached into the cup holder on their wheelchair that held a carton of juice. The surveyor then observed that the resident had placed the cigarette butt on the ground.
At that time, Smoke Aide (SA) #2 was present and had helped to search for the resident's cigarette butt. SA #2 reached into the back of the resident's wheel chair and pulled out a cigarette. SA #2 stated that Resident #72 had put a name brand cigarette into the pocket of their wheelchair. SA #2 explained that the facility made their own generic cigarettes and did not provide brand name cigarettes. SA #2 stated, The resident was suspended last week because they found cigarettes and a lighter in the back of [his/her] chair. SA #2 stated that the resident put the cigarette on the ground when it was supposed to have been put in an ashtray. SA #2 stated, No one should have a light, but us. SA #2 further stated, All [he/she] had to do was ask us for a light. SA #2 stated, a cigarette was a personal item and should not be shared due to germs, and it was still a fire at the end of the day. SA #2 further stated, We try to keep all hazards to a minimum.
On 10/25/24 at 11:40 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the SW handled everything that had to do with smoking in the courtyard and informed staff when a smoking violation occurred. LPN/UM #1 stated that she did not recall any smoking infractions within the past couple of weeks on the nursing unit. LPN/UM #1 stated that the facility stored the resident's cigarettes and lighters. LPN/UM #1 stated that if burn holes were noted on the resident's clothes, they informed the SW and evaluated the resident. LPN/UM #1 stated that if a smoking re-evaluation was needed, they notified the SW immediately.
On 10/25/24 at 11:44 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that Resident #72 was very argumentative outside during smoke break with the Smoke Aide. RN #1 stated that she did not see any burn holes in the resident's clothing. RN #1 further stated that the Smoke Aide was there because they needed to monitor the residents. RN #1 stated that residents were not permitted to keep their cigarettes or lighter on them for their safety. RN #1 stated that the Smoke Aides should watch to ensure that the cigarette ashes did not get too long. RN #1 stated that residents were not permitted to pass their cigarettes to one another to light their cigarettes because a disease may be transmitted and for the safety of the resident.
At that time, RN #1 further stated that she did not know why Resident #72 had a Band Aid on his/her thumb, but she would investigate and get an order for a treatment to the affected area. RN #1 stated that the facility had a container to put cigarettes out, but sometimes the residents had behaviors and threw it away instead, but that they were not allowed to because it could cause a fire. RN #1 stated that Resident #72 could smoke on their right side but needed assistance to light their cigarette.
On 10/25/24 at 11:57 AM, the surveyor interviewed the SW who stated that the Smoke Aides informed her that there was an issue with Resident #72 smoking and the resident was now suspended. The surveyor asked the SW to go out to the smoking area with the surveyor. The SW stated that when a resident was admitted , the SW was in charge of the smoking evaluation and supervision in the courtyard. The SW explained that the resident was given a cigarette and light and if there were signs of motor skill deficit, they got an apron and showed the resident how to dispose of the cigarette. The SW stated that they should put the cigarette butt in the receptacle, not on the ground for safety.
The SW further stated that two weeks ago, Resident #72 was found with a cigarette and lighter in their possession coming outside to the courtyard and they immediately grabbed him/her and suspended the resident for two smoke breaks. The SW stated, I try to be lenient. The SW stated that the resident tried to come after staff and was then suspended for one day. There was no documented evidence within the resident's electronic health record (EHR) that detailed the events described by the SW.
The SW further stated that residents should not light each other cigarettes for hygiene/infection reasons and the residents could get burned. The SW stated that the Smoke Aides should tell the resident to flick the ash and not allow it to get long because the ashes could be hot and the resident could get burned. The SW stated that the cigarette should be extinguished in the appropriate receptacle. The SW stated that the Smoke Aide should have paid attention and monitored what the residents were doing to avoid the resident putting the cigarette butt between their fingers and then placing the butt on the ground. The SW stated that the resident had a name brand cigarette in their possession and that needed to be investigated today, because sometimes visitors brought them in. The SW stated that the the aide should have notified them and made sure the resident was not burned when the ash fell on their clothes, because they needed to get an apron for that resident. The SW further stated, It will be addressed. Right now [he/she] is suspended. [He/she] will get an apron and take care of that. Residents having cigarettes is reported to me and we suspend smoking.
At that time, the surveyor asked the Social Worker why there were so many cigarettes on the ground? The Social Worker stated, They should sweep before 9 AM and after lunch. I have not seen this many butts on the ground and it is a safety issue. The surveyor noted that there were cigarette butts mixed in with trash in the trash cans which included napkins, Styrofoam cups, plastic cups, and food items and the Social Worker stated that it was unsafe to have cigarette butts on the ground and in the trash cans with refuge. The Social Worker stated, It is a problem. It is a fire hazard.
At that time, the surveyor asked the SW how Smoking Aide #1, who reportedly worked at the facility for one month, was expected to identify smokers and those residents who needed smoking aprons and the SW stated, We discussed who required an apron and any concerns. When the surveyor asked if there was a book that illustrated residents who needed aprons and those with identified safety concerns for the Smoking Aides to reference in the courtyard during smoking breaks, the SW stated, No, I notified everyone verbally.
On 10/25/24 at 12:20 PM, the surveyor conducted a follow-up interview with Smoking Aide (SA) #1 who stated that she never saw residents put cigarette butts in the trash cans and was not sure when it happened. The surveyor showed SA #1 that there were multiple cigarette butts in the leaves that were on the ground and in every trash can on the courtyard. SA #1 stated, Sometimes they [the residents] get lazy and forget to throw it out. SA #1 stated that Resident #72, did it like that for attention, [he/she] did it anyway. SA #1 stated that she was supposed to redirect the resident when their ash became very long because it could fall on the resident's clothes and burn them.
On 10/25/24 at 12:36 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team. The DON stated that if an ash were to drop on the resident's clothing, the aide should go and assist the resident. The DON stated that residents should not light cigarettes off one another for safety reasons. The DON stated that the resident should not extinguish their cigarette with their fingers because the facility did not want them to burn themselves. The Regional Licensed Nursing Home Administrator (RLNHA) was present and stated that all cigarettes should be placed in the noncombustible trash can or an ashtray. The RLNHA stated that cigarette butts should not be placed on the ground or in the leaves. The RLNHA stated that the yard was cleaned right after every smoke session and could not explain why the yard had not appeared to have been swept after the 9 AM smoking break, prior to the 11 AM smoking observation, or immediately after the 11 AM smoking break.
On 10/25/24 at 1:39 PM, the surveyor requested all investigations related to Resident #72's smoking and was provided with a copy of an untitled document, dated 9/18/24, which indicated that it was Resident #72's first violation of smoking and indicated that the resident's smoking privileges were suspended for one week. Further review of the document revealed that the resident's smoking privileges were stopped on 9/18/24 and resumed on 9/22/24. The document indicated that the resident refused to sign receipt. The facility also provided the surveyor with two signed smoking policies dated 4/19/23 and 5/3/24 that were signed by the resident, and a notice that a Smoker's Meeting was held on 4/1/24.
On 10/28/24 at 10:42 AM, the surveyor reviewed a Nursing Progress Note in Resident #72's EHR, dated 10/25/24 at 2:54 PM, that was written by RN #1, which indicated that the resident's right thumb finger tips were noted with small dried cracked skin 0.5 (no unit of measurement used) x 0.2 x 0. Resident's right hand dry with a callus to the palm. The progress note further indicated the resident was non-compliant with proper wheelchair propulsion, refused a complete body assessment, a pain assessment was done and resident denied pain when asked, and a treatment to right thumb finger tips.
On 10/28/24 at 1:47 PM, the surveyor interviewed the Regional Director of Nursing (RDON), in the presence of the survey team. The RDON stated that they had a smoking binder and it detailed who required a smoking apron and was kept out in the smoking area. The surveyor informed the RDON that it was confirmed that there was no smoking binder present at the time of the smoking observation on 10/25/24. The RLNHA stated that the SW ran the smoking program for 17 years and could speak to the fact that she did not voice prior resident infractions of Resident #72 having cigarettes and lighters in the building or any investigations related to such infractions. The surveyor asked why the two smoke aides who monitored a multitude of residents during the smoking observation failed to ensure that residents were properly monitored and cigarette butts were not placed in the ashtrays or proper receptacles and he stated, We have eighty three smokers, and they are non-compliant.
On 10/28/24 at 9:39 AM, the surveyor conducted a follow-up interview with the SW, in the presence of the survey team. The SW stated that she was a little upset when originally interviewed by the surveyor, but that there was a smoking binder that was kept in a closet in the door of the copy room, and it is listed who needs smoking aprons and who has smoking suspensions. The Licensed Nursing Home Administrator (LNHA) stated that the binder was kept with the cigarettes and smoking supplies. The SW stated that SA #1 knew about the binder. The surveyor reiterated that both SA #1 and the SW stated when previously interviewed that there was no binder, and communications between the SA and the SW were conducted verbally. The SW then stated, I do not know what she [SA #1] was thinking.
A review of the facility's Smoking policy,revised 5/24, revealed the following:
.Appropriate receptacles must be used at all times.
Residents are not permitted to use, have or store cigarettes, cigars, matches, or lighters without any exceptions. For the safety of all the residents smoke in groups a, b, c, and 4. Group 4 is a closely monitored group.
Residents who have smoking contracts agree to the facility policy. Residents are not permitted to keep any smoking items. Visitors and family members are asked not to provide lighters, matches and cigarettes or to light cigarettes for any residents. Cigarettes should be provided to the smoke aide, social worker, or Nursing Supervisor for distribution as appropriate
.Residents who do not adhere to the smoking contract will lose their smoking privileges. See schedule infractions
a. First Offense-Loss of all smoking privileges for a week, followed by loss of independent status.
b. Second Offense-Loss of all smoking privileges for 2 weeks, followed by loss of independent status.
c. Third Offense-Loss of smoking privileges for a month, followed by loss of independent status.
d. Fourth Offense-Loss of smoking privileges permanently. 30-day discharge.
The following are reasons for smokers to get their smoking privileges suspended
i. Noncompliance of facility rules and regulations related to smoking in non-designated areas.
ii. Smoking in an area of the facility and its campus that is not a designated smoking area.
iii. Providing or asking others for cigarettes and/or lighting materials.
iv. Having in their possession any smoking paraphernalia .
The surveyor reviewed SA #1's undated signed Job Description which revealed the following:
.The responsibilities of the smoking aide are to ensure that all residents are safe while smoking.
.Provide cigarettes for and light cigarettes for all residents.
The Aide will assure that all residents when needed will wear appropriate smoking aprons.
.You must maintain the area clean and organized.
You must report an issues immediately. You will call Social Worker or call the nursing Supervisor a [sic.] soon as possible.
.The smoking aide will maintain the courtyard area clean sweeping periodically, emptying the ashtrays.
.Residents are only allowed one cigarette at a time.
.You will ensure the Courtyard rules are followed.
A review of an untitled document signed by SA #1 on 9/4/24, revealed the following:
Pre-Smoke Break Preparation:
1. Verify Resident Eligibility:
Confirm that each resident scheduled for the break is permitted to smoke.
2. Gather and Check Supplies:
Ensure that you have the pre-rolled cigarettes, a lighter/matches, ashtrays, and any other needed supplies
.Safety Checklist During the Smoke Break:
.Maintain Supervision:
Stay close to the residents and observe them throughout the smoke break. Be vigilant for signs of distress, such as coughing, shortness of breath, or unsteady hands.
Please be on the lookout for residents who are violating any of the guidelines set forth in the resident's smoking contracts.
Use of Smoking Materials:
Light the cigarettes for the residents.
Ensure that ashtrays are used for all ash disposal to prevent accidental fires
.End of Smoke Break Procedures:
1. Extinguish and Dispose Properly:
Make sure each cigarette is completely extinguished and disposed of safely in the designated ashtray or disposal area
.Inspect Smoking Area:
Do a final check of the smoking area to ensure no smoldering butts or ashes are left.
NJAC 8:39-33.1(d), 27.1(a)

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to complete the dialysis communication book for a resident on dialysis (a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure).
This deficient practice was identified for 1 of 2 residents (Resident # 61) reviewed for dialysis and was evidenced by the following:
On 10/23/24 at 9:14AM, the surveyor reviewed the medical records for Resident #61.
A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dependence on renal dialysis.
A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/23/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired.
A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 8/17/224, that the resident received Dialysis treatment three times a week. Interventions included: the resident will have dialysis on the following days of the week: Tuesday, Thursday, Saturday.
A Review of the Order Summary report (OSR), dated as of 10/25/24, included the following physician's orders (PO):
A PO, dated 8/18/24, to check hemodialysis binder upon return from dialysis on Tuesdays, Thursdays, Saturdays, note any recommendations every shift for monitoring.
A PO, dated 9/17/24, for dialysis treatment three (3) times a week on Tuesdays, Thursdays, and Saturdays.
On 10/24/24 at 12:52 PM, the surveyor reviewed Resident # 61's Dialysis Communication Book which included Dialysis Communication Tool forms for the months of August, September, and October 2024 and revealed the following:
On 8/20/24 the dialysis center did not complete their portion of the Dialysis Communication Tool.
On 9/24/24 the dialysis center did not complete their portion of the Dialysis Communication Tool.
On 10/12/24 the dialysis center did not complete their portion of the Dialysis Communication Tool.
A review of the progress notes revealed the following nurses notes (NN):
A NN, dated 8/20/24 at 10:37AM, which included that the resident returned form dialysis.
A NN, dated 9/24/24 at 5:43AM, which included that the resident was out for dialysis.
A NN, dated 10/12/24 at 4:55 AM, which included that the resident left for dialysis.
A further review of the progress notes, from 8/17/24 through 10/25/24, did not include any documentation that the nurses contacted the dialysis center or obtained the post dialysis information for the following dates: 8/20/24, 9/24/24, and 10/12/24.
On 10/25/24 at 9:19 AM, the surveyor observed Resident # 61 awake and alert lying in bed. Resident #61 stated that he/she goes to dialysis and sometimes has problems with the transportation.
On 10/25/24 at 9:20 AM, the surveyor interviewed Registered Nurse (RN #2) who stated that the dialysis communication binder would be sent with the resident on dialysis days. The nurse would complete the top section of the form and the dialysis center would complete the bottom section. When the resident returned from dialysis, the nurse would check the communication binder and if the dialysis center did not complete their section, the nurse should call the dialysis center and obtain a report and document the information in the nurses' notes. RN #2 further stated that it was important that the communication tool was filled out completely because it is the facility's communication with dialysis. The dialysis center would communicate on the form if there were any new medications, medications that were administered at dialysis, or any recommendations for fluid restrictions.
On 10/25/24 at 9:33 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that nurses completed the top part of the communication tool form prior to going to dialysis, and the dialysis center would complete the bottom section after dialysis. If the dialysis center did not complete their section when the resident returned from dialysis, then the nurse should call the dialysis center and either fax the form to the center for completion or obtain a report and document the information on the form or in the nurses' notes.
On 10/28/24 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON) who stated that if the dialysis center did not complete their section of the communication tool form, the nurse would call the dialysis center and either obtain a report via the phone or fax the form to the center to be completed and faxed back to the facility. The DON stated that it was important that the communication tool form was completed by the dialysis center post dialysis so that the nurses knew what medications were given at dialysis, the pre and post weight of the resident, and if there were any new recommendations or orders.
A review of the facility's Dialysis Management (Hemodialysis) policy, undated, included to complete the Dialysis Communication Tool before and after dialysis and following up on any special instructions from the dialysis center.
NJAC 8:39-27.1(a)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders.
This deficient practice was identified for 1 of 7 residents (Resident #110) reviewed for unnecessary medications and was evidenced by the following:
According to the admission Record, an admission summary, Resident #110 had diagnoses including, but not limited to: paroxysmal atrial fibrillation (an irregular, often heart rate that commonly causes poor blood flow.)
A review of the Physician's Orders (PO) revealed a physician's order dated 5/27/24 for Cardizem oral tablet 120 milligram give one tablet by mouth three times a day for atrial fibrillation related to paroxysmal atrial fibrillation, hold for systolic blood pressure less than 130, to be crushed into pudding or applesauce.
A review of the June 2024 and July of 2024 Medication Administration Record (MAR) revealed the referenced medication was administered by nursing staff when the resident's systolic blood pressure (SBP) [the first number in your blood pressure reading] was below 130 mm HG (a unit of measurement used to record blood pressure) on the following dates:
On 6/1/24 at 1:00 PM with a SBP of 122 mm/HG
On 6/3/24 at 1:00 PM with a SBP of 119 mm/HG
On 6/17/24 at 5:00 PM with a SBP of 120 mm/HG
On 6/18/24 at 5:00 PM with a SBP of 105 mm/HG
On 6/23/24 at 9:00 AM with a SBP of 126 mm/HG
On 6/23/24 at 5:00 PM with a SBP of 118 mm/HG
On 6/27/24 at 1:00 PM with a SBP of 115 mm/HG
On 6/28/24 at 1:00 PM with a SBP of 96 mm/HG
On 7/1/24 at 1:00 PM with a SBP of 124 mm/HG
A review of the pharmacy consultant recommendation, dated 5/28/24 and signed by nursing on 6/21/24, revealed, medication error (s) noted. Cardizem is not always held as required by the physicians hold order. After the pharmacy recommendation, nursing staff continued to administer Cardizem to Resident #110 Cardizem outside of the SBP parameters ordered by the physician.
On 10/29/24 at 9:39 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the pharmacy recommendations were given to the unit manager and then the provider would be made aware for changes to be made according to the pharmacy recommendation.
During the same interview, Regional Director of Nursing (RDON) #2 stated the directions on the medication order should be followed and the nurse should notify the physician if they need to.
A review of the facility's Administering Medications policy, reviewed 5/18/24, revealed Medications shall be administered in a safe and timely manner, and as prescribed, and, must be administered in accordance with the physician orders, including any required time frame.
NJAC 8:39-29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) label all food items in the refrigerator.
This deficient practice was identified in the facility kitchen and in 1 of 1 nursing unit pantry and was evidenced by the following:
On 10/22/24 at 9:39 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen:
1.) In the refrigerator identified as the walk-in cooler, a cluster of bok choy and lemongrass was noted on the shelf. Both items were dated 10/9/24. At that time, the surveyor interviewed the FSD who stated that he was unsure of when the items needed to be discarded.
2.) In the food preparation area, a heavy duty commercial blender base was observed with hardened food stain and a moderate amount of discoloration. At that time, the surveyor interviewed the FSD who stated that the blender should be clean. He further stated that the facility planned on purchasing a new blender.
3.) When the surveyor opened the pellet heater (used to warm pellets - a plate-like device used to keep foods hot) door, the interior sides and multiple pellets were noted with small food particles and a moderate amount of thick brownish sticky-like residue. At that time, the surveyor interviewed the FSD who stated that the pellets were last used for breakfast (10/22/24). When asked if the pellets had been cleaned, the FSD stated, not yet, they are going to do that right now. When asked the process for when the pellets were returned to the kitchen, the FSD explained the pellets went to the dish room, were cleaned, allowed to be air dried, and then they were returned to the pellet heaters to get ready for the next meal.
4.) The surveyor requested to see the dish washer temperature and chlorine log. The FSD provided the surveyor with the log which revealed the Dish Machine Ware Washing- Low Temperature log for the month of October was incomplete; the lines to record the temperature and chlorine level for October 20th, 21st, and 22nd were blank for breakfast, lunch, and dinner. At that time, during an interview, Dietary Aide (DA) #1 stated the temperature and chlorine levels were tested before and after he started the wash. I make sure the machine is working right. When asked if the temperature and chlorine levels were checked today (10/22/24), DA#1 replied, Yes. He further stated that the results were not documented in the log. At that time, the FSD stated that the temperature and chlorine levels on 10/20, 10/21, and 10/22 should have been completed and documented in the log.
On 10/24/24 at 10:29 AM, the surveyor, accompanied by the FSD, observed the following in the food storage supply area located in the basement:
5.) There were two (2) boxes containing multi packages of barley from two (2) different manufacturers. The packages in Box #1 had a best by date of 10/18/23. The surveyor observed bugs crawling inside the packages. Box #2 did not have an expiration date on the individual packages or on the outside of the box. On the same shelf, there was also a box containing multiple packages of green split peas with the expiration date of 9/22/24. At that time, the surveyor interviewed the FSD who confirmed the surveyor's findings and discarded the expired barley and green split peas. The FDS stated that he was responsible for ensuring that there were no expired foods on the shelf. The FSD further stated, everything should be labeled with a receive date and discarded after six (6) months.
On 10/28/24 at 12:14 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that the pellets should be cleaned after every meal. When asked how often the dish machine solution should be tested, the LNHA stated, they do it every day. He further stated that the dish machine log should be completed and, I constantly audit the logs to make sure they fill them in.
On 10/29/24 at 9:03 AM, the surveyor, accompanied by Certified Nursing Aide (CNA) #1, observed the following unlabeled food items in the refrigerator/freezer designated for resident food in the B Wing pantry:
6.) In the refrigerator:
-Plastic container with soup
-Two (2) cups of juice
-A can of soda
-Bottle of strawberry banana juice
-Potato chips
7.) In the freezer:
-An insulated travel cup
-Ice cream
At that time, CNA #1 stated that all of the items in the refrigerator belonged to the residents. She further stated that staff members brought items from other units and placed them in the refrigerator and CNA #1 does not know what food belongs to each resident. She also stated that each food item should be labeled accordingly.
On 10/29/24 at 9:18 AM, Regional Director of Nursing (RDON) #2 confirmed the surveyor's findings. She stated that all items in the refrigerator should have been labeled with the resident's name and the use by date.
Review of the facility's Subject: Labeling and Dating Procedure Implemented in the Dietary Department policy, undated, revealed the following:
1. Food items, as appropriate will be labeled and dated by dietary staff using the facility labeling system, and the food service director/designee will oversee labeling and dating.
2. All perishable products will be dated using the date of production. The dated product will be used up to and including the 3rd day from the date of production unless otherwise marked. All products after this date will be discarded.
3. Perishable foods are checked for spoilage by the FSD/designee.
4. Dated products are checked for expiration by the FSD/designee.
Review of the facility's Dish Machine policy, reviewed/revised 6/21/24, revealed, The kitchen will wash, rinse and sanitize after each meal service. Procedure: Staff will scrape waste off dishes and trays into food waste container. Rinse dishes thoroughly into scrap sink. Remove all dishes and inspect for cleanliness and dryness . Dishwasher staff will monitor and record dish machine temperatures to assure compliance for wash and rinse cycles. Low Temp Machine (Wash 120 degrees F, rinse no higher than 150 degrees F) Must use chlorine test strip prior to and during use and must read 50-200 PPM. FSD or designee will monitor temp. log and PPM readings prior to each usage for compliance.
NJAC 8:39-17.2(g)

COMPLAINT#: NJ172102
Based on observations, interviews, medical records review, and review of other pertinent facility documentation, it was determined that the failed to maintain an accurate and complete medical record in accordance with acceptable standards and practice.
This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following:
1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it.
A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain).
A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/19/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired.
A review of the resident's electronic medical record (EMR) revealed that the resident had the following physician's orders:
-Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions. -Start Date: 12/12/23 -End Date: 6/16/24
-Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Start Date: 12/12/23 -End Date: 02/21/24
The surveyor requested Individual Patient's Controlled Record for January 2024 & February 2024. The sheet for 1/1/24 - 1/12/24 was not provided to the surveyor.
The surveyor reviewed the resident's Individual Patient's Controlled Drug Record for February 2024 which revealed the following:
A sheet with the date range of 1/23/224 - 2/5/24:
2/1/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
2/2/24: 2 Percocet tablets were signed out at 3 PM
2/3/24: 2 Percocet tablets were signed out at 7 AM, 12 PM, 4 PM, 8 PM
2/4/24: 2 Percocet tablets were signed out at 8 PM
2/5/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
An additional sheet with the date range of 2/4/24 - 2/23/24:
2/4/24: 2 Percocet tablets were signed out at 8 PM
2/5/24: 2 Percocet tablets were signed out at 12 AM
2/6/24: 2 Percocet tablets were signed out at 4 PM, 8 PM
2/7/24: 2 Percocet tablets were signed out at 12:30 AM, 4 PM, 11 PM
2/13/24: 2 Percocet tablets were signed out at 12:30 PM
2/14/24: 2 Percocet tablets were signed out at 9 AM
2/15/24: 2 Percocet tablets were signed out at 8 PM
2/16/24: 2 Percocet tablets were signed out at 9 AM, 8 PM
2/17/24: 2 Percocet tablets were signed out at 5 PM
2/18/24: 2 Percocet tablets were signed out at 11 AM, 5 PM
2/19/24: 1 Percocet tablet was signed out at 8 AM
2/19/24: 2 Percocet tablets were signed out at 5 PM
2/20/24: 2 Percocet tablets were signed out at 4 PM
A review of the Medication Administration Record (MAR) for February 2024 revealed the resident was prescribed:
Percocet Oral Tablet 5-325 MG (Oxycodone w/Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions -Order Date- 12/12/2023 -D/C Date- 06/16/2024
Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Order Date- 12/12/2023 -D/C Date- 02/21/2024
The surveyor further reviewed the February 2024 MAR for the corresponding dates which revealed the following:
2/1/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/2/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/3/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 7 AM, 12 PM, 4 PM, 8 PM.
2/4/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM
2/5/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/6/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/7/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/13/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/14/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/15/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM.
2/16/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 9 AM, 8 PM
2/17/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 5 PM.
2/18/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/19/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered.
2/20/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 4 PM
A review of the progress notes for the above corresponding dates did not include any additional documentation regarding Percocet administration for the aforementioned dates and times.
2.) Resident #365 was not at the facility on the day of the survey. A closed record review was completed.
According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to: opioid dependence, spinal stenosis (the narrowing of one or more spaces within your spinal canal), and fracture of the right tibia.
A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/13/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact.
A review of the electronic medical record (EMR) revealed the resident had the following physician's orders:
-Oxycodone HCl Oral Tablet 20 MG (Oxycodone HCl) Give 20 mg by mouth every 4 hours as needed for (severe pain 8-10) -Start Date: 11/13/23 -End Date: 12/26/23
The surveyor requested Individual Patient's Controlled Record for December 2023. The sheet for 12/13/24 - 12/24/23 was not provided to the surveyor.
The surveyor reviewed the resident's Individual Patient's Controlled Drug Record for December 2023 which revealed the following:
A sheet with the date range of 11/23/23 - 12/3/23:
12/1/23: 1 Oxycodone 20 mg signed out at 1:45 AM
12/2/23: 1 Oxycodone 20 mg signed out at 12 AM
An additional sheet with the date range of 12/4/23 - 12/12/23:
12/11/23: 1 Oxycodone 20 mg signed out at 2:46 PM
A review of the Medication Administration Record (MAR) for December 2023 revealed that the resident was prescribed:
Oxycodone HCl Oral Tablet 20 MG (Oxycodone HCl) Give 20 mg by mouth every 4 hours as needed for (severe pain 8-10) -Order Date- 11/13/2023 -D/C Date- 12/26/2023
A further review of the December 2023 MAR for the corresponding dates revealed the following:
12/1/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 1:45 AM
12/2/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 12 AM.
12/11/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 2:46 PM.
A review of the progress notes for the above corresponding dates did not include any additional documentation regarding Oxycodone administration.
On 10/25/24 at 2:19 PM, the surveyor interviewed the Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator (RLNHA) who stated that the facility policy on keeping medical records was to follow the regulation. The Regional Administrator further added that this included resident's narcotic sheets and he stated again that records were to be maintained for as long as the regulation required.
On 10/28/24 at 2:54 PM, the surveyor interviewed Regional Director of Nursing (RDON) #2 who stated that the Individual Patient's Controlled Record for Resident #58 & Resident #365 could not be located.
NJAC 8:39-27.1(a)

Complaint #: NJ175570
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a safe and sanitary physical environment in the central supply room.
This deficient practice has the potential to affect 3 of 3 nursing units and was evidenced by the following:
On 10/23/24 at 12:25 PM, the surveyor conducted a tour of the facility's basement, in the presence of the facility's Regional Licensed Nursing Home Adminstrator (RLNHA) and the staff member in charge of Central Supply. At that time, the surveyor entered the Central Supply room and observed, adhered on the wall board ceiling to the right of the doorway near the pipes, a black substance approximately 24 inches in length.
On 10/23/24 at 1:00 PM, the surveyor revisited the Central Supply room and observed the RLNHA and the Maintenance Assistant (MA) present in the room. The MA had a pitcher of white paint with a brush and was applying the white paint over the black substance on the ceiling. At that time, the surveyor interviewed the RLNHA who stated, it was dirt on the ceiling.
On 10/23/24 at 1:10 PM, the surveyor interviewed the staff member in charge of Central Supply who stated she was unaware of the black substance that was observed on the ceiling. She further stated the prior staff had resigned and she was covering.
On 10/23/24 at 1:15 PM, the surveyor interviewed the Maintenance Director who stated that he was unaware that there was a black substance on the ceiling in the Central supply room.
On 10/28/24 at 1:34 PM, the RLNHA, in the presence of the LNHA, Director of Nursing (DON), Regional DON (RDON) #1, RDON#2 and the survey team, stated that it was scud and dirt on the ceiling and it came right off. He further stated that the ceiling was cleaned and then painted over after surveyor inquiry.
The facility was unable to provide a policy related to maintaining a safe and sanitary physical environment. The RLNHA stated they followed their Infection Control policy.
NJAC 8:39-31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a.) ensure the facility policy for Falls Management was followed to appropriately assess a resident and determine the causal factor of a fall and implement appropriate interventions to prevent recurrent falls for a cognitively impaired resident (Resident #23), who was identified as a high fall risk, required extensive assistance with bed mobility, and had a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). A subsequent unwitnessed fall occurred on 05/21/23 and required 911 transport to the emergency room, and resulted in a laceration to the forehead measuring 6 centimeters (cm) x 5 cm and a mild frontal scalp swelling per a computerized tomography (CT) scan, b.) ensure a complete Head to Toe Assessment was completed as required by a Registered Nurse prior to transferring Resident #23 to the bed, when reportedly Resident #23 was found on the floor on 05/21/23 at 6:00 AM, c.) provide adequate supervision to prevent recurrent falls, and d.) ensure that existing interventions to prevent falls were consistently implemented.
This deficient practice occurred for 1 of 3 residents, Resident #23, reviewed for falls with injury and was evidenced by the following:
On 05/22/23 at 10:40 AM, the surveyor observed Resident #23, positioned on the right side, in a bed that was against the wall and the resident was facing the wall. The surveyor observed a pad on the floor next to the bed. Resident #23 was unable to maintain a conversation with the surveyor and the resident also had a blanket covering the head.
On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed, and was again positioned in the same manner as observed by the surveyor two days prior. At that time, the Certified Nursing Assistant (CNA) was inside the room and attempted to assist Resident #23 with the breakfast meal. The CNA stated to the surveyor that Resident #23 had a poor appetite and exited the room shortly after the surveyor entered.
On 05/24/23 at 10:25 AM, (two hours later) Resident #23 was observed still in bed and was in the same position facing the wall. The B-Wing Activities of Daily Living (ADLs) worksheet (a document that direct care staff documented the resident care that was provided), could not be located by the staff to verify any documented care that had been provided to Resident #23 regarding position change or being repositioned.
On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed, on his/her back with head elevated. At that time, the surveyor observed a large, black and blue in color hematoma (collection of blood) on Resident #23's right forehead. A Licensed Practical Nurse (LPN), who later identified herself as the Infection Preventionist (LPN IP) was in the room and assisted Resident #23 with the lunch meal. Upon surveyor inquiry regarding the observed injury on Resident #23's forehead, the LPN IP stated that the injury was from a fall the resident sustained and she would not elaborate further on the observed injury.
On 05/24/23 at 1:25 PM, the surveyor reviewed Resident #23's electronic medical record and could not locate any documentation regarding the observed injury that the LPN IP confirmed Resident #23 sustained during a fall at the facility. According to the admission Face Sheet, Resident #23 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, acute kidney failure, blindness left eye, and acquired absence of right leg above the knee.
A review of the Significant Change Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 02/28/23, revealed that Resident #23 was severely cognitive impaired. Resident #23 scored 6/15 on the Brief Interview for Mental Status (BIMS).
Section G of the MDS, which referred to activities of daily living (ADLs), revealed that Resident #23 was totally dependent on staff for care and required an extensive assistance of two-person physical assist for transfer, and one-person physical assist for care.
A review of the progress notes did not contain documentation regarding the fall that the LPN IP stated occurred on 05/21/23 for Resident #23, however a fall that occurred on 02/15/23 was documented. The following entry dated 02/15/2023 timed 19:42:31 [7:42 PM], Note Text: Notified by aide that resident was on the floor. I found resident laying on the floor on the right side. I observed no head injuries and resident said [his/her] head was fine. Resident expressed that [his/her] left arm was hurting, and [he/she] was in pain. Called MD to make aware. Called for X-ray of left arm. Neuro checks in progress. Made supervisor aware. Will continue to monitor resident throughout the shift. VS [vital signs] 95/51 [blood pressure] 74 [pulse] 97.3 [temperature] 95% [oxygen saturation] 17 [respirations].
Another entry dated 02/16/23 revealed the following: Resident had increased in pain, MD was notified and [Resident #23] was sent out to the hospital. CT scan cervical spine, CT head without contrast, X-ray left humerus and X-ray left shoulder done. Resident found to have acute fracture through the left humerus surgical neck extending into the greater tuberosity, without significant displacement. Small glenohumeral hemorrhagic effusion.
The surveryor reviewed the current Comprehensive Care Plan (CP) initiated 09/22/20, last revised 05/25/23 (revised four days after the fall that occurred on 05/21/23) which included 17 pages and had a Focus for ADL and functional mobility deficit related to: decreased strength, balance, endurance and coordination. I require extensive assistance/Total Dependence with ADLs, transfers, functional mobility and safety awareness. The Goal for this Focus was for Resident #23 to improve ADL and functional mobility level by next review. Initiated 09/22/20, and Revised 05/25/23, with a Target Date of 08/14/23, The CP interventions included: Converse during care, Ensure that all assistive devices are in place, and Introduce yourself and explain all care. Date Initiated: 10/15/21, Date Revised: 05/25/23.
Resident #23 also had a CP Focus for At Risk for falls due to Impaired balance/poor coordination, Date Initiated: 02/13/21. The Goal was Minimize risk for falls through next review, Date Initiated: 02/13/21. The following interventions were documented:
Provide assistance to transfer and ambulate as needed. Initiated 02/13/23.
Reinforce the need to call/ring for assistance. Initiated 02/13/23.
Reinforce wheelchair safety as needed such as locking brakes. Initiated 02/13/23.
Therapy evaluation and treatment as ordered. Initiated 02/13/23.
On 02/15/23 Resident #23 was found lying on the floor in his/her room. The following interventions were added to the care plan:
Assess for pain and medicate if needed. Initiated 02/15/23
Assessment Completed, Date Initiated 02/15/23.
Continue at risk for fall intervention, Date Initiated 02/15/23.
Monitor range of motion every shift x 72 hours, Date initiated 02/15/23.
Neuro check x 72 hours, Date initiated 02/15/23
Notify MD [Medical Doctor] of the incident and for any significant change, Date initiated 02/15/23.
Epic evaluation of meds[medications], Date initiated 02/16/23.
Floor mat at bedside, Date initiated 02/16/23.
Sent to Hospital for evaluation of pain. Initiated 02/16/23.
Sling to shoulder. Initiated 02/17/23.
Orthopedic appt [appointment] scheduled, Date Initiated 02/20/23.
Pain management adjustment, Date Initiated 02/20/23.
A review of the Fall Risk assessment dated [DATE], 13:30 [1:30 PM] revealed that Resident #23 was assessed as a High Fall Risk, Resident #23 received a score of 37 indicative of a high fall risk.
On 05/24/23 at 11:00 AM, the surveyor requested all investigations for Resident #23.
On 05/24/23 at 12:10 PM, the surveyor, again reviewed the electronic medical record. There was no documentation regarding the fall that occurred on 05/21/23.
On 05/24/23 at 1:30 PM, the surveyor reviewed the CP for Resident #23. There was no revision made to the CP, including additional interventions added, after Resident #23 sustained a fall on 05/21/23.
On 05/25/23 at 8:30 AM, the surveyor went to B-Wing and observed that Resident #23 was no longer in the room. The bed was stripped, and the mattress had been deflated.
On 05/25/23 at 9:10 AM, the LPN assigned to the B-Wing, informed the surveyor that Resident #23 was transferred on 05/24/23 to another facility that was owned by the same company. The LPN could not offer any details as to why Resident #23 was transferred the prior evening.
On 05/25/23 at 9:49 AM, the surveyor reviewed the electronic progress notes. There was no documentation in the medical record regarding Resident #23's transfer. When interviewed, the staff would not comment on who authorized or any reason for the transfer. There was no physician order for the transfer.
At that time, the surveyor attempted to contact Resident #23's physician and the responsible party. Messages were left for both, and neither returned the surveyor's phone calls.
The surveyor again, reviewed the electronic progress notes and noted the following entry dated 05/24/23 timed 21:37 [9:37 PM]:
This note is a follow up to:
5/21/2023 7:39:00 Nursing Progress Note (Other) Focus: Effective Date: 5/24/2023, 21:10:00 [9:00 PM]
Department: Nursing, Position: registered nurse, Created Date: 5/24/2023, 21:37:06 [9:37 PM], Note Text: On 5/21/23 at 7:39 AM, CNA advised me that res [resident] fell in [his/her] room. Upon arrival to res [resident] room, I observed res [resident] lying in bed. Res [resident] observed bleeding on head. Pressure dressing applied. Assessment and neuro (neurological assessment done to evaluate level of consciousness) check complete. Res [resident] was alert and oriented, responsive, PERRLA (Pupils Equal Round, Reactive to Light and Accommodation), hand grasp equal. Vital signs were taken (BP) blood pressure: 198/51 Pulse:86 Temp (temperature): 96.4 Respirations 18, Unable to obtain (SPO2) [Oxygen saturation]. 911 was called for immediate attention and MD was notified. No family listed. EMTs (Emergency Medical Transport) transferred res [resident] to [hospital name redacted] for further observation of the resident. Onboarding nurse made aware.
On 05/25/23 at 10:15 AM, the surveyor again requested any investigations for Resident #23 from the Director of Nursing (DON), including any statements that were obtained from staff that worked on 05/21/23 for the 11:00 PM-07:00 AM shift [when fall occurred]. The investigation, nor any supporting documentation was provided.
On 05/26/23 at 11:15 AM, the DON provided two Fall documents dated, 02/15/23 and 05/21/23 respectively. There were no statements attached to either document or that had been requested by the surveyor.
There were no statements attached to the Fall documents to inform the reader who had witnessed the fall. The causal factor/s were not identified. A note entered on the Fall document dated 03/03/23 (18 days after the first fall), indicated the following: Resident was found on the floor. When asked as to what happened, he stated, I was trying to leave. On assessment c/o[complain] of left arm pain. MD [Medical Doctor] notified and ordered X-ray left arm. Resident was medicated for pain and assessed every shift while waiting for the X-ray to be done. Floor Mat was placed at bedside. To continue current at-risk care plan. Resident #23 was transferred to the Emergency Department on 02/16/23 at 10:50 AM due to complaint of pain in left arm. Resident #23 was diagnosed with a comminuted mildly displaced fracture of the left humeral head.
The Fall document dated 02/15/23 timed 18:40 PM [6:40 PM], did not provide information regarding when Resident #23 was last observed and cared for and by whom. The Fall document did not include, and documentation in the Other section including if the bed was in low or high position, if the resident was in bed or in a wheelchair when found on the floor, if the call light was activated, if the resident was incontinent, the presence of absence of any devices that would alert the staff of the fall. The Predisposing Situation Factors section had History of Falls Bruising as the only checked area. Other. Alarm Sounded, Call Light on at Time, Reaching for Something, Wanderer, Attempted Self Toileting was left blank. The fall was unwitnessed. The revised care plan for falls dated 02/15/23 failed to address the line of supervision required by Resident #23 to prevent recurrence.
Another Fall document dated 05/21/23 timed 07:21 AM, revealed the following notes entered by the LPN (Licensed Practical Nurse) on duty that night: CNA notified nurse that resident fell while attempting to change [him/her]. Resident [hit his/her] head on the floor just missing the floor mat and was bleeding profusely.
The Registered Nurse (RN) who went to the room to assess the resident, documented the following on the Fall document: CNA notified nurse that resident fell when attempting to change [him/her]. Resident hit [his/her] head on the floor just missing the mat and was bleeding profusely. IDT Interdisciplinary Team discussed resident upon return from ER [emergency room] and [resident] will be treated with antibiotic per MD order, family also requested hospice services.
On 05/25/23 at 11:00 AM, the surveyor reviewed the assignment sheet dated 05/21/23 provided by the 07:00-3:00 PM shift which revealed that a Hospitality Aide (HA) was assigned to the B-Wing and cared for Resident #23 on the 11:00-PM-7:00 AM shift. The facility did not have a statement from the staff who cared for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23 according to the assignment sheet provided.
On 05/30/23 at 10:30 AM, the DON provided a witness statement dated 05/22/23, which was not attached to the Fall document dated 05/21/23. According to the CNA's statement, she was assigned to Resident #23 during the 11:00 PM-7:00 AM shift, not the HA per the original assignment sheet as provided to the surveyor.
On 05/30/23 at 11:00 AM, the facility provided a copy of a revised CP that included 26 pages, with additional interventions added that were not included on the CP that was revised on 05/25/23, and documented the following:
Focus:
[Resident #23] had a fall was found lying on the floor in [his/her] room. 05/21/23 Resident fell during care when [he/she] was turned to the side of the bed, it happened so fast, staff unable to prevent fall, Date Revised: 05/25/23.
The Goal was to Risks for falls will be mitigated, Date Initiated: 02/15/23, Date Revised: 05/25/23 and Target Date: 08/14/23.
The following interventions were documented:
2 persons assist during care, Date Initiated 05/21/23.
911 Was called and sent to hospital for evaluation, Date Initiated 05/21/23.
Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23.
Complete assessment with bleeding on left side of head, Date Initiated 05/21/23. Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23.
Pressure dressing applied, Date Initiated 05/21/23.
Primary physician made aware of the event, Date Initiated 05/21/23; Resident returned to the facility with antibiotic- Fosfomycin x 1 dose and doxycycline x 10 days, Date Initiated: 05/21/23.
On 05/30/23 at 11:30 AM, an interview with an additional CNA who worked the 07:00-3:00 PM shift on 05/21/23 on the B-wing and who was listed on the assignment sheet for the same day, confirmed that the CNA who documented the statement did not provide care for Resident #23 on 05/21/23 on the 11:00 PM-07:00 AM shift. The CNA confirmed that the HA provided care to Resident #23 when the incident occurred.
On 06/01/23 at 09:35 AM, the surveyor conducted a telephone interview with the Registered Nurse who worked on the 11:00 PM-07:00 AM shift on 05/21/23. The RN revealed that she was informed around 06:45 AM by the HA, that the resident sustained a fall. She went to the room and observed the resident was in bed and was bleeding profusely from the head, the resident reported feeling cold and was confused. The RN stated she then applied a pressure dressing, assessed the resident, implemented a neuro check, and called 911. Upon inquiry, the RN stated that the CNA who documented the statement was not assigned to Resident #23. In the presence of three other surveyors and the supervisor of the survey team, the RN stated that the HA was assigned to the resident. The RN further stated that when she questioned the HA regarding the mat that was to be in place to minimize injuries from falls, the HA changed his story several times. The RN also stated that she discussed the incident with the DON. The RN stated she did not know who transferred the resident back to bed after the resident was found on the floor. She further stated that she was made aware only two days ago that the staff who cared for Resident #23 on 05/21/23 during the 11:00 PM-07:00 AM shift, was a HA and was not a Certified Nurse Aide (staff trained to assist with certain non-resident care tasks).
On 06/01/23 at 11:30 AM, the survey team informed the DON that the CNA who signed the witness statement, per interview and review of the timecard, was not assigned to the 11:00 PM shift on 05/21/23. The DON stated that she was told that the CNA reported that Resident #23 fell during care, she was not aware that Resident #23 was found on the floor by the Hospitality Aide. The DON was unable to explain why the HA was documented on the assignment sheets as having a resident assignment and was assigned to provide direct care to Resident #23.
On 06/01/23 at 12:25 PM, the surveyor in the presence of the survey team, interviewed the CNA who signed the witness statement dated 05/22/23. The CNA stated that she was the CNA assigned to Resident #23 when the incident occurred, although her name was not listed on the schedule as being assigned to Resident #23 and contradicted the RN and LPN interviews. She stated during care Resident #23 fell, missed the mat and she yelled for help. The nurse then came into the room, assessed the resident on the floor and assisted her in transferring the resident to bed with a pulled sheet.
On 06/01/23 at 12:30 PM, a review of the CNA's timecard provided by the Staffing Coordinator, revealed that the CNA who signed the witness statement worked 16 hours on 05/20/21 and reported to work on 05/21/23 at 07:02 AM. The CNA was not at the facility when Resident #23 sustained the fall.
On 06/01/23 at 12:41 PM, the surveyor interviewed the Director of Nursing regarding the HA job description and inquired about who was responsible to monitor the HA. The facility had 8 Hospitality Aides assigned to the facility. The DON replied that the HAs had been working at the facility before she accepted the position as a DON, and she was not too sure of who was responsible to supervise or monitor the HAs. The DON then stated the nurses were responsible to monitor the HAs
A review of the job description for the HA provided by the facility on 06/01/23 at 12:15 PM, revealed under Duties
Report all pertinent information concerning resident care as directed to the appropriate supervisor/ personnel.
Transport residents to activities, therapy, outside to smoke.
Make beds, distributes linen as needed, and transports dirty linen to the linen room using established standards precautions.
Distributes and sets up food trays for residents during meal times and collects empty trays from resident rooms and dining rooms. Monitor dining areas as assigned. Passes water pitchers
Complete assignments timely, completely, and accurately.
Conduct resident rounds as assigned.
Answer call lights and obtain assigned staff members if direct patient care is needed. Cannot do any clinical care.
On 06/02/23 at 09:53 AM, a telephone interview with the HA revealed that he worked the 11:00 PM -07:00 AM shift on 05/21/23. He stated that around 06:00 AM he went to the room to distribute linen and confirmed that he found Resident #23 on the floor bleeding (not the CNA as documented on the statement) and then he informed the nurse. The HA stated that he discussed the incident briefly with the DON on 05/21/23 and was not asked to document a statement. The surveyor then inquired regarding his name being on the schedule with a full assignment, he could not provide the rationale why he had a resident assignment. He stated that his job was to assist with task not related to direct care such as passing water, make beds, distribute linen.
On 06/02/23 at 10:07 AM a telephone interview was conducted with the LPN who worked the 11:00 PM-07:00 AM shift. The LPN confirmed she worked on 05/21/23 and the HA was the person who reported the fall. The LPN continued and stated, that the RN went into Resident #23's room and assessed the resident after the fall. The LPN stated she did not go to the room, and she assisted with the paperwork for the emergent transfer. The LPN was unaware of who transferred the resident to bed. The LPN confirmed that the HA was the one assigned to and provided care for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23.
On 06/02/23 at 10:16 AM, during a second telephone interview with the RN, she stated that the HA had a resident assignment that day, and he cared for Resident #23 and confirmed that he was the one that reported the fall. The RN went on to state that when she entered the room, Resident #23 was already in bed and bleeding profusely. She did not ask who transferred the resident to bed. She was aware of the process to follow: Assessed while on the floor, ensure no head injury, implement neuro, alerted EMT (Emergency Medical Transport), notify the physician. She further stated that she discussed the fall with the DON.
The surveyor reviewed Resident #23's ADLs worksheet for the month of May, left blank and there was no staff initials documented to identify who cared for Resident #23 on 05/21/23 during any of the shifts.
On 06/02/23 at 11:15 AM, the DON was made aware of the discrepancy surrounding the fall dated 05/21/23. The DON was made aware of the telephone conversations with the nurses and the HA who worked the 11:00 PM-07:00 AM shift on 05/21/23. The DON stated that she was told that Resident #23 fell during care. The DON further stated since the resident was found on the floor, she considered the incident as a fall and did not investigate any further. The DON was asked to provide any additional information along with any Interdisciplinary Team Notes regarding the Fall document dated 05/21/23 for review on the exit day.
On 06/05/23 at 11:34 AM, in the presence of the acting Administrator, the DON stated she went along with the information that was provided to her that Resident #23 fell during care, and that the fall was a witnessed fall, and she did not investigate.
The facility did not present any further information.
A review of a form titled, Accidents and Incidents-Investigation and Reporting dated 11/15/22, indicated the following:
Policy Statement:
1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of accidents or incidents as appropriate.
2. The following data, as applicable shall be included on the Report of Incident/Accident form:
The date and the time the accident or incident took place.
The nature of the injury /illness.
The circumstances surrounding the accident/incident if known.
Where the accident/incident took place if known.
The name (s) of witnesses if any and their accounts of the incident or accident if known.
The injured person's account of the accident/incident if able to communicate.
Other pertinent data as necessary or required .
3. The Nurse Supervisor/ Charge Nurse and /or the department director or supervisor shall complete a Report of Incident/Accident form and get witness statements if any at the time of the incident. This individual will submit completed documents to the Director of Nursing Services /designee and discuss the incident at the morning management meeting.
Post Fall/ Injury Resident Management
In the event a resident has fallen and/ or is found on the ground, a complete head to toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.) Remain with the resident while calling for assistance.
If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later).
Upon arrival of the nurse, a quick head- to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings.
Fall Injury Prevention-Post Fall
1. Assess the resident/ patient and immediately implement appropriate measures to prevent injury.
Initiate and complete the Incident including pertinent witness statements. Review Fall Risk Assessment for any changes in fall risk, reassess post fall.
On 06/05/23 at 08:35 AM, the acting administrator provided a folder with in-services that were done regarding some of the concerns addressed with the facility on 06/02/23 during a pre-exit conference. Regarding the incident of 05/21/23 the acting administrator submitted a witness statement from a CNA that was not on the schedule. No statement from the nurses who worked that night were collected even when the facility was made aware of the discrepancy and the telephone interviews with staff that worked on 11:00 PM -07:00 AM shift.
The Acting Administrator also submitted an undated form titled, Falls and Falls Risk Management. Under Policy Statement the following were entered:
Based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Under procedure #7
Falls are discussed at the clinical meeting in an attempt to determine the root cause(s).
Review the fall, each morning and document in PCC (Point Click Care . However Resident 23 sustained a fall on 05/21/23. The facility did not submit the IDCP notes along with any root cause analysis that was done to identify the causal factor of the fall and rule out abuse.
(Resident #23 was transferred from the floor to the bed prior to the nurse arrival to the room. There was no facility information provided regarding the transfer that occurred on 05/21/23 when the resident was found in bed, profusely bleeding, and required 2 persons physical assist for transfer.)
NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the Standard Survey Date: 03/31/22
Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to identify and consistently comprehensively assess, implement, and modify interventions, consistent with professional standards of practice a.) in response to an unplanned significant weight loss of 16.38% in less than 6 months for (Resident #128), and b.) in response to a significant weight loss of 8.6 pounds (lbs) in four days for (Resident #51). This deficient practice occurred for 2 of 5 residents reviewed for nutrition.
The deficient practice was evidenced by the following:
Reference: The Academy of Nutrition and Deititians, Position of the Academy of Nutrition and Dietitianss: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated April 2018. Position Statement It is the position of the Academy of Nutrition and Dietitians that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered Dietitian nutritionist assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered Dietitian nutritionists in the implementation of individualized nutrition care.
a.) On 05/24/23 at 10:30 AM, Surveyor #1 observed Resident #128 as he/she attended the Resident Council Meeting (RCM). During the RCM, Resident #128 stated the food was inedible and that he/she had lost weight. Resident #128 stated that everything is mushy because it was steamed like the vegetables. I've eaten very few veggies (vegetables), too overdone. Resident #128 stated that he/she had spoken to the Dietitian twice and provided food preferences and that the Dietitian informed him/her that the vegetables were frozen and steamed. Resident #128 stated he/she would be happy with one piece of celery and a carrot, just fresh and that also the fruit was all canned and served at room temperature, not cold. Resident #128 stated that he/she was also informed by the Dietitian that whole grains never going to happen. Resident #128 further stated that the protein is inedible.
All six residents who attended RCM acknowledged that they were not offered an alternative menu such as the Asian menu provided to the Asian population of residents.
A review of Resident #128's admission Record (an admission summary), revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to; alcohol use, other psychoactive substance abuse, depression, atherosclerotic heart disease (arteries become narrowed and hardened from a buildup of plaque), hypertension (elevated blood pressure), Type 2 diabetes, hyperlipidemia (elevated lipids in the blood), folate (vitamin B) deficiency, anemia, and hyperkalemia (elevated potassium) in the blood.
A review of the facility provided, Weights and Vitals Summary, dated 05/31/23, revealed the following dates / weights:
01/31/23 weight 210 lbs (pounds)
02/01/23 weight 204.5 lbs
02/08/23 weight 202 lbs
02/13/23 weight 198.5 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -5.5%, -11.5 lbs]
02/20/23 weight 197.4 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -6%, -12.6 lbs]
02/22/23 weight 195 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -7.1%, -15 lbs]
03/06/23 weight 192.6 lbs -5.0% change [comparison weight 02/01/23, 204.5 lbs, -5.8%, -11.9 lbs]; -7.5% change [comparison weight 01/31/23, 210 lbs, -8.3%, -17.4 lbs]
04/08/23 weight 183 lbs
04/17/23 weight 177 lbs
04/24/23 weight 175.2 lbs
05/01/23 weight 176.2 lbs
05/08/23 weight 175.6 lbs.
There were no further documented follow up weights or re-weights in the electronic medical record (eMR).
A review of the Assessment section in the eMR did not reveal any nutritional assessments. A review of the Progress Notes (PN) in the eMR ranging from 02/01/23 through 06/01/23, revealed the following:
01/31/23, admission notes revealed weight 210 lbs.
02/01/23, the Physician's history and physical revealed a weight of 204.5 lbs.
02/15/23, a Physician's note indicated a weight of 202 lbs.
03/02/23, 31 days after admission, the first dietary note, indicated review of weights upon admission. The note included 'does not consume all vegetables in facility limiting intake of vitamins and minerals' 'resident educated .possibility of MVI (multivitamin) with mineral supplement' 'resident request [name redacted - supplement drink]' The note indicated a different supplement drink was requested by Dietitian. Food preferences reviewed and noted. There was no calculation of estimated protein or calorie needs, and determination of causal factor for the unplanned weight loss.
03/9/23, a nursing note indicated the resident was seen by the dentist and recommendations were made for periodontal scaling.
03/12/23, a Physician's note indicated a weight of 195 lbs.
04/03/23, a Physician's note indicated a weight of 192.6 lbs.
05/15/23, a Physician's note indicated a weight of 175.6 lbs 5/8 (on 5/8/23), admission weight 210 lbs. progressive wt (weight) loss from 210 lbs to 175 lbs-will sch (schedule) f/u (follow up) CBC (complete blood count), CMP (comprehensive metabolic profile), Hba1c (hemoglobin a 1 c - blood work to indicate blood sugar levels over a three-month period), TSH (thyroid-stimulating hormone), monitor po (intake by mouth) intake, dietary eval (evaluation), consider dietary supplement and Remeron (medication used for appetite stimulation).
The Progress Notes did not contain any additional notes from the Dietitian, any assessment to determine the causal factor of the weight loss and interventions to prevent weight loss. The PN dated 05/15/23, by the Physician did not indicate that a weight loss plan was ordered.
A review of the facility provided, Order Summary Report (OSR), dated active orders as of 05/31/23, included but was not limited to; an order dated 2/10/23 for renal/CCD (carbohydrate-controlled diet regular texture, thin consistency, for low potassium diet), and an order dated 03/02/23 for [name redacted] liquid supplement two times a day for supplement. An order dated 4/4/23, with no end date for a BMP (basic metabolic profile blood work).
There were no active orders for the Remeron, the follow up blood work, po intake monitoring, or dietary evaluation requested by the physician on 5/15/23. There were no active orders for a planned weight loss.
A review of the person-centered comprehensive Care Plan last review completed 05/10/23, with a print date of 05/31/23, revealed no focus area regarding Resident #128's significant weight loss, no Goals regarding the weight loss, and no interventions regarding the weight loss.
A review of the most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 05/02/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 14 out of 15; which indicated the resident was cognitively intact. Section K indicated a height of 71 inches and a weight of 176. K0300 loss of 5% or more in the last month or loss of 10% or more in last 6 months was inaccurately documented as 0 NO.
On 05/30/23 at 12:17 PM, during an interview with the surveyors, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the Dietitian was on vacation and unavailable for interview. The LNHA further stated she would have to see who is covering and that she was unable to locate the Dietitians credentials.
On 05/30/23 at 12:22 PM, the LNHA stated that the Dietitian was only gone for one week, so the facility did not need coverage. She also stated that the practice is the Dietitian would document in the eMR and that the Director of Nursing (DON) would confer with the Dietitian.
On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated she worked with the Dietitian and that every Monday weights and reweighs would be completed. On Thursday they would have a weekly weight meeting and discuss significant weight changes and interventions. She stated the Dietitian would make recommendations for the nurses to carry over. The DON stated, we discuss what could have caused the weight change, any supplements that may be needed, review what might be appropriate, speak to dietary to see that orders were carried out, monitor weights, we assign a specific Certified Nursing Aide (CNA) to do the weights. We have to investigate what's wrong with the weights like maybe a different wheelchair was used, and we notify the doctor for orders. The DON stated that the Dietitian would ask about food preferences and that some residents ask for organic food, but we can't accommodate organic for just one and we would have to tell resident. The DON stated that the weekly weights were documented in a log and the Dietitian would document them in the eMR as well. The surveyor inquired what would happen if a CNA obtains a resident weight and there was a 10 lbs difference, what would be the process. The DON stated that the CNA assigned should know to re-weigh the resident. The DON stated the Dietitian went on vacation 5/25/23 and was expected to return 6/8/23 (15 days later) and that the DON had only been with the facility for 3 months but the Dietitian was at the facility much longer. The DON stated she would provide the weight meeting information regarding Resident #128.
On 05/31/23 at 12:11 PM, Surveyor #1 observed Resident #128 in his/her room with their lunch tray on top of the over bed table. Resident #128 showed the surveyor that he/she only ate a chicken thigh and not the mashed potatoes or carrots. Resident #128 stated he/she had talked to Dietitian about fresh versus canned vegetables. Resident #128 stated he/she usually only drinks the supplement drink once a day not twice. He/she further stated the Dietitian knew about the weight loss and that he/she wanted to lose some weight but not because of (facility) food choices. Resident #128 stated I just want better food choices.
On 05/31/23 at 1:00 PM, the Regional Administrator #2, the DON, and the Regional [NAME] President of clinical services (RVPCS) were made aware of the above concerns.
On 06/02/23 at 9:00 AM, the DON provided four photocopied untitiled pages. The DON indicated the pages were the Weight Meeting notes. The pages included, but were not limited to Resident #128's name and the following information 1/31/2023 weight 204.5 # (pounds); 2/6/2023 weight 202 #; DO: (doctor order) 2/3/23 WW (weekly weights) x 4; and 2/10/23 WW x 3. Page 2 added 2/13/2023 weight 198.5 #; 2/20/23 weight 197.4 #; and 2/17/23 WW x 2. Page 3 added 2/27/23 weight 192.6 #, 3/6/23 weight 192.6 #, 3/13/23 weight 191.8 #; and 3/3/23 WW x 1, 3/10/23 WW x 4 due to monthly weight loss, and 3/17/23 WW x 1 since weight stable. Page 4 added 4/17/23 weight 177 #; 4/24/23 weigh 175.2 #; 5/1/23 weight 176.2 #; 5/8/23 weight 175.6 #; and 4/13/23 WW x 4; 4/20/23 WW x 3; 4/27/23 WW x 2; 5/4/23 WW x 1; and 5/11/23 monitor weights monthly. There was no documentation by the physician regarding a planned weight loss, any discussion of a weight loss plan with the resident or interventions ordered.
On 06/02/23 at 10:40 AM, the RVPCS stated that the weight sheets were worksheets, and they can't go by those weights. She stated that on Sunday the Dietitian would review Thursday's weights, and Tuesday she would review Thursday weights. The RVPCS further stated the weights would be in the weight meeting book and if a resident were being monitored for weight loss, that would also be in the eMR. She stated any interventions or orders would be implemented immediately.
A review of the weights revealed that on 01/31/2023, the resident weighed 210.0 lbs. On 05/08/2023, the resident weighed 175.6 pounds which was a -16.38 % loss in less than 6 months. The facility was unable to explain the discrepancies in the weights documented in the eMR versus the weight meeting logs; to provide documented evidence that interventions were revised in response to the significant weight loss; to provide any additional documentation of the weight loss by the Dietitian; to provide a Dietitian assessments, food preference list; or any person-centered comprehensive care plan of focus area, goals, or interventions for Resident #128's significant weight loss.
b.) On 05/22/23 at 10:25 AM, Surveyor #1 observed Resident #51 lying in bed with just a sheet on. Resident #51 appeared very thin, and the surveyor was able to observe bones under areas of his/her skin.
On 05/23/23 at 12:36 PM, Surveyor #1 observed Resident #51 in a high back wheelchair in the B-unit day room. The resident had a lunch tray with beef macaroni casserole and carrots. The resident was drinking his/her juice but not eating the casserole.
On 05/23/23 at 12:45 PM, the Licensed Practical Nurse (LPN) was encouraging Resident #51 to eat but the resident refused. The LPN asked if the resident wanted a peanut butter and jelly sandwich, and the resident nodded his/her head yes.
During an interview at that time, the LPN stated the resident likes peanut butter and jelly and would usually eat all of the breakfast meal. The LPN stated that the facility Dietitian would be the one in charge of the resident's weight loss if any.
A review of the facility provided, Weights and Vitals, dated 05/31/23, revealed the following:
03/09/23 a weight of 110 lbs.
03/14/23 a weight of 101.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.]
04/17/23 a weight of 100.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/09/23, 110 lbs., -8.7%, -9.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -8.7%, -9.6 lbs.]
A review of Resident #51's admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, hemiplegia (paralysis of one side of the body), and hypertension.
A review of the most recent Annual MDS dated [DATE], included but was not limited to a BIMS of 01 out of 15, which indicated the resident was severley cognitively impaired. Section G, Functional Status, revealed Resident #51 required limited assistance with a one-person physical assist for eating. Section K, Swallowing/Nutritional Status, revealed the resident weight as 110 lbs. and a score of 0 NO for weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months.
A review of the PN for Resident #51 date range 03/01/23 to 03/20/23, revealed a nursing entry on 03/08/23, that the resident's weight was 110 lbs. The next entry was dated 03/09/23, by Social Services and did not address the resident's weight. The next entry was dated 03/18/23, by nursing and did not address the resident's weight. There were no progress notes to indicate the Dietitian evaluated the resident or that the physician was notified of the resident's weight loss.
A review of Resident #51's person-centered comprehensive care plan printed 05/30/23, included but was not limited to a focus area of nutritional problem related to low body mass index (BMI) date initiated 03/21/23. Interventions date initiated 03/21/23, included monitor/record/report to MD (physician) PRN (as needed) signs / symptoms of malnutrition: significant weight loss: 3 lbs. in 1 week, > (over) 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no evidence in the eMR that the physician was notified of the weight loss of 8.6 lbs. in March 2023.
On 05/30/23 at 12:17 PM, during an interview with surveyors, the LNHA stated she would have to see who was covering for the Dietitian who was on vacation from 05/27/23 and to return on 06/03/23. The facility Dietitian was unavailable for interview.
On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated the weekly weight documented in a log and the Dietitian would document the weights in the eMR. Surveyor #1 requested the weight meeting notes.
On 05/31/23 at 10:07 AM, the DON stated that she was still looking for the weight meeting information. The DON acknowledged she could not locate any documentation to immediately address the 8.6 lbs. weight loss in 4 days and stated she did not know why Resident #51 was not reweighed.
On 05/31/23 at 11:10 AM, the DON provided an untitled paper and stated it was the weight meeting notes with resident names. Resident #51's name was included. The paper included monthly weight difference -3.6#/30 days -4.4#/6 months; monthly weight 3/2023 weight 98.6#, 2/2023 weight 102.2#, 9/2022 weight 103#; Date weekly weight 2/20/23 weight 102.2# w/c (wheelchair), 3/6/23 weight 98.6#, 3/13/23 weight101.2#. Interventions included 2/14/23 [name redacted] supplement drink four times a day, 2/17/23 WW x 4, 2/24/23 WW x 3, 3/3/23 WW x 2, 3/10/23 WW x 1, 3/17/23 monitor weights monthly. The interventions did not address the 8.6 lbs. weight loss in 4 days and the weights listed were either different or not documented in the eMR. There were no documented weights for 02/17/23, 02/24/23, 03/03/13, or 03/10/23.
On 05/31/23 at 11:10 AM, the facility provided, Nutritional Assessment-Quarterly, dated 03/22/23, which was reviewed and included but was not limited to; current weight 108#. The assessment was signed by the Dietitian on 04/08/23.
The eMR did not include a documented weight of 108 lbs. The facility provided hand written, paper weight meeting notes which reflected a weight for 03/13/23 of 101.2 lbs.
Surveyor #1 reviewed the weight logs on Resident #51's unit. An entry dated weekly weights March 14, 2023 indicated Resident #51's weight was 101.2 lbs. An entry dated April Monthly Weights indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights May 1, 2023 indicated Resident #51's weight as 98.2 lbs. An entry dated Weekly weights 05/08/23 indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights 05/15/23 indicated Resident #51's weight as 98.2 lbs. All of the entries were left blank in the area for staff to initial as having weighed the resident.
The 03/14/23 weight was not documented in the eMR. The April weight in the eMR was 04/17/23, 100.4 lbs. and 04/24/23, 100.6 lbs. The 05/01/23 weight was not documented in the eMR. The 05/09/23 weight was not documented in the eMR. The 05/15/23 weight in the logbook was 98.2 lbs. and the eMR had a documented weight of 103.0 lbs. indicating a 4.8 lb. discrepency.
On 06/01/23 at 10:05 AM, Surveyor #1 informed the facility of the weights which did not coincide with the eMR and Resident #51's 8.6 lbs. weight loss, and no documented reweigh or immediate interventions, as stated by the DON, upon discovery of a significant weight loss. At that time, the facility was unable to provide additional information.
On 06/02/23 at 9:39 AM, during an interview with Surveyor #1, the LPN working on B-Wing stated that if there was a large discrepancy in a resident's weight, the staff would first re-weigh the resident and then inform the DON and physician. Upon reviewing the weight on 03/13/23, the LPN stated that weight was entered by the Dietitian, and she would be the one responsible for comparing and reviewing the weights. The LPN further stated that if there was a re-weigh completed on 03/13/23, it would be located in the eMR. The LPN accessed the eMR in the presence of the surveyor and was unable to find a documented re-weigh for Resident #51.
On 06/02/23 at 10:40 PM, during an interview with the surveyor team, the RVPCS stated that the weight sheets were worksheets and you can't go by those weights.
A review of the facility provided, Dietitian job description, reviewed 06/10/22, included but was not limited to; communicates with medical staff, nursing and other department personnel; must be able to relate information concerning a resident's condition; conduct nutrition assessments of patients referred by healthcare providers; maintains nutritional care plans, reviews medical records, documents findings; collects patient information and records patient information; effectively and efficiently completes all paperwork requirements for billing and medical records compliance; evaluates how patients respond to their diets; and works to ensure patient satisfaction.
A review of the facility provided, Weight Assessment, Management and Intervention Procedure, undated, included but was not limited to Weight Assessment 1. The nursing staff will measure resident weight, weight will be placed in unit weight book for Dietitian review; 2. Any weight change of 3% or more since the last weight will be retaken for confirmation; 3. The Dietitian will respond within 24-72 hours of receipt of notification; 4. the threshold for significant unplanned and undesired weight loss will be based on: a. 1 month - 3% weight loss is significant; greater than 5% is severe; 6 months- 10% weight loss is significant; greater than 10% is severe; 5. If the weight change is desirable, this will be documented. Analysis 1. The interdisciplinary team will identify conditions and medications that may be causing weight loss or increasing the risk of weight loss. 2. The Dietitian will discuss undesired weight gain with the resident and/or family; 3. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement.
NJAC 8:39-17.1 (c); 17.2(d)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure: (a) that a resident received supplemental oxygen as prescribed by the physician, and (b) received the necessary respiratory care and services for residents who received oxygen (O2) treatment according to standards of practice for 2 of 3 residents reviewed (Resident #21 and Resident #33) for respiratory care.
The deficient practice was evidenced by the following:
1.) On 05/22/23 at 11:00 AM, the surveyor observed Resident #33 in bed wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time.
On 05/23/23 at 12:19 PM, the surveyor observed Resident #33 lying in bed with their eyes closed. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM.
On 5/24/23 at 8:41 AM, the surveyor observed Resident #33 lying in bed and was awake. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM. The resident stated that he/she was usually on 3 liters of oxygen.
According to the admission Record, Resident #33 was admitted to the facility with diagnoses which included, but were not limited to, pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), chest pain, anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs), end stage renal disease, paraplegia (paralysis of the legs and lower body), and generalized anxiety disorder.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/03/23, indicated that Resident #33 had a Brief Interview for Mental Status score of 12 out of 15, which indicated that the resident had moderately impaired cognition. The MDS also revealed that Resident #33 had shortness of breath or trouble breathing when lying flat, used oxygen therapy, that they needed extensive assistance from two staff members to transfer (from the bed to a wheelchair) and did not walk in their room during the assessment window of the MDS.
Review of the Physician's Order Form indicated that Resident #33 had an active physician order for Oxygen (2 liters) prn (as needed) for shortness of breath dated 10/20/22.
Review of the May 2023 Treatment Administration Record (TAR) and the Medication Administration Record (MAR) revealed that the nurses did not sign that oxygen was administered to Resident #33 on 5/22/23, 5/23/23, and 5/24/23.
During an interview with the surveyor on 05/24/23 at 8:57 AM, Resident #33's assigned Licensed Practical Nurse/Unit Manager (LPN UM #1), while reviewing Resident #33's physician orders, stated that the resident was supposed to be on 2 LPM of oxygen. The surveyor brought the LPN/UM #1 to Resident #33's room. The resident was wearing a nasal cannula that was connected to an oxygen concentrator. The surveyor asked the LPN/UM#1 what liters of oxygen the resident's oxygen concentrator was set to? The LPN/UM#1 stated that the oxygen concentrator was set to 3 LPM but should be set to 2 LPM as the physician ordered for shortness of breath (SOB). The LPN/UM#1 added that when a resident was ordered oxygen the nurse should check the physicians order and the TAR for the correct rate of oxygen, and during the nurse's rounds of the residents, the nurse should check that the oxygen is set at the correct LPM as ordered.
During an interview with the surveyor on 05/31/23 at 11:56 AM, in the presence of another surveyor and the facility's [NAME] President of Clinical Services (VPCS), the Director of Nursing (DON) stated that there should be a physician order for oxygen and the nurses should follow the physician orders for the liters of oxygen. When the nurses administer oxygen, whether prn (as needed) or continuous, they should document in the resident's TAR. The VPCS added that sometimes the nurses would document that oxygen was administered in the MAR. The DON further stated that the nurses should make sure that the correct liter of oxygen was set on the oxygen concentrator when making their resident's rounds.
The facility policy titled, Oxygen Therapy with a reviewed date of 11/02/22, indicated Oxygen is administered by licensed staff and with a physicians order. The Procedure section of the policy indicated to Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered.
NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) have a system in place to ensure that all nursing and related services were consistently provided for residents to maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident, as determined by resident assessments, individual plans of care and in accordance with the facility assessment. This deficient practice was observed on 1 of 3 nursing units and for 2 of 31 residents reviewed, (Resident #28, #35) for care.
This deficient practice was evidenced by the following:
Refer to F677
a) On 05/22/23 at 09:49 AM, Surveyor #2 toured the B-Wing of the facility and observed Resident #28 lying in bed. Resident #28 appearred disheveled and unkempt. The left hand was rested on the blanket with nails long and jagged with a black coated substance underneath the fingernails. Resident #28 was unshaven. At the surveyor's request, the resident was able to use the left hand to pull the cover and exposed the right hand. The right hand was contracted, and the fingernails were long and jagged with a black film coated underneath the fingernails.
On 05/23/23 at 12:35 PM during a tour of the B-Wing hallway, Surveyor #1 observed, in the presence of Surveyor #2, and while the lunch meals were being distributed, both surveyors smelled a pervasive odor of urine permeating in the hallway outside of room [ROOM NUMBER]. Residents were observed eating meals in both room [ROOM NUMBER] and the adjacent room [ROOM NUMBER]. At that time, the Director of Nursing (DON) was in the hallway and Surveyor #1 asked the DON if she could smell anything and the DON stated she could not and walked away from the surveyors.
On 05/23/23 at 12:36 PM, both surveyors interviewed the B-Wing Registered Nurse (RN) if there were any noticeable odors. The RN stated yes a little, like pee [urine]. The RN stated, it needs to be cleaned.
On 05/23/23 12:42 PM, Surveyor #1 interviewed two unsampled residents who were eating at their bedside in room [ROOM NUMBER]. Both residents confirmed that the room was malodorous.
On 05/23/23 at 2:13 PM, Surveyor #2 observed Resident #28 in bed. Resident #28 was unshaven, nails were long, jagged, and coated with the black coated substance underneath the fingernails.
On 05/24/23 at 10:27 AM, Surveyor #2 observed Resident #28 out of bed in the courtyard smoking. Resident #28 already received care and the nails were in the same condition, long and jagged. When asked about the nails and the facial hair, Resident #28 stated that he/she would like to be shaved.
Surveyor #2 reviewed Resident #28's admission Face sheet which revealed that the resident was admitted to the facility with diagnoses which included but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, hypertension.
Surveyor #2 reviewed the Quarterly Minimum Data Set (MDS) an assessment tool dated 04/04/23, which indicated that Resident #28 was totally dependent on staff for all activities of daily living (ADLs) and there was no rejection of care exhibited.
Surveyor #2 reviewed the electronic progress notes from 05/10/23 through 05/30/23 and could not locate any documentation regarding personal care was offered and Resident #28 refused.
Surveyor #2 reviewed the ADL worksheet (a form Certified Nursing Assistant's (CNAs) used to document the care provided) Resident #28 for the month of May 2023. The document revealed that hygienic care was completed however, there was no specific entry for nail and beard care.
On 05/26/23 at 7:40 AM, Surveyor #2 observed Resident #28 in bed, unshaven and nails were long with black coated substances underneath the fingernails.
During an interview with Surveyor #2 on 05/26/23 at 8:30 AM, the resident's assigned CNA acknowledged Resident #28 was dependent on staff for care. The CNA stated that she provided care to the resident this morning and she could not recall if the nails needed to be trimmed.
During a second interview with Surveyor #2 on 05/31/23 at 11:48 AM, the same assigned CNA for Resident #28 revealed that the facility did not have a CNA care type card (a document specific to the individualized care that CNA's needed to provide residents). She further stated that nail care was not listed on the ADL Worksheet and that she usually performed nail care and shaving on shower days.
During an interview with Surveyor #2 on 05/31/23 at 11:51 AM, another CNA confirmed that the CNAs do not have a care type card to follow for nail care and shaving. The CNA added that in the morning she received report from the nurse regarding resident care, and that the nurses did not address nail care and shaving. The CNA further stated that shaving and nails care were part of grooming and should be completed when nails were long and it could be visibly observed that the resident needed shaving. Surveyor #2 asked toe CNA what was the reason that nail care was not being completed for some residents and the CNA declined to comment.
Surveyor #2 reviewed the facility Activities of Daily Living policy, reviewed 11/22/22, revealed that a resident who cannot carry out ADLs will receive the necessary services to maintain grooming.
On 05/24/23 at 8:31 AM, Surveyor #3 observed Resident #35 in their room sitting in a wheelchair. Resident #35 reached towards Surveyor #1 and slightly scratched the surveyor's right arm. Surveyor #1 requested to see Resident #35's fingernails. The surveyor observed that all 10 nails on both hands were long, eight of the nails had jagged edges, and there was a visible black substance under the nails.
On 05/25/23 at 8:53 AM, Surveyor #3 observed Resident #35 in the hallway in their wheelchair. The resident's fingernails were still in the same condition. At that time, Resident #35 stated that he/she needed help to cut and clean his/her nails and would like his/her fingernails trimmed and cleaned.
On 05/25/23 at 9:10 AM, during an interview with Surveyor #3, the Certified Nursing Assistant (CNA) caring for Resident #35 stated that it was her responsibility to set up the resident to clean and wash him/herself. The surveyor asked about shaving and nail care. The CNA stated she could not answer that and that the resident probably refused. When asked the process when a resident refuses care, the CNA stated she would let the nurse know. The CNA stated that there was only one place to document nail care and that was if a resident needed their toenails cut and they had to call the podiatrist. Surveyor #3 and the CNA went to observe Resident #35's nails. The CNA stated, to me yes they (the fingernails) need to be done but only during shower days.
On 05/25/23 at 9:13 AM, during an interview with Surveyor #3, the Licensed Practical Nurse (LPN) caring for Resident #35 stated that if a resident refused nail care, the staff should wait and try to encourage the care later. She stated if the resident did not allow their nails to be cut, the staff should ask if they could file the resident's nails. If the resident refuses, the staff need to let the nurse know so it could be documented. The nurse would let the doctor know. The LPN stated she was never informed that Resident #35 refused nail care.
Surveyor #3's review of Resident #35's admission Record (an admission report) revealed that the resident had diagnoses which included but were not limited to unspecified convulsions, age related osteoporosis (early stages of bone loss), dementia, weakness, and chronic pain syndrome.
Surveyor #3's review of Resident #35's most recent Quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated 04/14/23, included but was not limited to a Brief Interview for Mental Status (BIMS) of 08 out of 15 which indicated the resident had moderately impaired cognition. Section G, Functional Status indicated that the resident required supervision and set up help for personal hygiene.
Surveyor #3s review of the person-centered comprehensive care plan, printed on 05/30/23, included but was not limited to a focus area of ADL deficit, needing supervision/limited assistance with ADLs date initiated 11/12/21 and revised 02/03/23. Interventions included bed bath daily and shower at least 2 x (times) a week.
Surveyor #3's review of the facility provided, Order Summary Report, dated active orders as of 05/30/23 for Resident #35, included an order dated 11/10/22 for weekly skin checks on shower days Tuesdays and Fridays.
Surveyor #3's review of the facility provided, IDCP (Interdisciplinary care plan) Team Care Conference, dated 04/19/23, included but was not limited to 2. B. Resident #35 requires extensive assist and direction with ADLs.
Surveyor #3's review of the facility provided Progress Notes (PN) ranging from 05/01/23 through 05/30/23, contained no documentation that Resident #35 had refused any ADL care.
Surveyor #3's review of the CNA Assignment for B-Wing dated 05/24/23 (Wednesday) and dated 05/25/23 (Thursday), both indicated the same CNA on both days. The Assignment sheet further indicated shave all residents, clip all nails on shower days. The resident had not received fingernail care during his/her shower on Tuesday 05/23/23 and there were no progress note to indicate any refusal of care.
A review of the New Jersey Department of Health (NJDOH) Certified Nurse Aide (CNA) Scope of Practice indicated that a Certified Nurse Aide shall provide care and assist residents with the following tasks related to the activities of daily living (ADL) only under the general supervision of a registered nurse. (a) Tasks associated with personal care included but were not limited to, Grooming, Shaving, and Caring for the nails.
The facility provided, Facility Assessment Tool, reviewed 10/2022, indicated to provide appropriate training/education and adequate staffing to meet its residents' daily needs, preferences, and routines to help each resident attain or maintain the highest practicable physical, mental, and social well-being. In the section titled, Staffing Plan, 3.2. The overall number of qualified staff provided to meet each resident's needs does not fall below the minimum daily average required by state law for direct care and services per resident per day.
NJAC 8:39-5.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review it was determined that the facility failed to ensure each resident was provided with meals that were palatable, met specific preferences related to their clinical condition and were offered alternate meal options, including options that the facility only provided to a subset of the resident population. The deficient practice occurred for 6 of 6 residents who attended a resident council meeting, for 1 of 3 residents reviewed for food (Resident #49) and was evidenced by the following:
Refer to 692G
On 05/23/23 at 2:23 PM, a copy of a three week menu cycle was provided by the Licensed Nursing Home Administrator LNHA and signed by [Name] Dietitian, and an unsigned two week [Asian] menu cycle.
On 05/24/23 at 10:30 AM, the surveyor conducted a resident council meeting with six residents. The residents were asked about the meals and residents stated to the surveyor the food is inedible, everything is mushy and the vegetables were over done, you get whatever they offer you, and the only alternate is a grilled cheese. One resident stated the Dietitian informed him/her that whole grains are never going to happen, and then stated mostly canned fruit instead of fresh and the canned fruit was not served cold. The residents were asked about the alternate [Asian] menu and 6/6 stated they were not offered those items. Six of six residents informed the surveyor that there was no food committee to discuss the menu or food concerns that were brought up by the resident council.
On 05/24/23 at 10:59 AM, the surveyor observed Resident #49 at the nurses cart outside of the resident's room. Resident #49 was using exploitive and telling the nurse about the poor quality of the food at the facility.
On 05/25/23 at 8:59 AM, the surveyor interviewed Resident #49, who stated, I can't eat this [exploitive redacted]. Resident #49 stated he choked on freezer burned chicken and then went to the hospital and they found out that he/she had a tumor. Resident #49 stated he she used to be 195- 200 pounds. Resident #49 stated again, I cannot eat this [exploitive redacted], and added I would not give it (food served) to a pig. The resident stated that the facility food was so bad, and there were no options, that he/she would rather just drink a supplement than eat the horrible food.
The surveyor reviewed Resident #49's medical record which revealed the following:
The admission record revealed, but was not limited to, a diagnosis of Malignant Neoplasm of Esophagus, and Dysphagia.
A Nursing Progress Note dated 05/05/23 at 17:30 revealed Resident not happy with meal he received this PM. Resident is on mechanical soft diet and states he can eat regular food as long as its soft. this nurse explained we can only give what was recommended after swallow evaluation. This [nurse] will put in for another consultation with dietitian so dietary can be aware of what specific foods resident would like to eat. Resident is receiving Ensure Plus bid [twice daily] will recommend for an increase in supplement.
A 5/18/2023 18:01 Dietary Note revealed Resident #49's May weight is 146#. A desirable .6# in 30 days. [His/her] diet texture was upgraded to mechanical soft texture last month but he expressed to DON he does not like meals and will prefer to drink more supplements. Writer visited resident and [he/she] confirmed preference of commercial supplements to present texture of food . Resident is on agreement to diet plan. Continue to provide trays for oral gratification rather than nutrition .
The Care Plan for Resident #49 was reviewed which revealed a Focus of At risk for weight loss secondary to cancer and increasingly difficulty with swallowing. I am also at risk because of my refusal to take my peg [nutrition provided through a tube into the stomach] tube feedings, Date Initiated 02/08/23. Goal: I will work with my dietician and medical team to understand my needs for diet adjustment including increase calories or change in food consistency. There were no interventions regarding specific preferences and concerns with dislike of food and there was no follow-up regarding preference updated or follow-up regarding concerns with food preparation or alternate options available.
On 05/24/23 At 12:06 PM, the cook identified as the special food cook for only the Asian menu per the FSD. The surveyor observed that he was cooking an item that looked very visually appealing and was in a large pan on the stove. The item also smelled very appetizing. When the the surveyor asked about the item the cook stated it was Garlic Shrimp, and Cabbage, the surveyor asked the FSD who was entitled to eat that item. The FSD stated only [Asian] people get it and then stated it is something that the [Asian] people sign for upon admission and it is never on the regular menu. The FSD then stated only if there were leftovers could other residents have it.
The Administration informed the survey team that the Dietitian was unavailable for the duration of the survey.
On 05/31/23 at 1:23 PM, the survey team informed the [NAME] President of Clinical Services (VPCS), Regional Administrator #2 (RA #2) and the Director of Nursing (DON) regarding the resident concerns regarding the food and the lack of choice.
During a facility pre-exit conference held on 06/01/23 at 10:05 AM. The RA #2 acknowledged the facility residents were not able to choose menus or have an alternate menu available.
Dietitian job Description, reviewed 06/10/2022 revealed: Responsibilities: Listens attentively to patient complaints and resolves or refers to appropriate individuals.
NJAC 8:39-4.1(12); 17.4(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, it was determined that the facility failed to ensure a Registered Dietitian provided resident care per the Facility Assessment and completed nutritional assessments, implemented and updated nutrition care plans and implemented and revised interventions. The deficient practice affected residents who resided on 3 of 3 resident care units and was evidenced by the following:
Refer to 692G, 693D, 800F
On 05/22/23 at 12:03 PM, the surveyor received the Facility Assessment, dated October, 2022, from the Licenced Nursing Home Administrator (LNHA). The document revealed Part 1: Our Resident Profile, 1.3, The [Facility Name] typically accepts residents or continues to provide care for residents that may develop the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Each resident is assessed and reviewed on an individual basis . ; Part 2: Services and Care We Offer Based on our Residents' Needs . Nutrition, Specific Care and Practices- Individualized dietary requirements, liberal diets, specialized diets, IV hydration, tube feeding, cultural or ethnic dietary needs . ; Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Poulation Every day and During Emergencies, Staff type, 1.1, The [Facility Name] has the following staff members, other health car professionals, consultants, and medical practioners to provide support and care for residents. This list includes but is not limited to: . Food and Nutrition Services: Certified Dietary Manager, cooks, dietary aides, porters, Registered Dietititian.
On 05/23/23 at 2:23 PM, a copy of a three week menu cycle was provided by the Licensed Nursing Home Administrator LNHA and signed by [Name] Dietitian, and an unsigned two week [Asian] menu cycle.
On 05/30/23 at 12:17 PM, during an interview with the surveyors and upon requests made by the survey team to interview the Dietitian, the LNHA stated she would have to see who was covering for the dietitian. She stated the Dietitian was on vacation from Saturday 05/27/23 through 06/03/23.
On 05/30/23 at 12:22 PM, the LNHA stated that since the Dietitian was only going to be gone one week, there would not be a dietitian covering. She stated that the Dietitian and the Director of Nursing (DON) would work together and that the dietitian would document in the electronic medical record (eMR). The surveyors requested the Dietitian's credentials.
On 05/30/23 at 1:29 PM, the survey team interviewed the DON about the function of the Dietitian. The DON stated the Dietitian would come to the facility on Monday and Thursday and look at weekly weights during her Monday visits. The Dietitian would meet with residents to discuss preferences and snacks. The DON confirmed the Dietitian was on vacation and she was unsure if she was contracted with the facility or worked for herself.
On 05/31/23 at 1:23 PM, the survey team with the DON, the [NAME] President of Clinical Services (VPCS) and the Regional Administrator (RA #2). The VPCS stated that the RA #2 was trying to locate the credentials and certification file for the Dietitian.
On 06/01/23 at 10:14 AM, the RA #2 stated that he was aware that the Dietitian's certificate expired in 2016 and he can get a copy when she returns. At that time he provided the survey team with a copy of an Academy of Nutrition and Dietetics Membership Card with the Dietitian's name on it and was for Membership Year June 1, 2015 - May 31, 2016, Membership Number #597919. The survey team requested the contract with the Dieititan. The survey team reviewed the online Academy of Nutrition and Dietetics Credential Verification system and entered the information provided by the facility for the Dietitian. The message received was There are no individuals in the CDR (Commission on Dietetic Registration) database who are credentialed and match the information provided.
On 06/05/23 at 8:40 AM, the RA #2 was unable to provide additional information to ensure the Dieitian was qualified to provide services at the facility, including a contract or any information regarding the a certification or credential for the Dietitian. The RA #2 stated the Dietitian was still on vacation and anything we gave you on the Dietitian was all we have.
NJAC 8:39-17.1 (a,d)

Based on observation, interview and document review it was determined that the facility failed to serve foods at an acceptable temperature for 1 of 6 residents interviewed during a resident council meeting and for 1 of 1 resident reviewed for Hospice Care (Resident #86). The deficient practice was evidenced by the following:
On 05/24/23 at 8:37 AM, Resident #86 was observed in bed, a puree meal tray was at the bedside. Resident #86 greeted the surveyor, and the surveyor observed that the meal appeared congealed and uneaten. When the surveyor asked the resident if he/she liked the food, the resident stated, food, not so good.
On 05/24/23 at 11:11 AM, during the surveyor conducted resident council interview, 1 of 6 residents stated the food was inedible, vegetables are over done, and the food is mushy.
On 05/24/23 at 11:15 AM, the surveyor observed that the posted menu for the lunch meal was barbeque chicken, steamed rice, oriental mixed vegetables, fruit cocktail, whole milk and coffee.
On 05/24/23 at 12:09 PM, the surveyor requested regular meal which consisted of barbeque chicken, mixed vegetable and rice and puree meal that consisted of puree chicken, mixed vegetables and mashed potato and a four ounce container of milk. The Food Service Director (FSD) accompanied the surveyor with what was identified as a calibrated thermometer and the meal trays arrived on the A-Wing at 12:10 PM, and the final tray was passed on the unit at 12:16 PM. The surveyor asked the FSD what the temperature of the hot foods should be and she stated 165 degrees Fahrenheit (F). The facility Administrator (LNHA) was also present at that time and the temperature of the meals was checked which revealed:
Barbeque Chicken 165 F.
Rice 120 F. At that time the surveyor asked the FSD if the temperature of 120 F was acceptable and the FSD stated it was not okay.
Mixed Vegetable 129 F.
Puree Chicken, 127 F. At that time the surveyor asked the FSD if the temperature of 120 F was acceptable and the FSD stated it was no, it should be hotter.
Puree Vegetable 127 F.
Mashed Potato 118 F.
Four ounces of milk, 58 F. At that time the surveyor asked the FSD if the temperature was acceptable and the FSD stated it was no, it should be 30 F.
At 12:29 PM, the surveyor entered the kitchen to review the final cooking temperatures with the Cook, and to review the temperature log. The [NAME] showed the surveyor the cooking temperatures, documented in the temperature log, for the Barbeque Chicken- 200F, Mixed Vegetable-200 F and the Starch (Rice) -197 F. The puree food temperatures were left blank. The [NAME] stated she did not write the temperatures in the temperature log, and was unable to provide the temperatures for the puree food to the surveyor. The [NAME] then stated we had to reheat them [puree food]. At 12:32 PM, the surveyor requested that the FSD calibrate the thermometer used for the test tray in the presence of the surveyor. The FSD stated the thermometer should be 32 F when calibrated and the surveyor observed the FSD place the thermometer in an ice bath which revealed 32 F.
On 05/24/23 at 1:27 PM, the surveyor asked the LNHA and FSD for a policy related to when food temperatures should be taken and what the food temperatures should be when the food was received by the residents. The LNHA stated the facility does not have a policy to determine what the food temperatures shoud be and when the staff should take the food temperatures.
The survey team requested to speak with the facility Dietitian throughout the survey and the facility LNHA and Corporate Administration had informed the survey team that the Dietitian was unavailable for the duration of the survey and there was no coverage for the position.
NJAC 8:39-17.4 (a)2

This is a repeat deficiency from the Standard Survey Date: 03/31/22.
Based on observation, interview and document review it was determined the facility failed to maintain the kitchen environment, and all of the equipment, dishware and other items in a clean, intact and sanitary manner to limit the potential of food borne illness and potential injury.
The deficient practice was evidenced by the following:
On 05/22/23 from 9:49 AM through 10:47 AM, the surveyor completed an initial tour with the Food Service Director (FSD) and Regional Administrator (RA #1) and observed the following:
1. A large black floor fan was in the back area of the kitchen, facing the food preparation area. The fan was running and the grate was embedded with dust like debris throughout. The surveyor asked the FSD who was responsible for cleaning the fan and she stated, it was just brought out.
2. The walk-in refrigerator had what appeared as rust through on the shelving which contained food items that included a glass jar of sliced pickles with hand-written date on metal lid 10-13 and the lid appeared visibly rusted in several areas. The pickles were discarded by the FSD. Underneath the shelves contained debris and the fan had dust like debris. A glass jar of maraschino cherries, had a white lid with a marker- type hand-written scribble on the top of the white lid which also had black spots on it and a date 1-6. The white label of the maraschino cherries had black mold-type markings throughout.
The surveyor asked the FSD what the use by date/expiration date was for maraschino cherries and the FSD stated she cannot see the expiration date because of the black marker on the top of the lids. The jar was discarded by the FSD.
3. The walk-in freezer had a diamond plate metal floor which had a large separated, unsealed seam throughout the middle of the diamond plate metal floor. The open area created an uneven walking surface inside the freezer and exposed the undersurface of the diamond plate floor. The freezer fan was running and did not have a fan grate. The diamond plate floor was soiled underneath the shelving throughout the freezer.
The surveyor asked the FSD about the floor and she stated, usually the black [rubber] mats are covering it. At that time, the RA #1 interjected and stated that is going to be fixed.The surveyor requested, from the RA #1, that all documentation regarding the pending repair of the floor be provided, including any estimates, contracts, etc. The RA #1 stated we are scheduled and there is no documentation.The RA #1further stated the maintenance person will fix the floor. At that time, the surveyor inquired to the FSD when the repair of the floor was scheduled and she stated she was unaware of the timeline for repair.
4. Two rolling racks near the tray line that contained insulated lids and bases identified as clean by the FSD. There were many lids and bases that were double and triple stacked in one of the slots of the rack, the edges of both racks had debris and did not appear clean. The surveyor asked the FSD to remove the wet lids to view. The FSD then washed her hands and proceeded to remove lids which revealed that 7 of the lids and 6 of the bases on both racks were visibly wet inside. During that time, the RA #1, without first washing his hands proceeded to touch the clean lids on the racks. The surveyor asked if he had washed his hands and he stated before, which was not observed by the surveyor as the RA #1 was observed on his cell phone immediately prior to the observation.
5. There were two rectangular black wall vents located behind the rolling racks and both vents had visible dust like debris on the grates.
6. The surveyor observed the emergency food supply storage area with the FSD. The emergency food supply was stored on a visibly disintegrated wooden pallet that was on the visibly rusted interior floor of a walk-in refrigerator that was not in use. Two cases of diced beets and a case of dice peaches were observed.
On 05/24/23, from 9:04 to 10:03 AM, two surveyors observed the following in the presence of the FSD:
7. Multiple dishes soiled with food debris including eggs were stacked on a cart by the dish machine and the FSD confirmed that they were going to be cleaned. Many of the dishes had visible chips on the edges, including one dish that had a missing piece and a jagged edge. There were 25/43 dishes observed that were chipped and as was counted and confirmed with the FSD. The surveyor asked the FSD if the chipped dishes were okay for use and she stated we try not to use the chipped dishes. The surveyor asked the FSD if the chipped dishes were going to be used and she stated, no, because you don't want anyone to get hurt. The FSD stated she was going to discard the chipped dishes.
8. The surveyor observed a staff member at the end of the tray line, a stack of dishes included visibly chipped dishes were placed in a plate warmer adjacent to the tray line.
At 9:15 AM, the Licence Nursing Home Administrator (LNHA) and the RA #1 joined the tour.
The FSD was alerted of the observation by the surveyor and stated the dishes in the plate warmer were clean, and proceeded to remove the stack of dishes from the plate warmer. The FSD removed the dishes which revalued 15 plates were chipped, 1 plate had food stuck to it and 9 were wet. The surveyor asked the FSD if the plates were clean and she stated yes, and then asked if it was okay for wet dishes to be in the plate warmer. The FSD stated that they can air dry in the well when it is plugged in. The surveyor asked the FSD to provide the surveyor with the specifications for the plate warmer and the RA #1 interjected and stated, If I can get it, it is a pretty old machine (the specifications were not not provided by the RA #1 throughout the course of the survey).
9. A separate pile of dishes was observed at the end of the dish machine. There were 20/41 dishes were chipped.
10. The top of the dish machine was observed being used and dust and debris were pervasive on the top of the machine.
11. The ice machine scoop was left uncovered and stored next to the ice machine.
12. Multiple ceiling tiles over the ice machine, blender area and can opener were soiled with splattered dark debris.
13. The blue can opener insert was embedded with a dark substance and was unable to be removed by the FSD.
14. The metal hood grates that were over the entire cooking battery were soiled with a shiny grease like substance throughout and grease like drips.
15. A food service worker was observed putting dishes in the dirty side of the machine and then removing from the clean side without first performing hand hygiene.
9. The basement dried storage area had two large dead cock roach type bugs. At that time the RA #1 looked at the dead bug and stated means the execrator is working and the surveyor requested all of the exterminator records. The concrete block area by the bottom of food storage shelves that contained food items such as a case of white vinegar had visible debris throughout.
The surveyor requested policies related to cleaning the kitchen and eqipment and sanitation and requested to interview the facility Dietitian. There was no additional information provided and facility managment informed the survey team that the Dietitian was not available for interview for the duration of the survey and there was no covering dietitian available for interview.
On 05/24/23 at 12:10 PM three surveyors observed the lunch tray line in progress. The RA #1 was also present in the kitchen at that time. Dietary staff was observed placing plates with food on wet bases and the wet lids over food. The surveyor observed a dripping lid that dripped fluid onto a meal tray that proceeded to be placed on the meal cart. During the surveyor inquiry at that time, the RA #1 interjected with a loud voice and stated you are not stopping the tray line, don't stop the tray line, residents need to be fed. The FSD proceeded to hurriedly go through the bases and lids that were on the tray line and separated the wet lids and one lid was noted with food debris.
The food Receiving and Storage Policy, Dated 01/05/23 revealed: Foods shall be received and stored in a manner that complies with safe food handling practices, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
Labeling and Dating Procedure in the Dietary Department, Reviewed 11/26/22 revealed: Procedure: 1. Food items, as appropriate, will be labeled and dated by dietary staff using the facility labeling system, and the Food Service Director/designee will oversee labeling and dating, Label System Process: 3. Opened Date, a. Food items will be labeled with an open date once the individual item is opened for use, including but not limited to: iii) Refrigerated salad dressings, mayonnaise, cherries, horseradish, etc.
NJAC 8:39-17.2(g)

Based on observation and interview it was determined that the facility failed to ensure that garbage was maintianed in a manner to prevent potential contamination as evidenced by the following:
On 05/22/23 at approximately 10:00 AM, the surveyor began a tour of the dietary department with the Food Service Director and observed the Dumpster area with 1/2 uncovered dumpsters. A Regional Administrator (RA #1) joined the tour. The area next to the dumpsters contained a large field of debris that included gloves, cups, papers and various other debris. There were two dumpsters observed and 1/2 dumpsters did not have a lid in place. When asked who was responsible for keeping the area clean the FSD stated she did not know and the RA #1 immediately interjected and failed to provide information pertinent to the surveyor inquiry.
On 06/02/23 at 2:05 PM, the Regional Administrator (RA #2) and Director of Nursing (DON) were informed of concerns regarding the debris. No additional information regarding the debris was provided.
NJAC 8:39-19.7(b)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to enhance their quality of life related by failing to ensure: a) a safe, sanitary, and home-like resident environment on 3 of 3 Resident Wings (Wing A, B & C), b) a thorough investigation of an injury of unknown origin was completed for 1 of 31 residents (Resident #23) reviewed, c) mandatory reporting to the New Jersey Department of Health (NJDOH) for a reportable event of an injury of unknown origin (Resident #23) for 1 of 31 residents reviewed, d) the facility Dietitian was a credentialed Registered Dietitian (RD) per the Facility Assessment, e) there was a process in place to respond to issues and concerns presented by residents during the Resident Council Meeting (RCM), and f) the LNHA provided oversight for the Quality Assurance Performance Improvement (QAPI) to ensure the facility consistently self-identified concerns. The deficient practice affected residents who resided on 3 of 3 Wings and resulted in Substandard Quality of Care in the area of Resident Rights (F565 and F584) and was evidenced by the following:
Refer to F584, F924, F610, F609, F801, F812, F867, and F565
a.) On 05/23/23 and 05/24/23, the survey team conducted environmental rounds on A, B, and C Wings. The LNHA and other facility staff were present with different surveyors on different Wings. There were multiple observations in the resident rooms, hallways, common areas and shower rooms. The surveyors observations included but were not limited to: ripped wallpaper, broken closets, missing closet drawers, holes in the ceilings and walls, loose handrails, broken dressers; visibly soiled: walls, floors, bathrooms, overbed tables, bed bases, window blinds, window curtains, and air conditioner units; air conditioner units with missing knobs, broken covers, and areas open to the outside; soap dispensers pulled from the wall, toilet paper holder pulled from the wall and leaving a hole, cracks in walls, cobwebs, a light over a residents head of their bed leaning towards the resident's bed unsecured, multiple wires hanging from ceilings in resident rooms, fall mats that were ripped and visibly soiled, missing tiles in rooms and shower rooms, and emergency call bell units ripped from walls; varied types of insects in resident rooms, hallways and large cock roach type insects in the dry food storage room.
On 05/23/23 at 12:54 PM, during the environmental rounds, the LNHA stated she would make rounds every morning with the maintenance and housekeeping directors. The LNHA acknowledged such things as rooms with ripped wallpaper, missing drawers on closets, damaged or missing furniture, holes in the walls, and loose or damaged handrails and stated that she had not been aware of all of the identified concerns.
On 05/23/23 at 1:14 PM, the LNHA stated that the whole floor does for themselves. When the surveyor inquired about her morning rounds, the LNHA stated to the surveyor, you do realize the whole building is behavioral? Upon inquiry by the surveyor regarding the process for identifying and addressing environmental issues, the LNHA was unable to provide a system that ensured items were repaired. The LNHA stated that maintenance would verbally inform her if items had not been fixed. No additional information was provided by the LNHA.
A review of the facility provided, admission Agreement, undated, included but was not limited to Resident Rights: .Physical and Personal Environment .To live in a safe, clean, comfortable, and home-like environment .
b.) On 05/24/23 at 9:30 AM, a surveyor observed Resident #23 in bed and noticed the resident had a hematoma to the forehead. At that time, there was a Licensed Practical Nurse (LPN) in the room who informed the surveyor that the hematoma was from a fall. The resident had a Brief Interview of Mental Status (BIMS) of 06 out of 15 which indicated he/she was cognitively impaired.
On 05/26/23, the Director of Nursing (DON) provided the fall investigation. A review of the facility provided fall investigation revealed there were no statements from staff that worked the shift when the resident allegedly fell to determine if it was witnessed or unwitnessed. The DON stated that she had been told Resident #23 fell during care and that she did not investigate further. The DON acknowledged that a resident found on the floor bleeding would be considered an injury of unknown origin and that resident abuse would need to be ruled out.
c.) On 05/26/23, during an interview with surveyors regarding Resident #23's injury of unknown origin, the DON stated that the facility would always investigate and report to all agencies required. She stated, I am sorry, I was told that the resident fell during care.
The facility had not obtained statements from the staff who had worked that shift and there was no investigation to rule out possible abuse. The facility had not reported the reportable event to the NJDOH.
A review of the facility provided Prohibition of Resident Abuse and Neglect policy, undated, included but was not limited to Injuries of unknown source Must be reported immediately to the employee's supervisor. The supervisor must immediately notify the LNHA and/ or the DON. injuries of unknown source will be reported to the appropriate authorities including not limited to local law enforcement agencies, NJDOH, and Ombudsman The investigation shall consist of: a comprehensive of the event . interview with the person (s) reporting the incident, interview with any witness, interview with the resident if possible, interview with staff members (on all shift as appropriate) having contact with the resident during the period of the alleged incident. The abuse coordinator / designee completes the investigation file to include Documents appropriate to the investigation. Quality Assurance: the official file is forwarded to the Administrator . the abuse coordinator/designee will consult with the Administrator concerning the progress of the investigation.
On 06/02/23 at 1:29 PM, the DON stated that she would talk to the LNHA every morning and that they would review any nurse's notes about any falls and the written incident reports. The DON stated, it must have been missed when asked about the review of Resident #23's conflicting progress notes regarding the injury of unknown origin.
The LNHA was unavailable for interview. The facility policy was not followed, the incident was not thoroughly investigated or reported to NJDOH.
d.) On 05/22/23, the survey team entered the facility and requested entrance documents.
A review of the facility provided Facility Assessment, dated 10/2022, included but was not limited to Part 2: Services and Care We Offer based on our Residents' Needs . Nutrition, individualized dietary requirements, liberal diets, specialized diets, IV (intravenous) hydration, tube feeding, cultural or ethnic dietary needs. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population 1.1 staff type, Food and Nutrition Services: Registered Dietitian.
On 05/30/23 at 12:17 PM, the surveyors requested to speak to the dietitian. The LNHA stated that she was on vacation from 05/27/23 through 06/03/23. The LNHA further stated that there was no dietitian to cover because the facility dietitian was only going to be gone one week. The surveyors requested the dietitians certification and contract. The surveyors were informed the Dietitian had worked at the facility for 20 years.
On 05/30/23 at 12:22 PM, the LNHA informed the surveyors that she could not find a certification for the Dietitian and was still looking for a contract with the dietitian.
On 06/01/23 at 10:14 AM, the Regional LNHA #2 had provided a copy of a membership card (for a professional organization) with the Dietitian's name on it and an expiration of May 31, 2016 which also included a membership number. The survey team attempted to find the certification through the Commission on Dietetic Registration (CDR) but received a response that there are no individuals in the CDR database who are credentialed and match the information provided.
On 06/05/23 at 8:40 AM, the Regional LNHA #2 stated the LNHA was wrong, and that the Dietitian was on vacation until 06/08/23. He further stated that anything we gave you on the Dietitian is all we have. The facility failed to provide any credentialing document to prove the Dietitian was a currently credentialed Registered Dietitian. No service contract was provided and the LNHA #2 was unaware the Dietitian membership had expired in 2016.
e.) The survey team entered the facility on 05/22/23 and requested documents which included the last three months of Resident Council Meeting Minutes.
The surveyor reviewed the Resident Council Meeting Minutes for dates 02/22/23, 03/24/23, and 04/19/23. The minutes provided failed to include any documented follow up information from prior months Resident Council Meeting Minutes.
On 05/25/23 at 8:20 AM, during an interview with the surveyors, the LNHA and Social Worker (SW) were asked about the follow up documentation to the resident council concerns. The LNHA stated there was no documentation or follow-ups. When asked about a specific concern over container bins, the LNHA stated she had looked at the minutes and did not see any need to address the bins. The LNHA stated that if there were a concern by an individual resident, it would be addressed through a grievance form.
The LNHA was unable to provide any policy or process to address the concerns expressed during Resident Council Meetings.
f.) On 05/22/23, the survey team entered the facility and requested documentation. The surveyor was provided with the facility Quality Assurance & Plan Improvement (QAPI) Plan for [facility name redacted], undated, and the QAPI Plan, undated.
A review of the QAPI Plan, undated, included but was not limited to Governance and Leadership: the governing body and/or administration of the nursing home will develop a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts.governing body is ultimately responsible for overseeing the QAPI committee. Responsibility and Accountability: The administrator and/or QAPI coordinator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our organization. The administrator, or designee, is responsible for assuring that all QAPI activities and required documentation is completed and/or up to date.
During the course of the survey ranging from 05/22/23 through 06/05/23, the survey team identified concerns with the environment and with resident falls.
On 06/01/23 at 10:05 AM, the Regional LNHA #2 stated that the LNHA had [redacted personal problems] and as you can see from QAPI that since April things were not completed such as audits were not done. The Regional LNHA #2 further stated that the LNHA did not have the support. The Regional LNHA #2 did not elaborate on the lack of support supplied to the LNHA.
On 06/02/23 from 10:53 AM to 11:00, during an interview with the surveyors, the Regional LNHA #2 stated he was asked by the Regional LNHA #1 to come for support and confirmed that the Regional LNHA #1 would be responsible for checking on the facility. He further stated that other facility staff should have identified the issues. The LNHA #2 did not offer a process that included either the Regional LNHA #2, or the Regional LNHA #1 (who the Regional LNHA #2 had identified as being ultimately responsible for the facility), providing oversight of the LNHA who he confirmed stopped completing facility audits approximately two months prior. Although the Regional LNHA #1 was identified as oversight of the facility, he did not provide responses to the surveyors.
On 06/05/23 at 9:40 AM, during an interview with the surveyors, the Regional LNHA #2 was unable to locate any follow up documentation for environmental concerns which began in QAPI in November 2022, or any follow up documentation for the QAPI Plan Goal 2 regarding the reduction of quality measure rate for falls with major injury.
A review of the facility provided, Administrator job description, reviewed 07/20/22, included but was not limited to The Administrator establishes, directs and is responsible for the overall operation of the facility's internal and external activities and works to ensure regulatory and corporate compliance, quality assurance, and the fiscal viability of the facility. General Tasks included but were not limited to responsible for the overall organization and management of the facility; directs, coordinates, and monitors the day to day operation and provision of resident services; acts as compliance officer; maintains a fundamental knowledge and awareness of the status of all residents; ensures that all services and documentation are in accordance with the NJDOH rules and regulations governing a SNF (skilled nursing facility); ensures compliance with all pertinent standards, regulations, and requirements; ensures proper resident care services; provides for the identification, analysis, and development of new systems and programs; ensures accurate documentation, implementation and compliance of all issues; represents facility dealings with outside agencies; and completes all other inherent and logical tasks.
NJAC 8:39-4.1 (a) (11, 29)
NJAC 8:39-9.2 (a)
NJAC 8:39-9.4 (f)
NJAC 8:39-17.1 (a,d)
NJAC 8:39-27.1 (a)
NJAC 8:39-31.2 (e)
NJAC 8:39-33.1 (a,c,d,e)
NJAC 33.32 (b,d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documentation, it was determined that the facility Quality Assurance Performance Improvement (QAPI) failed to make good faith attempts to correct and maintain identified issues to address conditions that adversely affected the resident population and were identified during Resident Council Meeting and the condition of the facility environment. The deficient practice was evidenced as follows:
Refer to F584 and F565
On 05/22/23, the survey team entered the facility. The Licensed Nursing Home Administrator (LNHA) was asked to provide the entrance documents which included the QAPI plan.
During the survey ranging from 05/22/23 through 06/05/23, the survey team made multiple observations on 3 of 3 Wing (A, B, and C) which included but were not limited to, resident rooms with broken, missing, or damaged furniture; visibly soiled walls, floors, furniture, toilets, air conditioner units, curtains, privacy curtains, window blinds; dead insects; exposed wires hanging from the ceiling; missing call bells from the wall in the bathroom; embedded stains on the base of multiple over bed tables and bed bases; cobwebs; holes in walls and ceiling; sprinkler rusted with pieces missing; damaged floor in the kitchen; unit shower rooms with missing tiles, visibly soiled shower handles, call bell pulled from the wall.
On 05/23/23 at 12:54 PM, the LNHA was made aware of the conditions and was asked to accompany two surveyors during the inspection of the resident rooms. When questioned about broken closets that were missing the drawers, the LNHA stated the resident pulls things out and she further acknowledged that it was not acceptable for the doors of the closet to be left like that. The LNHA stated that she would make round every morning with maintenance and housekeeping directors.
On 05/23/23 at 1:14 PM, the LNHA stated that the whole floor does for themselves. When the surveyor inquired about her morning rounds, the LNHA stated to the surveyor, you do realize the whole building is behavioral? The LNHA was unable to provide a process that ensured a list that she stated she provided to maintenance to fix was actually confirmed as fixed. She stated that maintenance would let her know if things were not fixed.
On 05/23/23 at 1:18 PM, the LNHA stated she was not aware of the condition of the rooms or the condition of the furniture in the rooms.
On 05/25/23 at 8:20 AM, during an interview with the surveyor, the LNHA stated that there was no documentation, or follow ups to ensure any concerns from the Resident Council meetings had been addressed.
On 06/02/23 at 10:53 AM, during an interview with the surveyors, the Regional LNHA #2 stated that he took every concern personally and called on sister facilities to come help with the environmental concerns that were identified during the survey. He stated, when you look at the building and clients, it doesn't take long for everything to go to [exploitive redacted].
On 06/05/23 at 9:40 AM, during an interview with the surveyors regarding QAPI, the Regional LNHA #2 stated that the QAPI committee meets on a quarterly basis and the members included the Medical Director, Director of Nursing, LNHA, Human Resources, Admissions, Medical Records, Maintenance, Housekeeping, Dietary, Therapy, Activities, the Social Worker, Pharmacy and sometimes the unit managers. He stated that each department does its own QAPI, will identify issues and goals, and would report them to QAPI during the meeting. When asked about input from the residents, the Regional LNHA #2 stated they obtain that input from Resident Council meetings. The surveyor asked about the follow up to Resident Council meetings and the Regional LNHA #2 had no information to provide.
A review of the facility provided QAPI Plan, undated, included but was not limited to Plan: the QAPI plan will guide performance improvement efforts. This is a living document that you (facility) will continue to refine and revisit. Goal 2: will reduce the quality measure for falls with major injury.
During the 06/05/23 interview, the Regional LNHA #2 was asked about the follow up for Goal 2 regarding the reduction of the quality measure for falls with major injury. The Regional LNHA #2 reviewed the facility QAPI book and replied there was no [documented] follow up.
A review of the facility provided QAPI book revealed a QAPI Topic: Foot Boards & Headboards, dated 01/18/23. The topic included but was not limited to an audit was being conducted and it was noted some were in need of repair. Causal factors included 1. Footboards and headboards have a lot of wear and tear due to resident population. 3. Time is needed to paint / replace parts and this repair is not considered an emergency. 4. Not always enough staff in the maintenance department to complete non-emergency repairs. 5. Need to schedule time and supplies to complete the repair. Goal: the facility will be 95% in compliance with headboards and footboards to be in appropriate condition within the facility. There was a worksheet included which indicated that this project had begun 11/18/22 and the end date was ongoing. A summary note included what we'll do in the future to sustain improvement: continue to audit / review, hire more maintenance staff. There were Rounds for A, B, and C units attached and dated 1/12/23. The rounds included repairs that were needed in 64 resident rooms and the shower room on B unit.
A review of the facility provided QAPI book revealed, Maintenance Issues 4/11/23 which included but were not limited to resident rooms which needed attention right away included room [ROOM NUMBER] bathroom needs to be spackled, wardrobe (closet) door is missing. The identified concerns included but were not limited to hole in the wall (room [ROOM NUMBER]), ceiling tiles need replacing, ceiling tiles moldy, air conditioner covers broken (room [ROOM NUMBER]), need new blinds, wardrobe missing drawers, wallpaper falling down, and no emergency pull station in bathroom.
The surveyor was provided with Monthly Room Checks, dated April 2023, March 2023, February 2023, and January 2023. The room checks were conducted per wing and included either a check mark, ok, or fix. When asked for the follow up on the room checks, the Regional LNHA #2 looked at the Monthly Room Checks document and stated there was no way to determine if the checks and x's meant good or something was bad. He stated the audits were common area audits with only some resident rooms. He further stated after the findings, there should have been a repair and the concern should have went back to QAPI committee. The Regional LNHA #2 stated the concerns should have been documented in QAPI that it was completed.
A review of the facility provided, QAPI plan for the [name redacted] facility, undated, included but was not limited to Purpose: to take a proactive approach to continually improve the way we (facility) cares for and engages our residents .To do this, all employees will participate in ongoing quality assurance and performance improvement efforts . to provide quality services in a caring environment where individuals can attain their highest level of functioning. Guiding Principles: #1 our organization uses quality assurance and performance improvement to make decisions and guide day-to-day operations. #2 the outcome of QAPI is to improve the quality of care and quality of life of our residents. #6 our organization sets goals for performance and measures progress toward those goals. Scope: the QAPI program encompasses all segments or care and services .The [name redacted] facility that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments. The Scope Segment of Care included but was not limited to: Maintenance and Housekeeping - provide and ensure that all health, sanitation, and OSHA (Occupation Safety and Health Administration requirements are met through regular cleaning, disinfection, and sanitation of all aspects of the building.
A review of the facility provided, QAPI Plan, undated, included but was not limited to documentation of performance improvement project activities: ongoing monitoring to be documented, outcomes, and lessons learned. Assuring sustained improvement: used to measure outcomes to assure continued improvement to identify any adjustments or corrective actions to achieve the established goals. To ensure the interventions are implemented and effective in making and sustaining improvements, indicators/measures are selected that tie directly to the new action and established threshold and outcomes are reviewed.
The facility failed to follow their QAPI plan and were unable to provide any follow up information or ongoing adjustments to address projects that had been started six months prior.
NJAC 8:39-33.1 (a)(c)(d)(e); 33.2 (b)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. ) On 05/22/23 at 12:23 PM, the surveyor went to the B-Wing to observed the lunch meal. The surveyor observed a Certified Nursing Assistant (CNA) delivered a lunch tray to a resident. While placing the tray on the bedside table, the linen that was on the bed fell on the floor. The CNA picked up the linen and placed it directly on the resident's bed.
The surveyor followed the CNA to the hallway and inquired about the linen that was on the floor which he returned to the resident's bed. The CNA stated that he should not have placed the soiled linen on the resident bed. When asked for the rationale, the CNA stated, for transmission of disease.
On 05/23/23 at 12:05 PM, the surveyor returned to the B-Wing to observe the lunch meal. The surveyor observed CNAs and nurses delivered trays from Rooms 47-58. The staff did not provide hand sanitizer or sanitizing wipes for the residents to sanitize their hands prior to the lunch meal.
On 05/23/23 at 12:40 PM, the surveyor interviewed the RN, who confirmed that the residents on the B-Wing high side, were not provided with the opportunity to sanitize their hands because the staff who went to get the sanitizing wipes had not returned to the B-Wing yet. Shortly after, the surveyor observed the Unit Manager in training arrived on the B-Wing with two containers of sanitizing wipes and proceeded to assist residents on the B-Wing low side with sanitizing their hands prior to the lunch meal. Upon inquiry regarding the above observation, the RN stated that she was not too sure of the facility's protocol for residents to sanitize their hands prior to receive their meals, she would inquire.
On 05/23/23 at 1:00 PM, the RN informed the surveyor that she spoke with the Infection Preventionist, and was informed that all residents should be provided with opportunities for hand hygiene prior to receive their meals.
On 05/26/23 at 8:30 AM, in the presence of the administrator, the surveyor observed an RN entered an isolation room to deliver the breakfast meal without wearing the proper (PPE) Personal Protective Equipment. The surveyor observed the RN with a surgical mask only. An isolation bin with PPE gowns, gloves and N-95 masks was observed in the hallway by the resident's room. Signage was posted at the door to inform staff and visitor of the proper PPE to wear prior to enter the room. Other staff who were assisted with the meal delivery attempted to alert the RN not to enter the room without the proper PPE. The RN handed the breakfast tray to the resident that was standing half way in the room. The administrator had a conversation with the RN and the RN went and washed her hands.
On 05/26/23 at 8:45 AM, the surveyor interviewed the RN in the presence of the Administrator. The RN stated, I should have donned PPE prior to enter the isolation's room.
The facility was made aware of the above concerns with infection control on 06/02/23 at 2:15 PM.
On 06/05/23 at 8:35 AM, the Regional LNHA #2 provide a folder with some in-services education that were done. No additional information was provided.
NJAC 8:39-19.4 (a)(b)(c)(k)(m)(n)
b.) On 05/22/23 at 12:15 PM, during the observation of the lunch meal tray distribution on Unit B, Surveyor #2 observed CNA #2 deliver lunch trays between 12:15 PM and 12:24 PM, without performing hand hygiene prior to or after delivery of the trays.
The trays were delivered to the following rooms. One tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; a second tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; one tray into room [ROOM NUMBER]; one tray into room [ROOM NUMBER]; a second tray to room [ROOM NUMBER]; one tray to room [ROOM NUMBER]; a second tray to room [ROOM NUMBER]; two trays into the unit day room.
On 05/22/23 at 12:29 PM, during an interview with Surveyor #2, CNA #2 stated the meal tray delivery process was for the nurses to check the trays, make sure all residents in the day room were eating together, clean the residents hands, and after every third tray delivery, the staff would clean their hands. When asked why she had not performed any hand hygiene between the delivery of the 16 meal trays, CNA #2 stated she was just trying to get it done.
On 05/22/23 at 12:34 PM, during an interview with Surveyor #2, LPN #2 stated the process was for the nurses to check the trays for the correct diets, hand the trays to the CNAs, clean residents hands, and after three resident trays were passed out, the staff would clean their hands. LPN #2 stated this was so don't pass on contamination.
On 05/23/23 at 1:31 PM, the LPN IP stated that during meal pass, residents would be provided hand hygiene and that the staff were to perform hand hygiene between each resident to prevent the spread of infection.
A review of the facility provided, Job Description: CNA, reviewed 11/20/22, included 4. Follows infection control procedures (i.e. hand washing).
A review of the facility provided, Hand Hygiene Competency Validation, Soap & Water Alcohol Based Hand Rub (ABHR), revealed that CNA #2 had been deemed competent on 02/15/23, and 03/26/23.
A review of the facility provided, Handwashing/Hand Hygiene policy, dated 11/22/22, included 2. Follow the handwashing/hand hygiene procedures to help prevent the spread of infections; When to wash hands: 5. F. before and after eating or handling food (hand washing with soap and water), G. before and after assisting a resident with meals.
c.) On 05/22/23 at 10:06 AM, Surveyor #2 observed Resident #83 in his/her bed and there was an oxygen concentrator next to the resident. The tubing of the oxygen was lying on the floor. Resident #83 stated that the staff doesn't care if it's dirty.
On 05/24/23 at 8:23 AM, Surveyor #2 observed Resident #83 lying in bed and his/her oxygen nasal cannula (n/c) was partially suspended in an open drawer with the oxygen tubing hanging within inches of a urinal containing urine. Surveyor #2 observed the oxygen concentrator with light brownish substance splattered on it.
On 05/24/23 at 8:52 AM, Surveyor #2 observed LPN #2 had been in Resident #83's room administering medications. Surveyor #2 looked into the resident's room and observed that the n/c and tubing were still in the same position next to the urinal containing urine.
On 05/24/23 at 9:24 AM, during an interview with Surveyor #2, LPN #2 stated that oxygen tubing was changed every Wednesday by the 11 PM to 7 AM staff. She stated her responsibility would be to ensure the oxygen was set at the prescribed liters per minute, if a resident used oxygen off and on, to ensure the tubing is kept in a bag. Surveyor #2 went with LPN #2 to Resident #83's room where we both observed the n/c exposed to the environment, not in a bag and in close proximity to the urinal with urine in it. LPN #2 acknowledged there was no bag in the room. At that time, Surveyor #2 also requested the LPN inspect the oxygen concentrator. LPN #2 acknowledged the oxygen concentrator was visibly soiled. LPN #2 stated the oxygen tubing and concentrator could cause cross contamination and it should be kept clean for infection control. LPN #2 stated she checked the tubing when she was in the room and thought there was a bag.
A review of the admission Record revealed that Resident #83 had been admitted to the facility with diagnoses which included but were not limited to metabolic encephalopathy (abnormalities that adversely affect brain function), chronic obstructive pulmonary disease (COPD), chronic viral hepatitis C, and hypoxemia.
A review of the Order Summary Report, active orders as of 05/30/23, included an order dated 02/08/23 to change and date oxygen tubing and humidifier bottle weekly.
A review of the most recent Annual Minimum Data Set (MDS) an assessment tool to facilitate care, dated 03/30/23, included but was not limited to a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated the resident was cognitively intact. Section O, which indicated the resident received oxygen therapy while a resident at the facility.
A review of the facility provided person-centered comprehensive care plan printed on 05/30/23, included focus: smoker and use tobacco frequently with an intervention to assess respiratory status q (every) shift and apply oxygen as needed; and focus: at risk for infection due to a history of COPD with an intervention to monitor for changes in respiratory status.
On 05/31/23 at 1 PM, the Regional Administrator #2, the Regional [NAME] President of clinical services, and DON were made aware.
At 1:25 PM, the Regional [NAME] President of clinical services stated the oxygen supplies should be cleaned weekly and PRN (as needed).
On 06/01/23 at 10:05 AM, the facility acknowledged that the oxygen concentrator should have been cleaned but was not.
A review of the facility provided, Job Description: LPN, reviewed 11/20/22, included 8. Practices standard precautions and adheres to infection prevention strategies.
A review of the facility provided, Oxygen Therapy policy, reviewed 11/20/22, included 1. Oxygen therapy is administered by way of a nasal cannula; 11. When not in use, the nasal cannula will be placed in a plastic bag labeled with the resident's name and dated.
A review of the facility provided, Cleaning and Disinfection of Resident-Care Items and Equipment, reviewed 11/22/22, included resident-care equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations and OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard. 1. The following categories are used to distinguish the level of disinfection necessary. 1. D. reusable items are cleaned and disinfected (durable medical equipment).
This is a repeat deficiency from the Standard Survey Date: 03/31/22.
Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) maintain proper isolation procedures for a resident identified as a Person Under Investigation (PUI) for Covid-19 for 1 of 1 resident (Resident #509) reviewed for Transmission Based Precautions (TBP), b.) perform hand hygiene during the passing out of the lunch meal trays on 1 of 3 units (Unit B), and c.) ensure the cleanliness of respiratory equipment for 1 of 3 residents (Resident #83) reviewed for respiratory care. This deficient practice occurred on 2 of 3 Wings (Wing B & C) was evidenced by the following:
a.) During a tour of Wing C on 05/23/23 at 11:53 AM, Surveyor #4 observed a three- tier white plastic bin which contained Personal Protective Equipment (PPE), two red paper signage attached to the doorway, indicating how to don (put on) and doff (take off) PPE and a red trash can located in the hallway outside Resident #509's room. The surveyor observed rolled up blue plastic isolation gowns inside the red trash can. At that time, the surveyor interviewed Resident #509 who stated he/she was on isolation because he/she did not receive all the Covid vaccinations required.
On 05/23/23 at 12:51 PM, Surveyor #4 observed the red trash can in the hallway outside Resident #509's room.
During an interview with Surveyor #4 on 05/23/23 at 12:02 PM, CNA #1 stated that when a resident was on PUI isolation, the staff were to remove all PPE prior to exiting the room and place the contaminated PPE in the designated trash can located in the hallway right outside the isolation room.
During an interview with Surveyor #4 on 05/23/23 at 12:52 PM, the Licensed Practical Nurse Unit Manager (LPN UM#1) stated that when a resident was on PUI isolation, the staff were to remove all PPE prior to exiting the isolation room and dispose of the PPE in the red trash bin located inside the room. LPN UM #1 further stated that it was important to dispose of the PPE in the trash can located inside the isolation room prior to exiting the room so you don't cross contaminate the infection and put other residents or staff at risk for spread of the infection.
At that time, Surveyor #4 accompanied LPN UM #1 to Resident #509's room and the LPN UM #1 confirmed the isolation red trash can was in the hallway outside the isolation room. The LPN UM #1 stated the isolation trash can should be located inside Resident #509's room.
During an interview with Surveyor #4 on 05/23/23 at 1:31 PM, the Infection Preventionist (IP) stated that the contaminated PPE trash bin should be located inside the room, by the door, before you exit the isolation room. The IP stated it was important to dispose of the contaminated PPE in the trash can inside the isolation room, so you don't spread infection. The IP further stated that when a new admission was not fully vaccinated for Covid-19, the resident will be placed under PUI isolation for 10 days and it was important to use proper infection control procedures.
During an interview with Surveyor #4 on 05/24/23 at 8:56 AM, the Director of Nursing (DON) confirmed that the contaminated PPE should be placed in the trash can located inside the PUI room.
During an interview with Surveyor #4 on 06/02/23 at 9:03 AM, the [NAME] President of Clinical Services stated the facility did not have a policy that included to keep the isolation trash can inside the isolation room but that the facility followed CDC (Centers for Disease Control and Prevention), CMS (Centers for Medicare & Medicaid Services), and DOH (Department of Health) regulations that required the isolation trash cans be located inside the isolation room.
A review of the facility's, Covid-19 Outbreak Response Plan, dated 02/08/23, reflected that the facility follows all CMS, CDC, Federal, State and Local DOH regulations regarding isolation and cohorting infected and at-risk residents from a communicable disease including Covid 19.
A review of the CDC recommendations titled, Transmission-Based Precautions, dated January 7, 2016, revealed that Transmission Based precautions are the second tier of basic infection control and are to be used in addition to Standard precautions for patients who may be infected or colonized with certain infectious agents. The recommendations also indicated to use PPE appropriately, donning PPE upon entry, and properly discarding before exiting the patient room was done to contain pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide: a) a comfortable chair for each resident in his or her room for use by the resident or the resident's visitor for 66 of 157 residents, (b) a bed table with drawers for 3 of 157 residents, and c) individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident for 2 of 157 residents. This deficient practice was observed on 3 of 3 resident Wings (Wing A, B, C) and was evidenced by the following:
1.On 05/30/23 at 8:47 AM, Surveyor #3 conducted resident room rounds on Unit A and observed the following:
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 3 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 3 residents and two chairs
On 05/30/23 at 8:48 AM, Surveyor #2 conducted resident rooms rounds on Unit B and observed the following:
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 1 resident and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and no chairs
On 05/30/23 at 8:53AM Surveyor #4 conducted resident room rounds on Unit C and observed the following:
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and no chairs
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 3 residents and no chairs
room [ROOM NUMBER] housed 3 residents and two chair
On 05/30/23 at 8:54 AM Surveyor #5 conducted resident room rounds on Unit C and observed the following:
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 2 residents and one chair
room [ROOM NUMBER] housed 1 resident and no chair
2. On 05/30/23 at 8:47 AM, Surveyor # 3 and #4 conducted resident room rounds on Unit A and observed the following:
room [ROOM NUMBER] housed 2 residents and one bedside table with drawers
room [ROOM NUMBER] housed 2 residents and one bedside table with drawers
room [ROOM NUMBER] housed 3 residents and two bedside table with drawers
3.On 05/30/23 at 8:54 AM, Surveyor #5 conducted resident room rounds on Unit C and observed the following:
room [ROOM NUMBER] housed 2 residents and there was no closet for each resident.
On 05/23/23 at 1:18 PM, Surveyor #2 accompanied by the Licensed Nursing Home Administrator (LNHA) completed environmental rounds on Unit B. The LNHA stated that she was not aware of the conditions of the rooms. She further stated that she made daily rounds on the units.
On 06/02/23 at 10:53 AM, in the presence of the survey team, and in response to the environmental rounds that were completed by the survey team and shared with the Administration, the Regional Administrator (RA #2) addressed the survey team. The RA #2 stated that every concern that was provided to the facility, he took personally and called on sister facilities to provide assistance. The RA #2 further stated that when you look at the building and the clients it doesn't take long for everything to go to [exploitive redacted]. The RA #2 further sated he was called into the facility for support as the RA #1 was responsible for checking on the facility.
The admission Agreement, undated, and was provided to the survey team during the entrance conference on 05/22/23 at 12:02 PM revealed the following:
Exhibit 5, Resident Rights: . Physical and Personal Environment . To live in a safe, clean comfortable and home-like environment .
NJAC 8:39-31.8(c)(1-4)(10)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility provided documentation, it was determined that the facility failed to ensure corridors were equipped with intact, firmly secured handrails. The deficient practice occurred on 3 of 3 units and was evidenced by the following:
On 05/23/23 at 1:02 PM, on A-Wing, two surveyors were observing the facility environment. In the hallway outside of room [ROOM NUMBER] A, the surveyors observed a broken handrail with sharp edges.
On 05/23/23 at 1:14 PM, during an interview with the two surveyors, the Licensed Nursing Home Administrator (LNHA) stated that she made rounds in the mornings. She stated that most of the whole floor (A Wing) does for themselves. She further stated, you do realize the whole building is behavioral.
On 05/23/23 at 1:16 PM, the two surveyors escorted the LNHA to the broken handrail. The LNHA stated, I didn't see it. The surveyors and LNHA observed a loose handrail in the hallway outside of room [ROOM NUMBER]. A Certified Nursing Assistant (CNA) was present and stated a maintenance staff member had been pulling at it yesterday. The LNHA stated she was unaware yesterday of the handrail being loose.
On 05/23/23 at 1:22 PM, the LNHA showed the two surveyors the A Wing maintenance book. She stated when you see something broke, I put it in here. They come in here every morning and look at the book and fix it. The last entry in the A Wing maintenance book was dated 05/08/23.
On 05/23/23 at 1:38 PM, during an interview with the surveyors, the LNHA stated that maintenance had two pieces to fix handrails. She stated until the handrails were fixed, the staff would have to watch the residents, so they don't go there. The surveyors and LNHA observed there were no staff at the nursing desk.
On 05/24/23 at 8:26 AM, on A Wing outside of room [ROOM NUMBER], Surveyor #1 observed the lower handrail was broken. The LNHA and Director of Nursing (DON) were at the nursing station. The LNHA stated she had looked at handrails that morning and that she was letting maintenance know.
On 05/24/23 at 8:37 AM, on B-Wing high side, Surveyor #3 observed a section of handrail leading to the resident smoking area. The handrail was visibly pulled away from the wall at the corners of the handrail. Survey #3 touched the handrail and it loose and able to be moved up and down.
On 05/24/23 at 9:08 AM, the LNHA was present, and Surveyor #3 asked where to find the maintenance department. The LNHA was shown the handrail and stated that the maintenance staff was out and he will return shortly.
On 05/24/23 at 9:11 AM, the Maintenance Director arrived on B-Wing and Surveyor #3 showed him the unsecured, loose handrail. The Maintenance Director stated he checks the handrails as needed and that it was important for the handrails to be secure so residents don't fall.
On 05/24/23 at 8:46 AM, on C-Wing, two surveyors observed a broken lower handrail on the corner with the corner cap missing. This was observed directly across from the nursing station with residents ambulating freely in the area.
A review of the facility provided, admission Agreement, undated, included but was not limited to Resident Rights .Physical and Personal Environment .to live in a safe, clean comfortable and home-like environment
A review of the facility provided, Facility Assessment Tool, dated 10/2022, included but was not limited to 3.8 The [name redacted] facility ensures equipment is maintained and monitored to protect and promote the health and safety of our residents. The facility's maintenance department has a preventative maintenance program in place to maintain the physical plant and equipment in a safe manner.
NJAC 8:39-27.1 (a); 32.1 (a); 32.3 (a)

Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure a.) Resident Rights were not violated, and b.) promote the dignity of one resident by ensuring residents who were awake alert and ambulatory were provided with regular clothing to wear and ensure their belongings were being protected. This deficient practice was identified for 1 resident reviewed, Resident #8. The deficient practice was evidenced by the following:
On 05/22/23 at 9:54 AM, the surveyor observed Resident #8 standing at the resident's room door in the hallway undressed. Resident #8 had no incontinent brief on. Resident #8 had a shirt covering his/her private area. The surveyor observed several staff ambulating back and forth in the hallway entering and exiting other resident's room. Resident #8 attempted to get the staff's attention but no staff stopped and asked Resident #8 if he/she needed assistance.
The surveyor continued to ambulate further in the hallway on the right side and was intercepted by Resident #8. Resident #8 was upset and stated, I tried to tell them I do not have any clothes to wear, I spoke with the nurses, the Social Worker, the administrator, no one listened to me. Please come and I will show you. Other residents just come to the room and stole my clothing. The resident escorted the surveyor to the room and opened the dresser's door. The surveyor observed some clothes hangers hung in the closet. The resident opened the bottom drawers and they were also emptied.
That same day at 10:18 AM, the surveyor left the room and observed the Director of Nursing (DON) in the hallway. The surveyor and the DON both observed again Resident #8 standing in the hallway undressed. Resident #8 escorted the DON to the room and opened the empty dresser. The DON told the surveyor that the facility was aware of the concerns with stolen clothing. The DON continued and stated that some of the residents did not have families and funds to buy clothing so they just helped themselves by stealing clothing from other residents. When the surveyor asked the DON what had been done to protect the vulnerable residents, she declined to comment.
On 05/23/23 the surveyor returned to the B-Wing and observed Resident #8 in bed and resting. There were no clothes in the dresser.
On 05/24/23 at 8:59 AM, the surveyor interviewed the Housekeeping Director (HD) in charge of the laundry. The HD revealed that most of the personal clothing were not labeled and after being washed, were kept in a bag in the laundry room or placed on the rack. The HD further stated that the CNA could come and retrieve some clothing for residents if needed. There was no system in place to return the unlabeled clothing to the residents.
On 05/24/23 at 9:10 AM, the surveyor interviewed the Social Worker (SW) regarding the missing clothing specifically for Resident #8. The SW informed the surveyor that she was aware of the issue with other residents stealing clothing from some residents. The SW added that currently the facility did not have a process in place to address the missing clothing. The SW worker further added that the facility could install locks to correct the situation but could not explain why it had not been done.
The surveyor then made the SW aware of Resident #8 standing in the hallway undressed and reported that he/she did not have clothing to wear. The SW informed the surveyor that she was in charge of ordering clothing for some of the residents. She further stated that she ordered clothing for Resident #8 last year and Resident #8 should have some clothes in the room.
On 05/24/23 at 9:30 AM, the surveyor requested the PNA (Personal Needs Allowance) account and any invoice for clothing for Resident #8.
On 05/25/23 at 9:10 AM, during an interview with the surveyor, the CNA assigned to Resident #8 revealed that Resident #8 did not have any clothing in the dresser this morning, she had to go and retrieve one set of clothing from the laundry.
On 05/25/23 at 11:30 AM, the surveyor reviewed Resident #8's medical record. According to the admission face sheet, Resident #8 had diagnoses which included but were not limited to, Unspecified dementia without behavioral disturbances, major depressive disorder, schizophrenia and anxiety.
The Annual Minimum Data Set (MDS) an assessment tool, dated 03/22/23, revealed that Resident #8 was moderately cognitively impaired. Resident #8 scored an 08 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #8 was able to communicate his/her needs and was independent with care.
The Comprehensive Care Plan (CP) dated 11/05/20, reflected a focus for communication due to hard of hearing. The Goal was for Resident #8 to communicate needs without frustration. The following interventions were to be implemented:
Allow adequate time for response. Initiated 12/10/20
Ask resident to repeat words as needed. Initiated 12/10/20.
Ask simple yes or no questions. Initiated 12/10/20
Assist resident to build up simple vocabulary of words or gestures to make needs known. Initiated 12/10/20.
On 05/26/23 the SW provided the PNA account balance along with the invoices.
An invoice dated 03/07/22 revealed that the SW bought clothing in the amount of $369. 84 from [name redacted] clothing store for Resident #8.
A second invoice dated 09/30/22 revealed that the SW bought clothing in the amount of $427.79 cents from [name redacted] clothing store for Resident #8.
On 05/27/23 the SW provided another invoice for $66.88 from [name redacted] store. She stated that she used her card to buy clothing for Resident #8 and the facility would reimburse the money for purchase from [name redacted] store.
The SW then reported that all clothing from [name redacted] clothing store was labeled prior to shipping. She could not provide the rationale for Resident #8 missing clothing since they were already labeled. Upon inquiry she stated that some residents who helped themselves to other residents clothing, would remove the labels. The SW could not provide any grievance that was done to address Resident #8 issue with stolen clothing.
On 05/26/23 at 10:16 AM, during an environmental round some of the dressers in other residents' room were noted with a lock. Upon inquiry, the CNA stated that the family would provide a lock to prevent other residents from entering the rooms and stealing their belongings.
The facility although aware of the concerns with missing clothing, did not implement any measures to protect Resident #8's belongings.
The administrative staff was made aware of the above concerns on 05/22/23, and again on 05/25/23.
On 06/01/23 at 1:45 PM, the SW stated that moving forward, the issue with missing clothing would be addressed through grievance. The facility did not have any additional information to provide on the exit day.
A review of the facility's policy for Resident Rights indicated in Exhibit 5 under physical and personal environment the following:
Resident has the right to be treated with courtesy, dignity and respect.
To wear your own clothes, unless this would be unsafe or impractical. All clothes provided by the nursing home must fit you properly.
To keep and use your personal property, unless this would be unsafe and impractical, or an infringement on the rights of other residents. The nursing home must take precautions to ensure that your personal possessions are secure from theft, loss and misplacement. You cannot be required to sign a waiver removing the facility's liability for lost property.
It is further stated under Protection of Your Rights:
To be given a copy of and informed about the facility's grievance policy which should include specific information on how to file a complaint orally, in writing and anonymously and should include a timeframe for the facility to review and respond.
To retain and exercise all the constitutional, civil and legal rights to which you are entitled by law. The Nursing Home is required to encourage and help you to exercise these rights.
The Facility on the first day of the survey was informed and made aware of the issue with Resident #8's missing clothing. The facility did not implement measures to protect Resident #8's possessions nor assisted the resident to file a grievance and exercise his/her rights.
N.J.A.C. 8:39-4.1(a)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 have a process in place to ensure that all recommendations, grievances and concerns presented by the residents during the monthly resident council meetings were consistently addressed. This deficient practice was identified for 6 of 6 residents who attended a resident council meeting and was evidenced by the following:
A review of the Resident Council Meeting 02/22/23, included the following: Maintenance: Issues in some bathrooms have been fixed; asking again not to flush paper towels, Dietary: Residents are requesting banana cream pie.
A review of the Resident Council Meeting minutes from 03/24/23, included the following: Repair has begun in the rooms and painting; Rooms too cluttered need to downsize; Social Worker is the only one that can go shopping, Social Services will assist resident buying container to help with decluttering. We ask all residents to stop giving their [type of card name redacted] money card to other people; and Residents requesting to have more fresh fruit and would like to have more hot dogs and hamburgers. Requesting liver be removed from the menu. There was no documented follow up from the 02/22/23 resident Council Meeting minutes, including the request for the banana cream pie.
A review of the Resident Council Meeting minutes from 04/19/23, included the following: Social Services will assist residents in buying containers to help with decluttering; and Social Worker is the only one that can go shopping, we ask all residents to stop giving their [name redacted] money card to other people. The Residents are asking if we could add filet [NAME] to the menu, they love when we make fried chicken. There was no documented follow up from the 03/24/23 Resident Council minutes, including the request for the more fresh fruit, more hot dogs and hamburgers, the removal of liver from the menu and the banana cream pie that was requested in the February 22, 2023 meeting. There was also no documented follow up regarding the status of Social Services providing containers for decluttering documented in the Resident Council Meeting minutes dated 03/24/23 .
On 05/24/23 at 10:36 AM, the surveyor was present for a Resident Council Meeting with six residents. At that time, 6/6 residents requested that they wanted fresh fruits and vegetables to be served, and this request was consistent with what was documented on the 04/19/23 Resident Council minutes. One resident stated the food was inedible, he/she had lost weight and talked to the dietitian twice about food preferences and there had been no resolution and no follow-up. The resident added he/she had eaten very few vegetables because the vegetables were frozen and then steamed. The resident stated he/she would be happy with one piece of celery and a carrot, just fresh. Another resident stated that the fruit was mostly canned and was served at room temperature which was warm. Another resident stated that the soda and snack machines were broken. A resident stated that any resolutions from the Resident Council was addressed a one on one thing (group concerns were not addressed by the facility).
On 05/25/23 at 8:20 AM, the LNHA was interviewed by surveyors who asked about the process regarding follow-up from the concerns expressed during the Resident Council meetings. The LNHA stated there was no documentation or follow- ups from the resident council meetings. When asked about the bins requested for the clothing that was cluttering the rooms, the LNHA stated she had looked at the minutes and did not see any need to address the bins. The Social Worker was present during the interview and stated that only a few people needed the bins so it was not done on a form that would be used to address a concern in the resident council. The LNHA stated that if there was a problem brought up by an individual resident, that the individual concern would be addressed through the grievance form. The LNHA, in the presence of the Social Worker, was unable to specify a policy or process that addressed the group concerns, and provided a response/action plan for the concerns that were voiced by the residents during the resident council meeting.
On 05/25/23 at 10:00 AM, the surveyors conducted environmental rounds on all three units. The surveyors observed multiple rooms with clothing in plastic bags that were lying on the floor, or on a chair and there were no observations of the bins identified in the resident council minutes, and as clarified by the Social Worker, as being needed for only a few of the residents.
A review of the facility provided, untitled and undated, Procedure: 1. Grievance form will be used to document all resident related problems, complaints or grievances. 2. The grievance form can be completed by anyone with knowledge or a resident problem or complaint. 3. The grievance form asks for the name of the person reporting but this is not required if the individual addressing the problem/complaint wishes to remain anonymous. 4. Social Worker will review the grievance form with the administrator. 5. The Administrator/Social worker will review the problem/complaint to determine validity of grievance, root cause of grievance, and action plan. 6. The summary & action plan will be reviewed with the person completing the grievance form by the Administrator or his designee upon completion of the form.
A review of the facility provided, Administrator job description, reviewed 7/20/22, included but was not limited to maintains a fundamental knowledge and awareness of the status of all residents; and ensures accurate documentation, implementation and compliance of all issues.
The facility provided, Facility Assessment Tool, reviewed 10/2022, included but was not limited to 1.6 Residents have the right to be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident, this includes but is not limited to food and nutrition.
On 05/25/23 at 8:20 AM, the LNHA and Social Worker were made aware of the fact there were no follow ups for the three months of resident council meeting minutes. The facility had no additional information to provide.
NJAC 8:39-4.1 (a)(29), 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of other facility documentation it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 3 of 3 resident Wings (Wing A, B, & C) and was evidenced by the following:
Observations conducted by Surveyor #1 revealed:
On 05/23/23 at 12:35 PM, during a tour of the B- Wing hallway, while the lunch meal was being distributed, and in the presence of Surveyor #2. Both surveyors smelled a pervasive smell of urine permeating in the hallway outside of room [ROOM NUMBER]. Residents were observed eating meals in both room [ROOM NUMBER] and the adjacent room [ROOM NUMBER]. At that time, the Director of Nursing (DON) was in the hallway and Surveyor #1 asked the DON if she could smell anything in the hallway. The DON stated she could not, and walked away from the surveyors.
On 05/23/23 at 12:36 PM, both surveyors interviewed the B-Wing Registered Nurse (RN) regarding any noticeable odors in the hallway. The RN stated yes a little, like pee [urine]. The RN stated, it needs to be cleaned.
On 05/23/23 at 12:42 PM, Surveyor #1 interviewed two unsampled residents who were eating at their bedside in room [ROOM NUMBER]. Both residents confirmed that the room was malodorous and told the surveyor they would also see roaches, especially at night in the bathroom. The surveyor did not observe any roaches at that time when entered the bathroom.
On 05/23/23 at 12:50 PM, Surveyor #1 & #2 observed room [ROOM NUMBER]. The surveyors observed that there was a missing privacy curtain over Resident #50's bed and the closet appeared broken and was missing two bottom drawers and was soiled inside. There was an unidentified person painting the wall behind the bed and he had identified himself as a maintenance person (MP) who worked at another facility. The MP stated he was pulled in to help during the survey. The surveyors inquired about the broken closet and the missing curtain. The MP stated to the surveyors that he was only painting and acknowledged that there was a missing privacy curtain and broken closet.
On 05/23/23 at 12:53 PM, Surveyor #1 & #2 observed Resident #28 in bed in his/her room located on A-Wing. The resident was alert and greeted the surveyors. There was a large ripped and stained piece of wallpaper approximately 1-2 feet in length which exposed the wall underneath and was adjacent to the closet.
On 05/23/23 at 12:54 PM, Surveyor #1 asked the Licensed Nursing Home Administrator (LNHA) to view Resident #50s room and the broken closet that was missing the drawers. The LNHA stated the resident pulls things out and should be care planned for that. The surveyor asked the LNHA if having a closet with missing drawers was safe and she stated no, it is not acceptable for the doors to be left like that. Surveyor #1 inquired how often the LNHA would make rounds of the resident rooms. The LNHA stated every morning she would make rounds with the Maintenance and Housekeeping Director.
On 5/23/23 at 12:59 PM, the LNHA accompanied Surveyor #1 into Resident #28's room to view the ripped wallpaper and asked the LNHA if she had been aware of it. The LNHA stated no, never noticed it and the surveyor asked if the wallpaper was okay to be left like that. The LNHA stated it has to be fixed.
On 05/23/23 at 1:02 PM, Surveyor #1 and #2 accompanied the LNHA into room [ROOM NUMBER] (B-Wing) to show the LNHA the writing that was in multiple colors and was all over the walls, a large, approximately 1-to-2-foot hole lengthwise in the wall opposite of the front of the bed and was close to the baseboard. There was also a hole in the ceiling above the closet on the opposite side of the room. The LNHA observed the holes and stated she had not been aware that there were holes in the walls. The LNHA stated the resident wrote on the walls and the facility repainted them. The LNHA stated it would be taken care of right away. Surveyor #1 asked why it needed to be taken care of right away, and the LNHA stated, because it is a problem.
On 05/23/23 at 1:14 PM, Surveyor #1 and #2 continued the observations and observed an unsampled resident in room [ROOM NUMBER]. The unsampled resident, who was sitting in a wheelchair in the room, was facing a broken lower drawer on the nightstand which was next to a tray table that was soiled on the base and dusty on the top.
Outside of the resident room [ROOM NUMBER] and across from the nurse's station in the A-Wing hallway, there was a handrail that was loose and one with a broken end cap that had sharp edges. The opposite side of the nurse's station had a broken handrail end cap which had a missing piece. A Certified Nurse Aide (CNA #3) was at the nurse's station at that time. The LNHA was present, and the Surveyors showed her the handrail that was loose and the LNHA then stated she was unaware of the loose handrail. The CNA #3 stated a resident was pulling the handrail yesterday, and when asked CNA #3 about the missing end cap, she stated I don't know. The LNHA stated that just so you know it could have happened a couple of minutes ago, we have behavioral people here.
Surveyor #1 then asked the LNHA about rounding on the units. The LNHA stated to the surveyor you do realize the whole building is behavioral? The LNHA stated every morning she completed rounds on the units and then gave a list to maintenance regarding items that needed repair. When asked for documentation regarding the lists, the LNHA stated she doesn't have a copy of the list.
At that time, both surveyors escorted the LNHA to room [ROOM NUMBER] and showed her the broken nightstand and asked the LNHA if she had been aware. The LNHA stated no, I was not aware. The LNHA could not provide a list of items that were identified for repair and stated maintenance would verbally tell her if items had not been fixed.
On 05/23/23 at 1:18 PM, Surveyor #2 asked the LHNA if she had been aware of the conditions observed inside of the resident rooms. The LNHA stated she was not aware of the issues with the furniture in the resident rooms.
On 05/23/23 at 1:22 PM, Surveyor #1 asked CNA #3 what the process was if there were items identified that needed repair. CNA #3 stated that if something was broken, she would put the information into the maintenance book. CNA #3 then showed the surveyor the maintenance book. CNA #3 stated that maintenance would come every morning and review the maintenance book and then would fix the items that were documented in the book. At that time, the surveyor reviewed the maintenance book. The last entry in the book was dated 05/08/23 (15 days prior) and the handrails and broken furniture were not documented.
On 5/24/27 at 9:03 AM, two surveyors proceeded through a resident day room by A-Wing and on the way to the kitchen. There were three residents sitting in the day room. One resident was sitting next to a window air conditioner that had a broken cover, missing knobs, was soiled with dust like debris throughout the vents, window, and the blinds were also soiled. There was an out of service empty snack vending machine and stains were on a wall next to a copy machine.
On 05/25/23 at 8:59 AM, Surveyor #1 interviewed Resident #49, on A-Wing inside the resident's room. The resident stated that he/she cannot wait to get the [exploitive redacted] out of here, this place is so filthy it is making me more sick. Resident #49 proceeded to point to the windowsill which the surveyor observed as being visibly soiled with dust like dark colored various debris on the length of the windowsill, and the window air conditioner unit had dark dust like debris throughout the vents. The blinds also had dust like debris and the resident then pointed to the window which was visibly cloudy and exclaimed, I cannot even see through the window. The window air conditioner unit also was not sealed and there were open gaps. The wall heat/ air conditioner unit was also soiled with debris on the unit and inside the vents. Resident #49 then pointed to the tray table bottom which was visibly soiled with various colored debris. There was also a soiled and stained fabric colored board located behind the resident's bed. Resident #49 then exclaimed this place is a [exploitive redacted] dump.
On 05/25/23 at 10:06 AM, the surveyor initiated a tour with the LNHA on A-Wing and observed a hallway ceiling vent outside of room [ROOM NUMBER] that had visible dust like debris in the vent. The surveyor asked about the vents and pointed to the debris on the vent. The LNHA stated the maintenance person cleaned the vents weekly, and at that time, the LNHA stated she needed a bigger pad and left the tour with the surveyor. At that time the surveyor entered room [ROOM NUMBER] where two unsampled residents resided. One resident was sleeping in bed, and the other resident conversed with the surveyor. The corner wall area by the bathroom had a stained wall, and the surveyor asked the unsampled resident if the facility cleaned that area. The unsampled resident stated, they don't touch that. At that time, the surveyor observed the blinds were soiled, the air conditioner unit was dusty with debris in the vents. Dust like debris was stuck to the wall by the tray table and the base of both tray tables was soiled. The area over the sleeping unsampled resident had what appeared to be a circular ceiling stain by the sprinkler head.
Observations conducted by Surveyor #3 revealed:
On 05/25/23 at 10:00 AM, Surveyor #3 conducted a tour of the B- Wing, in the presence of the facility Licensed Practical Nurse Infection Preventionist (LPN IP) and observed the following:
room [ROOM NUMBER]- In the area of the closet and room door, a white substance stained the floor. The LPN IP looked at the substance and stated, no, not clean. The bathroom had a black substance on the floor by the sink and the blinds were visibly covered with a black substance. The LPN IP stated it shouldn't be like that. There was dust like clusters stuck to the ceiling, ripped curtains on the windows, the dressers were soiled and there was a dusty floor mat that was positioned next to a resident bed. The LPN IP stated, it was supposed to be cleaned. The wardrobe closet drawers were hanging off the hinges. The LPN IP stated Housekeeping and Administration were supposed to tour the resident rooms.
room [ROOM NUMBER]- A white paint like substance was on the floor. The LPN IP stated she was unsure of what it was. The wallpaper was ripped, the light switch was soiled and there was a black substance on the bathroom floor.
room [ROOM NUMBER]-The air conditioner unit was soiled with a dust like substance, the side covers were not properly covered and had aluminum tape around the edges. The windowsill had layers of dust like, black substance with multiple dead insects. The closets had missing doors, and the bedside table base had layers of embedded stains and a dust like debris. The bathroom had black stains on the floor and sink, the soap dispenser was un-mounted and lying on the toilet, there was broken tile on the wall with an exposed hole, and the sprinkler head appeared loose. Both privacy curtains were visibly soiled and stained.
room [ROOM NUMBER]- There was an open hole in the corner of the bottom portion of the wall where it met the floor. Both privacy curtains were soiled, and the LPN IP stated they were not clean. The air conditioner unit had a dust like debris on it and there was a black substance on the bathroom floor and toilet. The LPN IP confirmed it was not clean.
room [ROOM NUMBER]-The base of the bedside table was soiled and visibly stained. The air conditioner unit was soiled with debris, there was a crack in the wall below the privacy curtain, and there were long exposed loose cable wires.
room [ROOM NUMBER]-The base of the bedside table was soiled and visibly stained. Both privacy curtains were soiled. The windowsill had layers of dust like debris, cobwebs were present along with a black substance and dead insects.
room [ROOM NUMBER], at 10:17 AM, the LNHA and two additional maintenance staff joined the tour. The base of the over bed tables were visibly soiled, both bed frames were visibly soiled, the heat radiator was missing a base plate cover, the window blinds and air conditioner unit were both visibly soiled, there was a hole by the vent in the bathroom, and the light above the bathroom mirror had a hole behind it.
room [ROOM NUMBER]- The wall by the call bell by the door was visibly soiled, the air conditioner unit and window blinds were visibly soiled.
room [ROOM NUMBER]- the base of both beds were visibly soiled, the air conditioner unit was visibly soiled, the window blinds were visibly soiled with dust like debris and the blind was cracked. There were wires hanging from the ceiling, the base of both beds were visibly stained, the call bell by the door was visibly stained, the wall closet by the door was visibly stained, the bathroom toilet had a visible rust colored substance around the base, the wall paper was ripped and discolored, and both privacy curtains were visibly soiled.
room [ROOM NUMBER]- There were wires hanging from the ceiling, the air conditioner unit was not sealed and was open to the outside environment, both dressers were visibly soiled, the ceiling sprinkler unit was rusted and portions of it were missing.
room [ROOM NUMBER]- The wall closet by the door bed had pieces missing and the bathroom door did not close shut.
room [ROOM NUMBER]- The dresser by the door bed was visibly soiled and areas were chipped away, the dresser by the window bed had a drawer was hanging off, the windows were visibly soiled, the toilet was visibly soiled, the bathroom had no soap or soap dispenser, the wall had a large hole where the toilet paper holder used to be, there was a large hole in the ceiling of the bathroom.
room [ROOM NUMBER]- The wall by the door was visibly stained, the closet was visibly stained, wires were hanging from the ceiling, there was an unfinished wall patching on the wall by the bathroom, the air conditioner unit had visible cobwebs and dust like substance, the blinds were visibly soiled, there was a cooler with juice in it and small fruit type flies all over both sides of the room.
room [ROOM NUMBER]- The bed by the door was bare and there was visible white discoloration towards the foot of the mattress, there were wires hanging from the ceiling, a visible hole in the radiator top with a towel draped over it, the bathroom call bell was hanging down via wires, the bathroom floor had a visible black substance.
room [ROOM NUMBER]- the window curtains were visibly soiled, the wall by the door was visibly stained, the closet by the door bed was missing one door and had no drawers, the corner molding was missing by the window bed were multiple wires hanging from the ceiling, visibly soiled walls, the air conditioner unit and window blinds were visibly soiled with a dust/dirt like substance, the bathroom floor was visibly soiled, there was a leaking faucet, and there were several bugs stuck to the floor.
room [ROOM NUMBER]- The baseboard by the door was missing, the chair covering was ripped, the LNHA stated, we need to throw that out, there was a missing drawer on the dresser, the light on the wall behind the bed was not secure to the wall and leaning over the head of the bed, there was a lock on top of the bathroom door, the LNHA stated the resident in the room needed a CNA to assist them to the bathroom, there was a missing call bell, there was a fall mat next to the window bed that was ripped, the LPN IP stated you can't clean the mat when it is ripped, there was a hole in the top of the radiator, the air conditioner unit and window blinds were visibly soiled.
room [ROOM NUMBER]- There was writing on the door, the light switch covered was cracked, and the doors of the closet were missing.
room [ROOM NUMBER]- The air conditioner unit was visibly soiled, the window sill and window blinds were visibly soiled and dusty, the bathroom paper towel dispenser was rusted, the toilet and bathroom floor were visibly soiled.
room [ROOM NUMBER]- The light switch was not working.
One shower room had missing tiles in the first stall where the toilet was, the second stall for the shower had a hole on the bottom right side, and eight tiles were cracked.
The second shower room located by the nursing desk had cracked tiles by the toilet handle, the first shower stall had visibly rusted areas, and the second shower stall had exposed wires and cracked tiles.
Observations conducted by Surveyor #4 & #5 revealed:
On 05/25/23 at 10:05 AM, Surveyor #4 and Surveyor #5 entered the C-Wing and requested the Licensed practical Nurse Unit Manager (LPN UM #1) to accompany the surveyors on an environmental tour of the unit. While waiting for the LPN UM #1, Surveyor #4 observed the following in the hallway of the Wing-C:
10:06 AM The heating grate by nurse desk and in the Wing- C dayroom contained dust like particles.
From 10:08 AM through 10:13 AM, the following was observed: water stains on the ceiling outside of room [ROOM NUMBER], the medication cart for the high side had a brown substance splattered on the cart by the trash can, the oxygen concentrator in room [ROOM NUMBER] contained dust on top of the concentrator, In the area by the exit door on Wing- C the wallpaper was missing around wander guard, the white 3 tier personal protective equipment bin outside of room [ROOM NUMBER] had white streaks and black stains on the top.
During that time Surveyor # 5 observed the following:
Next to the housekeeping closet in hallway across form the nurses' station, a protective strip was partially lifted off of the wall. Ceiling tiles in the hallway had a black and brown substance.
On 05/25/23 at 10:14 AM, Surveyor #4 and Surveyor # 5 completed a tour of Wing- C with LPN UM # 1 and observed the following:
room [ROOM NUMBER]- Bed A: Bedside Tabletop drawer broken. Over bed tables soiled with stains and debris/paint missing on bottom part of over bed tables.
room [ROOM NUMBER]- Bed A: Drawers in bottom of bedside table was missing. Bed B: Bottom drawers of closet were missing. Curtains were soiled.
room [ROOM NUMBER]- Bed B- Had a broken bed rail, the sink inside the room had a leaking faucet. The curtain was broken and off of the track. The LPN UM stated that the curtains were cleaned or replaced as needed.
room [ROOM NUMBER]- Bed A: The floor molding/floorboard was missing behind bed.
room [ROOM NUMBER]- Bed A: The side rail was broken on the bed, the closet door was missing and both bottom drawers were broken. Bed B: Window blinds were broken/missing.
room [ROOM NUMBER]- Blinds were soiled, and gnat type bugs were flying in room.
room [ROOM NUMBER]-Bed B: The front plate from the air conditioner was missing and the sink in the room had a leaking faucet .
room [ROOM NUMBER]-The bed side table drawer and handle was broken. The faucet in bathroom was leaking and the UM was unable to turn off. The air conditioner was soiled with a dust like debris.
room [ROOM NUMBER]- The air conditioner and blinds were soiled with a dust like debris.
room [ROOM NUMBER]- Bed B: The oxygen concentrator was soiled. The wall was broken by the bed and the air conditioner front plate missing. The wall by bathroom sink had an open area/cracked wall. Gnat type bugs were flying in the room near the resident.
room [ROOM NUMBER]- Bed A: The oxygen concentrator was soiled. Bed B: Baseboard with heater unit completely ripped off the wall.
room [ROOM NUMBER]- Observed gnat type bugs flying in the hallway outside of the room.
room [ROOM NUMBER]- Bed B: The closet door was broken and the air conditioner was soiled.
room [ROOM NUMBER]- Bed B: The oxygen concentrator was soiled, faucet was leaking in the sink inside the room, the wall in the outside bathroom was broken and missing tile/plaster, and baseboard heater vent was broken and soiled.
room [ROOM NUMBER]- Bed A: The ceiling tile above bed A was stained with blackish substance. Bottom of bedside table was missing. There was a broken bed rail.
room [ROOM NUMBER]- Outside of the room the wallpaper was lifted. The LPN UM #1 stated that the resident pulled off the wallpaper. Bed B: crayon drawings and markings all over the walls. Heating baseboard was lifted and the air conditioner was soiled. The bottom of the wall and baseboard outside the bathroom was coming apart.
room [ROOM NUMBER]- The air conditioner plate was missing. Bed A: The closet handle was broken, and the window in bathroom was soiled with a film and baseboards had debris.
room [ROOM NUMBER]- Bed A: Bedside table was soiled with a reddish substance. A brown and black substance was on the ceiling tile above the bed. The smoke detector had holes surrounding it. Bed B: The baseboard heater was coming off wall and the bedside table was soiled.
room [ROOM NUMBER]- Both bedside tables were soiled with debris. Bed B- unsampled Resident #17 had been in hospital since 05/24/23 and food/drink cartons were on the bed with gnat type bugs flying in room.
room [ROOM NUMBER]- Bed B wood was located in the windowsill, and LPN UM #1 stated it was probably used to keep the window from opening all the way.
room [ROOM NUMBER]- Unoccupied resident room. The area near the air conditioner on both sides was open to the outside. The faucet was leaking, the bathroom window was broken and open to the outside area. There was no cover over the baseboard heater. The ceiling light in the bathroom did not have a cover.
room [ROOM NUMBER]-The isolation cart outside the resident room was soiled, baseboard heater under sink with red rust like stains.
room [ROOM NUMBER]-Three-person resident room, C bed- Was missing a drawer of the bedside table and missing window curtains, missing the middle drawer in three drawer dressers. The ceiling tile above room [ROOM NUMBER] door, in the hallway, was loose and open. Behind the exit sign in the hallway by room [ROOM NUMBER] tile had an opening.
room [ROOM NUMBER]- The blue seat was stained on the seating area, the bathroom had drain type flies, and there was a brown substance on air conditioner unit.
On 06/02/23 at 10:53 AM, in the presence of the survey team, and in response to the environmental rounds that were completed by the survey team. The Regional Administrator (RA #2) addressed the survey team. The RA #2 stated that every concern that was provided to the facility, he took personally and called on sister facilities to provide assistance. The RA #2 further stated that when you look at the building and the clients it doesn't take long for everything to go to [exploitive redacted]. The RA #2 further sated he was called into the facility for support as the RA #1 was responsible for checking on the facility. The RA #2 stated that the facility maintenance staff should have identified all of the environmental concerns that the surveyors identified.
The admission Agreement, undated, and was provided to the survey team during the entrance conference on 05/22/23 at 12:02 PM revealed the following:
Exhibit 5, Resident Rights: . Physical and Personal Environment . To live in a safe, clean comfortable and home-like environment .
NJAC 8:39-4.1 (a)11; 31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to follow the facility policy and report to the New Jersey Department of Health (NJDOH) a facility reportable event for a resident with a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). A subsequent unwitnessed fall occurred on 05/21/23 and required 911 transport to the emergency room, and resulted in a laceration to the forehead measuring 6 centimeters (cm) X 5 cm and a mild frontal scalp swelling per a computerized tomography (CT) scan, that sustained an injury of an unknown origin. This deficient practice was identified for 1 of 3 residents reviewed for falls with injury and was evidenced by the following:
On 05/22/23 at 10:40 AM, the surveyor observed Resident #23, positioned on the right side, in a bed that was against the wall and the resident was facing the wall. The surveyor observed a pad on the floor next to the bed. Resident #23 was unable to maintain a conversation with the surveyor and the resident also had a blanket covering the head.
On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed, on his/her back with head elevated. At that time, the surveyor observed a large, black and blue in color hematoma (collection of blood) on Resident #23's right forehead. A Licensed Practical Nurse (LPN), who later identified herself as the Infection Preventionist (LPN IP) was in the room and assisted Resident #23 with the lunch meal. Upon surveyor inquiry regarding the observed injury on Resident #23's forehead, the LPN IP stated that the injury was from a fall the resident sustained and she would not elaborate further on the observed injury.
On 05/24/23 at 1:25 PM, the surveyor reviewed Resident #23's electronic medical record and could not locate any documentation regarding the observed injury that the LPN IP confirmed the Resident #23 sustained when fell at the facility. According to the admission Face Sheet, Resident #23 was admitted to the facility with diagnoses which included but were not limited to, unspecified Dementia, acute kidney failure, blindness left eye, and acquired absence of right leg above the knee.
The Comprehensive Care Plan (CP) initiated 09/22/20, last revised 05/25/23, had a Focus At Risk for falls due to Impaired balance/poor coordination, Date Initiated: 02/13/21 and Date Revised: 05/25/23. The Goal was Minimize risk for falls through next review, Date Initiated: 02/13/21, Date Revised: 05/25/23, Interventions Included: Maintain bed in lowest position Date Initiated: 05/24/22 (3 days after the fall); Provide assistance to transfer and ambulate as needed, Date Initiated: 02/13/21, Reinforce the need to call/ring for assistance, Date Initiated: 02/13/21, Reinforce wheelchair safety as needed such as locking brakes, Date Initiated: 02/13/21, and Therapy evaluation and treatment as ordered, Date Initiated: 02/13/21.
Resident #23's CP revealed a Focus [Resident #23] had a fall was found lying on the floor in [his/her] room. 05/21/23 Resident fell during care when [he/she] was turned to the side of the bed, it happened so fast, staff unable to prevent fall Date Initiated: 02/15/23, Date Revised: 05/25/23.
The Goal was to Risks for falls will be mitigated, Date Initiated: 02/15/23, Date Revised: 05/25/23 and Target Date: 08/14/23.
The following interventions were documented:
2 persons assist during care, Date Initiated 05/21/23; 911 Was called and sent to hospital for evaluation, Date Initiated 05/21/23; Assess for pain and medicate as needed, Date Initiated 02/15/23; Assessment Completed, Date Initiated 02/15/23; Complete assessment with bleeding on left side of head, Date Initiated 05/21/23, Continue at risk for fall intervention, Date Initiated 02/15/23; Epic Evaluation of meds, Date Initiated 02/16/23; Floor mat at Bedside, Date Initiated: 02/16/23; Monitor Range of Motion every shift X 72 hours, Date Initiated: 02/15/23; Neuro check Initiated, Date Initiated 05/21/23; Neuro check X 72 hours, Date Initiated 05/21/23; Notify MD of the incident and for any significant changes, Date Initiated: 02/15/23; Orthopedic appt scheduled, Date Initiated 02/20/23; Pain management adjustment, Date Initiated 02/20/23; Pressure dressing applied, Date Initiated 05/21/23, Primary physician made aware of the event, Date Initiated 05/21/23; Resident returned to the facility with antibiotic- Fosfomycin X 1 dose and N doxycycline x 10 days, Date Initiated: 05/21/23; Sent to Hospital for evaluation of pain, Date Initiated 02/16/23; Sent to hospital, missed ortho due to transportation. Returned same day with no new order, Follow up with Ortho. Left arm sling applied, Date Initiated 03/15/23; Sling to shoulder, Date Initiated: 02/17/23.
On 06/01/23 at 11:30 AM, the surveyor interviewed the DON regarding the incident dated 05/21/23. The DON stated that she was told that Resident #23 fell during care. She was not aware that the Hospitality Aide reported that he found the resident on the floor. Another surveyor then asked the DON if a resident was found on the floor, would that be considered as an injury of unknown origin. The DON hesitated and then replied, yes. The DON stated, the facility always reported and investigated all incidents. The DON stated that she was sorry and confirmed that the she did not report the incident to the Department of Health.
On 06/05/23, the facility did not provide any additional information and the incident had not been reported to the NJDOH.
Review of the facility's undated Prohibition of Resident Abuse and Neglect policy, reflected, Any witnessed, alleged, or suspected violations involving mistreatment, neglect or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported immediately to the employee's supervisor.
The supervisor must immediately notify the Administrator and/ or the Director of Nursing.
Abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) will be reported to the appropriate authorities by the Administrator and/or Director of Nursing including not limited to, local law enforcement agencies, NJDOH, and Ombudsman in compliance with regulatory requirements. The policy further reflected that Reports must be submitted in writing, which may include incident report, employee statement, grievance/concern form, or other written documentation.
Under Investigation the policy reflected, The investigation shall consist of:
A comprehensive of the event or incident.
An interview with the person(s) reporting the incident.
Interview with any witness of the incident;
An interview with the resident if possible;
Review of the resident's medical record;
An interview with staff members (on all shift as appropriate) having contact with the resident/patient during the period of the alleged incident;
Interviews with the resident's/patient's roommate, family members, and visitors; if applicable; and a review of all circumstances surrounding the incident.
Under Quality Assurance the policy reflected that the Abuse Coordinator /designee will interview residents, staff members and witnesses as appropriate and document the additional investigation.
The Abuse Coordinator /designee completes the investigation file to include the required Reportable Event Form, copies of the resident record as appropriate to investigation, staff assignments and all other documents appropriate to the investigation.
The policy reflected that Injuries of an unknown source, will be reported immediately to the appropriate authorities by the administrator and/or Director of Nursing as indicated in this facility's policy titled, Prohibition of Resident Abuse and Neglect.
The policy was not followed. The Hospitality Aide clearly stated via a telephone interview in the presence of all the surveyors that he found Resident #23 on the floor with bleeding at around 6:00 AM. He further stated that he reported it to the nurses and discussed the incident with the Director of Nursing on 05/21/23.
NJAC 8:39-9.4(f)

Based on observation, interview, record review, and document review, it was determined that the facility failed to conduct an investigation for an injury of unknown origin for Resident #23. This deficient practice was identified for 1 of 31 residents reviewed for incident investigations and was evidenced by the following:
On 05/22/23 at 10:40 AM, the surveyor toured the B-Wing of the facility and observed Resident #23 in bed positioned on the right side, facing the wall.
On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed and again was positioned in the same manner, facing the wall.
On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed positioned on the back side. The surveyor observed a large black raised area on the right forehead. The Licensed Practical Nurse (LPN) who was at the bedside assisting Resident #23 with the lunch meal, revealed that the observed injury was from a fall.
On 05/24/23 at 1:25 PM, the surveyor left the room and reviewed both the electronic and paper medical records which reflected that Resident #23 was admitted to the facility with diagnoses which included but were not limited to; blindness left eye, acute kidney failure, other non displaced fracture of the left humerus.
A review of the 02/28/23, Significant Minimum Data Set (MDS), an assessment tool, indicated the resident's cognitive skills for daily decision making were severely impaired. The resident required the total assistance of two caregivers for bed mobility and total dependence upon staff for all activities of daily living (ADL).
The surveyor reviewed a Progress Note dated, 02/15/23 and timed 06:40 PM, which revealed that the nurse was notified by the aide that Resident #23 was found on the floor while aide was passing out dinner trays. The nurse went to the room and observed the resident on the floor on the side of the bed facing the right side. The resident verbally informed the nurse that his/her right arm is hurting. I asked him/her what happened, and he/she said, I was trying to leave.
Further review of the Progress Notes dated 02/16/23, revealed that Resident #23 was transferred to the hospital for increased pain to the left arm. A CT (computed Tomography) result of the the left shoulder received and concluded there was an acute comminuted fracture of the left humoral head. The fall was unwitnessed, the facility did not investigate the incident. There were no employee statements included in the fall report.
On 05/25/23 at 9:40 AM, the surveyor reviewed a late entry in the electronic medical record dated 05/24/23 and timed 21:37:06, which revealed that Resident #23 sustained another fall with injury. The Registered Nurse (RN) documented that Resident #23 was found in bed bleeding profusely. Upon entering the room, Resident #23 was observed in bed bleeding profusely from the head and a pressure dressing was applied, the MD (Medical Doctor) was made aware, 911 activated. Resident sent out for evaluation. The RN stated that the Certified Nursing Assistant (CNA) reported that Resident #23 had a fall. However, Resident #23 was transferred to bed prior to being assessed by the nurse. The facility did not investigate to identify who transferred Resident #23 into bed.
On 05/26/23 at 11:30 AM, the Director of Nursing (DON) provided 2 fall reports and there were no statements from the staff who worked the days of the falls. During an interview with the DON on 05/30/23 at 10:30 AM, regarding the Fall report dated 02/15/23, she stated that she could not locate any investigation regarding the fall dated 05/21/23. The DON stated that she was told that Resident #23 fell during care. She did not investigate further. When asked if someone was found on the floor bleeding, would that be considered as an injury of unknown origin and should abuse be ruled out, the DON hesitated and then replied, yes. The DON further stated the facility always investigate and report all. She stated, I am sorry, I was told that the resident fell during care.
On 06/01/23 at 9:53 AM, the surveyor conducted a telephone interview with the RN who worked the 11:00 PM-7:00 AM shift. In the presence of the survey team, the RN confirmed that she was made aware around 6:45 AM, by the TNA (temporary nursing assistant) that Resident #23 sustained a fall. She went to the room and observed Resident #23 in bed. She was not aware of the exact time of the fall or who transfer Resident #23 to bed.
On 06/02/23 at 9:53 AM, during a telephone interview with the Hospitality Aide, in the presence of the survey team, the hospitality aide stated that he went to the room around 6:00 AM to distribute linen and found Resident #23 laying on the floor bleeding. He left the room and reported the incident to the nurse. The facility protocol was to remain with the resident and call for help.
Another telephone interview on 06/02/23 at 10:07 AM, with the Licensed Practical Nurse who also worked the 11:00 PM- 7:00 AM shift on 05/21/23, confirmed that she was informed of the fall by the Hospitality Aide at the end of the shift, she did not go to the room. She was assisting the RN with the paper work to transfer Resident #23 out to the hospital. The LPN provided the staff name who reported the fall. She stated that she did not know who or how Resident #23 was transferred into the bed. The LPN was made aware of a statement dated 05/22/23 provided by the facility from a CNA. The LPN confirmed that the hospitality aide was assigned and cared for Resident #23 and not the CNA. A review of the hospitality aide's punch card and the B-Wing assignment sheet confirmed that the hospitality aide worked and was assigned to the B-Wing. The CNA who wrote the statement clocked in on 05/21/23 at 7:02 AM and was not at the facility when the hospitality aide reported that Resident #23 was on found on the floor bleeding profusely.
On 06/02/23 at 11:15 AM, the DON was made aware of the discrepancies regarding the fall report, the CNA statement dated 05/22/23, and the telephone interviews with staff who worked on the 11:00 PM-7:00 AM shift. The DON maintained that she was told that Resident #23 fell during care and she did not investigate further nor collect any statement from staff who worked the 11:00 PM-7:00 AM shift on 05/21/23.
There was no statement from the Hospitality Aide although the hospitality aide had informed the surveyors that he discussed the incident briefly with the DON on 05/21/23. There was no investigation to rule out abuse. Resident #23 required extensive assistance of two persons assist with transfer. The facility did not investigate to identify who transferred Resident #23 into bed after the hospitality aide reported that he found Resident #23 laying on the floor bleeding profusely.
A review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting reflected under Policy Statement:
All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and results reported to the appropriate department manager and the Administrator.
(The policy was not being followed.)
A review of the facility's policy titled, Prohibition of Resident Abuse & Neglect, undated, included but was not limited to; Reporting 1. Any witnessed, alleged, or suspected violaitons ,including injuries of an unknown source .must be reported immediately to the employee's supervisor. 4. Reports must be submitted in writing which may include .employee statement. 7. Upon receiving reports the charge nurse and/or nursing supervisor shall immediately examine and interview the resident. 13. An immediate investigation will be conducted. Investigation 1. the nursing supervisor / designee will appoint a representative to investigate the incident. 3. the investigation shall consist of: a. a comprehensive review of the event; b. interview with the person (s) reporting the incident; c. interviews with any witness; f interview with staff members (on all shifts as appropriate) having contact with the resident during the period of the alleged incident. 4. a review of all circumstances surrounding the incident.
(The policy was not being followed.)
NJAC 8:39-27.1 (a)

**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 complete a resident assessment that accurately reflected the resident's status of weight loss. This was identified during a review of the Comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the management of care, for (Resident # 128) 1 of 31 residents reviewed for MDS.
This deficient practice was evidenced by the following:
On 05/24/23 at 10:30 AM, the surveyor observed Resident #128 during a Resident Council Meeting. At that time, Resident #128 stated that he/she had been losing weight because of lack of edible food.
A review of admission Record, an admission summary revealed diagnoses which included but were not limited to Type 2 Diabetes, Folate (Vitamin B) deficiency, Anemia, hyperkalemia (elevated potassium in the blood), Alcohol use, and other psychoactive substance abuse.
A review of the facility provided, Weights and Vitals Summary, undated, indicated Resident #128 had the following weights which included but were not limited to:
an admission weight dated 01/31/23, of 210 pounds (lbs.)
dated 02/01/23 of 204.5 lbs.
dated 02/08/23 of 202 lbs.
dated 02/13/23 of 198.5 lbs. with a notation -5.0% change [comparison weight 1/31/23, 210 lbs. -5.5%, -11.5 lbs.]
dated 02/20/23 of 197.4 lbs. with a notation -5.0% change [comparison weight 01/31/23, 210 lbs, -6%, -12.6 lbs.]
dated 02/22/23 of 195 lbs. with a notation -5.0% change [comparison weight 01/31/23, 210 lbs., -7.1%, -15.0 lbs.]
dated 03/06/23 of 192.6 lbs. with a notation -5.0% change [comparison weight 02/01/23, 204.5 lbs., -5.8%, -11.9 lbs.]; -7.5% change [comparison weight 01/31/23, 210 lbs., -8.3%, -17.4 lbs.]
A review of the person-centered comprehensive care plan revealed no focus area, no goals, no interventions to indicate Resident #128's weight loss.
A review of the MDS revealed a Brief Interview of Mental Status (BIMS) of 14 out of 15 which indicated the resident had intact cognition. Section K0300 (weight loss) indicates: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. This section indicated 0 meaning no weight loss or unknown. Weight listed as 176 lbs.
Upon admission on [DATE] Resident #128 weighed in at 210.0 lbs. and with the most recent weight on 05/08/23 the resident weighed in at 175.6 lbs. According to the MDS guideline as stated above the resident lost over 10% in less then 6 months. The resident had a total of 16.38% weight loss since admission on [DATE].
On 06/02/23 at 9:33 AM, during an interview with the surveyor, the MDS coordinator stated, I just modified the weight area. She also stated, the dietitian entered the wrong information, and it did get missed. The MDS coordinator acknowledged it was her responsibility to review the MDS's and that she was unaware until surveyors brought it to the attention of the facility.
A review of the facility provided, Electronic Transmission of the MDS, revised 11/22/22, included but was not limited to 6. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.
The dietitian was unavailable for interview during the survey. The facility did not follow its policy.
NJAC 8:39-11.1, 11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.)On 05/24/23 at 10:59 AM, the surveyor observed Resident #49 at the nurses cart outside of the resident's room. Resident #49 was using exploitive and telling the nurse about the poor quality of the food at the facility.
On 05/25/23 at 8:59 AM, the surveyor interviewed Resident #49, who stated, I can't eat this [exploitive redacted]. Resident #49 stated he choked on freezer burned chicken and then went to the hospital and they found out that he/she had a tumor. Resident #49 stated he/she used to be 195- 200 pounds. Resident #49 stated again, I cannot eat this [exploitive redacted], and added I would not give it (food served) to a pig. The resident stated that the facility food was so bad, and there were no other food options offered, that he/she would rather just drink a supplement than eat the horrible food.
The surveyor reviewed Resident #49's medical record which revealed the following:
The admission Record revealed a diagnosis of Malignant Neoplasm of Esophagus and Dysphagia.
A Nursing Progress Note dated 05/05/23 at 17:30 [4:30 PM] revealed Resident not happy with meal [he/she] received this PM. Resident is on mechanical soft diet and states [he/she] can eat regular food as long as its soft. This nurse explained we can only give what was recommended after swallow evaluation. This [nurse] will put in for another consultation with dietitian so dietary can be aware of what specific foods resident would like to eat. Resident is receiving Ensure Plus bid [twice daily] will recommend for an increase in supplement.
A Dietary Note dated 5/18/2023, 18:01 [6:01 PM] revealed Resident #49's May weight was 146 pounds. A desirable .6 pound in 30 days. [His/her] diet texture was upgraded to mechanical soft texture last month but [he/she] expressed to DON (Director of Nursing) [he/she] does not like meals and will prefer to drink more supplements. Writer visited resident and [he/she] confirmed preference of commercial supplements to present texture of food . Continue to provide trays for oral gratification rather than nutrition .
A Physician Progress Note Narrative dated 5/22/2023 11:49 revealed . weight 1456 pounds, s/p [status post] removal of peg tube on 4/28, pt [patient] upgraded to mechanical soft diet with supplements, wt [weight] stable .
The Care Plan (CP) for Resident #49 was reviewed which revealed a Focus of At risk for weight loss secondary to cancer and increasingly difficulty with swallowing. I am also at risk because of my refusal to take my peg [nutrition provided through a tube into the stomach] tube feedings, Date Initiated 02/08/23. Goal: I will maintain my weight through chemotherapy and radiation utilizing my peg tutee (a tube inserted through stomach wall to supply liquid nutrition support) when I am unable to tolerate by PO (by mouth) diet. Target Date: 07/13/23. Another goal revealed, I will work with my dietician and medical team to understand my needs for diet adjustment including increase calories or change in food consistency. Target Date: 07/13/23. The Interventions, Initiated 02/08/23 included: Educate on diet supplementation intake, Educate on proteins and nutrients necessary to maintain breakdown of skin of integrity of weight loss, encourage participation in swallow studies and compliance with recommendations, psych eval and treat. (The CP was not reflective of the residents status and there were no interventions regarding specific preferences and concerns with dislike of food, or follow-up regarding food preferences.)
On 05/30/23 at 12:17 PM, during an interview with the surveyors and upon requests made by the survey team to interview the Dietitian, the LNHA stated she would have to see who was covering for the dietitian. The LNHA stated the Dietitian was on vacation from Saturday 05/27/23 through 06/03/23. The LNHA stated that since the Dietitian was only going to be gone for one week that there would not be a dietitian covering.
Dietitian job Description, reviewed 06/10/2022 Responsibilities: revealed: . Maintains nutritional care plans . Listens attentively to patient complaints and resolves or refers to appropriate individuals.
3.) On 05/24/23 at 10:30 AM, Surveyor #3 observed Resident #128 as he/she attended the Resident Council Meeting (RCM). During the RCM, Resident #128 stated that the food was inedible and that he/she had lost weight. Resident #128 stated that he/she had spoken to the Dietitian twice about food preferences such as requesting fresh vegetables and fruit. Also, that the canned fruit was always served at room temperature and not cold.
On 05/31/23 at 1:00 PM, Surveyor #3 observed Resident #128 in their room with their lunch tray on the over bed table. Resident #128 informed the surveyor that he/she had only eaten one chicken thigh. He/she stated that the Dietitian knew about the weight loss but that he/she wanted to lose weight a healthy way not because of (facility) food choices. Resident #128 stated I just want better food choices.
A review of Resident #128's admission Record revealed he/she was admitted on [DATE], with diagnoses which included but were not limited to, alcohol use, psychoactive substance abuse, hypertension, Type 2 diabetes, and folate (Vitamin B) deficiency.
A review of the facility provided, Weights and Vitals Summary, dated 05/31/23, revealed the following dates / weights:
01/31/23 weight 210 pounds (lbs.)
02/01/23 weight 204.5 lbs.
02/08/23 weight 202 lbs.
02/13/23 weight 198.5 lbs. -5.0% change [comparison weight 01/31/23, 210 lbs., -5.5%, -11.5 lbs.]
02/20/23 weight 197.4 lbs. -5.0% change [comparison weight 01/31/23, 210 lbs., -6%, -12.6 lbs.]
02/22/23 weight 195 lbs. -5.0% change [comparison weight 01/31/23, 210 lbs., -7.1%, -15 lbs.]
03/06/23 weight 192.6 lbs. -5.0% change [comparison weight 02/01/23, 204.5 lbs., -5.8%, -11.9 lbs.]; -7.5% change [comparison weight 01/31/23, 210 lbs., -8.3%, -17.4 lbs.]
05/08/23 weight 175.6 lbs.
A review of the person-centered comprehensive Care Plan provided by the facility and printed on 05/31/23, revealed no focus area regarding Resident #128's weight loss, no goals regarding the weight loss, and no interventions regarding the weight loss.
A review of the most recent Quarterly MDS dated [DATE], revealed under Section K, a weight of 176 lbs. K0300, loss of 5% or more in the last month or loss of 10% or more in the last 6 months was documented as 0 No or unknown.
A review of a Physician's Progress Note, dated 05/15/23, revealed a weight of 175.6 lbs. on 5/8 (5/8/23), admission weight of 210 lbs. progressive wt (weight) loss from 210 lbs. to 175 lbs. The Progress Note went on to include to schedule follow up blood work, to monitor intake, a dietary evaluation, and to consider a medication used for appetite stimulation.
On 05/30/23 at 1:29 PM, during an interview with surveyors, the DON stated that she had a good relationship with the Dietitian and that every Monday weights would be done and reweighs. The DON stated that she and the Dietitian had a weekly weight meeting on Thursdays to discuss significant weight changes and interventions. The DON stated that weight concerns should be documented on the care plans so everyone knows.
A review of the facility provided, Dietitian job description, dated 06/10/22, included but was not limited to maintains nutritional care plans.
4.) On 05/22/2023 at 9:46 AM, during the initial tour of Unit C, the surveyor observed Resident #138 awake and alert, lying in bed. The surveyor was unsure if the resident understood the surveyor and then asked the resident understood English and the resident stated no. When asked if he/she understood some English, the resident stated yes.
At that time, the surveyor interviewed the Director of Nursing (DON) who stated that some residents were [of Asian descent] and some spoke [a foreign language]. The DON stated that some residents could understand and speak basic English and the staff would use simple words so they would understand.
Review of the admission Record revealed Resident #138 was admitted to the facility with medical diagnoses included, but not limited schizophrenia, anemia, and noncompliance with other medical treatment and regimen due to unspecified reason,
Review of the Annual Minimum Data Set (MDS), an annual assessment tool dated 04/10/23, indicated the resident had a Brief Interview of Mental Status of 7, meaning the resident severely impaired cognition. Section B revealed the resident had clear speech, could make him/herself understood and had the ability to understand others. Section G of the MDS, functional status showed the resident was a set up/supervision for hygiene, eating, and ambulation.
Review of Resident #138's current and active care plan did not include communication as part of the resident's care plan.
On 05/23/23 at 11:49 AM, the surveyor observed Resident #138 awake and alert sitting in bed. The surveyor greeted the resident with Good Morning and the resident replied back Good Morning.
On 05/24/23 at 8:43 AM, the surveyor observed Resident #138 standing in the hallway waiting to go outside to the smoking area. The resident stated Good Morning to the surveyor.
During an interview with the surveyor on 05/25/23 at 9:26 AM, CNA #2 stated that Resident #138 did not speak English and there was usually an interpreter in the building if needed. CNA #2 further stated that the resident could understand basic English and was able to tell us if he/she was hungry or needed to use the bathroom.
Review of the social service note, dated 04/29/23, revealed that the resident was a [AGE] year old [of Asian decent] and the social service notes from April to May 2023 did not reveal any documentation regarding speaking a primary language that was not English.
Review of the progress notes form March 2023- May-2023 revealed two physician progress notes, dated 04/10/23 and 05/10/23, which indicated that the translator reported that that the resident used to live with a sibling but due to his/her mental disability the resident could no longer live there and had no place to go.
During an interview with the surveyor on 05/30/23 at 1:14 PM, the LPN UM #1 stated that if a resident spoke a different language, it should be care planned. LPN UM #1 further stated that the care plan was important because the staff needed to know what is going on with the resident. The care plan needed to have interventions to help the residents and if the interventions were not working then the interventions needed to be revised.
During an interview with the surveyor on 05/31/23 at 11:51 AM, in the presence of the VPCS and Regional Nursing Director, the DON stated that if a resident spoke another language, then it should be documented on the care plan. The DON further stated that it was important to care plan for communication because we need to know how to communicate with them and to understand what they are trying to tell us.
During an interview with the surveyor on 06/01/23 at 11:34 AM, the Director of Asian Care Services confirmed that Resident #138 primary language was [a foreign language], and that an interpreter was available for assessments and team meetings.
During an interview with the surveyor on 06/01/23 at 11:47 AM, the VPCS stated that if a resident had a language barrier it should be documented in the care plan.
Review of the facility's policy titled Interdisciplinary Care Planning Protocol, dated 11/22, revealed that problems established by the team with the resident/family input MUST be specific and individualized.
5.)On 05/24/23, a surveyor reviewed the closed medical record for Resident #157.
A review of the admission Record revealed Resident #157 had been admitted and readmitted to the facility with diagnoses which included but were not limited to, heart failure, endocarditis, sepsis, bacteremia, opioid abuse, and anemia.
A review of the Quarterly MDS, dated [DATE], included but was not limited to Section O, IV (intravenous) medications and indicated administered while a resident.
A review of the facility provided, Order Summary Report, active orders as of 02/25/23, included but was not limited to, an order dated 02/17/23 change IV transparent dressing and needleless connector on admission or 24 hours post insertion, then Q (every) 7 days and PRN (as needed) for IV therapy; Ampicillin (an antibiotic) Sodium Solution Reconstituted 2 gm (gram) use 100 ml (milliliter) intravenously every 4 hours for endocarditis until 03/06/23; and ceftriaxone sodium solution reconstituted 2 gm use 2 gram intravenously every 12 hours for endocarditis until 03/05/23.
A review of the facility provided, Skilled Charting, dated 02/23/23, included but was not limited to, L. medications/orders 2a. IV medication was checked off as in use.
A review of the facility provided Care Plan for Resident #157, care plan closed date 03/10/23, included all areas as closed reason being discharge. A review of the entire 10 pages provided by the facility indicated there was no focus area, goal, or interventions related to the resident having an intravenous access or the use of antibiotics for endocarditis.
NJAC 8:39-11.2 (e)(i) ;27.1(a)
Based on interview, observation, and record review it was determined the facility failed to develop person-centered comprehensive care plans to address the residents medical, physical, mental, and psychosocial needs. This deficient practice was identified for 4 of 31 residents reviewed (Resident #33, #49, #128, #138), for 1 of 2 closed records reviewed (Resident #157) for care plans and was evidenced by the following:
1.) On 05/22/23 at 11:00 AM, during the initial tour of the facility, the surveyor observed Resident #33 in bed and was wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time.
On 05/23/23 at 12:19 PM, the surveyor observed Resident #33 lying in bed with their eyes closed. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM.
On 5/24/23 at 08:41 AM, the surveyor observed Resident #33 lying in bed awake. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM. The resident stated that he/she was usually on 3 liters of oxygen.
According to the admission Record, Resident #33 was admitted to the facility with diagnoses which included, but were not limited to, pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), chest pain, anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs), and generalized anxiety disorder.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/03/23, indicated that Resident #33 had a Brief Interview for Mental Status score of 12 out of 15, which indicated that the resident had a moderately impaired cognition. The MDS also revealed that Resident #33 had shortness of breath or trouble breathing when lying flat, used oxygen therapy, that they needed extensive assistance from two staff members to transfer (from the bed to a wheelchair) and did not walk in their room during the assessment window of the MDS.
Review of the Physician's Order Form indicated that Resident #33 had an active physician order for Oxygen (2 liters) prn (as needed) for shortness of breath dated 10/20/22.
Review of Resident #33's current and active comprehensive care plan did not include oxygen therapy as part of the resident's care plan.
During an interview with the surveyor on 05/30/23 at 1:16 PM, Resident #33's assigned Licensed Practical Nurse/Unit Manager (LPN/UM #1) stated that if someone was on oxygen, they should have a care plan for oxygen. A care plan was for whatever the person has, such as ongoing antibiotics, ongoing oxygen, anything. It was important to care plan because you need to know what is going on with the patient to give good care and would need to have interventions in place to help the residents and if the interventions are not working need they needed to be changed.
During an interview with the surveyor on 05/31/23 at 11:56 AM, in the presence of the [NAME] President of Clinical Services (VPCS), the Director of Nursing (DON) stated that when a resident was on oxygen it should be included in the resident's care plan.
Review of the facility's policy titled Interdisciplinary Care Planning Protocol, dated 11/22, revealed that problems established by the team with the resident/family input must be specific and individualized.

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a.) a resident dependent on staff for Activities of Daily Living (ADL) received nail care, and b.) a resident dependent on staff for ADLs received nail care and was shaved. This deficient practice was identified for 2 of 3 residents (Resident #35 and #28) reviewed for ADL care.
The deficient practice was evidenced by the following:
a.) On 05/24/23 at 8:31 AM, Surveyor #1 observed Resident #35 in their room sitting in a wheelchair. Resident #35 reached towards Surveyor #1 and slightly scratched the surveyors right arm. Surveyor #1 requested to see Resident #35's fingernails. The surveyor observed that all 10 nails on both hands were long, eight of the nails had jagged edges, and there was a visible black substance under the nails.
On 05/25/23 at 8:53 AM, Surveyor #1 observed Resident #35 in the hallway in their wheelchair. The resident's fingernails were still in the same condition. At that time, Resident #35 stated that he/she needed help to cut and clean his/her nails and would like his/her fingernails trimmed and cleaned.
On 05/23/23 at 9:10 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) caring for Resident #35 stated that it was her responsibility to set up the resident to clean and wash him/herself. The surveyor asked about shaving and nail care. The CNA stated she could not answer that and that the resident probably refused. When asked the process when a resident refuses care, the CNA stated she would let the nurse know. The CNA stated that there was only one place to document nail care and that was if a resident needed their toenails cut and they had to call the podiatrist. Surveyor #1 and the CNA went to observe Resident #35's nails. The CNA stated, to me yes they (the fingernails) need to be done but only during shower days.
On 05/25/23 at 9:13 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) caring for Resident #35 stated that if a resident refused nail care, the staff should wait and try to encourage the care later on. She stated if the resident did not allow their nails to be cut, the staff should ask if they could file the resident's nails. If the resident refuses, the staff need to let the nurse know so it could be documented. The nurse would let the doctor know. The LPN stated she was never informed that Resident #35 refused nail care.
A review of Resident #35's admission Record (an admission report) revealed that the resident had diagnoses which included but were not limited to unspecified convulsions, age related osteoporosis (early stages of bone loss), dementia, weakness, and chronic pain syndrome.
A review of the most recent Quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated 04/14/23, included but was not limited to a Brief Interview for Mental Status (BIMS) of 08 out of 15 which indicated the resident had moderately impaired cognition. Section G, Functional Status indicated that Resident #35 required supervision and set up help for personal hygiene.
A review of the person-centered comprehensive care plan, printed on 05/30/23, included but was not limited to a focus area of ADL deficit, needing supervision/limited assistance with ADLs date initiated 11/12/21 and revised 02/03/23. Interventions included bed bath daily and shower at least 2 x (times) a week.
A review of the facility provided, Order Summary Report, dated active orders as of 05/30/23, included an order dated 11/10/22 for weekly skin checks on shower days Tuesdays and Fridays.
A review of the facility provided, IDCP (Interdisciplinary care plan) Team Care Conference, dated 04/19/23, included but was not limited to 2. B. requires extensive assist and direction with ADLs.
A review of the facility provided Progress Notes (PN) ranging from 05/01/23 through 05/30/23, contained no documentation that Resident #35 had refused any ADL care.
A review of the ADL Worksheet, dated May 23 (2023), included but was not limited to a section for bathing. The worksheet indicated that every day on the 7 am to 3 pm shift from 05/01/23 through 05/24/23, Resident #35 had been given a bed bath. The worksheet indicated that on the 3 pm to 11 pm shift from 05/01/23 through 05/24/23, Resident #35 was provided either a bed bath or shower every day. The worksheet included an area for the staff to document their initials, full signature, and title, but those areas were left blank.
A review of the CNA Assignment for B wing dated 05/24/23 (Wednesday) and dated 05/25/23 (Thursday), both indicated the same CNA on both days. The Assignment sheet further indicated shave all residents, clip all nails on shower days. The resident had not received fingernail care during his/her shower on Tuesday 05/23/23 and there were no PN to indicate any refusal of care.
b.) On 05/22/23 at 9:49 AM, the surveyor toured the B-Wing of the facility and observed Resident #28 lying in bed. Resident #28 was disheveled and unkempt. The left hand was rested on the blanket and observed with nails long, jagged and with a black coated substance underneath the fingernails. Resident #28 was unshaven. At the surveyor's request, the resident was able to use the left hand to pull the cover and exposed the right hand. The right hand was observed to be contracted and the fingernails were long and jagged with a black film coated underneath the fingernails.
On 05/23/23 at 2:13 PM, the surveyor observed Resident #28 in bed. Resident #28 was unshaven, nails were long, jagged and coated with a black coated substance underneath the fingernails.
On 05/24/23 at 10:27 AM, the surveyor observed Resident #28 out of bed in the courtyard smoking. Resident #28 already received morning care, the nails were observed in the same condition, long and jagged. When asked about the nails and the facial hair, Resident #28 stated that he/she would like to be shaved.
On 05/24/23 at 12:15 PM, the surveyor reviewed Resident #28 clinical record. The admission Face sheet revealed that Resident #28 was admitted to the facility with diagnoses which included but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and hypertension.
The Quarterly Minimum Data Set (MDS) an assessment tool dated 04/04/23, coded Resident #28 as scoring a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated that Resident #28 had some moderate cognitive impairment. Section G of the MDS which referred to ADL's, indicated that Resident #28 was totally dependent on staff for all activities of daily living. The MDS further coded Resident #28 with no rejection of care exhibited. (Section E, E 0800 = 0).
The surveyor reviewed the electronic progress notes from 05/10/23 to 05/30/23, and could not find any documentation regarding that personal care was offered and Resident #28 refused.
The comprehensive care plan dated 11/26/2020, documented a focus area for Resident #28 with ADL self-care deficit related to hemiplegia (paralysis of one side of the body). history of dementia, history of cerebro-vascular accident.
The goal: Will maintain current ability without decline and participate daily to level of capacity. Some of the interventions to manage the goal included:
Bed bath daily and shower at least twice a week. Initiated 12/11/20.
Converse during care. initiated 12/11/20.
Ensure all assistive devices are in reach. Initiated 12/11/20.
If combative with care, leave Resident #28 alone and return at a later time. Initiated 08/03/21.
Explain to Resident #28,what you are doing before beginning activity. Initiated 08/03/21.
Resident #28's ADL worksheet (form CNAs and staff used to document the care provided) for the month of May was reviewed and revealed that Resident #28 received a bed bath almost daily. The documentation revealed that hygienic care was completed, but there was no specific entry for nail and beard care.
On 05/26/23 at 7:40 AM, the surveyor observed the resident in bed, unshaven, nails long with black coated substances underneath the fingernails.
An interview was conducted on 05/26/23 at 8:30 AM, with the CNA who cared for Resident #28 over the last 3 days. The CNA acknowledged Resident #28 was dependent on staff for care. The CNA stated that she provided care to Resident #28 this morning and she could not recall if the nails needed to be trimmed.
On 05/31/23 at 11:48 AM, a second interview with the CNA who provided care to Resident #28, revealed that the facility did not have a CNA care card. She further stated that nail care was not addressed on the ADL Worksheet and usually she will perform nail care and shaving on shower days.
On 05/31/23 at 11:51 AM, an interview with a random CNA regarding nail care and shaving, confirmed that the CNAs do not have a care card to follow. In the morning she received report from the nurse regarding care. The nurses do not address nail care and shaving. The CNA further stated that shaving and nail care are part of grooming and should be done when nails are long and the resident could be visibly seen in need of shaving. When asked for the rationale for nail care not being done for some residents, she declined to comment.
On 05/31/23 at 11:20 AM, Resident #28 was observed in Physical Therapy, appearance was disheveled and nail care still had not been done.
On 06/02/23 at 2:15 PM, the facility was made aware of the above concerns.
On 06/05/23 at 8:35 AM, the Regional Administrator (RA#2) provided a folder with in-services only. No further information was provided.
A review of the facility provided, Activities of Daily Living policy reviewed 11/22/22, included a resident who cannot carry out ADLs will receive the necessary services to maintain grooming.
NJAC 8:39-27.1(a), 27.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to arrange for an audiology consult when a hearing impairment was identified. This deficient practice was identified for 1 of 31 residents (Resident #8) reviewed and was evidenced by the following:
On 05/26/30 at 9:30 AM, the surveyor observed the Certified Nursing Assistant(CNA), while in in Resident #8's room repeat herself several times during a conversation she had with Resident #8, the resident responded huh? to several questions/comments from the CNA. Resident #8 stated when people talk to me, I can't hear them, I cannot hear on both ears. The CNA stated to the surveyor that Resident #8 had some hearing loss, but she had not observed him/her wearing hearing aides.
The surveyor reviewed Resident #8's medical record. Resident #8 was admitted to the facility with diagnoses which included but were not limited to, unspecified dementia without behavioral disturbances, major depressive disorder, schizophrenia and anxiety.
The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #8 was moderately cognitively impaired. Resident #8 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required limited assistance of one staff for activities of daily living (ADLs). The resident had hearing loss. Resident #8 was assessed as having clear speech, usually understood, understands, mild cognitive deficits, and difficulty hearing.
The Comprehensive Care Plan (CP) dated 11/05/20, reflected a focus for communication due to hard of hearing. The Goal was for Resident #8 to communicate needs without frustration. The following interventions were to be implemented:
Allow adequate time for response. Initiated 12/10/20
Ask resident to repeat words as needed. Initiated 12/10/20.
Ask simple yes or no questions. Initiated 12/10/20
Assist resident to build up simple vocabulary of words or gestures to make needs known. Initiated 12/10/20.
On 05/26/23 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the B-Wing regarding Resident #8's hearing impairment. The LPN stated that for any resident with hearing impairment a consultation had to be initiated for an evaluation to see if the resident had ear wax build up, and then the resident would be referred to the audiologist at the ENT (Ears, Nose,Throat) clinic. The surveyor reviewed the clinical record and was unable to locate any follow-up that was done regarding what the LPN stated would be the protocol for a resident with a hearing impairment.
On 05/26/23 at 12:30 PM, during an interview with the Social Worker (SW), the SW stated that Resident #8's concerns with hearing aids had first been identified in 2019. However, the SW stated stated that she could not tell if Resident #8 ever had hearing aids. The SW further stated that the nursing department was responsible to follow up with any appointments. The SW declined to answer further questions regarding the above issue and deferred to nursing for follow-up.
On 05/30/23 at 10:43 AM, the SW provided a form titled, Report of Consultation, dated 12/17/19. Under report the following was documented:
Findings: Wax AU- CNT [ear wax]
Diagnosis: Cerumen Bilateral.
Recommendations: Continue wax treatment and go to ENT clinic.
On 05/30/23 at 11:05 AM, the surveyor returned to the B-Wing and reviewed the clinical record again with the LPN to locate any documented follow-up for the 12/17/19 recommendations. The LPN was unable to locate any documentation regarding the follow-up.
On 05/30/23 at 11:15 AM, the above concern was presented to the Director of Nursing (DON). The DON stated that all consultation recommendations should be followed-up. The DON added that she was not aware of any consultation regarding the hearing concerns for Resident #8 and stated she was not working in the facility at that time. She could not comment on what had been done regarding the referral.
On 05/31/23 at 9:32 AM, the surveyor conducted a follow up interview with the SW. During the interview, the SW stated that she obtained the request for the audiology consult from an old chart but could not verify if the follow up appointment was completed. The SW could not provide any information documented evidence regarding if the referral had been made for a hearing aide and was rejected by Medicare.
A review of Resident #8's Personal Needs Allowance (PNA) provided by the SW dated 12/31/22, revealed that Resident #8 had over $ 2,721 dollars in the account. There was no documented evidence that Resident #8 was asked if he/she would consider paying for hearing aids to improve his/her quality of life.
On 06/02/23 at 2:15 PM, the facility was again made aware of the above concern. No additional information was provided on the exit day for review.
NJAC 8:39-27.5(a)