Alaris Health At Cedar Grove

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 32 residents (Resident #13) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: On 9/10/2025 10:42 AM, the surveyor observed Resident #13 in bed, awake, unable to answer the surveyor's inquiry. The surveyor observed that the call device was located between the siderails and away from the resident's reach. On 9/11/2025 at 10:45 AM, the surveyor observed that the resident's call device was hanging on the side of the resident's bed and not within the reach of the resident. On 9/11/2025 at 11:15 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to Alzheimer's disease (loss of memory), unspecified. A review of the significant change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 8/29/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the SC/MDS, as reflected in section GG, revealed that the resident was dependent on staff for daily living activities. A review of the Care Plan (CP) report initiated on 8/16/24 focused on the resident's use of oxygen therapy related to respiratory illness. Interventions included, but were not limited to, encouraging the resident to call for assistance, but did not indicate that the call device should be within the reach of the resident. On 9/11/2025 at 10:48 AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that after she gives care to the resident, she will put the call device within the resident's reach, but did not provide further information on why Resident #13's call device is not within reach. On 9/11/2025 at 10:51 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the call device must have been put there by the CNA when he was giving care to the resident. The call device should be placed within the reach of the resident. On 9/11/2025 at 11:01 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that the call device should be within the resident's reach so they can call the staff if they need help. On 9/17/2025 at 1:03 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN to discuss the above concern, but did not provide further information. A review of the facility policy titled Subject: Call Bells with the revision date in January 2025, revealed under Procedure: 9. Call bells should be within reach of resident. NJAC 8:39-31.8(c)9

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to maintain and provide readily accessible medical documents for 1 (one) of 32 residents (Resident #4) reviewed for medical records. This deficient practice was evidenced by the following: On 9/11/25 at 11:42 AM, the surveyor observed Resident #4 in bed, awake, and able to answer the surveyor's inquiry. On 9/16/25 at 10:54 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #4 was admitted with diagnoses that included but were not limited to diabetes mellitus (increased blood sugar level) due to underlying conditions. A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) on 7/19/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. A review of medical records revealed that there was no documented evidence that the Physician Progress Notes (PPN) were done by the primary physician or by an alternating advanced practice nurse from February 2025 through July 2025. On 09/15/2025 at 11:47 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) in the pink unit, who stated that she would get the medical records from the medical record room. The RN/UM added that the PPN should be in the medical record, but cannot tell why it is not in the resident's hybrid medical records. The RN/UM did not provide the PPN record to the surveyor. On 9/16/2025 at 12:56 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional RN regarding the concern above. But did not provide further information. On 9/17/2025 at 10:19 AM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN regarding the concern above. The LNHA stated that all the PPN from February to July 2025 of Resident #4 is now available in the electronic record under the miscellaneous tab. The LNHA added that she got the PPN from the doctor's office and uploaded it to the system after the surveyor's inquiry. A review of the facility policy titled Subject: Medical Records with a reviewed date in January 2025, under Procedures: 1. The facility shall maintain medical records on each resident that are: c. Readily accessible. NJAC 8:39- 35.2(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure consistent accountability and reconciliation of narcotic medication for Resident #95's and 151's narcotic medications. These deficient practices were identified for one (1) of five (5) medication carts inspected and was evidenced was as follows:On 9/16/25 at 11:57 AM, in the presence of the Licensed Practical Nurse (LPN) the surveyor began the narcotic medication inspection, stored in a mounted, double locked portion of the medication cart (narcotic box) located on the high side of the pink unit. A review of the facility's Controlled Medication Accountability Sheet (a shift-to-shift count/sign in sheet, used to account for the narcotics and syringes within the medication cart) for September 2025, reflected that the inventory counts were performed on three shifts (7:00 AM, 3:00 PM and 11:00 PM), daily from 9/1/25 at 7:00 AM, to at 9/15/25 at 7:00 AM by the two nurses, the outgoing shift and the incoming shift. At that time, the surveyor and the LPN observed Resident #95's Clonazepam 0.5 milligram, tablets (a narcotic psychotropic indicated for anxiety, seizure and panic disorder; mg) bingo cards (a multidose card containing individually packaged medications) contained a total of 47 tablets. At that time, the surveyor compared the count of the bingo card against the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #95's Clonazepam 0.5 mg tablet which reflected a balance of 48 tablets and was last signed by the administering nurse on 9/15/25 at 21:00 PM (9:00 PM). At that time, the surveyor questioned the one (1) tablet discrepancy of the Clonazepam count. The LPN stated she administered the Clonazepam that morning to Resident #95 and forgot to sign that she removed the medication from the inventory against the facility's policy. At that time, the surveyor and the LPN reviewed the declining inventory log for Resident #95's Morphine 20 mg/ml which reflected a balance of balance of 26 milliliters and was last signed by the administering nurse on 9/15/25 at 9:00 PM. At that time, the surveyor and the LPN reviewed the electronic Medication Administration Record (eMAR) for Resident #95's Morphine which reflected an administration on 9/16/25 for the 9:00 AM dose. This administration was not reflected on the declining inventory log. At that time, during an interview with the surveyor, the LPN stated that she also administered the Morphine that morning to Resident #95 and forgot to sign that she removed the medication from the inventory because she was distracted. On 9/16/2025 at 12:10 PM, in the presence of the LPN, the surveyor observed Resident #'151's Alprazolam 0.5 mg, tablets (a narcotic psychotropic indicated for anxiety) bingo cards contained a total of 69 tablets. At that time, the surveyor compared the count of the bingo card against the declining inventory log for Resident #151's Alprazolam 0.5 mg tablet which reflected a balance of 70 tablets and was last signed by the administering nurse on 9/16/25 at 8:00 AM. At that time, during an interview with the surveyor, the LPN could not explain why the discrepancy was not identified during the shift-to-shift count earlier that day. At that time, during a meeting with the Registered Nurse/Unit Manager (RN/UM) the surveyor discussed the concerns regarding the discrepancy for the accountability of Resident #95's narcotic medications (Clonazepam and Morphine) and the failed reconciliation of Resident #151 Alprazolam that resulted in a discrepancy of one (1) pill. At that time the RN/UM stated an in-service would be provided to the nurses, an investigation for the shortage would be initiated and the Director of Nursing (DON) along with the Assistant Director of Nursing (ADON) would be informed. On 9/16/25 at 1:22 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse, the surveyor discussed the concern regarding the failure to ensure that the declining logs were signed upon removal from active inventory and implement reconciliation of the narcotic inventory during the shift-to-shift counts. On 9/17/25 at 10:15 AM, during a meeting with the survey team, the LNHA, and the Regional Nurse, the DON stated that in-services were provided regarding signing the declining sheet upon removal and ensuring that the counts were conducted during the shift-to shift counts. An investigation was conducted regarding the shortage of Resident #151's Alprazolam and found that the outgoing nurse from the 11 to 7 shift destroyed a loose pill in the medication cart and destroyed the pill in the drug buster without a witness since he did not realize it was a controlled substance. The DON stated that the nurse should have tried to identify the loose pill prior to destroying the narcotic medication and should have been done in the presence of another nurse as a witness of the destruction/disposal. A review of the provided policy for Inventory of Controlled Substances dated/revised on 1/2025 included that the controlled substances are counted by the oncoming nurse and outgoing nurse at the change of each shift and documented.a documentation of any discrepancy must be reported to the Director of Nursing. Further review of the policy reflected that all medication destructions in the facility must be witnessed by at least two persons, each of whom shall be the registered professional nurse, licensed practical nurse or pharmacist consultant. NJAC 8:39-11.2(b), 29.2(d), 29.4(g)(i) .

REPEAT DEFICIENCYBased on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's primary physician accurately dated their Physician Progress Notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 1 (one) of 32 residents (Resident #13). This deficient practice was evidenced by the following: On 9/10/2025 10:42 AM, the surveyor observed Resident #13 in bed, awake, unable to answer the surveyor's inquiry. The surveyor observed that the call device was located between the siderails and away from the resident's reach. On 9/11/2025 at 10:45 AM, the surveyor observed that the resident's call device was hanging on the side of the resident's bed and not within the reach of the resident. On 9/11/2025 at 11:15 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to Alzheimer's disease (loss of memory), unspecified. A review of the significant change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 8/29/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the SC/MDS, as reflected in section GG, revealed that the resident was dependent on staff for daily living activities. A review of the PPNs in the eHR reflected the following Effective Date, Created Date, and/or Late Entry (any documentation that is recorded in the eHR beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated the PPN of medical doctor (MD) was not documented on the effective date (Date of Service): 1. PPN with an effective date of 1/5/25 and a created date of 3/5/25. 2. PPN with an effective date of 1/12/25 and a created date of 3/5/25. 3. PPN with an effective date of 1/18/25 and a created date of 3/5/25. 4. PPN with an effective date of 2/2/25 and a created date of 3/5/25. 5. PPN with an effective date of 2/9/25 and a created date of 3/5/25. 6. PPN with an effective date of 2/16/25 and a created date of 3/5/25. 7. PPN with an effective date of 2/23/25 and a created date of 3/5/25. 8. PPN with an effective date of 5/11/25 and a created date of 5/4/25. 9. PPN with an effective date of 4/30/25 and a created date of 5/4/25. 10. PPN with an effective date of 5/8/25 and a created date of 5/22/25. 11. PPN with an effective date of 3/9/25 and a created date of 5/27/25. 12. PPN with an effective date of 3/10/25 and a created date of 5/27/25. 13. PPN with an effective date of 3/14/25 and a created date of 5/27/25. 14. PPN with an effective date of 3/15/25 and a created date of 5/27/25. 15. PPN with an effective date of 3/17/25 and a created date of 5/27/25.16. PPN with an effective date of 3/19/25 and a created date of 5/27/25. 17. PPN with an effective date of 3/20/25 and a created date of 5/27/25. 18. PPN with an effective date of 3/31/25 and a created date of 5/27/25. 19. PPN with an effective date of 4/6/25 and a created date of 5/27/25. 20. PPN with an effective date of 4/13/25 and a created date of 5/27/25. 21. PPN with an effective date of 4/19/25 and a created date of 5/27/25. 22. PPN with an effective date of 4/27/25 and a created date of 7/19/25. 23. PPN with an effective date of 5/9/25 and a created date of 7/19/25. 24. PPN with an effective date of 5/11/25 and a created date of 7/19/25. 25. PPN with an effective date of 5/13/25 and a created date of 7/20/25. 26. PPN with an effective date of 5/15/25 and a created date of 7/20/25. 27. PPN with an effective date of 5/19/25 and a created date of 7/20/25. 28. PPN with an effective date of 5/20/25 and a created date of 7/20/25. 29. PPN with an effective date of 5/22/25 and a created date of 7/22/25. 30. PPN with an effective date of 5/26/25 and a created date of 7/22/25. 31. PPN with an effective date of 5/29/25 and a created date of 7/22/25. 32. PPN with an effective date of 6/1/25 and a created date of 7/22/25. 33. PPN with an effective date of 6/2/25 and a created date of 7/22/25. 34. PPN with an effective date of 6/4/25 and a created date of 7/22/25. 35. PPN with an effective date of 6/8/25 and a created date of 7/22/25. 36. PPN with an effective date of 6/10/25 and a created date of 7/22/25. 37. PPN with an effective date of 6/15/25 and a created date of 7/22/25. 38. PPN with an effective date of 6/20/25 and a created date of 7/22/25. 39. PPN with an effective date of 7/8/25 and a created date of 7/22/25. 40. PPN with an effective date of 6/25/25 and a created date of 8/24/25. 41. PPN with an effective date of 7/9/25 and a created date of 8/24/25. 42. PPN with an effective date of 7/10/25 and a created date of 8/24/25. 43. PPN with an effective date of 7/21/25 and a created date of 8/25/25. 44. PPN with an effective date of 7/23/25 and a created date of 8/25/25. 45. PPN with an effective date of 7/24/25 and a created date of 8/25/25. 46. PPN with an effective date of 7/28/25 and a created date of 8/25/25. 47. PPN with an effective date of 7/30/25 and a created date of 8/25/25. 48. PPN with an effective date of 8/4/25 and a created date of 8/25/25. 49. PPN with an effective date of 8/7/25 and a created date of 8/25/25. 50. PPN with an effective date of 8/12/25 and a created date of 8/25/25. 51. PPN with an effective date of 8/19/25 and a created date of 8/25/25. On 9/15/2025 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the physician comes into the facility regularly and writes their notes in the eHR. On 9/15/2025 11:33 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) from the pink unit, who stated that the physician visits their residents regularly and documents the progress notes in the computer. The RN/UM did not provide further information on why the PPN has a late entry. On 9/17/2025 at 11:30 AM, the surveyor called the primary physician and left a message to call back for an interview, but the primary physician did not return the call. A review of the facility policy titled Subject: Physician Visits and Services, with a reviewed date in January 2025, under Procedure: 5. Progress notes and orders must be written, signed, and dated at each physician visit, which may be done in a physical or electronic chart. NJAC 8:39-23.2(a)

Based on observation, interview, and record review it was determined that the facility failed ensure consistent provision of care/services in accordance with professional standards, consistently assess residents' vital signs and dialysis access site before dialysis treatments and provide ongoing communication with the dialysis center regarding a medication that was held. This deficient practice was identified for 1 of 2 residents (Resident #12) reviewed for dialysis and was evidenced by the following: Reference: According to the manufacturer's specifications for Midodrine under Mechanism of Action; Standing systolic blood pressure is elevated by approximately 15 to 30 mmHg at 1 hour after a 10-mg dose of midodrine, with some effect persisting for 2 to 3 hours. On 9/10/25 at 11:06 AM, during the initial tour of the facility the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that Resident #12 was at the hemodialysis (HD) center and picked up on Monday, Wednesday and Friday at 10:15 AM. On 9/15/25 at 9:13 AM, the surveyor observed the resident in their room with their eyes closed. The surveyor reviewed the medical record of Resident #12. According to the admission Record face sheet, an admission summary, reflected that Resident #12 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool dated 7/3/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #12 was cognitively intact. Section O reflected the resident received hemodialysis during their stay at the facility. A review of the individualized comprehensive care plan reflected a focus that the resident received HD and had an access site arteriovenous fistula (AV; an irregular connection between an artery and a vein) at the left upper arm. The interventions included ensure the resident reports to HD, monitor bruit and thrill (indicator of proper functioning of an AV fistula). Monitor labs and report to the doctor as needed. A review of the electronic Treatment Administration Record (eTAR) for September 2025 included the following physician's orders:-Check left arm AV fistula for bruit and thrill, initiated on 4/26/24 reflected charting blanks.-Assess dressing site for bleeding upon return form dialysis and removal, initiated on 4/26/24, reflected charting blanks. -Remove dialysis access dressing 4 hours post dialysis treatment every evening and night shift initiated 4/26/24 reflected a charting blank. A review of the Nurse's Progress Notes from August to September 2025 reflected that on the following dates the resident was not assessed prior to attending HD treatment-9/1/25-8/29/25-8/22/25 no documented vital signs prior to leaving the facility-8/20/25-8/18/25-8/15/25 no documented vital signs prior to leaving the facility-8/13/25 no documented vital signs prior to leaving the facility-8/8/25-8/6/25-8/1/25 no documented vital signs prior to leaving the facility A review of the resident's electronic Medication Administration Record (eMAR) for September 2025 included a PO for 10 milligrams (mg) of Midodrine (a medication use to treat orthostatic hypotension, a condition wherein the blood pressure drops significantly upon standing from sitting or lying position, with effects from 1 hour up to 3 hours) with a scheduled administration time of 9:00 AM; Give 1 tablet one time a day every Monday, Wednesday and Friday prior to dialysis. Hold for systolic blood pressure higher than 140. Further review of the Midodrine reflected the following:-9/1/25 not administered; blood pressure not documented-9/3/25 not administered; blood pressure not documented-9/5/25 not administered; blood pressure not documented-9/8/25 administered; 122(systolic)/78(diastolic) millimeters of mercury (mmHg)-9/10/25 administered; 132/67 mmHg-9/12/25 not administered; blood pressure not documented -9/15/25 not administered; blood pressure not documented-9/17/25 not administered; 144/85 mmHg A review of the Dialysis Progress Notes (DPN) for August to September 2025 did not reflect documentation was made regarding the dose of the Midodrine that were held or the assessment conducted prior to HD treatment. On 9/17/25 at 9:53 AM, during an interview with the surveyor, the RN/UM stated that the facility had a communication form, DPN that was sent with the resident for the HD center to fill out. The RN/UM stated that they did not send information with the resident and stated that no information meant that there were no issues with the resident. An issue would result into a phone call made to the HD center. If no information was sent that is to say, the resident is fine. At that time, the surveyor and the RN/UM reviewed the resident's electronic Medical Record (eMR) together. The eMR reflected that the resident had Midodrine that was scheduled for administration on HD treatment days prior to treatment and had parameters for when to administer based on the resident blood pressure condition. The RN/UM could not show evidence that communication with the HD center was made when the Midodrine was held or administered. The RN/UM stated that the communication form did not have an area or requirement for her or the nurses on duty to document that information for the HD center. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern that Resident #12's pre-dialysis assessment were inconsistent and the missing proof of communication of the resident's pre-assessment and the administration or the holding of the Midodrine dose prior to HD treatment, in order to better manage and assess the changing blood pressure of the resident during and after the HD treatment. On 9/18/25 at 10:57 AM, in the presence of the survey team, the LNHA and the DON, the R/RN stated that the facility used the Dialysis Progress Notes as a communication form for the HD center to communicated with the facility and documented their assessment in the eMR [which the HD had no access to review for shared communication]. The R/RD stated the form has been updated to include the pre-assessment and ancillary information such as medication(s) initiated, administered, held or discontinued which would be available for the HD center to review. A review of the provided facility policy dated/revised did not reflect a process for shared communication between the nursing home and the HD facility. NJAC 8:39 - 27.1 (a)

NJ 404793 Based on observations, interviews, records review, and review of other facility documentation, it was determined that the facility failed to ensure Resident #178's care plan was individualized, reflective of the resident's assessment, consistently provided full assistance to a resident who was dependent when eating, and the nutritional status was monitored by following the weekly weights intervention. This deficient practice was identified for one (1) of one (1) resident reviewed for nutrition (Resident #178) and was evidenced by the following: The surveyor reviewed the medical record of Resident #178 The resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included dementia (decline in cognitive abilities), diabetes (high blood sugar), congestive heart failure (a condition of weakened, stiffened heart muscle causing the heart to ineffectively pump blood leading to fluid buildup in the lungs and other parts of the body) and pulmonary embolism (clot travels from one part of the body and blocks an artery in the lungs. The resident's most recent comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 10/014/24, reflected that a Brief Interview for Mental Status was not conducted since the resident was rarely/never understood. The resident had no indicators of hallucination and delusion. Section GG revealed that the resident was dependent (wherein the helper is required for the resident to complete the activity) for activities of daily living that included eating. Section K reflected that the resident complained of difficulty or pain when swallowing. The resident received mechanically altered diet (a change in texture of food or liquids such as pureed food, thickened liquid). A review of the resident's comprehensive individualized Care Plan (CP) included a focus on the resident's nutritional problem related to diagnoses, impaired mobility, advanced age, textured modified diet, body mass index (measurement used to assess a person's weight status and potential health risk) and underweight (UW) status, started on 10/4/24. The interventions included to monitor, record, and report to MD signs and symptoms of malnutrition, emaciation, muscle wasting significant weight loss of three (3) pound (lbs.) a week. Further review of the CP reflected that the resident required assistance with meals as needed, which was inconsistent with the comprehensive assessment that reflected the resident was dependent when eating. A review of the electronic Medical Record (eMR) reflected one weight measurement; (wheelchair) on 10/3/2024 that equaled to 113.8. No other weights were recorded for this resident. A review of the Documentation Survey Report (the report of the electronic point-of-care system (POCS) where the Certified Nursing Assistants (CNAs) electronically document patient care activities). The POCS revealed that during the resident's stay, 24 of the 73 shifts the CNAs documented the resident was independent while eating and 3 of the 49 shifts, the resident received set-up or clean-up assistance. On 9/11/25 during an interview with the surveyor, the Speech-Language Pathologist (SLP) stated that the resident from admission was on puree and nectar thick and had not changed Resident #178's diet texture. On 9/15/25 at 12:29 PM, during an interview with the surveyor the Registered Dietician (RD) stated that all residents admitted received a nutritional assessment, medical record review to ensure a resident was on a proper diet. The RD stated the hemodialysis and CHF residents are monitored for diet, food consumption, labs, signs of fluid overload. At that time, the surveyor and the RD reviewed the formed RD's progress note that indicated the previous RD spoke with the resident's family who requested nutrition supplement for Resident #178. The record reflected the RD increased the resident's nutritional supplement from twice a day to three times a day. At that time, the RD stated that the assessment for Resident #178 was made by the former RD. The RD confirmed and acknowledged the record reflected the resident was underweight, was on puree and thickened liquid, had dementia, diagnosis of CHF and had an increase of nutrition as part of the family's request. At that time, the RD stated that the increase of supplement was reflective of the resident's status of not eating well and acknowledged that the record did not reflect how the effectiveness of the nutritional intervention was measured. On 9/16/25 at 1:22 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse, the surveyor discussed the concern regarding the care plan that reflected the resident required assistance with meals, opposed to the assessment that reflected the resident was dependent for activities of eating and the POCs that reflected the resident did not receive full assistance 27 out of 73 shifts. Additionally, the surveyor discussed the concern that the former RD increased the resident's nutritional supplement with no method of measurement for the effectiveness of the intervention, and the care plan intervention to monitor, record and report greater that three (3) pound weight loss to the Medical Doctor (MD) was not followed. On 9/17/25 at 10:15 AM, during a meeting with the survey team, the R/RN, the DON and the LNHA, the RD stated that the care plan was generic and should have been individualized. The RD acknowledged that the CP of weekly weight monitoring was not followed and should have been. The DON stated in-services were given to staff that the care plan should follow the assessment and the POC documentation should be accurate. A review of the undated facility policy for Weights reflected that monthly, and weekly weights per the discretion of the dietician and/or physician) shall be obtained by the CAN and record on the weight sheet form. A review of the job description for the dietician included to assess the nutritional status of residents that included weight maintenance, resident's independence and overall nutritional well-being. A review of the provided facility policy dated 1/2025 included that the care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development foals for the resident that are reasonable and measurable. NJAC 8:39-27.1(a),27.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on long-term use of insulin medication. This deficient practice was identified in 1 (one) of the 32 residents (Resident#11) reviewed for CP.This deficient practice was evidenced by the following: On 9/10/2025 at 10:16 AM, the surveyor observed Resident #11 out of bed to the wheelchair, able to propel themselves, and able to answer questions appropriately. On 9/15/25 at 1:18 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #11, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #11 was admitted with diagnoses that included but were not limited to hemiplegia (weakness of one body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a blood vessel in the brain was blocked) affecting the right dominant side and type 2 diabetes mellitus (elevated blood sugar). A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) on 8/18/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that the resident had impaired cognition. Further review of Q/MDS reflected in Section N recorded that Resident #11 is taking insulin injection and anticoagulant medications. A review of the Order Summary Report (OSR) is as follows: 1. Insulin glargine 100 unit/ml (milliliter) inject 10 units subcutaneously (SQ, fatty layer of the skin) one time a day, with the start date of 8/8/25. 2. Heparin sodium 5000 unit/ml inject 5000 unit SQ every 8 hours with a start date of 8/7/25. A review of Resident #11's comprehensive CP report revealed no CP for the use of insulin and anticoagulant medication. On 9/15/2025 at 11:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the above concern. The LPN stated that there should be a CP for insulin and anti-coagulant medications. On 9/15/2025 11:52 AM, the surveyor interviewed the Registered Nurse/ Unit Manager (RN/UM) in the blue unit, who stated that the CP should include using insulin injections and anticoagulant medications. The RN/UM did not provide further information on why insulin and anticoagulants are not in the CP for Resident #11. On 9/17/2025 at 1:06 PM, the team of surveyors discussed the above concern with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN, but did not provide further information. A review of the facility policy titled Subject: Plan of Care and IDCP Team Meeting Policy with a reviewed date in January 2025 revealed under Procedures: The plan of care shall be individualized, based on the diagnosis, resident assessment, and personal goals of the resident and his/her family. NJAC 8:39-11.2(d)

NJ 2594265 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident on 6/14/25 and 6/15/25, related to an allegation of being dropped by transport for Resident #182. This deficient practice was identified for one (1) of three (3) residents reviewed for accidents and was evidenced by the following:A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 6/16/25 at 11:37 AM, with an event date of 6/14/25 and 6/15/25 at 12:24 PM. The incident was reported as an allegation of being dropped by ambulance transport and involved two (2) personnel on 6/14/25 and 6/15/25. The event was described as follows: On 6/14/25 the resident reported to the nurse while reaching for their urinal, the resident heard a pop and immediately experienced pain on their elbow and shoulder. The notified physician ordered to transfer the resident to the hospital. The transport [name redacted transport #1] arrived at the facility at 8:49 PM and transported the resident to the hospital. The hospital report did not reflect inconsistent injury from their current diagnosis. The resident returned to the facility on 6/15/25 at 3:47 AM, via Transport #2. On 6/15/25 after lunch the resident informed a staff member that they were dropped by both transport on to the floor and did not inform the facility staff because they did not want to get someone in trouble. The surveyor reviewed the closed medical record for Resident #182. The admission Record (AR; or face sheet; an admission summary) reflected that the resident had been admitted with diagnoses which included multiple myeloma (a type of cancer which affects the white blood cells that produces antibodies to fight infection) , fatigue fracture of the vertebrae (small crack on the bone due to repetitive, excessive stress), pathological fracture (bone fracture due to underlying condition that weakens the bone rather than external trauma) in neoplastic disease, malignant neoplasm of the bone (cancerous tumor that originated from the bone tissue). The Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 7/18/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Section E. of the MDS did not reflect behaviors related to rejection of care. Further review of the SCMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident #182 was dependent for all activities of daily living including all surface transfers. The individualized comprehensive Plan (CP) revealed a focus that included, Resident #182 was at risk for falls related to generalized weakness initiated on 1/7/25. The interventions included to anticipate and meet the resident's needs, initiated on 1/8/25. The goals were to the resident would be free of falls through the review date, initiated on 1/8/25. A review of the investigation revealed that after reporting a fall from transport the resident received a skin assessment by a Licensed Practical Nurse. The investigation and the medical record did not reflect that a Registered Nurse assessed the resident immediately after the fall was reported. Further review of the investigation did not reflect an effort was made to contact Transport #2 to completely investigate the incident/allegation of a fall during transport. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern regarding the resident's missing assessment from a Registered Nurse and evidence that Transport #2 was contacted as part of the investigation of the alleged fall. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern regarding the missing assessment after the reported fall and the missing statements from Trasport #2 as part of the investigation On 9/18/25 at 10:57 AM, during a meeting with the survey team, the DON, and the LNHA, the R/RN stated that they had tried to contact the former LNHA to learn more information regarding the investigation and if an interview had occurred. The R/RN also stated that Transport #2 was contacted and confirmed of the transport that occurred on 6/15/25 and would send information regarding the concern. The facility team acknowledged that the information received by the survey team and the investigation conducted by the previous LNHA was in-fact incomplete. A review of the facility policy for Accident/Incident Investigation dated/revised 1/2025 included that investigation would include interviewing staff, resident, and witness statements.The witness statements would be attached to the incident report and kept on file at the DON's office. No further information was provided. NJAC-8.39-4.1(a)5

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the incontinence care plan was developed according to the resident's assessment to provide appropriate treatment and services for the care of the resident who had frequent urine and occasional bowel incontinence according to the facility's policy and procedure, for one (1) of one (1) resident, Resident #134, reviewed for bowel and bladder incontinence.
This deficient practice was evidenced by the following:
On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch.
The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134.
Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder.
The most recent Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had moderately impaired cognition. The SCMDS also showed that the resident was coded for frequently incontinent of urine and occasionally incontinent of bowel. Also, the SCMDS revealed that the resident was not on a bladder and bowel toileting program.
Further review of the SCMDS revealed that on Section V Care Area Assessment (CAA) Summary, #6 Urinary Incontinence and Indwelling Catheter that area was triggered and was checked to proceed with Care Plan (CP). The CAA included that the urinary incontinence was an actual problem, and the nature of the problem: Resident is noted more B & B (bladder and bowel) accidents. Resident is assisted with his/her toileting for safety. The CP's consideration was to address the problem to proceed with CP, with an overall objective to slow or minimize the decline.
A review of the personalized CP showed that there was no focus CP, goals, and interventions for B & B incontinence.
Further review of the medical records showed that the above SCMDS CAA for #6 was not followed to proceed with CP for B & B incontinence.
A review of the Tasks for the Certified Nursing Aide (CNA) in the electronic medical records revealed that the task description for bladder continence and bowel continence, frequency was every shift.
On 6/25/24 at 9:54 AM, the surveyor interviewed the Registered Nurse (RN). The RN stated that the resident was alert with some forgetfulness with behavior of verbally abusive to staff and other residents at times. She further stated that Resident #134 with periods of B & B incontinence, staff assisted the resident in toileting.
On 6/28/24 at 8:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that Resident #134 was incontinent of B & B. The RN/UM stated that she was responsible for initiating, reviewing, and revising the CP. She added that RN Coordinator (RNC) was also responsible for the resident's CP. The RN/UM further stated that she was unsure if incontinence should be care planned for.
At that time, the surveyor notified the RN/UM of the above concerns.
On 6/28/24 at 9:13 AM, the surveyor interviewed the assigned CNA of Resident #134. The CNA stated that the resident was alert with periods of confusion, with periods of incontinence in both B & B. The surveyor asked the CNA how often she checked on the resident for incontinence and what kind of care and assistance was provided to the resident. The CNA responded that at least every two hours or more. The surveyor then asked again the CNA, how she knew the resident should be checked for two hours or more, the CNA responded that based on her experience as a CNA.
On 6/28/24 at 9:20 AM, the surveyor interviewed the MDS Coordinator/RN (MDSC/RN). The MDSC/RN stated that she was responsible for the CAA in the MDS for the nursing side including the Continence/incontinence.
At that same date and time, the surveyor notified the MDSC/RN about the above findings and concerns including the CAA for #6 that there was no CP. The MDSC/RN stated that there should be a CP for incontinence and that she will check on it and get back to the surveyor.
On 6/28/24 at 10:21 AM, the MDSC/RN in the presence of the survey team informed the surveyor that she did not see a CP for incontinence and that should have been care planned.
On 6/28/24 at 11:29 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the [NAME] President of Operations (VPoO). The surveyor notified the facility management of the above findings and concerns.
A review of the facility's Incontinence Care Policy with a reviewed/revised date of 01/2024 that was provided by the LNHA included that the facility shall provide care for all incontinent residents. The Procedure included that the check residents at least every two hours.
A review of the facility's Plan of Care and IDCP Team Meeting Policy with reviewed date of 01/2024 that was provided by the LNHA included that the facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, and goals. Procedures:
-The plan of care shall be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as appropriate.
-the plan of care shall be documented in the facility's EMR (electronic medical record) system.
Interdisciplinary Care Plan (IDCP) Team meeting:
-The IDCP Team meeting shall be held after completion of the comprehensive assessment, quarterly or more frequently, as needed.
On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings.
NJAC 8:39-11.1, 11.2 (e)(1,2), 27.1(a)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that
a discharge summary was completed for two (2) of two (2) residents, Residents #13 and #142 reviewed for discharge to home, according to the facility policy and procedure .
This deficient practice was evidenced by the following:
1. On 6/26/24 at 10:10 AM, the surveyor reviewed the hybrid (combination of paper and electronic) closed record of Resident #13 and revealed the following:
The admission Record (AR, or face sheet, an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to urinary tract infection (UTI, an infection) site not specified, hypothyroidism (underactive thyroid), chronic obstructive pulmonary disease with acute exacerbation (COPD, group of lung diseases that block airflow and make it difficult to breathe), depression unspecified, anxiety disorder unspecified, and fibromyalgia (long-term condition that involves widespread body pain and tiredness).
A review of the modified Comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/27/24 showed a brief interview for mental status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. The CMDS also showed that the overall goal for the resident was to be discharged (DC) to the community.
Further review of the MDS revealed that the most recent DC Return Not Anticipated ARD was on 6/20/24 and was export-ready (which means it was completed but was not submitted to the Centers for Medicare and Medicaid Services or CMS).
The Order Summary Report (OSR) for June 2024 showed a physician's order (PO) dated 6/20/24 for DC home with home care services.
The Progress Notes (PN) dated 6/20/24 at 02:43 PM that was electronically signed by Licensed Practical Nurse #1 (LPN#1) included that patient (resident) DC to a private home, left in the company of the resident's representative (RR).
Further review of the PN showed that the last note of the physician was on 6/19/24 and did not include the DC information and plan for the resident.
The DC Summary in the electronic medical records (EMR), assessment tab showed that it was In Progress date 6/20/24 and the lock date was blank. The DC Summary dated 6/20/24 showed the following were left blank and no documented information found:
SECTION 103. Social Services
1. admission Status=left blank
SECTION 104. Rehab
1. admission Status=left blank
2. Discharge Status=left blank
SECTION 105. Dietary
1. admission Status=left blank
SECTION 106. Activities
1. admission Status=left blank
Further review of the DC Summary showed that there was no physician DC summary.
On 6/27/24 at 12:20 PM, the Director of Nursing (DON) with the Registered Nurse/Unit Manager (RN/UM) met with the surveyor. The RN/UM notified the surveyor that the facility did not have a DC summary from the physician, and it was not the facility's practice. The RN/UM also stated that the only requirement from the physician was to have an order for DC and the facility to document that the physician was notified of the DC of the resident. He further stated that that was the reason why there was no DC summary from the physician in the EMR and the actual paper closed chart.
On 6/27/24 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPoO), and the DON. The surveyor notified the facility management of the above concerns and findings. The surveyor also notified the facility management of the RN/UM interview in the presence of the DON.
On 6/28/24 at 11:29 AM, the survey team met with the LNHA, DON, and the VPoO. The VPoO stated that we have to put back the system for DC summaries, and moving forward that would be done, the DC summaries of the physician. The VPoO acknowledged that the DC summary of the physician was not something new in the requirements, and should have been done.
On that same date and time, the surveyor also notified the facility management that the DC Summary that was in the Assessment tab of the EMR was still in progress and was not completed, where multiple areas were blank.
On 7/01/24 at 11:09 AM, the survey team met with the LNHA, DON, and the VPoO. There was no additional information provided with regard to the above concerns.
A review of the facility's DC Policy with a reviewed date of 01/2024 by the LNHA included that when a resident's DC is anticipated, a DC plan, summary, and instructions will be developed to assist the resident to adjust to his/her new living environment. The IDT (interdisciplinary team) will document the DC summary in the EMR.
On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings.
2. On 6/26/24 at 12:58 PM, the surveyor reviewed the hybrid closed record of Resident #142 and revealed the following:
The AR showed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder, unspecified, and essential (primary) hypertension (high blood pressure).
A review of the DC MDS reflected BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. Further review of the MDS section A0310F. revealed that MDS assessment was coded 10. DC assessment- return not anticipated.
A review of OSR showed a PO dated 4/27/24 for DC home with home care services.
A review of PN dated 4/27/24 at 9:30 AM that was electronically signed by LPN#2 included resident was seen this morning in their wheelchair no signs of distress or discomfort noted. Vitals taken and recorded; due medications (meds) tolerated. Resident DC, left the building @ 9:30 AM, with RR. Resident has been educated on his/her meds and oxygen use; list of meds had been faxed to [name redacted] pharmacy.
Further review of the PN showed that the last physician note titled as H&P was on 4/15/24 and did not include the DC information and plan for the resident.
Further record review did not reveal a physician DC summary for Resident #142.
NJAC 8:9-36.1(b)

Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received consistent daily treatment of a hand splint to prevent contractures or further contraction for one (1) of two (2) residents reviewed for position and mobility (Resident #94).
This deficient practice was evidenced by the following:
On 6/24/24 at 10:45 AM, the surveyor observed Resident #94 seated in a wheelchair and wore a splint on their left hand. Resident #94 stated that he/she wore the splint during the day.
On 6/25/24 at 11:48 AM, the surveyor reviewed Resident #94's electronic medical record.
Resident #94's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to flaccid hemiplegia affecting left nondominant side (affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), type 1 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) and unspecified disorder of thyroid (medical condition that keeps your thyroid from making the right amount of hormones).
Resident #94's electronic physician order set (POS) included the following active order:
*FMP* (Functional Maintenance Program) PROM L UE (passive range of motion left upper extremity) in all planes as tolerated 3-5x/WK (week) 10-20 reps (repetitions). Donn (to put on) L (left) hand orthotic after AM care and doff (to take off) before PM care daily. Further view of the order indicated POS only and did not transfer to the TAR (Treatment Administration Record) for staff signatures.
A review of Resident #94's care plan included the following focus area with an initiated date of 01/23/2023:
Restorative Nursing Program: Passive ROM (range of motion) left upper extremity 3-5x/week 10-20 reps, Donn left hand orthotic device (splint) on after AM care and off before PM care daily.
A review of Resident #94's January 2024 through June 2024 TAR did not have a physician's order for the splint for nurses to sign as administered.
There was no documented evidence in Resident #94's hybrid (a combination of paper, scanned, and computer-generated records) medical record that the physician's order or care plan was being carried out.
On 6/26/24 at 9:18 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding splints. The CNA stated that everyone could do the splint and that it was documented in the computer. The CNA stated that Resident #94 was currently receiving therapy and that therapy was doing the splint now. She added that when the resident was not in therapy that nursing staff would do the splint and document it.
A review of Resident #94's Documentation Survey Report (CNA documentation for interventions or tasks) for January 2024 through June 2024 did not include any documentation regarding splints.
On 6/26/24 at 9:23 AM, the surveyor interviewed the Director of Rehab (DoR). The DoR stated that the Restorative Nurse Aid (RNA) documented on paper when she applied the splint.
On 6/26/24 at 9:33 AM, the surveyor interviewed the RNA. The RNA stated that she had a binder that she documented in for Resident #94.
On 6/26/24 at 12:09 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of Pink unit regarding the process of splints and documentation. The RN/UM requested that the DoR be present.
On 6/26/24 at 12:50 PM, in the presence of the DoR, the RN/UM stated that there was a physician order in the computer that was on the TAR and that the nurse would sign it but that it was only when resident was not on therapy. She added that when the resident was on therapy the RNA would leave the binder for the other staff to document. The surveyor requested to see the documentation.
On 6/27/24 at 10:06 AM, the DoR provided the surveyor a copy of Resident #94's RNA's documentation for the splint.
A review of the provided Functional Maintenance Program Flow Record for Resident #94's Splinting/Brace program included the following:
June 2024 had 18 days that the RNA signed that Resident #94's splint was donned and doffed by the RNA. There were 8 days that were blank.
May 2024 had 19 days that the RNA signed. There were 12 days that were blank.
April 2024 had 20 days that the RNA signed. There were 10 days that were blank.
March 2024 had 21 days that the RNA signed. There were 9 days that were blank.
February 2024 had 19 days that the RNA signed. There were 9 days that were blank.
January 2024 had 21 days that the RNA signed. There were 10 days that were blank.
The surveyor asked the DoR about the blanks. The DoR stated that he did not know how nursing documented the splint.
There was no documented evidence that Resident #94's splint was applied on the days that the RNA was not at the facility.
On 6/27/24 at 10:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the process for splint. The LPN stated that the RNA applied the splint when she was working. She added that when the RNA was not here that the CNA or the nurse would apply the splint and that here was a section in the TAR that they signed. The surveyor asked the LPN if the CNA also documented the splint applied. The LPN stated that she believed that the CNA also documented in the computer but was not sure. She added that she did not think that the CNA documented in a binder and that the RNA only had a binder.
At that same time, the surveyor then showed the LPN the forms that the DoR provided and she confirmed that there were blanks and that the CNA's were not documented on that form. The LPN then viewed the TAR and confirmed that there was a new order placed in the TAR on 6/26/24, after surveyor inquiry, for Resident #94's splint. The surveyor asked the LPN what the importance of having the order in the TAR. The LPN stated that it was to ensure that the splint was applied each day and to prevent further contractures.
On 6/27/24 at 10:24 AM, the surveyor interviewed the RNA regarding the binder that she documented in. The RNA stated that she did not leave the binder for the CNA's when she was not here.
There was no documented evidence that Resident #94's splint was applied on the days that the RNA was not at the facility.
On 6/27/24 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for splinting. The DON stated that the RA documented the splint in a binder. The surveyor then asked if the RA was at the facility seven days a week. The DON stated that the RA was not at the facility seven days a week and that the nurses documented the splint in the TAR. The surveyor then asked the DON about the missing documentation of the splint for Resident #94. The DON stated that she was informed after surveyor inquiry and that they failed to have the documentation.
On 6/27/24 at 01:10 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Operations (VPoO) the concern that Resident #94 did not have any documented evidence that the splint was applied on the days that the RA was not there.
On 6/28/24 at 11:41 AM, in the presence of the survey team, LNHA and DON, the VPoO stated that the staff was inserviced on documentation for splints.
The facility did not provide any additional information.
A review of the facility provided policy titled, Functional Maintenance Program with a revised/reviewed date of 01/2024, included the following:
The facility's Functional Maintenance Program (FMP) is designed to assist residents to achieve and maintain an optimal level of function.
When a resident is discharged from skilled therapy to FMP, the following steps are followed:
The treating therapist will initiate recommendations for FMP and notify nursing of these recommendations with appropriate instructions and training of recommendations.
An FMP order will be placed in the resident's electronic chart and care planned.
The care plan shall be written with nursing interventions which will give direction to the CNA's for assisting the resident in the program.
CNA's shall aid the residents in performing the recommended FMP.
These CNA's will be under the direction of a licensed nurse who will collaborate their activities with PT/OT (physical therapy/occupational therapy).
The CNA's shall document daily in the FMP log.
This log will be reviewed monthly by the nursing and rehab team and monthly nursing summary will be completed to evaluate the current program.
The policy did not contain any information in regards to splints and documentation while a resident received skilled therapy.
N.J.A.C. 8:39-27.1(a)

Based on interviews, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days from January 2024 through June 2024 according to the facility's policy and procedure. This deficient practice was identified for one (1) of 28 residents, Resident #134 was reviewed for physician visits and was evidenced by the following:
On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch.
The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134.
Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder.
The most recent Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had moderately impaired cognition.
There was no documented evidence that the physician visited and examined Resident #134 at least every 60 days from January 2024 through June 2024.
On 6/26/24 at 11:14 AM, the surveyor called the physician of the resident and the surveyor spoke to the receptionist of the physician's office. The receptionist informed the surveyor that the physician was not available and would let the physician know to call the surveyor for an interview.
On 6/26/24 at 12:03 PM, the surveyor interviewed the Registered Nurse Coordinator (RNC) of the Peach unit (Behavioral unit). The surveyor asked the RNC what was the facility's protocol regarding the physician visit notes, and the RNC responded that he would get back to the surveyor.
On that same date and time, the surveyor notified and showed to the RNC that the resident's visits notes for dates 01/25/24 (History and Physical) and 3/10/24 (Progress Notes) were both done by the Advance Practice Nurse (APN), and there were no further notes found in the resident's hybrid medical records.
On 6/28/24 at 11:29 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), [NAME] President of Operations (VPoO), and Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns. The surveyor asked the facility management if that was the facility's policy and practice that the primary physician does not write visit notes. The LNHA stated no, and that the physician should see the resident once every 60 days, the APN can come in between months and do the alternating visits and notes.
A review of the facility's Physician Visits and Services Policy with a reviewed date of 01/2024 that was provided by the LNHA included that the attending physician shall visit the resident at least once during the 30 days following admission and/or as required by the resident's needs. The attending physician shall visit the resident in accordance with the resident's needs, but at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter and as needed.
On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings.
NJAC 8:39-23.2(d)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure a.) a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days for one (1) of two (2) NAs reviewed during the Sufficient and Competent Nurse Staffing task (NA #1); and b.) there was a delineated policy and/or program in place for the hiring of non-certified NAs.
This deficient practice was evidenced by the following:
Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following:
On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. At that time, all Temporary Nurse Aides (TNAs) hired prior to the end of the PHE and who have enrolled in a NATCEP program and completed the first 16 hours of training prior to May 11, 2023, must complete the NATCEP and pass the nurse aide written exam and the clinical skills competency exam by September 10, 2023. Nurse aides hired after the end of the PHE will have four months to complete a NATCEP program and pass the exams, as required by N.J.A.C. 8:39-43.1. The New Jersey Department of Health issues this memorandum to update facilities on the interpretation of the CMS guidance, P.L. 2021, c. 326, c. 368 and Executive Directive (ED) 20-004 (Revised July 6, 2022).
Facilities are advised as follows:
II. Nurse Aides
Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing.
On 6/26/24 at 9:50 AM, the surveyor randomly chose ten new hire employee files to review and requested the files from the Licensed Nursing Home Administrator (LNHA).
On 6/27/24 at 12:00 PM, the surveyor reviewed the facility provided file of one of the new hired employees which revealed the following:
-NA #1 had a date of hire of 01/30/24.
-NA #1 had a competency report skills test dated 7/27/23.
-NA #1 was terminated on 6/11/24.
The time between NA #1's date of hire and termination date was greater than 120 days.
On 6/28/24 at 9:08 AM, the surveyor interviewed the Business Office Manger (BOM) regarding the process for NA employment. The BOM stated that she reviewed the skills test to see if it was within 30-60 days since they passed it. She added that they could only work at the facility for 120 days from the skills test date.
On 6/28/24 at 10:06 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for NA employment. The DON stated that they would make sure that the NA's skill test was within 120 days. She added that if they do not pass the test within 120 days then the NA would be removed from the schedule.
On 6/28/24 at 10:09 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for the facility's policy process for NA employment.
On 6/28/24 at 12:06 PM, in the presence of the survey team, the surveyor notified the LNHA, DON and [NAME] President of Operations (VPoO) the concern that NA#1 worked at the facility for more than 120 days after their date of hire and their skills test.
On 7/01/24 at 10:18 AM, in the presence of the survey team, the LNHA stated that the only policy for NA's was the Nurse Aide Orientation policy that was provided at an earlier time.
On 7/01/24 at 11:11 AM, in the presence of the survey team, DON and the VPoO, the LNHA stated that NA #1 was no longer employed at the facility.
The facility did not provide any additional information.
A review of the facility provided policy titled, Nurse Aide Orientation with a reviewed date of 01/2024, included the following:
Purpose and Policy: This facility is committed to ensuring newly hired Nurse Aides (NA) have the knowledge, skills and abilities to have their own assignment to function effectively in this facility. This facility has established a NA orientation program to help them fully utilize their capabilities.
Procedures:
1. Newly hired NA's will take part in the facility general orientation program on the first day of employment which covers the policies of the facility.
2. All newly hired NA's will shadow a C.N.A. and undergo a competency evaluation covering core competencies which include, but not limited to:
a. Bed bath
b. Bed making occupied/unoccupied .
p. Ambulation with assistance.
3. The NA will be given an assignment after they have successfully demonstrated competency in the above skills.
The policy did not include information regarding the requirement of becoming certified within 120 days or the NA hiring process.
N.J.A.C. 8:39-43.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report was posted and in a prominent place within the facility readily accessible to the residents and the visitors.
This deficient practice was evidenced by the following:
On 6/24/24 at 9:00 AM and 6/25/24 at 8:55 AM, the surveyor entered the facility and observed that there was no Nursing Home Resident Care Staffing Report (NHRCSR) posted in the entrance area.
On 6/25/24 at 9:37 AM, the surveyor interviewed the Receptionist regarding the posting of the NHRCSR. The Receptionist stated that the NHRCSR was usually posted on the wall behind her. The surveyor observed three sheet protectors that did not have any documents in them hanging on the wall. The Receptionist stated that the Staffing Coordinator (SC) would post them and that the last time she saw them posted was last week.
On 6/25/24 at 9:44 AM, the surveyor interviewed the SC regarding the posting of the NHRCSR. The SC stated that she posted it daily and would try to post them by 9:30 or 10 am and that the night receptionist would discard them.
On that same date and time, the surveyor notified the SC that the NHRCSR was not posted for the last two days. The SC stated that she was off yesterday. She added that she was having an issue with connection to the printer but could send it to admissions to print. The surveyor asked the SC who would post the NHRCSR in her absence. The SC stated that a colleague should print them out and the Director of Nursing (DON) or Licensed Nursing Home Administrator (LNHA) would post it.
On 6/27/24 at 01:08 PM, in the presence of the survey team, the surveyor notified the LNHA, DON and VP of Operations (VPoO) the concern that 24-hour staffing report was not posted and in a prominent place within the facility readily accessible to the residents and the visitors.
On 6/28/24 at 11:56 AM, in the presence of the survey team, LNHA and DON, the VPoO stated that the SC was off. The LNHA stated that he would post it if it was not posted and that staff were inserviced.
The facility did not provide any additional information.
A review of the facility provided policy titled, Posting Nurses Staffing Information with a revised/reviewed date of [DATE] included the following:
1. The required information that needs to be posted includes:
Facility name
Current date
Resident Census
Total number of staff and actual hours worked per shift for: Registered Nurses; Licensed Nurses; Certified Nurse Aides
2. The facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors.
3. The data should be clear, readable, up to date and current.
4. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift .
A review of the facility provided policy titled, Facility Staffing Policy with a revised/reviewed date of [DATE] included the following:
8. The facility is responsible for posting nurse staffing as well as have it available upon request and retain it per regulatory requirements.
N.J.A.C. 8:39-41.2 (a)(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of 28 residents reviewed. (Resident #67).
The deficient practice was evidenced by the following:
On 6/24/24 at 11:17 AM, the surveyor observed Resident #67 lying in bed. The resident agreed to speak with the surveyor. During the brief interview, the surveyor asked the resident if they can toilet themselves. The resident stated, no, the nurses aides come to assist them and change if needed.
The surveyor reviewed Resident #67's electronic medical record (EMR) which revealed the following.
Resident #67's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (a disease where the body does not regulate blood sugar properly, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and gastritis with bleeding (inflammation and irritation of the stomach lining that may bleed).
The Medicare 5-day Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/12/24, reflected that the resident had a Brief Interview for Mental Status (BIMS), a tool used to screen and identify cognitive condition, score of 8 out of 15, which indicated that Resident #67 had moderately impaired cognition.
Further review of the resident's Medicare 5-day MDS dated [DATE] revealed under section H the resident was described as always incontinent. A review of the resident's MDS Care Area Assessment (CAA) (triggered responses to items coded on the MDS specific to a resident's possible problems) revealed that the resident needed assistance for toileting and was always incontinent. It also revealed the analysis of findings that the resident had a long-standing condition of bladder incontinence and was on routine incontinence care.
The resident's medication orders in the EMR included the following order:
Tamsulosin Capsule 0.4 MG (milligram) (Tamsulosin HCL) (used to treat [redacted] who have symptoms of an enlarged prostate gland, which is also known as benign enlargement of the prostate or BPH) give one capsule by mouth one time a day for overactive bladder, with a start date of 5/09/24.
Further review of Resident #67's AR did not reveal a diagnosis of BPH but did reveal a diagnosis of overactive bladder in a Physician's progress note dated 02/16/24 that was created on 02/26/24.
The surveyor reviewed the manufacturer package insert for Tamsulosin. The section labeled Indications and Usage reflected, Tamsulosin is an alpha1 adrenoceptor antagonist indicated for treatment of the signs and symptoms of benign prostatic hyperplasia.
On 6/25/24 at 10:15 AM, the Licensed Nursing Home Administrator (LNHA) provided the survey team the pharmacy consultant recommendations binder which included reports from January 2024 through May 2024.
On that same date and time, the surveyor reviewed the recommendations and did not observe any mention of Tamsulosin use for Resident #67.
On 6/25/24 at 01:20 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the unit where Resident #67 resides. The surveyor asked the LPN/UM about the change in BIMS recently. The UM stated that the recent BIMS was done by the social worker and that Resident #67 has her days and may be an 8 on one week then might be a 3 on another week and can vary how they answer questions.
On 6/27/24 at 10:10 AM, The surveyor interviewed the Consultant Pharmacist (CP) by telephone. The surveyor asked the CP if they would normally comment on the use of Tamsulosin for an unapproved use. the CP stated, sometimes. The CP had nothing further to add that was pertinent to this resident's use of Tamsulosin.
On 6/27/24 at 12:42 PM, the surveyor requested, from the LNHA, in the presence of the survey team, any further documentation regarding the use and effectiveness of Tamsulosin in Resident #67.
On 6/28/24 at 10:20 AM, the LNHA provided several Physician progress notes (PN) for Resident #67. Two of the notes, dated 5/27/24 and 6/13/24 were observed as being late entries, created 6/24/24, after survey entrance and surveyor inquiry, one note dated 01/20/23 and one note dated 02/16/24 observed as a late entry created 02/26/24. The note dated 02/26/24 revealed documentation by the attending physician that the resident has an overactive bladder, frequent urination and it is managed with Flomax (the brand name of Tamsulosin).
Further review of the above documentation by nursing in the MDS and the Physician's PN showed that there were inconsistencies with regard to resident's incontinence condition.
Furthermore, there were no documentation regarding use of Tamsulosin outside the manufacturer's approved indication or the benefit versus the risk in relation to the effectiveness.
On 7/01/24 at 11:59 AM, the survey team met with the Director of Nursing, the LNHA and the [NAME] President of Operations. The surveyor discussed the concern with the documentation with the facility administrative team regarding the inconsistency in the documentation. No further documentation was provided regarding Resident #67.
N.J.A.C. 8:39-11.2(b)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 6/26/24, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 25 opportunities for error, and three (3) errors were observed which calculated to a medication administration error rate of 12%. This deficient practice was identified for two (2) of six (6) residents, (Resident #34 and Resident #132), that were administered medications by two (2) of four (4) nurses that were observed.
The deficient practice was evidenced by the following:
1. On 6/26/24 at 8:31 AM, during the medication (med) administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) preparing to administer medications (meds) to Resident #34. The surveyor observed the resident's Electronic Medication Administration Record (eMAR) which reflected an order for Colace oral capsule (a medication used to soften the stool), give one (1) capsule by mouth two (2) times a day for constipation. The order did not reflect a strength or dosage. The surveyor observed LPN #1 prepare one (1) tablet of Docusate (the generic equivalent to Colace) 100 mg (milligram). The surveyor asked LPN #1 how they knew that was the correct dose. LPN #1 stated that those were the only ones they use there.
The Surveyor continued to observe LPN #1 administer meds to Resident #34. LPN #1 returned to the med cart to electronically sign the eMAR for the meds that were administered. The surveyor observed LPN #1 electronically sign by checking the box for Enoxaparin (an injectable medication used to prevent blood clots). The surveyor did not observe LPN #1 prepare or administer this med to resident #34. The surveyor asked LPN #1 why they were signing for that med. LPN #1 stated that they gave the Enoxaparin earlier, prior to the surveyor observation. The surveyor asked LPN #1 if they always sign for meds at times other than when they were administered. LPN #1 stated, no they do not. The surveyor asked LPN #1 if this was the only med that they administered earlier and signed after administering meds to another resident. LPN #1 responded, yes.
2. On 6/26/24 at 8:56 AM, during the med administration observation, the surveyor observed LPN #2 preparing to administer meds to Resident #132. The surveyor observed LPN #2 place the resident's oral meds in a plastic dose cup on top of the med cart and prepare a container of Glucerna (a nutritional supplement), Prostat (a protein supplement) and a cup of water. The surveyor then observed LPN #2 take the Glucerna, Prostat and water to the resident who was in the day room (a common area often used for recreation) while leaving the dose cup of other oral meds on top of the med cart unattended in the hallway. The surveyor asked LPN #2 if meds should be left on the med cart unattended. The LPN responded, no, but I wanted the resident to finish the Glucerna first.
On 6/26/24 and 10:58 AM, the Licensed Nursing Home Administrator (LNHA)provided the facility's Policy and Procedure for Med Administration. The surveyor reviewed the policy. The policy reflected an effective date of 11/2010 and a reviewed date of 01/2024. The policy reflected on page 1 item 6, The individual administering meds must check the label to verify the right med, right dosage, right time and right method (route) of administration before giving the med. The policy reflected on page 2 item 12, The nurse administering the med must electronically sign, date and time the resident's eMAR by selecting 'Y' (yes) after giving each med. The nurse will then select the 'Save' button to finalize the administration of given meds before moving on to the next resident. The policy reflected on page 2 item 11, .No meds are kept on top of the cart.
The surveyor reviewed the med information sheet for Colace capsules (docusate sodium). The information reflected that Colace capsules are available in multiple strengths, including 50 mg, 100 mg and 250 mg. The information also reflected that the daily dose can be from 50 mg to 300 mg per day.
On 6/27/24 at 10:10 AM, the surveyor interviewed the consultant pharmacist (CP) by phone and asked if they perform Med Pass observations. The CP responded yes. The CP stated that she was aware of the med pass observation results and was usually aware of what was happening in the facility. The surveyor asked the CP if the order for Colace was appropriate and if LPN #1 signed meds appropriately. The CP responded that the provider pharmacy should have addressed the incorrect Colace order. The CP offered no further information pertinent to the med pass observation.
On 6/27/24 at 12:42 PM, the surveyor, in the presence of the survey team, discussed the Med Pass Observation concerns with the Director of Nursing, the LNHA, and the [NAME] President of Operations. No further information was provided to the surveyor.
N.J.A.C 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of five (5) medication carts inspected and two (2) of two (2) medication storage rooms inspected on three (3) of four (4) units. This deficient practice was evidenced by the following:
On [DATE] at 10:35 AM, the surveyor inspected the Pink Unit Medication (med) Room. The surveyor accessed the med refrigerator located in the med room. The surveyor observed an unlabeled amber plastic vial in the refrigerator. Upon inspection of the amber vial, the surveyor observed an unlabeled vial of Retacrit (a med used to increase red blood cell production) located inside. The surveyor opened an under counter drawer in the med room and observed a Novolin R Flex Pen (a self-contained device used to administer insulin, a med used to treat high blood sugar) with a pharmacy label and dispensed date of [DATE].
At that same time, the surveyor interviewed the Assistant Director of Nursing (ADON) who was present on the unit if they thought the medications (meds) were stored properly. The ADON stated that the insulin pen should have been in the refrigerator and the Retacrit should have had a label identifying who it was prescribed to.
The surveyor then inspected a room labeled Pharmacy Room on the Pink Unit. The surveyor observed the med refrigerator which contained vaccines. The surveyor also observed a temperature log on the outside of the refrigerator that reflected documentation of the refrigerator temperature once per day. The surveyor observed a bag of medical supplies that contained individually wrapped tubes labeled BD Viral transport tubes. The wrapper reflected an expiration date of [DATE]. The surveyor asked the ADON to check the expiration date. The ADON agreed that the tubes were expired.
The surveyor inspected the High Side med cart on the Blue Unit. The surveyor observed one (1) foil package of Ipratropium/Albuterol nebulizer solution (an inhaled med used to treat asthma) that contained 1 vial and was not dated when it was opened. The surveyor asked the med nurse assigned to the med cart if there was a date on the opened package or box and what were there any manufacturer instructions after opening. The med nurse stated there was no date and the package reflected instructions to dispose one (1) week after opening.
On [DATE] at 12:42 PM the surveyor, in the presence of the survey team, discussed the Med Storage and Labeling concerns with the Director of Nursing, the Licensed Nursing Home Administrator (LNHA), and the [NAME] President of Operations. The facility did not provide requested policy for Med Storage. The facility did not provide any further pertinent information regarding med storage and labeling.
A review of the facility's Medication Administration Policy that was provided by the LNHA reflected on page 2 item 8, The expiration date on the med label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container. On page 2 item 9, Med and Treatment carts are checked by 11-7 nurse for any discontinued or expired meds.
The surveyor reviewed the CDC (Centers for Disease Control and Prevention) guidelines for vaccine storage which reflected for Monitoring Vaccine Temperatures, To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday).
The surveyor reviewed the manufacturer packaging and labeling for Ipratropium/Albuterol nebulizer solution. The product packaging and labeling reflected under Storage Conditions: Once removed from the foil pouch, the individual vials should be used within one week.
The surveyor reviewed the manufacturer information sheet for Novolin R Flex Pen. The manufacturer information sheet reflected under 16.2 Table 2: Storage Conditions and Expiration Dates for Novolin R. Single patient use Flex Pen, storage at room temperature either in use (opened) or not in use (unopened) is 28 days.
NJAC 8:39-29.4(d)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch.
The surveyor reviewed the hybrid medical record for Resident #134.
Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder.
The most recent Significant Change Minimum Data Set (SCMDS) dated [DATE], reflected a BIMS score of 09 out of 15, which indicated the resident had moderately impaired cognition.
A review of the hybrid medical records reflected there was no documented evidence that the physician visited and examined Resident #134 at least every 60 days from January 2024 through June 2024.
The Advance Practice Nurse (APN) had a printed documented History and Physical (H & P) dated 01/25/24 and a Progress Note (PN) dated 3/10/24 that was in the paper chart of the resident.
Further review of the resident's hybrid medical records showed that there were no other PN from the physician and the APN except for the 01/25/24 and 3/10/24 of the APN.
On 6/26/24 at 12:03 PM, the surveyor interviewed the Registered Nurse Coordinator (RNC) of the Peach unit (Behavioral unit). The surveyor asked the RNC what was the facility's protocol regarding the physician visit notes, and the RN responded that he would get back to the surveyor.
On that same date and time, the surveyor notified and showed to the RNC that the resident's visits noted for dates 01/25/24 and 3/10/24 were both done by the APN, and there were no further notes found in the resident's hybrid medical records.
At that same time, the surveyor asked the RNC if physician and APN notes should be available and easily accessible as part of the resident's medical records, and the RNC responded yes.
On 6/27/24 at 12:41 PM, the survey team met with the LNHA, [NAME] President of Operations (VPoO), and DON. The surveyor notified the facility management of the above findings and concerns.
On 6/28/24 at 8:59 AM, the surveyor reviewed the paper chart of Resident #134 in the Peach unit nursing station. There were a total of 12 PN (not previously seen in the chart) and revealed the following:
Service Date
Created and
Provider
Electronically signed
6/19/24
6/20/24 at 01:20 PM
APN
5/14/24
6/24/24 at 04:31 PM
APN
4/11/24
6/24/24 at 01:29 PM
APN
3/07/24
3/14/24 at 07:29 AM
APN
3/06/24
3/14/24 at 05:34 AM
APN
3/04/24
3/14/24 at 07:27 AM
APN
2/29/24
3/14/24 at 05:40 AM
APN
2/28/24
3/14/24 at 05:39 AM
APN
2/25/24
3/14/24 at 05:32 AM
APN
2/24/24
3/14/24 at 05:34 AM
APN
2/16/24
3/04/24 at 01:53 PM
APN
1/26/24
2/04/24 at 01:39 AM
APN
On 6/28/24 at 11:29 AM, the survey team met with the LNHA, VPoO, and DON. The DON stated and acknowledged that the above PN was not on the physical chart of the resident not until the surveyor's inquiry. She further stated that the facility management spoke to the APN about the visit notes and that was why all PNs were in the chart now. The facility management acknowledged that the visit notes of the APN should have been completed on time and readily accessible to the resident's medical records.
On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings.
NJAC 8:39-35.2 (d)(6)
COMPLAINT: NJ#172727
Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, and readily accessible medical records. This deficient practice was identified for three (3) of the 31 residents reviewed (Residents #86, #134, and #196).
This deficient practice was evidenced by the following:
1. On 6/24/24 at 9:15 AM, during an interview with the surveyor, regarding the process for reportable, the Licensed Nursing Home Administrator stated that when an incident occurred, he was supposed to be notified with the Director of Nursing (DON) immediately. We also notify the physician, family, state agency and the ombudsman's office for a reportable. The LNHA also stated that determining the cognitive level such as the BIMS (Brief Interview for Mental Status) score, when a resident was not able to explain, that needs to be investigated and depending on what was learned will depend on if it should be a reportable or not. All staff that sees an abuse, incident or accident must report to the nurse, or supervisor. Multiple parties investigate such as the Unit Manager (UM), the Social Services, the DON and LNHA we are all in the process for the investigation. Sometimes the UM and Social Worker (SW) will gather information and we review those. Any questions remained unanswered, we follow up and seek, we have the initial investigation and follow-up with the aid, family member etc.
At that time, the LNHA stated that the initial investigation consisted of resident statements, witnesses, assessments, skin checks, neuro checks, pain assessment, range of motion, review of the CCTV (closed circuit television; video surveillance) of the common areas, courtyard outside, nursing station and day room. I don't know how far back it [CCTV] goes.
At that time, the LNHA stated that the Summary and conclusion were done within five days of the incident/accident/ abuse.
At that time the surveyor submitted the requests for the Investigative File for Resident #196 and #86.
A review of the reportable event record/report (FRE; Facility Reported Event) reflected that it was called in on 4/04/24 at 9:47 PM, with an event date of 4/04/24 at 9:15 PM. The incident was reported as an allegation of resident-to-resident altercation.
The event was description included but was not limited to the following:
Resident #196 was walking down the hallway by Resident # 86, then was hit by Resident #196 on the right side the head without provocation. Staff in the area immediately intervened separating both residents preventing further harm to Resident #86, who sustained no injury or falls from the incident.
Resident #196's diagnoses included schizoaffective disorder, mood disorder, bipolar disorder with psychotic features, anxiety (mental disorders) The resident had a BIMS score of 15, which indicated the resident was cognitively intact.
Resident #86 diagnoses included mood disorder, psychotic disorder, and anxiety (mental disorders). Review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated 5/18/24, reflected BIMS score of five (5) out of 15 which indicated the resident had severe cognitive impairment.
A review of the facility's investigative folder included the following under Summary and Conclusion:
The investigation summary included review of staff statements, CCTV.
The CCTV feedback showed Resident #86 walking towards the nurses' station speaking with an aide, then Resident #86 began to walk away from the nurses' station at around 9:15 PM, Resident #196 was walking in the same direction. Resident #86 did not address Resident #196, nor was anything spoken in between both residents. Resident #196 stepped toward Resident #86 and struck him/her one (1) time at on the left side of the head. Resident #196 provided no warning to staff or residents about his intent to hit someone and was unprovoked. The staff that were actively monitoring the hallway, acted immediately to ensure separation of resident and no additional aggression was witnessed by either resident. Resident #86 did not fall, nor did he suffer injury from this accident; signed by the LNHA.
A review of the nursing progress notes (PN) for Resident #196 included the following:
Incident #1
On 4/04/24 at 18:27 [6:27 PM], the nurse documented that Resident #186 had a verbal argument with another patient. Resident #186 became anxious after being told that he/she had to wait until 7:30 PM which was the next scheduled of the smoke break. The resident went to the hallway and pulled the smoke alarm and then went to his/her room and threw furniture around.
Incident #2
On 4/04/24 at 21:10 [9:10 PM], the nurse documented that Resident #196 asked the aid for a diaper change. The aid stated that she would in a few minutes when she completed her tasks. Resident #196 did not want to wait, and pulled the fire alarm, and threw a cart that had food and drinks on it and made a mess in the day room.
Incident #3 (associated with the FRE)
On 4/04/24 at 21:41 [9:41] the nurse documented that after the resident pulled the fire alarm the nursing supervisors were called in to the unit. In front of both supervisors and this nurse, the patient ripped multiple picture frames off the walls, punched the nurses station Plexiglas, and punched another patient completely unprovoked. The Physician was made aware of the situation and ordered to have the resident sent out for psychiatric evaluation. 911 was called and EMS arrived but refused to transport the resident because the resident would not cooperate in the ambulance, and they felt it would be a risk to their safety. Crisis intervention was contacted and at this time we are waiting for another ambulance to arrive. Patient refused to have his vital signs taken at this time.
The surveyor reviewed the facility provided investigative folder, the hybrid (combination of paper and electronic) medical records and staff statements. The medical records did not show evidence that the resident was de-escalated, redirected, or monitored for safety.
On 6/25/24 at 12:18 PM, during an interview with the surveyor, the Registered Nurse/Unit Coordinator (RN/UC) stated that the nurse on duty for incident #1 was a good nurse.
At that time, the surveyor and the RN/UC reviewed Resident #186's electronic Medical Record together. The RN/UC confirmed that the record did not show how the abuse on 4/04/21 at 9:15 PM was prevented when there were two incidents on the same day that began at 6:27 PM followed by 9:41 PM.
At that time the surveyor discussed the concern and the RN/UM stated that he would investigate the matter and inform his supervisors.
On 6/26/24 at 9:43 PM, during a meeting with the DON, RN/UM, the LNHA provided three new signed statements that addressed what was done in between incidents.
At that time, the LNHA and the RN/UM acknowledged that the statements were collected yesterday (6/25/24) and was not part of the original investigative summary folder.
At that time, the surveyor asked the LNHA, how long should the statements be gathered, for the root cause analysis that was required to arrive at the result of the resident to resident abuse investigation.
At that time, the LNHA stated no excuse why it was not immediately done.
On 6/26/24 at 12:03 PM, in the presence of the surveyors, the UM and the LNHA confirmed the statements were obtained yesterday (6/25/24) only to show that there was a de-escalation of what the nurses described as anxious behavior.
A review of the provided policy and procedure for the Abuse Prevention Program, dated/revised on 02/08/23, under Part VII Investigation, subsection Procedure included the following: The results of the investigation are reported within five days of the incident.
Reference
483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken

REPEAT DEFICIENCY
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection: a) improper storage of a urinary drainage bag for one (1) of two (2) residents (Resident #103), reviewed for urinary catheter care, b) performing hand hygiene during a wound treatment observation by one (1) of one (1) nurse (Licensed Practical Nurse), and c) doffing (taking off) of Personal Protective Equipment (PPE) when exiting an Enhanced Barrier Precaution (EBP) room during a wound treatment by one (1) of one (1) nurse.
This deficient practice was evidence by the following:
1. On 6/24/24 at 10:49 AM, the surveyor observed Resident #103 with their face only visible from behind the privacy curtain drawn. Resident #103 greeted the surveyor and for the surveyor to approach their bedside. Resident #103 was observed lying in bed, alert and verbally responsive. The surveyor observed the resident's incontinent brief was open, their pants were below their knees, and the resident had a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). The resident's urinary catheter was connected to a large urinary drainage bag, which was resting on top of the resident's mattress at the foot of their bed. The large drainage bag was not full and cloudy, yellow colored urine was draining from the catheter into the large urinary drainage bag. Resident #103 stated staff was helping them, were to return and could not say how much time had passed. The resident was agreeable for the surveyor to follow up with nursing staff. The surveyor did not observe any staff or cart near the resident's room.
On 6/24/24 at 10:50 AM, the surveyor approached the Licensed Practical Nurse (LPN) who was seated at the nurses' station. The LPN accompanied the surveyor to Resident #103's room. Resident #103's incontinent brief remained open, and their urinary drainage bag on the foot of the resident's mattress. The LPN stated that Certified Nurse Aide (CNA) provided hygiene care to the resident and was to let her know when she was done, to provide wound treatment to the resident's sacral wound. The LPN stated she would do the resident's wound dressing and assist resident.
On 6/24/24 at 10:58 AM, the surveyor interviewed the CNA who was assigned to Resident #103. The CNA had been in another room assisting a resident. The surveyor discussed with the CNA the observation of Resident #103 in bed. The CNA stated she pulled the privacy curtain prior to exiting room and stated that she informed the LPN that the resident was ready for their wound dressing to be changed. The CNA stated she did not realize she left the resident's urinary drainage bag on the foot of the mattress and acknowledged it should not have been left there. The CNA stated the drainage bag should be in a privacy bag hanging on the side of the resident's bedframe.
On 6/24/24 at 11:15 AM, the surveyor interviewed the LPN about the observation of the resident's urinary drainage bag. The LPN stated the resident's urinary drainage bag was supposed to be hanging by gravity below the resident's bladder level. The LPN further explained that the drainage bag was placed on the mattress at the foot of the bed because the resident was going to be transferred out of the bed with a hoyerlift (an electric patient lift to safely transfer patients). She acknowledged that the urinary drainage bag should not have been placed on the mattress and it should have been moved at the time of the resident being transferred out of bed.
On 6/24/24 at 11:20 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) about the observation of Resident #103's drainage bag. The RN/UM stated the urinary catheter drainage bag should be hanging by gravity. She further explained that while a resident was in bed, the drainage bag should be hanging by gravity from the bed frame positioned below the resident's bladder level as to allow the urine to drain freely. The RN/UM stated the urinary drainage bag should not have been on the foot of the resident's mattress even if the resident was being transferred out of bed.
On 6/27/24 at 12:41 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Operations (VPoO) of the above concerns. There was no verbal response from the facility at this time.
On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The VPoO acknowledged the drainage bag should not have been on the resident's mattress and provided staff with in-service education for catheter care.
The surveyor reviewed the facility policy titled, Catheter Care, Urinary with a reviewed date of 01/2024. Under catheter care it read, .3. The urinary drainage bag must always be positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .
2. On 6/27/24 at 10:15 AM, the surveyor observed the LPN perform a sacral wound treatment for Resident #103. The LPN informed the surveyor that Resident #103 was on EBP, which required providers and staff to don (put on) gown and gloves when performing high-contact resident care activities, such as wound care. The surveyor observed signage at door which indicated the resident was on EBP precaution. The LPN and CNA, who was to assist the LPN with the positioning of the resident during the wound treatment, donned gown, and gloves prior to entering the resident's room.
The LPN took germicidal disposable wipes and cleaned the bedside table by the resident's bed. The LPN disposed the used wipe in the garbage bin, removed her gloves, and disposed it in the garbage bin. The LPN went to the bathroom sink to wash her hands. She turned on the faucet, applied soap to her hands first, then wet her hands with the running water, lathered her hands for 22 seconds, dried her hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet.
On 6/27/24 at 10:27 AM, after the LPN set up a field with the wound treatment supplies on the resident's bedside table, the surveyor observed the LPN wash her hands at the sink. She turned on the faucet, applied soap to her hands first, then wet her hands with water from the sink, lathered her hands for 21 seconds, dried her hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet.
The LPN applied new gloves, removed the wound dressing covering the resident's sacral wound and removed the packing dressing from the wound bed with a tongue depressor. She disposed of the old dressing in the plastic garbage bag attached to the bedside table. She did not remove her gloves, opened two normal saline solution (NSS) vials removing the tops and placed the vials back on the supply field of the bedside table. The LPN removed her gloves, did not wash her hands, and applied new gloves. She then picked up the two NSS vials, applied the NSS to 4x4 gauzes, and cleansed the wound.
On 6/27/24 at 10:31 AM, the LPN removed her gloves, did not wash her hands, opened the door of the room, and retrieved gloves from the top of the treatment cart outside doorway of the room. She returned to the room, placed the gloves on the supply field on the bedside table and then closed the room door.
The LPN washed her hands at the sink. She turned on the faucet, applied soap to her hands first, then wet her hands with water from the sink, lathered her hands for 24 seconds, dried her hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet.
The LPN applied new gloves, then applied the ointment medication and calcium aliginate (an absorptive dressing) to the wound bed. The LPN with gloves retrieved a marker, wrote the date and time on the bordered dressing on the bedside table. She lifted her PPE gown with one hand and with the other hand placed the marker into her jacket pocket. She removed her gloves, did not wash her hands, and applied new gloves.
On 6/27/24 at 10:37 AM, the LPN cleaned the supply field and disposed items in the plastic garbage bag. She tied off plastic garbage bag, removed gloves, and stated to the surveyor I'm going to throw this out in the soiled utility room. The surveyor observed the LPN wearing a PPE gown and holding the plastic garbage bag walk out of the room and down the hallway of the unit.
On 6/27/24 at 10:39 AM, the surveyor observed from the doorway of the resident's room, the LPN walking back toward the room with the PPE gown balled up in her right hand. She stated to the surveyor I'm not supposed to walk in the hallway with this [showing PPE gown in hand] and explained that there was a red bin in the room to throw the gown away before exiting room. She threw the gown away in the red bin of the room.
On 6/27/24 at 10:50 AM, the surveyor interviewed the LPN after the wound treatment about hand hygiene. She stated the steps for hand hygiene were to open the faucet, apply soap to hands, then wet hands, scrub hands, dry hands with paper towel, and then when hand are dried use another paper towel to turn off the faucet. The LPN replied to surveyor when asked about the sequence of applying soap prior to wetting hands, that it was the appropriate sequence and to not get the soap dispenser wet with water.
The surveyor asked the LPN about hand hygiene when changing gloves. The LPN stated when changing or removing gloves hand hygiene should be performed. The surveyor discussed observations during the wound treatment when hand hygiene was not performed. She replied she was trying to save time and get the wound treatment done.
The surveyor discussed observation of wearing PPE gown in the hallway. The LPN stated she should not have been in the hallway wearing the used PPE gown and it should have been thrown out in the red bin of the room prior to exiting room.
On 6/27/24 at 11:03 AM, the surveyor interviewed the RN/UM about the wound treatment observation. The RN/UM demonstrated hand hygiene and stated hands should be wet first prior to applying soap. RN/UM stated that when changing gloves hand hygiene should be performed and PPE gowns should not be worn in the hallway.
On 6/27/24 at 11:40 AM, the surveyor interviewed the Infection Preventionist (IP) about the wound treatment observation. The IP stated the steps of hand hygiene were to turn on the water faucet, wet hands, apply soap, scrub hands at least 20-30 seconds, rinse, dry hands with paper towel, and use another paper towel to turn off faucet. IP stated when changing gloves hand hygiene was to be performed. IP stated applying soap then wetting hands was not the appropriate sequence and hand hygiene should have been performed when the nurse changed her gloves. The IP continued that PPE should be disposed of prior to exiting the room and not worn in the hallway. The IP stated she would provide in-service education to the LPN.
On 6/27/24 at 12:41 PM, the surveyor informed the LNHA, the DON, and the VPoO, of the above concerns observed during the wound treatment. There was no verbal response by the facility at this time.
On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The VPoO stated wound care and hand hygiene competency was completed with the LPN and in-service education was being provided to all nursing staff. There was no additional information provided by the facility.
A review of the facility's policy titled Handwashing/Hand Hygiene with a reviewed date of 6/28/2024, under Guidelines: Hand hygiene will be performed by staff as follows it read: .On entering and leaving an isolation room .Before and after contact with wounds .Before gloving and after gloves are removed .
Under Hand Washing Procedure it read, Turn on water and adjust temperature .wet hands and wrist thoroughly .apply soap to hands .Rub hands briskly, pay attention to areas between the fingers, for at least 20 seconds .
A review of the facility's policy titled Infection Control- Standard Precautions, EBP and Transmissions Based Precautions with last reviewed/revised date of 3/22/24, documented that CDC (Centers for Disease Control and Prevention) guidelines were the primary resource for determining the type of precaution and duration of isolation. The policy did not further address doffing of PPE when exiting EBP rooms.
N.J.A.C. 8:39-19.4

Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure have an Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) who worked at least part-time and had completed specialized training in infection control and prevention for one (1) of two (2) staff.
According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits.
According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available.
On 6/24/24 at 10:04 AM, during entrance conference, the Licensed Nursing Home Administrator (LNHA) informed the Team Coordinator (TC) the current IP was full-time and started working in the facility at the beginning of this year. The TC requested the LNHA for the IP timeline since the last recertification survey.
On 6/28/24 at 10:05 AM, the surveyor interviewed the LNHA about the IP timeline. The LNHA stated he started working in the facility in May 2023 and at the time there was no IP. The LNHA stated there were ongoing attempts to recruit and hire without success. The LNHA acknowledged they did not have an IP in the facility from May 2023 until the current IP started working in January 2024. The surveyor asked the LNHA who was responsible for overseeing the IPCP in the facility during the time there was no IP. The LNHA replied that the Director of Nursing (DON) was responsible for the IPCP and that he assisted with the reporting of data to outside agencies such as the New Jersey Department of Health.
A review of the timeline provided by the LNHA revealed the previous IP, last day of employment at the facility was 4/22/2023. The current IP began working on 01/25/2024 at the facility.
On 6/28/24 at 11:30 AM, the surveyor informed the LNHA, DON and [NAME] President of Operations (VPoO) of the concern that there was no IP working at the facility from May 2023 until when the current IP was hired in January 2024. Additionally, the full-time DON, was responsible for the IP role which was to be at least a part-time position.
On 7/01/24 at 9:46 AM, the TC interviewed the LNHA regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. The TC asked about two (2) of three (3) QAPI meeting quarters there was no IP present. The LNHA stated there was no on-site IP at the time. The TC asked how infection reports were being communicated for QAPI meetings. The LNHA replied that statistics data for COVID-19 were reviewed and he could not further explain what other infection control reports were reviewed.
On 7/01/24 at 11:09 AM, the LNHA, DON, and VPoO met with the survey team. There was no additional information provided by the facility.
The surveyor reviewed the facility's policy titled Infection Prevention and Control Program with an effective date of 9/12/2017. Under Policy it read, .7. The Infection Prevention and Control Program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices and guidelines .9. There shall be a collaboration between the Infection Preventionist and all departments to identify any HAI (Hospital Acquired Infection) trends or patterns that may occur, as well as identification of opportunities to improve outcomes in the reduction and control of infections .
The surveyor reviewed the facility's policy titled Surveillance Plan with an effective date of 9/15/2017 read under Procedure, 1. The Infection Preventionist(s) shall have overall responsibility for the Surveillance Plan .
The qualifications and job responsibilities of the Infection Preventionist were outlined in the Infection Preventionist Job Description. The position summary read The Infection Disease Preventionist is an RN (Registered Nurse), with a BSN (Bachelor of Science in Nursing) preferred, that performs all nursing functions related to Infectious Disease prevention. These include but are not limited to surveillance, data collection, assessment, teaching, and policy development.
NJAC 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that a.) each resident was offered influenza and pneumococcal immunizations, b.) education was provided regarding the benefits and potential side effects of the immunizations, c.) resident or representative has the opportunity to refuse immunizations unless the immunization was medically contraindicated or the resident had been immunized. This deficient practice was identified for one (1) of five (5) residents, Resident #134, reviewed for unnecessary medications.
This deficient practice was evidenced by the following:
On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch.
The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134.
Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), chronic systolic (congestive) heart failure, depression unspecified, and anxiety disorder.
The most recent Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had moderately impaired cognition. The SCMDS revealed that the resident did not receive the influenza and pneumococcal vaccines because it was offered and declined.
A review of the Immunization tab in the electronic medical record (EMR) showed that there was no documentation about the influenza and pneumococcal vaccines. There was no documented evidence that the immunizations were offered and declined.
The Miscellaneous tab in the EMR revealed a hospital records with a printed date of 02/06/24 that showed:
Influenza vaccine this season?-refused
Pneumococcal vaccine ever?-unsure
A review of the personalized care plan (CP) showed that there was no focus CP, goals, or interventions about the immunizations or vaccines status of the resident.
Further review of the hybrid medical records showed that there was no documentation from the facility that the influenza and pneumococcal vaccines were offered and declined. There was no documentation that the education was provided to the representative about the benefits and potential side effects of the vaccines. Also, there was no documentation that the representative was provided an opportunity to refuse the vaccines and no documentation that the vaccines were contraindicated and previously received.
On 6/26/24 at 10:46 AM, the surveyor interviewed the Registered Nurse Coordinator (RNC) of the Peach unit (Behavioral unit). The surveyor asked the RNC regarding the immunization and where it was documented that the resident received or declined influenza and pneumococcal vaccines. The RNC stated that it should be documented in the EMR in the Immunization tab.
At that same time, the surveyor showed the RNC the Immunization tab of the resident wherein there were no influenza and pneumococcal vaccines documented except for TB (tuberculin) test results and COVID vaccinations. The RNC then stated that he would get back to the surveyor and he would ask the Infection Preventionist Nurse (IPN).
On 6/26/24 at 12:03 PM, the RNC informed the surveyor in the presence of the survey team that the resident's representative (RR) told him (RNC) that the resident was probably vaccinated at the previous facility. The RNC stated that he called the RR today to verify the resident's immunization status.
On that same date and time, the surveyor then asked the RNC what was the facility's protocol and policy with regard to offering vaccines to the resident. The RNC stated that it was the facility's policy and protocol to offer vaccines including influenza and pneumococcal to all residents upon admission, and quarterly. The RNC was not able to provide and show documentation that the vaccines were offered from admission and the most recent quarterly MDS.
At that same time, the RNC further stated that he was still waiting for RN/Unit Manager #1 (RN/UM#1) from the Pink unit if the vaccines were offered prior to transferring the resident to the Peach unit.
On 6/27/24 at 8:14 AM, the surveyor interviewed the IPN in the Peach unit. The IPN informed the surveyor that she started working in the facility end of January 2024 and there was no IP at that time she started as an IPN, and unsure when the last IP worked in the facility. The IPN stated that she was responsible for tracking the immunization records of staff and residents. She further stated that she gathered information from the records of the resident. The IPN also stated that when the resident comes in for admission, the receptionist will page or notify the IPN of the admission Monday through Friday when I'm here, the IPN check the records for immunization of new admit and document it in the Immunization tab of EMR.
On that same date and time, the IPN informed the surveyor that as per facility policy and protocol, influenza vaccine was being offered during flu season. The IPN acknowledged that flu season was from October through March. She further stated that the facility offers pneumococcal vaccine if the resident has not received the vaccine. The IPN also stated that the consent should be gathered from the resident or RR, and documented in the Immunization tab and IDT (Interdisciplinary) notes in the EMR.
At that time, the surveyor asked the IPN if there was a form the facility used to offer, consent, and decline the vaccines, and the IPN responded that there was no form. The surveyor then notified the IPN of the above findings and concerns. The IPN stated that the information regarding the resident's immunization for influenza and pneumococcal should have been documented and it should have been offered.
Furthermore, the surveyor asked the IPN if she was responsible for tracking influenza and pneumococcal immunization records. The IPN said yes, but the immunization tracking was for COVID-19 and influenza, and there were none for pneumococcal. The surveyor asked the IPN why the pneumococcal was not being tracked, and the IPN did not respond. The surveyor then asked for the tracking log for the vaccinations of the residents in the facility and she stated that she would get back to the surveyor.
On 6/27/24 at 8:25 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room with other residents, and RN/UM#2. RN/UM#2 was the UM in the Peach Unit.
At that time, the surveyor interviewed RN/UM#2 when she left the Therapy room when another nurse stepped in to watch the room. RN/UM#2 informed the surveyor that it was the responsibility of the admitting nurse to check, verify, and document in the Immunization tab in the EMR the immunizations of the resident including influenza and pneumococcal. She stated that the admitting nurse would check the hospital records for immunization if there was none in the record, the nurse would have to ask the resident or RR for the history of vaccinations. She further stated that if the resident or RR did not have or was unsure, the facility's responsibility was to offer the vaccines and document the information and the refusal in the Immunization tab and IDT notes in the EMR. The surveyor asked if there was a consent form for the immunization, and RN/UM#2 stated yes, there's a form on paper. The surveyor then asked RN/UM#2 to provide a copy of the consent form and she stated that she would get back to the surveyor.
At that same time, the surveyor notified RN/UM#2 of the above findings and concerns. RN/UM#2 stated that she was unaware that the RR was called by RNC yesterday, to verify the vaccination status of the resident. She further stated that she thought this was done before and was documented in the IDT notes, she also stated that she would verify it with the RNC.
On 6/27/24 at 8:32 AM, RN/UM#2 informed the surveyor that there was no consent form for the refusal of vaccinations.
On 6/27/24 at 9:01 AM, the IPN in the presence of the survey team informed and showed to the surveyor the copy of Transmission Based Precautions (TBP) log dated 6/25/24, and IPN stated the TBP forms was where the immunization status of their residents was being tracked. The IPN showed that influenza and COVID were being tracked but not the pneumococcal vaccination.
At that same time, the surveyor asked the IPN if she should track the pneumococcal vaccination status of their residents, and the IPN responded that she should track them as well. She further stated that if she needed the list of residents with their pneumococcal vaccine she could just print it from EMR. The surveyor then asked how she would know who needed to offer and who was due for pneumococcal vaccines, the IPN did not respond. The IPN also stated that she would get back to the surveyor to provide a copy of the IDT notes that the influenza and pneumococcal vaccines were offered and declined for Resident #134.
A review of the provided TBP log revealed that Resident #134 was on the list, but the influenza log was blank (no information if it was offered and declined).
On 6/27/24 at 12:25 PM, the MDS Coordinator (MDSC) in the presence of the RNC provided a copy of the hospital records when the resident was admitted to the facility that included the following the influenza vaccine for the season was refused and the pneumococcal vaccine was unsure. The surveyor then asked the facility management if that was from the hospital, should the facility offer the influenza vaccine because it was flu season when the resident was admitted to the facility, and also offer the pneumococcal vaccine since the hospital records showed it was unsure if the resident received the vaccine.
At that same time, the RNC stated that the facility was waiting for the RR to respond regarding the vaccination status of the resident at this time. The surveyor then asked, if should there be documentation that vaccines were offered and declined on admission. The RNC stated that he was aware that there was no documentation that the vaccines were offered in the medical records which was why the facility was trying to get the email correspondences from the RR.
On 6/27/24 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), [NAME] President of Operations (VPoO), and Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns.
A review of the facility's Influenza Vaccine Policy and Procedure with a reviewed/revised date of 01/2024 that was provided by the LNHA included that influenza vaccination is the primary method for preventing influenza and its severe complications. Therefore, vaccination against influenza will be offered to residents of this facility.
Procedure:
-All persons, upon admission to long-term care programs, shall be assessed for recent and past flu vaccinations.
-The influenza vaccine shall be offered to all residents annually during flu season. Education shall be provided regarding the risks vs benefits of the vaccine. The resident or resident's representative may refuse immunization.
-Those residents who are admitted during the winter months after completion of the program's vaccination program, will be offered the vaccine at the time of their admission.
-The facility shall document the provision or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal of the flu vaccine for each resident.
A review of the facility's Pneumococcal Vaccination Policy and Procedure with a reviewed date of 01/2024 that was provided by the LNHA, included that in order to prevent the spread of infectious diseases and decrease the morbidity and mortality associated with pneumococcal pneumonia, the facility will offer pneumococcal vaccinations to residents as per the following procedures. Administration of pneumococcal vaccines will be made in accordance with current CDC (Centers for Disease Control and Prevention) recommendations. CDC recommends pneumococcal vaccination for [AGE] years old and older, adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors which include but were not limited to chronic heart disease (including congestive heart failure and cardiomyopathies).
On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings.
NJAC 8:39-19.4 (a,4)(d)(h)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. This deficient practice was identified in behavioral unit for four (4) of six (6) residents rooms, one (1) of one (1) shower room, and one (1) of two (2) unit rooms.
This deficient practice was evidenced by the following:
On 6/25/24 at 10:08 AM through 10:49 AM, the surveyor conducted a Behavioral Unit (BU) tour with the Licensed Nursing Home Administrator (LNHA) and Registered Nurse/Unit Coordinator (RN/UC) in the presence of a second surveyor. The following was observed during the tour:
1. At 10:08 AM, the surveyor entered into room [ROOM NUMBER] and observed a gray-black colored substance on the air vent cover on the ceiling of the room. The LNHA stated, the gray/black substance was an accumulation of dust. The LNHA was unable to state when the air vent was last cleaned. The surveyor observed one ceiling tile near the window area with a large circular, brownish colored stain in the middle of the tile. The LNHA responded that it was probably due to condensation, and he was unsure when that had happened. The RN/UC stated, the tile should not be there.
The surveyor entered the bathroom and observed a laundry bin with one piece of black colored clothing inside of it. The RN/UC stated, the clothing was probably from other resident who was transferred to another room last Friday. The RN/UC acknowledged that the room and the dirty clothing should have been cleaned immediately after the resident was moved to another room.
2. At 10:15 AM, the surveyor entered into room [ROOM NUMBER] and observed dry debris hanging from the upper area of the window. The RN/UC confirmed that it was dust. The LNHA and RN/UC acknowledged that the window should have been cleaned.
3. At 10:21 AM, the surveyor entered into the bathroom of room [ROOM NUMBER] and observed two toilet paper holders with brownish discoloration. The RN/UC acknowledged it was rust and stated it should not be like that. The surveyor observed a white hat [a plastic container for urine collection] on the floor. The RN/UC stated, it was a urine collection container, and it should not be on the floor for infection control. It was used to measure the resident's urine output. The RN/UC further explained that there was currently no resident in the room and the resident was transferred to the hospital yesterday.
4. At 10:27 AM, the LNHA opened the unlocked door of the Motor Access Room and informed the surveyors that it was an electrical room. The surveyor observed a brown colored, dried-up substance on the floor. There was a blanket on the floor with brownish discoloration. The LNHA acknowledged that the room door should have been locked.
5. At 10:30 AM, the surveyor entered into room [ROOM NUMBER] and observed that the smoke detector on the ceiling. The smoke detector was detached and hanging from the ceiling. The LNHA stated, it should have been fixed and attached to the ceiling.
6. At 10:43 AM, the surveyor entered the room labeled the Eyewash Station. Inside the room there were three shower stalls on the right side. The surveyor observed in the second shower stall, a square shaped opening on the right wall of the shower where there was a knob to control the water. The RN/UC acknowledged that the part to close the opening was missing.
The surveyor observed an air vent on the ceiling which had no cover. The RN/UC stated that it should have been covered and acknowledged that there was an accumulation of dust, and it should have been cleaned.
On 6/27/24 at 8:53 AM, the surveyor interviewed the Director of Housekeeping (DoH) who stated that the housekeeping staff were supposed to clean the resident rooms and hallway daily. The DoH stated he was responsible to make daily rounds on the units to ensure that housekeeping staff were completing their responsibilities. He further stated that he did not have any logs or documentation to account for the cleaning of vents and windows, or for his daily rounds.
On 6/27/24 at 12:41 PM, the survey team met with the LNHA, Director of Nursing (DON), and [NAME] President of Operations (VPoO). The surveyors notified the facility management of the above concerns and findings regarding the resident rooms, bathrooms, shower room, and motor access room.
On 6/28/24 at 11:29 AM, the LNHA, DON, and VPoO met with the survey team. The VPoO stated in-service was provided to housekeeping staff regarding environmental concerns and high dusting issues. The LNHA stated that the valve in the middle shower stall was temporarily covered and closed until a new cover was received. The LNHA further explained the air vent cover in the shower room was replaced and the smoke detector was properly mounted to ceiling.
A review of the facility provided Facility Environment policy with a revised date January 2024, included:
Policy: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Procedure: 1. The facility shall provide a safe, clean, comfortable and homelike environment, allowing the resident to use their personal belongings to the extent possible.
2. Housekeeping and maintenance shall maintain a sanitary, orderly and comfortable environment.
NJAC 8:39-31.4 (a)(b)(f)

Based on observation, interview, and record review it was determined that the facility failed to provide full visual privacy when providing wound care treatment, for one (1) of 28 residents, Resident #103.
The deficient practice was evidenced by the following:
On 6/27/24 at 10:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a treatment to the sacral wound of Resident #103. The Certified Nurse Aide (CNA) was assisting the LPN with the positioning of Resident #103 during the wound treatment.
On 6/27/24 at 10:31 AM, during the wound treatment, Resident #103 with the assistance of the CNA was lying on their left side on the bed facing away from the door. The back of the resident's body was exposed. The privacy curtain was partially pulled, around the foot of the resident's bed. The resident's bed was visible to the door of the room, which was closed.
The LPN after cleansing the resident's wound, removed her gloves and went to the door of the room. LPN #1 fully opened the door, went to the treatment cart positioned in front of the door to get gloves from the box on top of the cart. The back side of the resident's body was visible to the hallway as the privacy curtain was not closed fully and the resident's door was widely open. LPN #1 retrieved the gloves from the top of the treatment cart, came back in room, put the gloves on the bedside table, next to the resident's bed and then closed the door of the resident's room.
On 6/27/24 at 10:50 AM, the surveyor interviewed the LPN after the wound treatment about privacy for residents. The LPN stated visual privacy should be provided and maintained for residents. The surveyor discussed the observation during the wound treatment. The LPN acknowledged that she should have drawn the resident's curtain further or closed the door of the room when she went to the treatment cart to ensure that the resident was not visible from the hallway.
The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #103 which revealed the following:
According to the admission Record (an admission summary), Resident #103 had diagnoses that included but were not limited to, urinary tract infection, sacral pressure ulcer wound, and epilepsy (a seizure disorder).
An Annual Minimum Data Set (MDS), an assessment tool to facilitate management of care, dated 5/10/24, indicated the facility assessed the resident's cognition using a Brief Interview for Mental Status (BIMS) test. Resident #103 scored a 9 out of 15, which indicated the resident had moderate cognitive impairment.
On 6/27/24 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the [NAME] President of Operations (VPoO). The surveyor notified the LNHA, DON, and VPoO of the concern observed during the wound treatment of the resident's full visual privacy not being maintained. There was no verbal response by the facility at this time.
On 6/28/24 at 11:30 AM, the LNHA, DON, and VPoO met with the survey team. The VPoO stated in-service education about resident's privacy was being provided to all staff. There was no additional information provided by the facility.
A review of the facility's Resident Rights To Privacy and Confidentiality with a reviewed date of 01/2024. Under Procedure it read, Every nursing home resident has the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care.
A review of the facility's Resident's Rights, which was undated. Under I. Each resident shall be entitled to the following rights .16) To have physical privacy. The resident shall be allowed, for example, to maintain the privacy of his or her body during medical treatment and personal hygiene activities, such as bathing and using the toilet, unless the resident needs assistance for his or her own safety .
NJAC 8:39-4.1(a)12,16

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of five (5) newly hired licensed staff reviewed, (Staff #5, #8 and #10).
This deficient practice was evidenced by the following:
1. On On 6/27/24 at 12:00 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following:
Staff #5, a Social Worker, hired 8/21/23, had a New Jersey Division Consumer Affairs license verification printout was dated 10/02/23. The verification was completed after the staff member was hired. There was no documented evidence that Staff #5's license was verified prior to the date of hire (doh).
On 6/28/24 at 10:00 AM, the surveyor interviewed the Business Office Manager (BOM) regarding license verification. The BOM stated that she would check the license and print a copy and that it had to be done before orientation. The surveyor showed the BOM Staff #5's license verification dated after the doh. The BOM stated that she was not employed at the facility at that time. She added that the license should be verified prior to doh.
On 6/28/24 at 10:04 AM, the surveyor interviewed the Director of Nursing (DON) regarding license verification. The DON stated that the BOM checked the license prior to doh.
On 6/28/24 at 12:06 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Operations (VPoO) the concern that Staff #5's license was not verified prior to the doh. The LNHA stated that he was the stand in BOM and that he missed it.
On 7/01/24 at 10:04 AM, in the presence of the survey team, DON and VPoO, the LNHA confirmed that the license should have been verified prior to the doh.
2. On 6/27/24 at 10:30 AM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following:
Staff #10, a Certified Nurse Aide (CNA), hired 10/23/23, had a New Jersey Division Consumer Affairs license verification printout that had no date the verification was completed visible on the printout. There was no documented evidence that Staff #10's license was verified prior to the doh.
On 6/27/24 at 12:15 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following:
Staff #8, a Registered Nurse, hired 8/25/23, had two New Jersey Division Consumer Affairs license verification printouts that were dated 10/02/23 and 11/14/23. The verification was completed after the staff member was hired. There was no documented evidence that Staff #8's license was verified prior to the doh.
On 7/01/24 at 9:48 AM, the LNHA provided another copy of Staff #10's printout. The printout reflected handwriting that was highlighted printed on 6/28/24 print no date shown. The License verification printout did not reflect any other date that it was printed. There was no documented evidence that Staff #10's license was verified prior to the doh.
A review of the facility provided policy titled, New Hires with a reviewed date of 01/2024, included the following:
1. All new hires shall complete the following paperwork and the paperwork will have to be reviewed by the BOM: .
f. Original licenses/certification with verification by the BOM (if applicable)
A review of the facility provided policy titled, Abuse Prevention Program with a revised date of 02/08/2023, included the following:
.Part III-Screening .
Potential hires of professional staff will have their license verified by their licensing boards prior to hire
NJAC 8:39-43.15(a,b)

Based on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and the resident's representative written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for two (2) of three (3) resident's (Resident #195 and #41) reviewed for hospitalization.
This deficient practice was evidenced by the following:
1. A review of Resident #195's electronic medical record included the following:
Resident #195's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, for the three DRAMDS, reflected that the resident was transferred to the hospital.
A review of Resident #195's hybrid (a combination of paper, scanned, and computer-generated records) medical record did not include a written notification of the reason for transfer to the resident or resident representative (RR) and a copy to the LTCO for each transfer to the hospital.
2. The surveyor reviewed the hybrid medical records of Resident #41 which revealed the following:
A New Jersey Universal Transfer Form (NJUTF) and nurse progress notes documented that Resident #41 was transferred to an acute care hospital in May 2024.
According to the DRAMDS in May 2024, Resident #41 was discharged (d/c) to an acute care hospital with a return anticipated to the facility.
There was no documentation in the hybrid medical record of Resident #41 to indicate that the facility provided written transfer notification to the resident or RR. Additionally, there was no documentation in the hybrid medical records to indicate written transfer notification was provided to the Ombudsman's office.
On 6/25/24 at 9:52 AM, the surveyor interviewed the Director of Social Services (DSS) about written emergency transfer notifications. The DSS stated social services department was not responsible for providing written emergency transfer notifications and did not provide notice to the Ombudsman's office. The DSS stated he was not sure who was responsible for providing the notifications.
On 6/25/24 at 9:57 AM, the surveyor interviewed the Admissions Director and Regional Director of Case Management and Admissions (RDCMA) about written emergency transfer notification. The RDCMA stated nursing was responsible for providing the written transfer notification to the resident or RR.
On 6/25/24 at 11:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated written emergency transfer notification was not provided by nursing. The DON further stated she was not sure which department was responsible for providing and would follow up to provide further information.
On 6/25/24 at 12:01 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the medical records department was responsible for providing written emergency transfer notification to resident and/or RR and the Ombudsman's office.
On 6/25/24 at 12:07 PM, the surveyor interviewed the medical records staff (MRS) who stated she was not responsible for providing any written emergency transfer notification. The MRS further explained that she would complete a monthly spreadsheet of residents that were d/c and send directly to the LNHA. The MRS stated she had no knowledge about written emergency transfer notifications and did not know who was responsible for providing.
On 6/27/24 at 12:41 PM, the survey team met with the LNHA, the DON, and the [NAME] President of Operations (VPoO). The surveyors notified the facility of the concerns that there was no written emergency transfer notification provided to the resident/RR and no notification provided to the Ombudsman's office. There was no verbal response by the facility at this time.
On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The VPoO stated in-service education was provided to staff to put the process of providing emergency written transfer notifications back into place as it was not being completed. There was no additional information provided by the facility.
The surveyor reviewed the facility provided policy titled Emergency Transfer Notification with a reviewed date of 01/2024. Under Policy it read It is the policy of this facility to provide guidelines for the notification requirements when transferring residents to an acute care facility on an emergent basis.
Under Procedure it read: 1. When a resident is temporarily transferred to an acute care facility a notice of the temporary transfer will be provided to the resident and/or RR as soon as practicable .2. A copy of the notice will also be sent to the Ombudsman when practicable, such as a list of residents on a monthly basis .3. The notice will contain: a. The reason for transfer; b. The effective date; c. The location to which the resident is transferred; d. Contact information .
NJAC 8:39-5.3; 5.4

Based on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for one (1) of three (3) residents, Resident #142 reviewed for closed records.
This deficient practice was evidenced by the following:
On 6/26/24 at 12:58 PM, the surveyor reviewed the closed medical chart for Resident #142 whose discharge MDS was coded for discharge (dc) to an acute hospital.
Review of Resident #142's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder, unspecified, and essential (primary) hypertension (high blood pressure).
Review of A section of the 4/27/24 Discharge MDS for Resident #142 revealed that section A2105 DC Status documented, 04. Short-Term General Hospital.
The Order Summary Report (OSR) reflected a physician order dated 4/27/24 - dc home with home care services.
The Progress Notes dated 4/27/24 at 9:30 AM that was electronically signed by Licensed Practical Nurse (LPN) included resident was seen this morning in their wheelchair no signs of distress or discomfort noted. Vitals taken and recorded; due medications (meds) tolerated. Resident dc, left the building at 9:30 AM, with resident representative. Resident has been educated on their meds and oxygen use; list of meds had been faxed to [name redacted] pharmacy.
The dc Summary, with effective date 4/27/24 12:44 PM revealed under section 103 Social Services documented, 2. dc Status - dc home, family support. Ref (referred) to [name redacted] Home Care for home services.
On 6/27/24 at 11:28 AM, the surveyor interviewed the MDS Coordinator (MDSC). MDSC explained, I do remember him/her, that Resident was dc to home. I made a mistake and entered their information transferred to hospital. The MDSC acknowledged that the MDS was coded inaccurately and Resident #142 went home and did not go to the hospital.
On 6/28/24 at 11:28 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and [NAME] President of Operations (VPoO) regarding the above concerns. The VPoO stated, she [the MDSC] made an error in MDS. She further stated that the resident was dc home and did not go to the hospital. No further information provided.
NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch.
The surveyor reviewed the hybrid medical record for Resident #134.
Resident #134's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified, traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder.
The most recent Significant Change MDS (SCMDS) dated [DATE], reflected that the resident had a BIMS score of 09 out of 15, which indicated the resident had moderately impaired cognition.
A review of the OSR for May and June 2024 reflected a PO dated 3/07/24 for the following:
Hydralazine HCL (hydrogen chloride) oral tab 25 mg give one tab orally every 12 hours (hrs) to treat high blood pressure hold if SBP (systolic blood pressure [the top number measures the pressure in the arteries when the heart beats]) less than 120.
Toprol XL (extended-release) oral tab 50 mg give one tab by mouth one time a day for HTN (hypertension) hold for SBP less than 100 and HR (heart rate) less than 60.
The above orders for Hydralazine and Toprol Xl were plotted in the eMAR for May and June 2024, were administered by nurses (checked mark), and did not follow the PO:
Toprol XL hold for SBP less than 100:
Date
Time
BP
Nurse
6/22/24
8 PM
96/61 [SBP 96]
Registered Nurse#1 (RN#1)
HydrALAZINE HCl hold for SBP less than 120:
Date
Time
BP
Nurse
6/09/24
9 AM
115/73 [SBP 115]
LPN#2
6/12/24 9 PM
112/68 [SBP 112]
LPN#2
6/19/24 9 PM
18/67 [SBP 118]
LPN#2
6/20/24 9 PM
103/64 [SBP 103]
LPN#2
6/22/24 9 PM
105/70 [SBP 1050
LPN#3
5/03/24 9 AM
113/96 [SBP 113]
RN#1
5/10/24 9 PM 116/72 [SBP 116]
LPN#2
5/14/24 9 PM
116/68 [SBP 116]
LPN#2
On 6/25/24 at 9:54 AM, the surveyor interviewed RN#1 who informed the surveyor that she was a regular full time per diem nurse for a year now in the Behavioral Unit (BHU). The RN informed the surveyor that the meds with parameters like the BP meds should follow the order of the physician if needed to hold, then it should be followed. She further stated that she checked BP first prior to administering the BP meds, and documented the BP in the eMAR. The RN also stated that the checkmark in the eMAR means it was administered. The RN further stated that it was considered a med error if BP meds were administered beyond the parameters.
On that same date and time, the surveyor notified RN#1 of the above concerns and findings regarding the Toprol she administered on 6/22/24 and Hydralazine on 5/03/24 not following the parameters. The surveyor with another surveyor and RN#1 went to the BHU nursing station. RN#1 checked the eMAR and acknowledged that she was the nurse that administered the BP meds and it should not administered due to parameters. She further stated that she did not know why it was administered and did not follow the PO for parameters.
On 6/25/24 at 11:22 AM, the surveyor called and left a message to an agency nurse, LPN#3.
On 6/25/24 at 11:23 AM, the surveyor called and spoke to LPN#2 regarding the above concerns and findings. LPN#2 informed the surveyor that she was from an agency and had been working in the facility since June 2023 as a float nurse.
On that same date and time, LPN#2 stated that meds with parameters example the BP meds should follow the PO for parameters. She further stated that she checked BP first prior to administering meds and documented the BP in the eMAR. LPN#2 admitted that she usually works the 3-11 shift.
At that time, the surveyor notified LPN#2 of the above findings regarding her administered Hydralazine on 6/09/24, 6/12/24, 6/19/24, 6/20/24, 5/10/24, and 5/14/24 not following the parameters. She further stated that the above meds should not be administered due to parameters. LPN#2 had no answer as to why she did not follow the PO for parameters.
On 6/25/24 at 11:38 AM, the DON provided a copy of the Med Administration Policy with a reviewed date of 01/2024. The DON stated that the policy about meds with parameters was incorporated in this policy (Medication Administration Policy with a reviewed date of 01/2024) and the DON pointed to Procedure #3: Meds must be administered in accordance with the orders, including any required time frame.
The surveyor did not receive a call back from LPN#3.
On 6/27/24 at 9:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM stated that she notified the physician yesterday about the concerns with the parameters, the physician had no new order and instructed the nurse to continue the parameters. She further stated that there was no adverse effect on the resident.
On 6/27/24 at 12:41 PM, the survey team met with the LNHA, the VPoO, and the DON. The surveyor notified the facility management of the above concerns and findings.
On 6/28/24 at 11:29 AM, the survey team met with the LNHA, DON, and the VPoO. The DON stated that one-to-one education was provided to LPN#2 regarding following the PO for parameters. The DON acknowledged and stated that meds were given beyond the parameters and that should have been held for both meds Toprol and Hydralazine.
A review of the facility provided policy titled, Medication Administration Policy, with a reviewed date of 01/2024. Under Policy it read: Meds shall be administered in a safe and timely manner, as prescribed.
Under Procedure it read: .3. Meds must be administered in accordance with the orders, including any required time frame .7. The following information must be checked/verified for each resident prior to administering meds .b. Vital signs, if necessary .
NJAC 8:39-11.2(b); 29.2(d)
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow the physician's orders for medications with parameters for two (2) of 28 residents, Residents #44 and #134, reviewed for physician orders according to standards of clinical practice.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
1. The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #44 which revealed the following:
The admission Record (AR, an admission summary) revealed that Resident #44 had diagnoses that included but were not limited to, end stage renal disease, hypotension (low blood pressure), and anemia.
A Quarterly Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 4/03/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #44 scored a 15 out of 15, which indicated the resident was cognitively intact.
A physician's order (PO) dated 5/10/24 read: Midodrine HCl Oral Tablet (tab) 10 MG (milligram) (Midodrine HCl) Give 1 tab by mouth two times a day for hypotension hold for BP [blood pressure] > [greater than] 120.
A review of the June 2024 electronic Medication Administration Record (eMAR) revealed the nurses signed for midodrine medication (med) being administered on 6/04/24 at 1700 [5 PM], 6/10/24 at 1700, 6/11/24 at 0900 [9 AM], 6/16/24 at 0900, 6/18/24 at 1700, 6/19/24 at 1700 and 6/24/24 at 1700. On these entries the BP was documented to be a BP greater than 120 and the midodrine med should have been held per the PO.
On 6/27/24 at 11:12 AM, the surveyor interviewed a Licensed Practice Nurse (LPN) #1 (LPN #1) assigned to care for Resident #44 about medications (meds) with parameters. The LPN stated a PO should be followed. If the BP results were outside the parameters of the med order, the med should be held and not administered to the resident.
On 6/27/24 at 12:41 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Operations (VPoO) of the concerns that the PO for the midodrine med with parameters was not being followed. The facility was to follow up and provide additional information.
On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The DON acknowledged the nurses did not follow the parameters ordered by the physician for the midodrine med and nurse in-service education was ongoing.

Based on interview, record review, and review of other pertinent documentation, it was determined that the facility failed to enter signed progress notes (PN) in the hybrid medical record (electronic or paper) at each visit. This deficient practice was identified on 4 of 4 units and was evidenced by the following.
On 01/11/23 through 01/13/23, the surveyor began to review the hybrid medical records of sampled residents. The surveyor reviewed the following:
The Behavioral Health Unit (BHU):
Resident #6: hybrid record revealed late entries:
Effective Date (the date the resident was seen by the practitioner): 12/23/2022; Department: Physicians; Position: Physician; Created By: a physician's name was entered; Created Date: 01/3/2023. This represented an 11-day delay in the Progress Note (PN) being entered into the hybrid record.
Effective Date: 12/15/2022; Department: Physicians; Position: Physician; Created By: a physician's name was entered; Created Date: 01/9/2023. This represented a 25-day delay in the PN being entered into the hybrid record.
Effective Date: 01/06/2023; Department: Physicians; Position: NP Created By: the NP's name was entered; Created Date: 01/11/2023. This represented a 5-day delay in the PN being entered into the hybrid record.
Resident #41: hybrid record revealed late entries:
Effective Date: 12/26/2022; Department: Physicians Position: NP (Nurse Practitioner) the NP's name was entered; Created Date: 01/03/2023. This represented an 8-day delay in the PN being entered into the hybrid record.
Effective Date: 12/23/2022; Department: Physicians; Position: NP, the NP's name was entered; Created Date: 01/02/2023. This represented a 10-day delay in the PN being entered into the hybrid record.
Effective Date: 12/18/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/02/2023. This represented a 15-day delay in the PN being entered into the hybrid record.
Effective Date: 12/15/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/10/2023. This represented a 26-day delay in the PN being entered into the hybrid record.
Resident #90: hybrid record revealed late entries:
Effective Date: 12/26/22; Department: Physicians; Position: NP, the NP's name was entered; Created Date: 01/03/23. This represented an 8-day delay in the PN being entered into the hybrid record.
Effective Date: 12/18/22; Department: Physicians: Position: Physician; Created By: the physician's name was entered; Created Date: 01/2/23. This represented a 15-day delay in the PN being entered into the hybrid record.
Effective Date: 12/15/22; Department: Physicians: Position: Physician; Created By: the physician's name was entered; Created Date: 01/09/23. This represented a 25-day delay in the PN being entered into the hybrid record.
Effective Date: 1/06/23; Department: Physicians: Position: NP; Created By: the NP's name was entered; Created Date: 01/12/2023. This represented a 6-day delay in the PN being entered into the hybrid record.
Resident #118: hybrid record revealed late entries:
Effective Date: 12/26/2022; Department: Physicians; Position: NP, the NP's name was entered; Created Date: 01/3/2023. This represented an 8-day delay in the PN being entered into the hybrid record.
Effective Date: 12/23/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/3/2023. This represented an 11-day delay in the NP being entered into the hybrid record.
Effective Date: 12/15/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered;
Created Date: 01/10/2023. This represented a 26-day delay in the PN being entered into the hybrid record.
Effective Date: 1/06/2023; Department: Physicians: Position: Physician; Created By: the physician's name was entered; Created Date: 01/11/2023. This represented a 5-day delay in the PN being entered into the hybrid record.
Resident #278: hybrid record revealed late entries:
Effective Date: 12/26/2022; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date:
01/3/2023. This represented a 7-day delay in the PN being entered into the hybrid record.
Effective Date: 12/23/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/3/2023. This represented an 11-day delay in the PN being entered into the hybrid record.
Effective Date: 12/18/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/2/2023. This represented a 15-day delay in the PN being entered into the hybrid record.
Effective Date: 12/15/2022; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/9/2023. This represented a 25-day delay in the PN being entered into the hybrid record.
Effective Date: 01/07/2023; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date:
01/11/2023. This represented a 4-day delay in the PN being entered into the hybrid record.
Effective Date: 01/07/2023; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/11/2023. This represented a 4-day delay in the PN being entered into the hybrid record.
On 01/11/23 at 10:16 AM, during an interview with the surveyor, the Registered Nurse Unit Manager (RN UM) stated all physician, and NP progress notes were located in the eMR on the BHU and not the chart. The RN UM further stated the progress notes would be entered when the physician or NP were there to see the resident so that staff could access the notes if needed. The RN UM further stated that the nursing supervisor or MDS (Minimum Data Set) nurse would review the charts to monitor if notes were entered.
On 01/11/23 at 11:26 AM, during an interview with two surveyors, the MDS Coordinator stated that physicians would document their progress notes in a resident's hybrid chart. The MDS Coordinator stated there was no physician logbook or any other place that the NP or physician would document or that the facility would be able to keep track of the visits.
On the [NAME] unit:
Resident #11: hybrid record revealed late entry.
Effective Date: 01/7/2023; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date: 01/12/2023. This represented a 5-day delay in the PN being entered into the hybrid record.
Resident #106: hybrid record revealed late entry.
Effective Date: 01/7/2023; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date: 01/12/2023. This represented a 5-day delay in the PN being entered into the hybrid record.
On the Pink unit:
Resident #46: hybrid record revealed late entry.
Effective Date: 12/1/2022; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date: 12/14/2022. This represented a 12-day delay in the PN being entered into the hybrid record.
Effective Date: 12/19/2022; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date: 12/30/2022. This represented an 11-day delay in the PN being entered into the hybrid record.
Effective Date: 01/2/2023; Department: Physicians; Position: NP; Created By: the NP's name was entered; Created Date: 01/10/2023. This represented an 8-day delay in the PN being entered into the hybrid record.
On the Blue unit:
Resident #181: hybrid record revealed late entry.
Effective Date: 01/4/2023; Department: Physicians; Position: Physician; Created By: the physician's name was entered; Created Date: 01/6/2023. This represented a 2-day delay in the PN being entered into the hybrid record.
On 01/13/23 at 10:31 AM, during a phone interview with the survey team, the physician and Medical Director for the BHU stated that the physicians and NP's in his group would go to the BHU at the facility twice a week. The physician stated the visit notes were entered into the electronic medical record and that he would expect the physicians in their group to enter the progress notes immediately. The physician further stated the rationale was so the all the team could reference the visit for continuity of care. The physician stated that his office would monitor to be sure the staff were entering the notes immediately.
On 01/13/23 at 10:34 AM, during a phone interview with the survey team, the physician and Medical Director for the remaining three units, stated the physicians and NP's in his group would dictate PNs in their own system. The physician stated that those PNs should be faxed to the unit the same day. The physician further stated, I am not sure if anyone monitors this. The physician stated the importance of having the progress notes right away was so that others may see what was done and for continuity of care.
On 01/13/23 10:52 AM, during an interview with the survey team, the Licensed Nursing Home Administrator (LNHA) stated some doctors and NP's document electronically and some in written form. When asked about any concerns with them not being able to access the eMR, the LNHA stated she would know if there were problem with the access. The LNHA stated that the PNs on BHU would be eMR. The surveyor inquired when the PNs should be on the eMR or chart. The LNHA stated when the physician or NP completed the resident visit, the PN should be entered at that time to be able to be used for communication. The LNHA stated the nurses on the units should be monitoring if the physician and NP notes were being entered before they leave the unit. The LNHA acknowledged again that the expectation for the physician and NP notes was to document that same day before they leave.
On 01/13/23 at 11:34 AM, during an interview with the survey team, the Director of Nursing (DON) stated all physicians or NP's who see residents were to write or enter notes when they were at the facility for timely documentation. The DON further stated some physicians and NP's write notes in their office and fax or scan to the appropriate unit and that was expected to be done immediately as well.
A review of the facility provided, EMR [electronic medical record] Documentation Policy, reviewed 01/2022, included but was not limited to primary physicians/practitioners may document .progress notes in the EMR system or on paper filed in the resident's hard chart. Consultant physicians/practitioners documentation are filed in the resident's hard chart.
A review of the facility provided, Administrative Services Agreement, signed by the BHU Medical Director and dated 07/06/22, included but was not limited to Article III Time Records: The parties (facility and physician) agree that the physician shall record promptly and maintain all information pertaining to the performance of the services. Appendix A, 7. Provide a copy of your clinical report for inclusion in patient records.
A review of the facility provided, Administrative Services Agreement, signed by the facility Medical Director and dated 01/08/20, included but was not limited to Article III Time Records: The parties (facility and physician) agree that the physician shall record promptly and maintain all information pertaining to the performance of the services.
On 01/20/23, the above concerns were brought to the attention of the facility administration. The facility had no additional information to provide.
NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to provide sufficient and competent staff to provide: a.) nursing and related services to meet the residents's needs as determined by resident assessments and individual plans of care and b.) sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was identified on 2 of 4 nursing units and for 6 of 23 sampled residents, Resident #19, #45, #66, # 72, #92 and #179, reviewed for care related services. The deficient practice was evidenced by the following.
Refer to F677 and F 689
1.) On 01/03/23 at 10:05 AM, on 01/04/23 at 8:15 AM, and on 01/04/23 at 10:30 AM, the surveyor observed Resident #19 in bed in dorsal recumbent position. The resident indicated that he/she had not been turned and had not been provided with incontinence care. Resident #19's mouth was dry and a crusty white substance was noted around the mouth.
On 01/05/23 at 11:30 AM, the surveyor observed during a care tour, that the resident had not been changed and was noted soiled with feces from the waist to the upper thighs.
On 01/05/23 at 1:30 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #19. The CNA stated that she reported to work at 8:30 AM, and had not had the time to check on the resident prior to entering the room with the Unit Manager (UM) at 11:30 AM.
2.) On 01/04/23 at 9:16 AM, and on 01/05/23 at 9:18 AM, the surveyor observed Resident #45 after morning care was provided. The surveyor observed the resident with nails long, jagged and dirty and the resident was unshaven.
On 01/11/23 at 7:15 AM, the surveyor observed Resident #45 in bed, their clothing was visibly soiled with a yellow substances. The surveyor noted a strong odor of feces while approaching the resident's bed. At the surveyor's request, the resident's incontinent brief was checked by the staff and the resident was found to be soiled with feces.
On 01/11/23 at 8:23 AM, the surveyor interviewed the CNA who cared for the resident. The CNA revealed that the resident would be soiled with urine and feces most of the time in the morning. The CNA stated that she expressed her concerns to the nurse and nothing had been done. The CNA further stated that most of the time there was only one CNA to start the 07:00 AM-3:00 PM shift. The 11:00-07:00 AM shift staff were gone and she could not get to all residents in a timely manner as she would like to. The facility was aware of the concerns with staffing.
3.) On 01/04/23 at 10:45 AM, on 01/05/23 at 9:15 AM, and on 01/06/23 at 7:15 AM, the surveyor observed Resident #66 in bed. Resident #66 had not received morning care yet. Resident #66 was noted to be soaked with urine and had double incontinent briefs on when checked with a random CNA.
On 01/05/23 at 9:15 AM, the surveyor observed the resident in bed, resting. The surveyor inquired about incontinence care. The CNA checked the resident and the resident was soaked with urine.
An interview on 01/05/23 at 10:47 AM with the CNA, revealed she worked mostly during the 07:00 AM-3:00 PM shift and they were often short handed. The CNA stated they were short staffed, people called out and there was no back up plan for call outs.
On 01/06/23 at 7:15 AM, the surveyor made a care tour with the CNA who worked the 11:00 PM-07:00 AM shift. Resident #66 was soaked with urine and had double incontinent briefs on.
An interview with the CNA who worked the 11:00 PM-07:00 AM shift, revealed that all heavy wetters had double incontinent briefs on. The CNA also stated that she had 20 residents on her assignment most of the time and could not provide incontinence care to all the residents in the morning. The last round was made around at 5:00 AM.
On 01/06/23 at 10:30 AM, the surveyor interviewed the nurse regarding incontinence care. The nurse revealed that the facility was aware of the workload and she had no control over staffing.
4. ) On 01/03/23 at 9:50 AM, and 11:30 AM, and on 01/04/23 at 9:30 AM, the surveyor observed Resident #75 in bed, eyes closed, and the sheet including the blanket were yellow stained. An interview with the resident revealed that incontinence care had not been provided during the night and the nurse was made aware. The resident further stated that he/she had been left sitting in the wheelchair soiled with urine and feces for hours. The staff indicated they were short handed.
On 01/05/23 at 12:03 PM, Resident #75 informed the surveyor in the presence of the DON that incontinence care was not provided in a timely manner due to the facility being short staffed.
5. ) On 01/04/23 at 10:36 AM, and on 01/05/23 at 8:37 AM, the surveyor observed Resident #92 in bed, facing the wall. The breakfast tray was observed on the bedside table untouched. Resident #92's mouth was covered with a dark brown substance, and dry brown food residual was noted in between the teeth and upper lip. The nails were jagged and a black coated substance was noted underneath the finger nails.
On 01/05/23 at 10:30 AM, Resident #92 was observed soiled with feces. Resident #92 had a sacral wound that was not protected with a dressing. The CNA stated that this morning not only did she have to change one of the residents, but she had to scrub to remove all the dry feces that were left from the lack of incontinence care during the 11:00 PM-07:00 AM shift.
On 01/10/23 at 10:44 AM, the surveyor interviewed the Regional Nurse regarding the care. She stated that staffing was a challenge for the facility. She went on to state that the agency staff did not report to work on time. She was aware that most of the time there was only one CNA to start the 07:00 AM-3:00 PM shift. She did not discuss or elaborate on what measures the facility would implement to improve resident care.
On 01/10/23 at 11:30 AM, the surveyor interviewed the Unit Clerk/Scheduler who stated that she had been in this position for 2 weeks. The Unit Clerk indicated that she had not been trained on how to calculate the staffing ratio but was aware of the staffing ratio requirements. The Unit Clerk indicated that she prepares the schedule and tries to cover the units but the facility would be short handed due to a lot of call outs with agency staff. The Unit Clerk further stated they are short staffed on some days due to call outs, and on some occasions no one available to come in.
An interview on 01/17/23 at 10:00 AM with the Director of Nursing (DON), revealed it was her expectation that residents be checked and changed as needed every 2 hours and more often if required. The DON also stated their staffing levels were challenging and they were not where she wanted them to be and hoped that with hiring staff it would enable her to increase the number of Nursing Assistants.
A review of the facility's census and staffing on the assigned unit where the above concerns were noted, revealed that the facility failed to meet the staffing ratio almost daily. The census for most of the day during the survey was 39 on the Unit. The facility would have sometimes 4 CNA and other times 3 CNA for the 07:00 AM -3:00 PM shift and 2 CNA assigned to the 11:00 PM -07:00 AM shift.
During the survey from 01/04/23 to 01/20/23, the surveyor observed several residents in the dayroom watching TV. There were no staff observed around to supervise or engage the residents in some forms of activities.
On 01/19/23, the surveyor observed 7 residents in the dayroom, there was no staff in the hallway nor at the nursing station. The surveyor asked the Unit Manager who was assigned to the dayroom to monitor the residents about the supervision and she could not comment. Upon further inquiry, the nurse stated, If I was in charge I would have someone to supervise the dayroom. The surveyor escorted the Unit Manager to the dayroom where we both observed the residents sitting in the dayroom. The census was 39 and only 3 CNA were assigned to care for the residents. The dayroom was left without supervision. (This failure resulted in the staff not being able to meet the residents' needs in a timely manner. This deficient practice had the potential to affect all residents who resided in the dayroom.)
6. On 01/03/23 at 11:14 AM, Surveyor #2 observed Resident #179 lying in bed awake. Resident #179 did not respond to the surveyor when spoken to. Surveyor #2 observed the resident's mouth and lips were very dry. There was an intravenous (IV) running which contained Dextrose 5. There was no water cup visible in the room.
On 01/04/23 at 8:35 AM, the surveyor observed Resident #179 with eyes closed, lying in bed and the breakfast meal had not yet arrived on the unit. The surveyor observed a brownish tan flaky food like substance on Resident #179's top right shoulder. The surveyor engaged the resident who opened his/her eyes, looked at surveyor and did not verbally respond.
On 01/04/23 at 8:46 AM, Surveyor #2 observed Resident #179 lying in bed. There was no breakfast tray in the room, but there was a brown flaky substance that resembled food on the resident's gown, top right shoulder. There was no water cup visible in the room. Resident #179's mouth and lips were still very dry in appearance.
On 01/04/23 at 11:06 AM, the surveyor while the surveyor was in Resident #179's room, a Certified Nurse Aide (CNA) entered and stated that she had to change the resident's position. The CNA left the room and stated she needed someone else to help, returned and stated she could do it her self. She boosted the resident up, and the CNA did not converse with the resident at that time. The surveyor asked the CNA what type of care she provided for the resident and the CNA stated I don't know, I just came in yesterday and stated I change [him/her] and feed [him/her]. The CNA did not mention anything about mouth care or offering the resident a drink and there was no water cup or swabs to clean the resident's mouth observed in the room. The surveyor timed the interaction, which lasted four minutes and the CNA left without saying anything to the resident.
On 01/04/23 at 11:16 AM, the surveyor interviewed the Unit Manager (UM) about the care that was supposed to be provided for dependent residents. The UM stated bath, feed and report anything that was wrong to the nurse.
On 01/04/23 at 12:14 PM, the surveyor observed Resident #179 lying in bed. There was still no water cup visible in the room, but there was an untouched lunch tray out of reach of the resident on the overbed table.
On 01/04/23 at 12:28 PM, the CNA set Resident #179 up for the meal and proceeded to use the hand wipe that was on the resident's tray to clean her own hands, and not the resident. The surveyor watched as the CNA began to feed the resident. The surveyor asked the CNA if the resident was offered water, as there was no water at the bedside or on the meal tray. The CNA stated, I forgot, when the surveyor asked where the water was. The surveyor asked the CNA if she had offered the resident any water during her shift and the CNA confirmed she had not. The CNA then left the resident in the middle of the meal, and did not say anything to the resident and exited the room. (Surveyor observations over approximately a four hour period revealed that the Resident had not been offered water, which was confirmed by the CNA who was assignened to the resident )
On 01/04/23 at 12:35 PM, the surveyor asked the UM to come into Resident #179's room. The surveyor asked the UM about the mouth care as the resident's mouth looked very dry. The UM stated mouth care should be done and proceeded to look for mouth swabs in resident's drawer. The UM was unable to locate cleaning swabs and confirmed they were not there. The surveyor asked the UM if water should also be available for the resident, and the UM stated yes.
The surveyor reviewed Resident #179's admission Record which revealed diagnoses that included sepsis, anemia and malignant melanoma of the skin. A Physician's Progress note, dated 12/24/2022 at 11:25 AM, revealed a problem list that included: Metastatic Melanoma, presented with recurrence of large mass at left buttock, with probable liver and lung metastatic disease, sacral wound stage 4, Hypernatremia (elevated blood sodium level) due to poor oral water intake, The Care Plan revealed a Focus: Initiated 12/16/2022 and Revision: 12/22/2022, revealed Resident has a nutritional problem or potential nutritional problem r/t (resulted to) .need for ADL assist .Interventions included: Encourage PO (by mouth) fluids dated 12/22/2022 and Assist resident at meals, dated 02/22/2022.
On 01/04/23 at 1:28 PM, the surveyor observed a black substance under Resident #179's right hand fingernails.
On 01/04/23 at 1:37 PM, the surveyor interviewed the UM, in the presence of another surveyor. The surveyor asked the UM if he checked the care being provided to the residents by his staff and asked if he had checked if Activity of Daily Living (ADL) care had been provided to Resident #179. The UM stated he did not check the care of Resident #179 and stated, I am pretty sure that someone checked it yesterday, and he would have to check the computer for the ADL completion, and stated he had not done that. The surveyor asked the UM if fingernails would be cleaned as part of ADLs and the UM stated, yes of course. At that time, both surveyors asked the UM to accompany them to Resident #179's room and look at the resident hands. The UM opened Resident #179's hands and stated, I see as he observed the black substance under Resident #179's fingernails on the right hand.
On 01/09/23 at 8:55 AM, the surveyor observed an undated, open cup of water in Resident #179's room. There was no ice in the water and the resident's mouth and lips looked dry. The resident was alert and responded to the surveyor. At 8:59 AM, a different CNA then previously brought in the meal tray. The surveyor asked the CNA about the open cup. The CNA stated, it looked like from 11-7 shift, looked like they didn't throw it out, and the cup should be covered with a lid and have a straw inside. The surveyor asked if the cup is usually dated, and the CNA stated that they don't tell them to date it.
01/10/23 at 9:18 AM, the surveyor interviewed the UM regarding the water policy. The UM stated that every shift must provide fresh water and as needed. The UM stated the water cups were supposed to be dated because it would be a problem if not dated since you would not know what date it was poured.
On 01/01/10/23 at 11:14 AM, the surveyor interviewed the Registered Dietitian (RD) about Resident #179. The RD stated she reviewed the resident's labs and I put in for PO hydration encouragement, which I know they are already doing. The RD stated she had spoken with nursing to encourage water, juices fluid and the resident should have a water cup in the room.
The policy for oral hygiene was reviewed and indicated the following:Purpose: Regular oral hygiene will help prevent mouth infections, dental decay and gum disease and will promote personal hygiene.
All residents will receive care of the mouth and teeth every morning and night and as needed to maintain good oral hygiene. The policy was not being followed.
The policy for ADL care dated 06/18/24 last revised 12/15/17, indicated: Residents shall receive assistance with activities of daily living (ADL's) every shift, as appropriate, ADLs include: Bathing, Grooming, Dressing, Eating, Oral hygiene, Ambulation, Toilet activities.
The Resident Hydration and Prevention of Dehydration Policy, undated revealed: This facility will endeavor to provide adequate hydration and to prevent and treat dehydration, .4. Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine base as part of daily care, 5. A 16 oz cup of containing ice water will be placed at each residents' bedside within arm's reach .11. Nursing will monitor fluid intake .
A review of the Position Title: Unit Manager job description revealed under responsibilities/accountabilities: 1. Takes an active role in direct resident assessment and care; including but not limited to, ADL care, Personal Hygiene and Psycho-social support.
On 01/13/23 at 9:35 AM, an unsampled resident on the Blue Unit requested to speak with the surveyor. The resident stated the short staffing is abominable, even with the state [Department of Health] in the building.
On 1/19/21 at 8:54 AM, the surveyor reviewed the Blue Unit assignment sheet with the Unit Manager (UM), there were two Certified Nurse Aides listed for the 7:00 AM to 3:00 PM assignment. The surveyor asked the UM what the resident census was and he stated 38 residents and confirmed there were only two CNAs. The surveyor asked if that was the normal staffing and the UM stated there were normally 5 to 6 CNAs. He stated that he was not sure who had called out for the day.
NJAC 8:39-5.1(a)

Based on interview, and review of pertinent documents, it was determined that the facility failed to a) identify through their Quality Assurance Performance Improvement (QAPI) program, that their abuse prevention program did not incorporate a component to protect all residents from potential abuse. The deficient practice was evidenced by the following.
Refer to F 600 J and F 607 F
On 01/03/23 at 10:26 AM, the facility provided the survey team with a copy of their, Abuse Prevention Program, revised 10/21/22.
On 01/19/23 at 8:27 AM, the survey team reviewed an allegation of abuse reported by a resident's family member. The abuse allegation referred to a Certified Nursing Assistant (CNA) being abusive towards a resident on the 7:00 AM to 3:00 PM shift on 01/17/23.
On 01/19/23 at 8:46 AM, a surveyor interviewed the resident who confirmed on 01/17/23, a CNA was nasty, threw down a meal tray, and refused to provide incontinent care. The resident stated that the incident had been reported to the Director of Social Services (DSS) on 01/17/23 (no time provided).
On 01/19/23 at 9:23 AM, a surveyor interviewed the DSS who stated that he was made aware of the situation on 01/17/23. The DSS stated he went to see the resident and took information down on the facility, Grievance/Missing Item Report. The DSS provided the report to the survey team which was dated 01/17/23, but not timed. The DSS stated that he immediately told the Director of Nursing (DON) because he had to do with nursing allegations, and it was the DON's responsibility to investigate and obtain statements from the nursing staff. The DSS acknowledged that the situation constituted an allegation of abuse. The CNA had completed the 7:00 AM to 3:00 PM shift on 01/17/23.
On 01/19/23 at 9:50 AM, the Unit Manager (UM) on the resident's unit, stated that he was informed by the family member on 01/17/23, but was unsure of the time. The UM stated that he informed the DON that day as well. The UM further stated he was told only to take statements, but the CNA in mention had left for the day before the UM could obtain her statement. The UM confirmed that the CNA in mention, worked on the same unit on 01/18/23, but not caring for the resident. The UM confirmed that the statement he read constituted abuse.
On 01/19/23 at 10:46 AM, both the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged they were made aware in the afternoon of 01/17/23. The LNHA further stated that during an allegation of abuse investigation, the staff member (CNA) would be suspended until the investigation was complete. The LNHA and DON both acknowledged the CNA worked on the same unit as the resident on 01/18/23. The CNA had access to the resident who made the allegation as well as other residents on the unit who were not interviewed to determine if anything had happened to them by the same CNA. The residents were not protected during the investigation.
On 01/20/23 at 9:23 AM, during an interview with the survey team, the LNHA stated that abuse was not part of QAPI but would be moving forward. She further stated that it was not in the policy, but the facility would move forward with having the Social Worker to start obtaining statements immediately including residents and nursing staff.
A review of the facility provided, Abuse Prevention Program, revised 10/21/22, included but was not limited to Part II - Prevention: staff and resident will be protected from retaliation. Part V - Investigation: the administrator and the DON will initiate investigations, determine necessary response, and report to the Ombudsman and Department of Health and Senior Services as necessary. Employees involved in the investigation will be reminded of the prohibition on breach of confidentiality and retaliation. Part VII - Protection: staff members being investigated for possible involvement in abuse will be removed from contact with the resident, as necessary. Staff, family, and residents will be protected from retaliation due to their reporting of possible abuse. Part VIII - Reporting / Response: when an incident is reported to the supervisor, the supervisor is responsible for ensuring that the resident is safe. Coordination with QAPI: review would allow the committee to determine whether the resident is protected. Whether there is further need for systemic action such as: needed revisions to the policies and procedures.
The Abuse Prevention Program Policy and Procedure did not address obtaining statements from all associated staff and residents on the unit; who would be responsible to obtain statements and when that should begin; and how to protect all other residents on the unit and or in the facility.
On 01/11/23 at 12:44 PM, a review of the QAPI meetings scheduled for 2022, revealed fourth quarter 1/18/22, first quarter 4/19/22, second quarter 7/19/22, and third quarter 10/18/22. The meetings included but were not limited to the following.
Fourth quarter: abuse in-service will be done on all staff. There was no mention of the Abuse Prevention Program being addressed.
First quarter: There was no mention of the Abuse Prevention Program being addressed.
Second quarter: There was no mention of the Abuse Prevention Program being addressed. There was no mention of the BHU.
Third quarter: There was mention of incidents on the BHU.
There were no mentions of the Abuse Prevention Program Policy and Procedure in the QAPI meetings.
On 01/20/23 at 9:42 AM, the LNHA provided the survey team with a revised QAPI, dated 01/29/23, in response to the allegation of abuse. The revised QAPI failed to address a plan to protect all residents from potential abuse.
A review of the facility provided, Quality Assurance and Performance Improvement Plan, undated, included but was not limited to Design and Scope: A vision of creating an environment where care, treatment, and services contribute to .safety and quality of life for the residents. The QAPI committee analyzes performance to identify and follow up areas of opportunity for improvement. QAPI focuses on systems and processes, the emphasis is on identifying gaps. Feedback, Data Systems and Monitoring: on a quarterly basis, data will be collected and reported to QAPI from the following areas: any area identified as important to report to team. Performance Improvement Projects (PIP): QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures measurement of performance.continually monitors for improvement. System Analysis and Systemic Action: the executive leadership and center management teams, along with QAPI committee, will conduct a facility wide systems evaluation utilizing the QAPI self-assessment.
NJAC 8:39-31.6 (g); 33.1 (d); 33.2 (a)(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record reviews, and review of pertinent documents, it was determined that the facility failed to: a.) implement infection control practices and adhere to the facility's policy in regards to hand hygiene during medication administration, b.) store a Foley urinary catheter drainage bag in a manner to prevent infection for 1 of 1 residents reviewed for urinary catheters (Resident #19), c.) ensure a visitor was educated and instructed to wear a mask while in the facility, d.) wear Personal Protective Equipment (PPE) while in the room of a residents on transmission-based droplet precautions for 2 of 4, and use hand hygiene prior to donning (putting on) PPE on 1 of 4 units, and e.) follow their Covid-19 Outbreak Response Plan and Policy for Infection Control, and follow the latest guidance from the Centers for Disease Control and Prevention (CDC) for the surveillance of Healthcare Personnel (HCP) to prevent the spread of infection. This deficient practice was observed during medication administration and was evidenced by the following:
a.) On 01/06/23 at 7:30 AM, Surveyor #1 observed the Registered Nurse (RN) preparing Insulin (an injectable medication used to treat diabetes) for Resident #42 an unsampled resident. The RN donned (put on) gloves, administered the Insulin, returned to the medication cart, removed the gloves and documented in the electronic medical record on the medication administration record (MAR). The RN did not perform hand hygiene with soap and water before exiting the room nor use Alcohol Based Hand Rub (ABHR) upon returning to the medication cart. The surveyor observed that ABHR was easily accessible in the hallway and a bottle of ABHR was noted on top of the medication cart.
On 01/06/23 at 8:05 AM, the RN prepared and administered medications to Resident #5 an unsampled resident. The RN did not perform hand hygiene with soap and water before exiting the room nor use ABHR upon returning to the medication cart.
On 01/06/23 at 8:17 AM, the RN returned to the medication cart and started preparing medication for Resident #18 an unsampled resident. The RN informed the surveyor she needed to check Resident #18's blood pressure before medication administration. The RN went to the nursing station and returned with a bag which contained a blood pressure cuff and a pulse oximeter. The RN went to the room, checked the resident's vital signs, and returned the blood pressure cuff and the digital pulse oximeter to the bag prior to exiting the room. Then the RN retrieved the key from her scrub top pocket, opened the medication cart, placed the bag in the bottom drawer, then prepared and administered medications to Resident #18. The RN exited the room and did not perform hand hygiene.
On 01/06/23 at 8:22 AM, the RN returned to the medication cart and was about to pour medication for another resident when the surveyor stopped the RN and informed her that she had not used ABHR or performed hand hygiene between residents. The RN stated, OH, I forgot. The RN went to the sink and washed her hands with soap and water.
On 01/06/23 at 8:45 AM, an interview with the RN revealed that she had received in- service education on hand hygiene but could not remember the date. The RN stated that she should have used ABHR between residents and performed hand hygiene with soap and water after the third resident. She apologized for not washing her hands.
On 01/17/23 at 12:30 PM, the facility was made aware of the above observations. The Director of Nursing (DON) stated that she was made aware by the RN and the RN was reeducated on hand hygiene.
b.) Resident #19 was admitted to the facility with diagnoses which included but were not limited to: Severe sepsis from urinary source with septic shock, chronic kidney disease, Flaccid neuropathic bladder, hemiplegia and hemiparesis following cerebral infarction. Resident #19 had a Suprapubic Foley urinary catheter (tube inserted into the bladder to drain urine) in place for neurogenic bladder.
On 01/03 at 10:05 AM, the Surveyor #1 observed Resident #19 in bed, the Foley catheter drainage bag was observed in a dignity bag and hung on the bedframe.
On 01/13/23 at 11:24 AM, the surveyor observed Resident #19 in a recliner chair next to the bed. Resident #19 did not have a drainage bag on. The surveyor observed a drainage bag stored in a plastic bag which was hung on the rail in the bathroom. The drainage port was not capped and the bag was not dated.
On 01/18/23 at 10:40 AM, the surveyor entered the room and observed Resident #19 in the recliner chair in the room. Resident #19 had a leg bag on and the drainage bag was observed in a plastic bag hung on the rail in the bathroom. The drainage port was not capped. The bag was not dated.
On 01/18/23 at 11:15 AM, the surveyor interviewed the Unit Manager (UM) regarding storage of the Foley Catheter Drainage bag. The UM stated that the bag should be cleaned and rinsed from any residual urine. The UM further stated that the drainage port should be capped to prevent infection. The surveyor then inquired about the timing for changing the Foley catheter drainage bag. The UM added that the Foley Catheter drainage bag was changed weekly on the 11:00 PM- 07:00 AM shift and the bag should be dated to remind staff when the bag was last changed.
On 01/18/23 at 11:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #19. The CNA stated that the leg bag was changed daily and the Foley catheter drainage bag was changed weekly. The CNA stated that she washed and rinsed the Foley catheter drainage bag of residual urine and stored the Foley catheter drainage bag in a plastic bag in the bathroom. The CNA was not aware that the drainage port was to be capped to prevent infection.
On 01/18/23 at 12:30 PM, the surveyor entered the room with the UM and observed the nurse assigned to the 200's Unit low side was in the room. The surveyor escorted the UM to the bathroom where we all observed the Foley catheter drainage bag stored in the bathroom and the drainage port was not capped.
On 01/19/23 at 9:30 AM, the UM informed the surveyor that the Foley catheter drainage bag was discarded and the staff was in-serviced.
Review of the facility's policy titled, Handwashing/Hand Hygiene dated 10/18 and last revised 12/22, documented the following:
Policy: Provide guidelines for effective handwashing/hand hygiene in order to prevent the transmission of bacteria, germs and infection.
Guidelines: Handwashing will be performed by staff as follows
1. When coming on duty.
2. Before and after contact with patients and between patient contacts.
3. Before gloving and after gloves are removed.
The nurse failed to adhere to the facility's policy for hand hygiene.
On 01/19/23 at 10:25 AM, the DON provided a policy titled, Catheter Care, Urinary dated 10/09 and last revised 12/22, which revealed the following:
Policy: It is the policy of the facility to prevent catheter associated urinary tract infections and to maintain the dignity and privacy of our residents utilizing urinary catheters. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. The policy did not address the storage of the Foley catheter drainage bag.
2. On 01/04/23 at 11:25 AM, the surveyor observed a Certified Nurse Aide (CNA) wearing a cloth mask, a surgical mask over the cloth mask and an N95 Respirator mask with only one strap secured, and was outside Resident #279's room that had Droplet Precaution sign and a large STOP sign posted on the outside of the room do to being on observation for COVID-19. The signs also indicated how to put on a respirator, Position your respirator correctly and check the seal to protect yourself from COVID-19, Do not allow facial hair, jewelry, glasses, clothing, or anything else to prevent proper placement or to come between your face and the respirator. The CNA then put on a disposable gown, secured the back, and proceeded to put gloves on without first performing hand hygiene. At 11:29 AM, the CNA exited the room holding a cup and went to the ice machine to get ice for the cup. Upon return the surveyor interviewed the CNA about the purpose of the white respirator mask. The CNA stated it was for the isolation rooms, and she was told how to wear it.
On 01/04/23 at 11:34 AM, the surveyor interviewed the Unit Manager (UM) and asked him to observe the CNA with three masks on, including the unsecured N95 Respirator and asked him what should be worn in the isolation room and informed him of the surveyor's observation. The UM confirmed that the N95 Respirator was unsecured and stated she shouldn't be wearing the N95 over another mask.
On 01/06/23 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) regarding what personal protective equipment (PPE) was worn in the observation rooms. The surveyor asked the DON what ppe is worn in observation rooms. The DON stated and N95, face mask. The surveyor asked why do people need to wear N95 masks and the DON stated it protects from exposure to Covid and it should be fit tested to give them a good seal.The surveyor asked how is should be worn. The DON staed both straps have to be on and if not it won't maintain a proper fit. Asked if the mask could be worn over other masks and the DON stated no will affect the fit and the effectiveness of the mask. The survyor informed the DON of the observation and asked if it was okay. The DON stated no, that is not okay and the CNA had been educated on the masks, and she needs to follow the proper way to don and doff, must use alcohol based hand sanitizer before putting on gloves.
c.) On 01/09/23 at 8:57 AM, Surveyor #2 observed a lady walking down the hall from the reception area, down the hall where the rehabilitation gym was located, into the blue unit nursing desk area, and down the blue unit middle hall. Surveyor #2 observed that the lady was not wearing any mask. Surveyor #2 observed the lady stop within arm's length of another resident and speak to that resident. At that time, Surveyor #2 stopped and questioned the lady who was identified as a visitor. Surveyor #2 asked the visitor if she had been offered a surgical mask when she entered the facility. The visitor stated she didn't think so and that she would go back to the reception area to get a mask. The visitor walked back down both areas of the blue unit, down the rehabilitation gym hall, and to the reception desk to obtain a surgical mask.
On 01/09/23 at 9:02 AM, during an interview with Surveyor #2, the staff member at the reception desk identified herself as normally working in the Business office but was working at the reception area. The staff member stated she had been outside at the time the visitor entered the facility and that a dietary aide (DA) had been at the reception desk.
On 01/09/23 at 9:05 AM, Surveyor #2 interviewed the DA who was at the reception desk regarding the visitor. The DA stated that a mask was given to the visitor but that she wasn't watching and had no idea if the visitor put the mask on. The DA further stated the visitor should have had a mask on prior to entering the facility.
On 01/09/23 at 9:37 AM, during an interview with Surveyor #2, the DON was informed about the situation. The DON stated the visitor should have been instructed to wear a mask prior to go into facility. The DON stated the visitor could expose others or be exposed to COVID-19. The DON stated the DAs responsibility did not end by just handing the visitor a mask.
d.)1. On 01/18/23 at 12:14 PM, Surveyor #2 observed a resident room on the Peach unit with signage for Droplet Precautions and a bin containing PPE inside of the door. Surveyor #2 observed a staff member inside the room within arm's length of Resident #280. The staff member was wearing a surgical mask and eye protection. The staff member had no other PPE on and was delivering and helping to set up the resident's lunch tray. The resident was sitting on the side of his/her bed with no mask on.
The staff member exited the room and was interviewed by Surveyor #2 at that time. The staff member was identified as a Registered Nurse (RN) who stated she was just bringing the tray in to Resident #280. The RN stated that the resident was a new admission, and the facility was waiting to learn of the resident's COVID-19 status. The RN further acknowledged that the transmission-based precaution signs were visible on the resident's door and that she should have been wearing full PPE.
On 01/18/23 at 12:27 PM, the LNHA was observed on the Peach unit and was made aware of the above situation.
On 01/18/23 at 12:49 PM, Surveyor #2 interviewed the facility RN Infection Preventionist (RN IP) who stated that a new admission and unsure of their vaccination status, would be placed as a PUI for 7 days droplet precaution isolation. She stated that with droplet transmission-based precaution, the staff should wear an N95 mask, full PPE gown, gloves and eye protection, and use hand sanitizer. The RN IP stated that the PPE bins should be kept in front of the resident door for PUI, and stated, I don't know why we keep PPE outside the door, and I would expect to see them (staff) in PPE as per the signage on the door.
A review of Resident #208's hybrid medical record revealed an admission Record revealed that the resident was admitted on [DATE] with no diagnoses listed. The Order Summary Report revealed an order dated 01/18/23 for transmission-based droplet precautions until 01/24/23. A review of the Immunizations revealed only a tuberculosis skin test step 1 administered on 01/17/23. A review of the Medication Administration Record (MAR) for January 2023, revealed an order for transmission-based droplet precautions every shift for 5 days and had been signed off on 01/18/23 by the RN who had been in the room without all the required PPE. A review of the on-going Care Plan (CP) revealed a focus area dated 01/18/23, is at risk for COVId-19 infection due to no history of vaccine cards, transmission droplet base precaution times seven days; interventions included but were not limited to maintain transmission-based precautions .use PPE per CDC guidelines.
A review of the facility provided, Handwashing Competency Checklist, dated 08/01/22, revealed the RN was deemed competent to perform handwashing tasks independently and without supervision.
A review of the facility provided, PPE Use When caring for Patients with Confirmed or Suspected COVID-19 Competency, dated 08/01/22, revealed the RN had been deemed competent in PPE Donning (putting on) and PPE Doffing (taking off).
A review of the facility provided, Cohorting and PPE during the COVID-19 Public Health Emergency, revised 03/22/22, included but was not limited to new or readmitted asymptomatic residents who are not up to date with all recommended COVID-19 vaccine doses . Precautions to take included N95 mask or higher-level respirator, gloves, gown, and goggles or shield.
e.) On 01/05/2023, a review of the facility's Covid-19 Pandemic Exposure Control and Response Plan indicated that the facility requires employees to report immediately to their immediate supervisors if they are experiencing signs and symptoms of Covid-19. In addition:
1) If an employee develops any signs or symptoms of Covid-19 or a respiratory illness, such as fever, an atypical cough or shortness of breath, they must: not report to work, notify their immediate supervisor, self-isolate and consult with their healthcare provider.
2) All employees will be screened for signs and symptoms of Covid-19 on a daily basis prior to the start of their shifts, which screening will also include a daily temperature check.
3) Any employee exhibiting signs and symptoms of Covid-19 will not be permitted to work and will be immediately sent home to self-isolate and/or seek medical attention.
On 01/05/2023, a review of the facility's Infection Control policy: Protocol for an Outbreak revised and dated 09/06/2022, indicated that staff exhibiting signs and symptoms of Covid-19, to inform the facility prior to coming to work and follow Department of Health (DOH) guidelines for return to work. Staff, both vaccinated and unvaccinated, with signs and symptoms must be tested. The policy also indicated to refer to current Centers for Disease Control and Prevention (CDC) guidance for ongoing testing recommendations.
On 01/05/2023, a review of the CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) during the Covid-19 Pandemic, last updated on 09/23/2022, recommends for HCP to monitor themselves for fever or symptoms consistent with Covid-19, and not report to work when ill. Any HCP who develop fever or symptoms consistent with Covid-19, should immediately self-isolate and contact their established point of contact to arrange for medical evaluation and testing. Facility staff with signs or symptoms must be tested, regardless of Covid-19 vaccination status. Symptomatic HCP who test negative for Covid-19 should be excluded from work.
On 01/06/2023 at 09:38 AM, in the presence of the survey team, the Director of Housekeeping (DH), wearing an N95 mask, stated that he would have to sit away from the surveyors because he had been sick and his voice still sounded funny. This surveyor observed the DH's voice to sound hoarse with an occasional cough and clearing of throat while talking to the surveyors.
On 01/06/2023 at 11:31 AM, the Director of Nursing (DON) stated that she was unaware that the DH was sick or had any symptoms. The DON stated that the DH should have been tested right away and sent home. The DON also added that the DH was due to be tested for Covid-19 on 01/06/2023 because he is unvaccinated.
On 01/06/2023 at 12:03 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a negative Covid-19 rapid test result for the DH dated 01/06/2023. The surveyor observed that the DH's negative test result did not indicate the time the Covid-19 test was performed. The LNHA stated that the facility's testing form to document Covid-19 testing results only indicated a date of the testing, not a time that the testing was performed. The LNHA and DON confirmed that the DH was unvaccinated, that the DH did not notify them of having symptoms, and the DH was not tested for Covid-19 prior to entering the facility before surveyor inquiry.
On 01/10/2023 at 12:32 PM, in the presence of the survey team, the LNHA stated that the DH should have notified administration about symptoms and tested prior to entering the facility. The LNHA added that all testing was done at the beginning of the shift to be sure staff are not positive before entering the facility to work. The LNHA stated that the day shift Nursing Supervisor was responsible for the testing and the DON was responsible to follow up on the testing. The LNHA and DON were asked what the facility policy was for staff that test negative for Covid-19 but are still symptomatic? The LNHA and DON were unable to clearly state the facility policy. The LNHA stated, I will have to check the policy to see what should be done for symptomatic staff.
On 01/11/23 at 9:39 AM, the surveyor interviewed the LNHA regarding if the DH was currently at the facility. The LNHA stated he was not there today or yesterday. The surveyor inquired if he was sent home on [DATE], the day he reported to the surveyors that he had been ill. The LNHA stated no, he wasn't sent home because it was the end of the day. The surveyor asked the LNHA if scratchy throat was a symptom of COVID-19. The LNHA stated yes, it is a symptom.
On 01/17/2023 at 11:00 AM, the LNHA provided the surveyor with the DH's Staff /Visitor Screening form for Covid-19 dated 01/06/2023. The surveyor observed that the DH indicated NO for signs or symptoms of Covid-19. The LNHA stated that both the LNHA and DON monitor the Staff/Visitor Screening Form for Covid-19.
On 01/20/23 at 9:43 AM, during an interview with the surveyor, the DH, employed at the facility for 7 months, stated that on 01/06/2023 he only had a scratchy throat which made him have a raspy voice. The DH added that he indicated no symptoms on the Covid-19 Screening Form because he didn't have a fever and had no symptoms other than a scratchy throat. The DH stated that he had been educated about notifying the facility if having any symptoms and, if having symptoms or feeling sick to get tested prior to entering the facility. The DH confirmed that on 01/06/23 he should have notified the LNHA about his symptom of a scratchy throat and should and been tested before coming to work.
The Policy/Procedure: PPE during the COVID-19 Public HealthEmergency, Revised 09/10/21 revealed in Observation rooms (New or Readmission), the Type of PPE Needed for Droplet Precautions: N95 Mask, Gloves, Gown, Goggles or shield.
The Donning and Doffing Personal Protective Equipment (PPE) policy, undated revealed It is the policy of this facility to follow the CDC guidelines for donning and doffing of PPE. Procedure: See attached CDC donning and doffing sequence. 2. Mask or Respirator, secure elastice bands at middle of head and neck, Fit flexible band to nose bridge, Fit snug to face and below chin, Fit check respirator
Handwashing/Hand Hygiene Policy, Reviewed 12/2022, Policy: To provide guidelines for effective handwashibng/hand hygiene, in order to prevent the transmission of bacteria, germs and infections. Guidelines: Handwashing/Hand hygiene will be performed by staff as follows: .Before gloving and after gloves are removed .
NJAC 8.39-19.4 (a)

Based on interview, record review and review of pertinent documents, it was determined that the facility failed to protect a resident (Resident #182) from abuse by a Certified Nurse Aide (CNA #1) by failing to ensure: a.) the facility policy was followed to identify an allegation of abuse, b.) that upon receiving an allegation of abuse on 01/17/23 during the 7:00 AM to 3:00 PM shift, the facility immediately protected Resident #182, and other residents from potential abuse, and c.) a thorough investigation was immediately initiated. This deficient practice occurred for 1 of 2 residents reviewed for abuse, and on 1 of 4 resident units.
The facility's failure to ensure the abuse policy was followed to protect a resident from abuse, and ensure a process was in place to protect all residents from potential abuse resulted in an Immediate Jeopardy (IJ) situation that began on 01/17/23 when a family member of Resident #182 informed the facility that CNA #1 was not nice to Resident #182, and had and attitude, and the facility failed to immediately initiate an investigation and CNA #1 proceeded to work on the same resident unit the following day, 01/18/23, and was assigned to nine residents.
The facility administration was notified of the IJ situation on 01/19/23 at 2:56 PM.
The facility submitted an acceptable removal plan on 01/20/23 at 9:00 AM.
On 01/20/23 at 9:00 AM, the removal plan was verified as implemented by the survey team during the survey.
The non-compliance remained on 01/20/23 for no actual harm with the potential for more than minimal harm, that is not Immediate Jeopardy, based on the following:
The evidence was as follows:
On 01/19/23 at 8:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a written memo that she had received regarding a request to speak with a family member.
On 01/19/23 at 8:46 AM, the surveyor contacted the family member (FM) of Resident #182 and conducted a telephone interview. The FM stated Resident #182 had an issue with CNA #1 who had walked into Resident #182's room and was nasty to Resident #182 on 01/17/23. The FM stated CNA #1 told the resident that she was not going to have to change (provide incontinence care) the resident again, since Resident #182 was not her only resident. CNA #1 told Resident #182 that she was on her break at the time, and CNA #1 refused to change Resident #182. CNA #1 then proceeded to throw down the food plate lid with force on Resident#182's over bed table. The FM stated that he/she had made the Director of Social Services (DSS) aware of what happened on the same day, 01/17/23.
On 01/19/23 at 8:50 AM, the surveyor interviewed Resident #182 while the resident was in bed. Resident #182 stated that he/she had a problem with a female Certified Nurse Aide (CNA #1) on Tuesday (01/17/23). Resident #182 stated that CNA #1 told him/her that he/she was not her only resident, and CNA #1 also threw the meal tray down. Resident #182 stated that CNA #1 had seemed mad at the time because CNA #1 stated she was on her break. Resident #182 stated he/she had informed the DSS what happened on the same day, 01/17/23.
On 01/19/23 at 8:54 AM, the surveyor reviewed the CNA assignment sheet for 01/19/23, with the Unit Manager (UM). The assignment sheet for 01/19/23, revealed that there were two CNAs listed to care for the residents on the unit. The surveyor inquired to the UM what the current resident census was for the unit. The UM stated thirty-eight residents were on the unit, and the surveyor asked what the staffing typically was, and if any of the CNAs that had worked on 01/17/23 were removed from the schedule for any reason. The UM stated that there was usually five or six CNAs staffed on the unit, and he was not sure who had called out sick. The UM then stated no, CNAs had been removed from the schedule for any reason and stated there were three CNAs that had scheduled days off (which included CNA #1).
On 01/19/23 at 9:23 AM, the surveyor conducted an interview with the DSS and inquired if there were currently any investigations in progress. The DSS stated that he had received a grievance from Resident #182 on 01/17/23. At that time the DSS provided the surveyor with the copy of the [Facility Name], Grievance/Missing Item Report, which revealed: Date: 01/17/23 (untimed), Resident: [#182], Room: [Resident #182's room number]. Complaint Made By: Patient, Complaint Made to: DSS, Statement of Complaint:, On 01/17/23, at about lunch time, the patient stated a CNA threw the lid cover on the food/tray table. A handwritten Addendum documented directly below the 01/17/23 Statement of Complaint revealed On 01/18/23, on the date above, the Patient stated that the same CNA, while on the total lift machine, wanted to be placed in bed .The statement continued on a blank page which revealed . and in need of a change of [his/her] disposable brief, the CNA stated, Your [sic.] not my only patient, there's no way I'm doing this tomorrow. While in bed, [he/she] was not changed by that CNA. After a while, [he/she] was changed by someone else. The DSS stated that he completed his portion on 01/17/23, when the FM of Resident #182 brought him into the resident's room to speak with Resident #182, and he confirmed that he took the statement from Resident #182 and stated, the complaint was made to me. The DSS stated he brought the initial complaint, on 01/17/23, to the Director of Nursing (DON), because when the complaint involved nursing the DON was responsible for getting statements. The DSS stated that the DON was responsible for the investigation, along with the LNHA, who was the facility abuse coordinator. The DSS stated I would imagine the Director of Nursing has followed up on it [the complaint made by Resident #182]. The DSS stated that he conducted a follow-up interview with Resident #182 on 01/18/23, and at that time, the resident provided an additional statement that he also documented on the form. At that time, the surveyor requested and the DSS provide the surveyor with a copy of the facility abuse policy. The surveyor inquired to the DSS if what Resident #182 stated to the DSS would fall under the abuse category. The DSS stated, yes, that it is verbal abuse, neglect, and it touches many bases. The DSS stated again, he immediately informed the DON of the allegation made by Resident #182 on 01/17/23. The surveyor inquired to the DSS what the process was when an allegation of abuse occurred, and what his involvement was. The DSS stated he was not involved with the abuse investigation, he assisted with grievances, and missing items, and because the allegation received from the FM and Resident #182 was related to abuse. The DSS stated I immediately told the DON and stated, I would imagine that the DON has followed up on it. The surveyor asked the DSS if this allegation would be a priority, and he stated, yes, and the first thing that would be done would be [CNA #1] would be removed from providing care, and stated if it is alleged abuse, then she cannot come to the facility until the investigation is completed, because you would not want someone who was alleged to have performed an abusive act working because it could happen again. The DSS stated when he took the initial complaint from Resident #182, he had initially thought it was an allegation of abuse and neglect because CNA #1 failed to perform care for the resident, and then slammed the lid down which was aggressive and possibly violent. The DSS stated he was instructed by the DON to provide the UM with blank statement forms on 01/17/23, which he had done, and he instructed the UM to get the statements per the DON's instructions. The DSS stated he provided the copy of the grievance form to the UM on 01/18/23. The surveyor asked the DSS what further involvement he had in the abuse investigation process, and had he received any further communication regarding the allegation provided by the DON/ LNHA, and he stated, no, not to me. An initial review of the Facility Policy/ Procedure, Abuse Prevention Program, Original Issue Date: 2/2014, Revised: 10/21/22, in the presence of the DSS revealed under Part V, Investigation, Procedure: The administrator who is the Abuse Prevention Program Coordinator, and the DON will initiate investigations of any allegations of abuse, determine necessary response, and report to the office of the Ombudsman and the Department of Health and Senior Services, as necessary. The scope of the investigation shall be determined by the Administrator and/or the DON. The Protection Procedure revealed, When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor, notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary.
On 01/19/23 at 9:50 AM, the surveyor conducted an interview with the UM for the unit that Resident #182 resided on. The surveyor inquired to the UM if he had received any complaints or was currently involved in any investigations regarding any residents. The UM stated that the FM of Resident #182, came to him on 01/17/23 and informed him that CNA #1 had an attitude, and she was not nice to the resident. The UM stated that he informed the DON and the DSS the same day of the FM's complaints. The surveyor inquired if the UM had been instructed to do anything because of the complaint. The UM stated, I was told to take statements, but because the UM found out late in the afternoon on 01/17/23, CNA #1 had already left for the day and he was unable to obtain a statement. The UM confirmed to the surveyor that CNA #1 was the CNA assigned to Resident #182, and then stated he obtained a statement from CNA #1 on 01/18/23, which was the following day after the allegation The UM stated that CNA #1 worked her full resident assignment on 01/17/23 and again on 01/18/23.
At that time, the surveyor reviewed the 01/18/23, 7:00 AM-3:30 PM assignment sheet for the CNAs, and CNA #1's assignment included nine residents. Resident #182's room had both beds crossed off, and it was replaced with two other beds in another room. The UM stated that when CNA #1 arrived to work on 01/18/23, that she had started her assignment first, and then he had spoken to her (time not provided by UM) regarding the reason for being removed from providing care to Resident #182. However, the UM confirmed that CNA #1 continued to work and was assigned to a resident care assignment which included nine residents. The assignment was located on the same unit where Resident #182 still resided and had access to Resident #182, and all other residents. The surveyor asked the UM if he had been provided a copy of the grievance from the DSS, and he stated, yes. The surveyor asked the UM if what was written on the form represented abuse and neglect, and the UM stated, yes, and stated CNA #1 told him, it never happened, and that Resident #182 was happy with the care she had provided. The surveyor asked the UM if he had interviewed anyone else regarding the allegation. The UM stated he had interviewed the four CNAs (including CNA #1) that worked on the unit on 01/17/23, the date when the allegation was received, and the surveyor asked if the UM had interviewed anyone else in addition to the CNAs. The UM stated, no, and the surveyor then asked if the UM had interviewed any residents. The UM stated, no, and that he provided the statements he collected to the DON. The surveyor inquired to the UM if it was still an ongoing investigation, and the UM stated yes.
On 01/19/23 at 10:46 AM, the surveyor, in the presence of the survey team, interviewed the DON and LNHA. The surveyor asked what the process was if there was an allegation of abuse. The DON stated the process was, if there was an allegation of abuse, an investigation would be started immediately, and stated right away after she received the complaint. The surveyor inquired if there had been any recent complaints, or allegations of abuse. The LNHA stated there was a grievance provided by the DSS, and the DON and LNHA confirmed it was provided to both on 01/17/23, and the LNHA stated she had been made aware by the UM on 01/17/23 at 4:00 PM. The surveyor asked what the process was when a grievance was received. The DON stated as soon as she received it, that she would identify the caregiver and nurse assigned to the patient, and then she would obtain a statement from the staff that were involved with the resident, including the family, doctor, nurses, and other residents assigned to the staff. The DON stated that the assigned aide to the person who had the complaint would be suspended while the investigation was ongoing, because we don't want any incident to happen, we want to protect the resident and any other resident assigned. The surveyor informed the DON and LNHA that CNA #1 worked on 01/18/23, despite the DON stating the staff would be suspended during the investigation, and the surveyor informed the DON and LNHA that the UM had confirmed he was made aware of the allegation on 01/17/23 and CNA #1 was allowed to work and provide resident care the following day. The surveyor asked about Resident #182's allegation that CNA #1 threw the lid cover, and the DON stated, I would say that was an attitude, and the DON stated based on that assumption she took CNA #1 off Resident #182's assignment. The surveyor asked where attitude would fall in the abuse policy and the LNHA stated it was just sensitivity, and the DON stated the employee could have burnout but may not have intended to be insensitive to the resident. The DON stated we would have to investigate to see if there was an intention of abuse. The DON was asked if there had to be intention for abuse and the DON responded to the survey team, no. The DON then stated that we spoke with the aide on 01/17/23 (no time provided), after the complaint was made. When the surveyor inquired to the DON when she was informed about the incident from the UM, the DON stated, I could not even remember what he told me on 01/17/23, because it was late in the afternoon. The surveyor inquired to what time the DON received the statement from CNA #1, and the LNHA stated we found out at 4:00 PM about the allegation, and that was when the statement was written. At that time, the surveyor inquired to the LNHA who had the facility received statements from, and the LNHA confirmed she had a statement from CNA #1, and three other CNAs who worked that day. The DON stated we didn't get statements from the nurses that worked that day and then stated that they received statements from the four CNAs that worked on 01/17/23, and the UM. The surveyor inquired to the DON if she had interviewed the resident when she had found out about the allegation on 01/17/23, the DON stated yes, at 3:00 PM, but that was late in the afternoon. The surveyor asked what the DON had asked the resident, and the DON stated, how are you today and no other specific questions per the DON. The DON stated the UM also spoke with the resident on 01/17/23 and confirmed there was no documented evidence when inquired by the surveyor. The DON stated that other alert and oriented residents would still need to be interviewed to obtain statements, and confirmed the investigation was not complete yet, that they cannot just let it go, and we don't tolerate that. The surveyor asked was anything done for residents who were not alert and oriented and the DON stated we would do a body assessment. The surveyor inquired if that was done and the DON stated no, and the LNHA stated we could ask the family members about any concerns with the caretaker. The LNHA stated yesterday was really when the investigation began, and the other day was just a comment. The surveyor inquired if the investigation was completed on 01/18/23, and the DON stated, no. The surveyor then asked if it the investigation was not completed, was CNA #1 supposed to work and have a resident assignment on 01/18/23. The DON stated, this was given to us late, and the DON and LNHA did not offer an explanation as to why CNA #1 worked on 01/18/23 and provided resident care. The surveyor asked why it was important to interview other staff, and the LNHA stated to make sure other residents are safe. The surveyor asked what kind of an allegation the statements made by Resident #182 represent, the DON stated, a complaint. The surveyor asked if the allegation was an allegation of abuse, and the LNHA stated, yes. The surveyor asked is there anything else that should be done when an allegation of abuse was made. The LNHA stated I have to report it to the State and Ombudsman within two hours, and confirmed it was reported to the State Department of Health on 01/19/23, two days later, and not within two hours.
On 01/19/23 at 12:00 PM, the surveyor reviewed the medical record for Resident #182 which revealed the following: An admission Record revealed the resident had diagnoses which included, but were not limited to; respiratory failure, chronic obstructive pulmonary disease, and pneumonia. The admission Minimum Data Set, an assessment tool, dated 01/14/23, revealed the resident was totally dependent on one person for toileting, and had no behavioral symptoms. The Care Plan included a Focus: date initiated 01/11/2023 for an ADL (Activity of Daily Living) deficit r/t (resulted to) general weakness, Goal: Resident will improve current level of function in (bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score) through the review date, a Focus: date initiated 01/11/23 for Resident is at risk for falls r/t general weakness, osteoarthritis, Goal: Resident will not sustain serious injury through review date, Interventions: Anticipate and meet needs, Anticipate toileting needs, Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance, Monitor effects of medications, a Focus: date initiated 01/11/23, Resident has a potential for skin breakdown secondary to limited mobility in bed, Goal: Resident will have care needs met as evidenced by no skin breakdown, Interventions included: keep skin clean and dry, sheets as wrinkle free as possible, observe skin during bathing, turning, and incontinence care for early signs of breakdown, turn and reposition resident every 2 hours and as needed, use proper positioning, transferring, and turning techniques to minimize skin injury due to friction and shear force (all interventions date initiated 01/11/2023).
On 01/19/23 at 12:21 PM, the surveyor requested a copy of the investigation file from the LNHA and the LNHA stated the DSS was still in the process of collecting interviews.
On 01/19/23 at 12:23 PM, the LNHA provided the surveyors with an incomplete copy which included page one and three of the Reportable Event Record that was submitted to the Department of Health, Dated 01/19/23 and Timed, 9:55 AM, along with a copy of a statement from CNA #1, dated 01/17/23 (untimed), a statement, dated 01/17/23 (untimed) from CNA#2, a statement from CNA #3, dated 01/18/23 (untimed), and a statement from CNA #4, dated 01/17/23 (untimed). The statements also included the Grievance/Missing Item Report from the DSS with additional information added in the Department Responsible for Resolution section statement, dated 01/18/23 and a statement dated, 01/17/23 from the DON (untimed), and a statement from the UM, dated 01/17/23 (untimed). The handwritten statement dated 01/17/23 and signed by the UM revealed .8:00 AM During rounds, pt [patient] was in bed eating breakfast and watching TV [television], 10:20 AM pt was helped with his/her am [morning] care and went to rehabilitation gym for pt/ot [therapy], 12:00 PM pt in bed having lunch, 2:00 PM CNA's helped with diaper change spouse at the side, 3:00 PM Pt [patient] was in bed resting. Pt did not voiced [sic.] any complaint to me. The statement written by the UM failed to include the allegations confirmed by the UM that he had received from the FM of Resident #182 on 01/17/23, who had informed him that CNA #1 had an attitude, and she was not nice to the resident, and the statement failed to document any follow-up from the allegations the UM received from the DSS which the UM confirmed had confirmed receiving, and failed to document any follow-up regarding the allegations that the UM confirmed he received from the DSS. The statement provided from CNA #1 on 01/17/23 contradicted what the UM stated regarding not being able to obtain a statement from CNA #1 because she had already left for the day, and he stated he informed her of the allegations on 01/18/23.
On 01/19/23 at 1:02 PM, the surveyor, in the presence of another surveyor, interviewed Resident #182 with the FM present. The surveyor asked Resident #182 about the incident that occurred with CNA #1, and how it made the resident feel. Resident #182 stated it made him/her feel not good, and he/she was upset and shocked, and the resident was concerned for how he/she would receive care the following day after the incident. Resident #182 stated CNA #1 was mad and left the room and then stated there was no one present when the CNA was not nice to the resident. The FM stated they now had to hire private care to ensure Resident #182 would receive care.
On 01/19/23 at 1:30 PM, the DON provided the Time Card Report, for CNA #1 which revealed CNA #1 worked 01/17/23 from 6:55 [AM] to 15:30 [3:30 PM], and on 01/18/23 from 6:53 [AM] to 15:47 [3:47 PM].
On 01/19/23 at 1:36 PM, Surveyor #2 conducted an interview with the UM. Surveyor #2 asked the UM when he was first made aware of the allegations made by Resident #182. The UM stated the FM of Resident #182 told the UM on 01/17/23, and the UM immediately informed the LNHA and DON. Surveyor #2 asked the UM if he had interviewed Resident #182, and he stated I just asked how [he/she] was and [he/she] stated fine. The UM failed to document the allegation received from the FM, failed to document any interviews with Resident #182 regarding the allegations made by Resident #182, nor with the resident's spouse or FM.
A further review of the Policy/Procedure: Abuse Prevention Program, Original Issue Date: 2/2014 revealed Policy: This facility prohibits abuse, neglect, involuntary seclusion, and misappropriation of property from residents and will utilize the abuse prevention program to effectively prevent occurrences, screen and train staff, identify, investigate, report, and respond to any occurrences .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Forms of resident abuse: Active Forms of Abuse: .2. Verbal Abuse: Talking to residents in a demanding manner, shouting, cursing, and name-calling ., Passive Forms of Abuse: 1. Emotional Abuse: Deliberately ignoring a resident's request, denying a resident water, food, a bedpan, a call bell, etc. for a period of time., 2. Neglect: The failure of the facility, it's employees, or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (ex: [example] allowing a resident to lie in urine or feces, ignoring a resident, not providing daily cleanliness, personal hygiene, proper mouth care, shaving, hair washed and combed, dressing a resident inappropriately and or in dirty clothing. Leaving resident exposed during bathing, dressing, changing etc .). Neglect of goods or services may occur when staff are aware of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (Example-suctioning, transfers, use of equipment. Lack of sufficient staffing to be able to provide the services, lack of supplies, or lack of knowledge of the needs of the resident. Abuse Prevention Program-Part VII- Protection, Procedure: When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. Abuse Prevention Program-Part V1- Identification, Procedure: .Any unusual occurrence, which may potentially constitute abuse, neglect, or involuntary seclusion, will be identified as a potential abuse incident and investigated as such .Abuse Prevention Program-Part V11 Reporting/Response .When an incident is reported to the supervisor, the supervisor is responsible for ensuring that the resident is safe and will notify the administrator as well as the DON, or their designees The administrate and DON will initiate the investigation of the potential abuse incident, determine the necessary response and report to the Department of Health and Senior Services and/or the office of the Ombudsman (if applicable) as per regulations including Peggy's Law. Alleged violates involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .The scope of the investigation shall be determined by the administrator and/or the DON .
N.J.A.C. 8:39-4.1 (a)5,12; 27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to have a process in place to identify a bed that was broken for 1 of 26 residents reviewed who had a visibly broken bed (Resident #180). The deficient practice was evidenced by the following:
On 01/03/23 at 12:09 PM, the surveyor interviewed Resident #180 while the resident was sitting in bed. The resident stated the only issue was that he/she could feel the screws from the bed frame and it was hard to sleep. Resident #180 stated he/she had to sleep a certain way, and kept telling them (the facility staff) and nothing is done. Resident #180 was sitting in the bed and the surveyor was unable to observe the mattress at that time.
On 01/04/23 at 11:53 AM, the surveyor observed that Resident #180 was not in the room and observed that the mattress was not covered by a blanket and was visibly sunken in, in a circular pattern about a foot long. The surveyor brought the Unit Manager (UM) into Resident #180's room and asked him to look at the mattress. The UM looked at the mattress, felt the indent, and stated the mattress needs to be changed. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to Resident #180 regarding the resident's mattress. The LPN stated to be honest, [he/she] did not tell me about the mattress.
On 01/04/23 at 11:59 AM, the surveyor brought Resident #180's Certified Nurse Aide (CNA) into the resident's room for an interview at the same time Resident #180 was self propelling in a wheelchair into the room. At that time the surveyor asked the CNA if she ever changes Resident #180's bed and she stated I always change the bed, [he/she] didn't tell me. Resident #180 stated to the CNA and Surveyor I have told everybody about the bed, I may be able to sleep better. The CNA felt the middle of the mattress and stated, oh yes, that needs to be changed. The UM entered the room and the CNA then stated that she never took care of Resident #180 until that day. Resident #180 told the CNA and UM, in front of the surveyor, I have told so many people about my mattress, and if you lay on it you can feel the screws. The CNA and UM both denied, to the resident, that he/she told either one of them about the mattress. The UM stated to Resident #180 that if you told me, I would have changed it.
On 01/04/23 at 12:17 PM, the surveyor reviewed the 12/29/22 nursing assignment sheet, provided by the UM, which revealed the CNA was also assigned to Resident #180 on that day. The UM stated if the resident has a complaint we can call or put in the maintenance book. At that time, the surveyor reviewed the maintenance book, along with the surveyor, from the time Resident #180 was admitted . The maintenance book did not have any documented evidence of Resident #180's broken bed.
On 01/04/23 at 12:21 PM, the UM informed the surveyor that a new mattress was provided to Resident #180.
On 01/06/23 at 8:30 AM, the surveyor observed Resident #180 sleeping in bed.
On 01/06/23 at 9:01 AM, the surveyor observed Resident #180 sitting at the side of the bed, eating breakfast. The surveyor interviewed the resident how the bed was, and the resident stated much improved, the surveyor asked the resident if he/she was more comfortable. Resident #180 stated, yes, my body is not in one position and I don't have to contort my body to sleep, the pain is greatly improved. Resident #180 stated he/she was looking forward to going home.
On 01/06/23 at 9:28 AM, the surveyor interviewed the Regional Maintenance Director, along with the facility Maintenance Director (MD) regarding mattress repair. The MD stated he was not responsible for mattresses and that housekeeping was responsible.
On 01/06/23 at 9:38 AM, the surveyor interviewed the Housekeeping Director (HD), in the presence of two surveyors, regarding any responsibility that his department had regarding mattresses. The HD stated he was primarily responsible for changing the mattresses, and he did not recently change Resident #180's mattress. The HD stated he was not made aware that the resident needed a new one. The surveyor inquired to the HD about what kind of mattress was the dark matter, and he stated a standard mattress. The surveyor asked if the mattresses could sink in. The HD stated he didn't see that often, but it does happen, and stated that maybe the housekeeper changed it, and he would look into it. When asked who was responsible for checking if the mattress was in good condition. The HD stated the housekeepers do not determine the integrity of the mattress, and they were responsible for keeping it clean.
On 01/20/23 at 10:24 AM, the survey team met with the administrative team which included the Director of Nursing, Administrator, Corporate Director of Operations, and Quality Assurance Nurse. The surveyor informed the administrative team about Resident #180's sunken in bed, confirmed by the UM and CNA and was not documented in the maintenance log.
On 01/20/23 at 12:44 PM, the administrative team did not provide additional information regarding the broken bed.
The facility provided Maintenance Service Policy, undated, revealed a policy Statement: It is the policy of this facility that maintenance service be provided to all aeas of the building, grounds, and equipment. Procedure: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limeited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, b. Maintaining the building in good repair and free from hazards, f. Establishing priorities in providing repair service, h. Providing routinely scheduled maintenance service to all areas, i. Others that may become necessary or appropriate.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) provide adequate supervision, b.) follow the facility accident policy and initiate new fall prevention interventions in response to falls, and c.) implement existing interventions to prevent falls (5 of 6 falls reviewed were determined that the resident was left unsupervised). These failures resulted in Resident #92 sustaining multiple falls including a fall on 11/08/21 that required an emergency room transfer on 11/08/21, when Resident #92 fell out of a wheelchair, hit a tray table, sustained a laceration to the right frontal scalp, and was admitted to the hospital with a mechanical fall with head trauma and laceration without obvious intracranial bleed. This deficient practice occurred for 1 of 1 residents reviewed for falls (Resident #92) with injury and was evidenced by the following:
On 01/06/23 at 10:20 AM, the surveyor entered the room and observed Resident #92 in bed, positioned on the right side at the edge of the bed, with no device in place to prevent him/her from sliding off of the bed. The surveyor left the room and alerted the staff that Resident #92 was at the edge of the bed. At 10:30 AM, the Regional Nurse informed the surveyor she had observed the same positioning of the resident and she had placed a cushion to prevent Resident #92 from sliding off of the bed. The surveyor later returned to the room, and observed Resident #92 in a recliner chair inside the room.
On 01/09/23 at 11:30 AM, the surveyor observed Resident #92 in the dining room seated at a table. The nurse attempted to assist Resident #92 with the lunch meal, Resident #92 could not open their eyes or his/her mouth to eat. The Licensed Practical Nurse (LPN) attempted to stimulate the resident, she was calling the resident's name and asked the resident to wake up. The LPN was unsuccessful. Resident #92 was transferred to bed and the physician was contacted.
On 01/10/23 at 9:15 AM, the Unit Manager informed the surveyor that Resident #92 was transferred to the hospital and was admitted .
On 01/10/23 at 12:05 PM, a follow up interview was conducted with the nurse who was observed in the dining room with the resident on 01/09/23. She stated that she was assigned to Resident #92 on 01/09/23 during the day shift. The nurse stated a Certified Nursing Assistant (CNA) was having difficulty getting her/him to eat and drink. Resident #92 would eat a bite or two, and then his/her alertness would come and go. The physician was called and Resident #92 was admitted to the hospital with hypernatremia (elevated levels of sodium in the blood).
On 01/10/23 at 12:30 PM, the surveyor requested all fall investigations for Resident #92 and a timeline for review from the Director of Nursing (DON).
On 01/10/23 at 1:30 PM, the surveyor reviewed Resident #92's medical record. The admission Face Sheet reflected that Resident #92 had diagnoses which included but were not limited to; history of falling, major depression disorder, pressure ulcer of sacral region and anxiety disorder.
Review of the the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/05/22, revealed that Resident #92 received a score of 03 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe cognitive impairment.
A review of the facility provided Fall Risk assessment dated [DATE], revealed Resident #92 scored 15 which indicated the resident was a high fall risk.
Review of Resident #92's undated Comprehensive Care plan provided by the facility on 01/09/23, revealed: A focus area: Resident #92 has a history of frequent falls related to poor balance, unsteady gait as evidence by syncope and collapse, had a prior fall prior to hospitalization sustained left humerus fracture. Readmit 10/05/2021, with fall incident at facility 09/29/21, sustained bump forehead, no other abnormalities noted . The goal was that Resident #92 will resume usual activities without further incident through the review date.
The interventions /Tasks included:
Check range of motion.
Continue on the at-risk plan.
Keep needed items, water, etc, in reach.
Monitor side effects of medication.
Monitor/document /report PRN [as needed] x 72 hours to physician for sign/symptoms: pain, bruises, change in mental status, new onset: confusion, inability to maintain posture, agitation.
Pharmacy consultant to evaluate medications. Provide activities that promote exercise and strength building where possible.
Provide 1:1 activities if bedbound.
Physical therapy consult for strength and mobility.
Rehab [rehabilitation] screen.
Sent the Resident to Emergency Department for evaluation.
Staff to assist Resident #92 back to bed before 11:00 PM.
Anticipate and meet needs.
Be sure call light is within reach and encourage to use it for assistance as needed.
Provide prompt response to all requests.
keep residents in common areas for increased observation.
Place patient close to the nursing station for monitoring.
Further review of the Care Plan revealed that Resident #92 sustained falls at the facility on the following dates:
1. 09/28/21 at 5:45 AM, Found on the floor and had a bump on the forehead. A review of the incident report revealed that Resident #92 received the following medications Xanax , an anti-anxiety medication at 12:48 AM. Tylenol with Codeine an narcotic analgesic for pain at 12:50 AM. Resident #92 was left in the room in the wheelchair unsupervised.
According to the facility, the contributing factor was behavior.
2. 11/08/21 at 9:25 PM, fell from wheelchair in the dayroom sustained laceration on the right forehead measuring 4 centimeters (cm) x 0.1 cm. Resident unable to recall what happened. Transfer to hospital for evaluation. Contributing factors: Resident #92 was confused, poor safety awareness.
The surveyor reviewed the Medication Administration Record (MAR) and noted that Resident #92 was medicated with Remeron (an antidepressant medication) used as a sleep aid at times, and was left unsupervised in the dayroom in the wheelchair.
A review of the history and physical from the hospital record dated 11/09/21, revealed the following: Presented to the Emergency Department (ED) for evaluation after patient fell out of a wheelchair, hitting a tray table, sustained a laceration to the right frontal scalp. The diagnosis was: Mechanical fall with head trauma and laceration without obvious intracranial bleed.
The surveyor did not observe any updated interventions on the Care Plan specific for the 11/08/21 fall.
3. 04/25/22 at 11:00 PM, heard resident calling out for help. Was found sitting on the floor leaning on the bed, in front of the wheelchair. Resident #92 informed the staff that he/she was trying to self transfer to bed, but could not do it. Prior to the fall at 9:00 PM , Resident #92 received Depakote a mood stabilizer and Remeron 15 mg. Resident #92 was left unsupervised in the wheelchair in the room. Contributing factors: Behavior, confusion.
Interventions: Staff to assist patient back to bed before 11:00 PM.
A Drug regimen review completed by the Consultant Pharmacy and dated 04/24/22, documented, Resident found on the floor on 04/25/22 leaning on the bed in front of wheelchair. Resident #92 claimed to have fallen while trying to transfer to bed. Resident is on Depakote and frequently takes Tylenol with Codeine which can both contribute to dizziness and falls. Please encourage to call for assistance when needing to transfer to and from bed.
There was no documentation in the medical record that Resident #92 was being monitored after being medicated with the above medications.
4. 05/16/22 at 9:00 PM, Resident #92 slipped out of the wheelchair while in the room. Resident unable to describe what happened. Resident #92 received Remeron 15 mg orally and was left in the wheelchair unsupervised.
Interventions: Keep bed in the lowest position, floor mat to the floor. Dycem (non-slip cushion) applied to wheelchair. Rehabilitation screen.
5. 07/21/22 at 11:05 PM, the nurse was sitting at the desk, heard patient screaming, I am on the floor, help me, help me . Resident #92 was found on the floor on the right side next to the wheelchair.
The care plan did not include any new interventions in response to this fall, to prevent further falls, or to ensure Resident #92's safety in the event of further falls.
A Drug Regimen Review from the Consultant pharmacy dated 07/23/22, again documented, Staff responded to Resident screaming from room, Resident claimed to have slid from wheelchair. Resident is on routine Desyrel/ Depakote which may increase risk for dizziness and falls. Resident also has orders for PRN [As needed] Xanax and Tylenol with Codeine which may further contribute to falls.
6. 11/29/22 at 13:20 PM [1:20 PM], found on the floor mat next to the bed, redness noted to the left hip. Patient transferred to nursing station for close supervision.
Resident #92's MAR dated November 2022, revealed that Resident #92 received the following medications at 21:00 [9:00 PM]: Remeron 15 mg, Trazodone 150 mg, Depakote 250 mg, Buspar 10 mg and Gabapentin 300 mg prior the fall
The interventions /Tasks included:
Check range of motion.
Continue on the at-risk plan.
Keep needed items, water, etc, in reach.
Monitor side effects of medication.
Monitor/document /report PRN [as needed] x 72 hours to physician for sign/symptoms: pain, bruises, change in mental status, new onset: confusion, inability to maintain posture, agitation.
Pharmacy consultant to evaluate medications. Provide activities that promote exercise and strength building where possible.
Provide 1:1 activities if bedbound.
Physical therapy consult for strength and mobility.
Rehab screen.
Sent the Resident to Emergency Department for evaluation.
Staff to assist Resident #92 back to bed before 11:00 PM.
Anticipate and meet needs.
Be sure call light is within reach and encourage to use it for assistance as needed.
Provide prompt response to all requests.
keep residents in common areas for increased observation.
Place patient close to the nursing station for monitoring.
On 01/13/23 at 10:30 AM, the surveyor interviewed the Director of nursing (DON). The DON reported that the Interdisciplinary Team (IDT) which included all the department heads, met once a week to discuss, falls, pressure ulcers, weight loss, and psychotropic medications. She stated that on 11/09/21, the IDT had met and discussed Resident #92's fall that occurred on 11/08/21. She indicated that the IDT team did not discuss the use of the psychotropic medication as a contributing factor for Resident #92's fall nor suggested that Resident #92 should be returned to bed after being medicated for pain/anxiety. The DON stated that Resident #92 would refuse to go to bed, however there was no documented evidence that staff offered Resident #92 to be returned to bed after being medicated, or that he/she had refused. On 04/25/22, the fall investigation documented the following under Resident Description, Patient said, he/she was getting up to transfer to his/her bed and could not do it.
On 01/19/23 at 9:30 AM, the surveyor interviewed the Registered Nurse (RN) who worked on the 11:00 PM -7:00 AM shift regarding the protocol after any resident received pain medication and other medications used to facilitate sleep. The RN stated that staff were to check residents after 30 minutes for the effectiveness of the medication and the residents should be in bed to prevent falls. The RN could not remember the exact incident but she remembered she administered Xanax and Tylenol with Codeine to Resident #92, after the surveyor presented her with the investigation report dated 09/23/21 for review. She indicated that Resident #92 reported having pain and was anxious. She stated that she should have documented it in her notes the resident's response after the medication was administered. When asked if she had tried non-pharmacological approach prior to administering the Xanax, she stated that she could not recall. The nurse also stated that she didn't know why she did not document that Resident #92 was reassessed 30 minutes after the medication was administered.
On 01/19/23 at 9:42 AM, the surveyor interviewed the Unit Manager (UM) regarding the facility's fall protocol. The UM stated that all residents identified to be high risk for falls, were to be closely supervised. When prompted regarding the protocol after pain medication and psychotropic medications had been administered, she replied, Residents should be in bed and closely monitored for safety. The surveyor then asked the UM who was responsible to monitor the dayroom when residents were in attendance. The UM stated that activity staff were to be with residents in the dayroom. The surveyor then escorted the UM to the dayroom and we both observed 7 residents sitting in the dayroom, and there was no staff monitoring the residents.
A review of the facility's policy titled, Accident/ Incident Report dated 02/12 and last revised 12/15/17, reveled the following:
Policy: The facility has a system whereby all residents incidents/accidents are reported to the department supervisor and implementation of timely interventions to establish a reduction of repeated incidents/accidents.
Procedure: Carry out physician orders and ensure appropriate interventions are in place. Update care plan with new interventions as appropriate.
All incident/accident reports are tracked and reviewed by the IDCP team for trends and appropriateness of current interventions.
A summary of all incidents/accidents will be reviewed quarterly by the QAPI Committee for trends, locations, times and related hazards. If a trend is identified, the IDCP team will assess the system for additional and necessary interventions.
NJAC 8:39-27.1 (a)

**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 appropriate care and related services were provided, and failed to follow their change in condition policy to identify and assess a resident who had a change in condition, and there was a delay in treatment, and the resident subsequently required hospitalization on 01/09/23. This deficient practice occurred for 1 of 26 residents reviewed for care, (Resident #92), and who was transferred to the hospital emergency department via 911, and was diagnosed with hypernatremia and sepsis and was evidenced by the following:
During the initial tour of the facility on 01/03/23 at 10:15 AM, the surveyor observed Resident #92 in bed facing the wall.
On 01/04/23 at 10:36 AM, the surveyor observed Resident #92 in bed, and was facing the wall. The breakfast tray was on the bedside table and was untouched.
On 01/05/23 at 8:37 AM, the surveyor entered the room and observed Resident #92 in bed and was facing the wall, the breakfast tray was observed on the bedside table. The surveyor removed the lid from the breakfast tray and observed that the breakfast food was untouched. Resident #92's mouth was covered with dry food between the teeth extended to the upper lip and nasal area.
On 01/05/23 at 9:30 AM, the surveyor returned to the room and Resident #92 was observed still in the same position, facing the wall. The breakfast tray was on the bedside table and untouched. The surveyor asked the nurse regarding Resident #92's breakfast tray. The nurse informed the surveyor that Resident #92 was a late sleeper.
On 01/05/23 at 9:50 AM, the surveyor inquired regarding meal tray delivery on the unit. According to the meal delivery log provided by the facility on 01/05/23 at 9:55 AM, the breakfast tray arrived between 7:45 AM- 7:55 AM. There was no evidence that Resident #92 had eaten any breakfast that morning. (This was more that one and one-half hours from the surveyors initial observation)
On 01/05/23 at 10:20 AM, the surveyor escorted the Unit Manager (UM) to the room where we both observed the condition of Resident #92's mouth, hands and nails.
At the surveyor's request, Resident #92's incontinence brief was checked. Resident #92's sacral and perineal area was covered with black tarry stool. Resident #92 had a sacral wound that had no dressing coverage, and was covered with feces.
On 01/05/23 at 11:00 AM, the surveyor entered the room with the Director of Nursing (DON), the UM and the Certified Nursing Aide (CNA). The DON instructed the nurse to assist the CNA and to clean the wound.
On 01/06/23 at 10:30 AM, the surveyor observed Resident #92 in bed, and was positioned at the edge of the bed. Resident #92 had no device in place to prevent Resident #92 from sliding off of the bed. The surveyor informed the nurse who was in the hallway. The regional nurse was also in the hallway and stated that she also had observed that Resident #92 was at the edge of the bed. The regional nurse stated she had applied a cushion to prevent Resident #92 from sliding off the bed.
On 01/09/23 at 9:00 AM, the surveyor observed Resident #92 in bed with their eyes closed. Around 11:30 AM, the surveyor went to the dayroom and observed Resident #92 sitting in a wheelchair with his/her head down toward his/her chest. The nurse attempted to wake up the resident for lunch, however, the resident was unable to keep his/her head up and could not open his/her eyes. The surveyor then observed that the nurse wheeled the resident to the room and had returned Resident #92 to bed.
On 01/10/23 at 9:30 AM, Resident #92 was observed as not in their room. During a conversation with the UM, she had stated that Resident #92 was transferred to the hospital, and was admitted with hypernatremia (high concentration of sodium in the blood).
On 01/10/23 at 11:00 AM, the surveyor reviewed Resident #92's medical record.
The admission Face Sheet reflected that Resident #92 had diagnoses which included but were not limited to; a history of falling, major depression disorder, pressure ulcer of sacral region and anxiety disorder.
Review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/05/22, revealed that Resident #92 received a score of 03 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of a severe cognitive impairment.
Review of Resident #92's, undated Comprehensive Care plan that was provided by the facility on 01/09/23, revealed: A focus area for nutrition. The goal was for Resident #92 to tolerate oral intake 50-100%, meet nutritional needs for wound healing, maintain moist mucous membranes, and good skin turgor. A focus area for dehydration revealed a goal that Resident #92 will be free of symptoms of dehydration. The interventions included: Assist resident at meals. Encourage oral intake. Administer medications as ordered. Monitor/document medications side effects. Encourage to drink fluids of choice. Ensure Resident #92 has access to fluids i.e. cold water, milk, tea. Offer frequent small amount of liquid.
The surveyor observed Resident #92 in bed, facing the wall on 01/03, 01/04, and 01/05/23. During those observations, there was no water or fluid at the bedside. A cup of liquid was noted on the bedside table on 01/06/23, but was out of reach and was not accessible to the resident.
There was no documented assessment for Resident #92 in the medical record which included observations made by the surveyor on 01/03, 01/04 and 01/05/23, when the surveyor observed Resident #92 in bed, with the breakfast meal untouched, and no fluid at the bedside. There was no documentation regarding the sacral wound that was observed by the surveyor and UM to be covered with feces and, and there was no dressing to protect the wound.
Additional documentation revealed:
A late entry dated 01/09/23 at 7:32 AM, revealed, During morning care Resident noticed with change in condition. bleeding from the nose. Applied pressure dressing, packed with gauze. Primary physician paged, awaiting call back.
01/09/23 at 12:40 PM, Awaiting phone call back. (this was five hours later from the original call to the physician)
01/09/23 at 15:16 PM [3:16 PM], received in bed, sleepy, appetite with breakfast poor, consumed 10% liquid, 20% solid. Appetite remained poor with lunch, difficulty swallowing, blood pressure 80/48, temperature 99.6, pulse 119, respiration 22, difficulty swallowing, sleepy, called the physician and updated with change in condition, left message with receptionist. (This was almost eight hours after the initial call was placed to the physician) Vital signs rechecked, oxygen saturation 88%, (normal 96-100%) (3rd call) to the physician, new order received to transfer Resident #92 to the Emergency Department for evaluation, 911 called. (On 01/09/23 timed 7:32 AM, the documentation was not clear to a full assessment regarding the change in condition, other than that Resident #92 had a nose bleed and the physician was paged.)
On 01/18/23 at 10:15 AM, during an interview with the DON regarding Resident #92's change in condition, the DON stated that staff were responsible for observing, assessing, documenting and notifying the physician of any change in health condition.
On 01/18/23 at 12:30 PM, the surveyor reviewed the readmission hospital record and the following entry dated 01/09/23, was noted regarding the sacral wound:
Images for :Wound on 01/09/23 open wound Sacrum.
Wound properties: Date first assessed 01/09/23. Time first assessed 23:35 PM [11:35 PM]. Date Wound acquired:01/09/23 Present on hospital admission :Yes. Primary wound type: Open wound. Location: Sacrum Pressure Injury Stage: -- Wound Description (Comments): Quarter size deep wound, Wound bed is black with slough.
Prior to the hospital admission on [DATE], there was no supporting documentation of symptoms or a nursing assessment to indicate how the pressure ulcer appeared, or an assessment completed to determine if there were symptoms of a potential infection. The documentation addressed only poor oral intake and fair appetite.
On 01/18/23 at 6:00 PM, the surveyor conducted a telephone interview with Resident #92's representative. The representative stated she had concerns with the care at the facility and was scheduled to meet with the facility on 01/19/23. The representative stated over the last 4 months she had noticed a decline in the care that was provided to the resident. The representative stated that Resident #92 had been left in the room alone and would cry out because he/she was isolated. The representative further stated that Resident #92 was sent to the hospital on [DATE], and the hospital informed the representative that the Resident was admitted with sepsis and had an unstageable (full thickness tissue loss and unable to be staged due to being covered by other tissue) wound that the representative had not been made aware of prior to admission to the hospital.
On 01/19/22 at 10:30 AM, during an exit conference with the administrative staff regarding Resident #92's diagnoses of Sepsis and hypernatremia, the Administrator stated that the wound had worsened at the hospital. However, the readmission record revealed that Resident #92 was admitted with Sepsis (a serious condition resulting from the presence of microorganisms in the blood or other tissues) and hypernatremia (a high concentration of sodium in the blood). sodium level was 152 milligram per deciliter (mg/dl). Resident #92's wound had to be debrided (removal of damaged tissue from a wound) at the hospital. The Resident returned to the facility with a wound vacuum (device used to remove fluid and infection from a wound).
A Note Text dated 01/19/23, entered by the Dietitian revealed, Readmit/significant change in status with hospitalization for sepsis, Urinary Tract infection, intravenous fluid, electrolyte repletion and antibiotic, metabolic encephalopathy, wound status post debridement, sacral osteomylitis (infection of the bone) . Discussed with nursing, oral intake had been fair since readmit and receiving 1:1 assistance with meals.
A review of the facility's policy titled, Change in Condition, dated 10/91 and last revised 09/23/22 indicated the following:
Policy: The purpose of this policy is to take timely action to identified any change in resident condition and to notify the resident physician/ practitioners and responsible family members or legal representative of the change in condition as soon as possible, or within 24 hours.
Resident changes in condition should include significant changes in physical, mental and psychosocial status as well as any incidents/accidents.
Procedure: When a resident change in condition is noted, the nurse assigned to the resident shall document the onset and symptoms in the resident's medical chart.
The assigned nurse to the resident shall also review the resident medical history and complete an evaluation of the resident in regards to the identified change.
The assigned nurse shall also document any pertinent additional information and interventions on the medical record as well as note the change in hour report.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 6 of 26 residents (Resident #19, #45, #66, #75, #92 and #179) sampled on 2 of 4 resident units, and failed to offer oral hydration and mouth care to a dependent resident (Resident #179). The deficient practice was evidenced by the following:
1. On 01/03/23 at 10:05 AM, the surveyor observed Resident #19 in bed, the head of the bed was elevated, and the resident was able to answer questions. The residents lips appeared very dry and crusty. The resident's right hand was contracted.
On 01/04/22 at 8:30 AM, the surveyor observed Resident #19 in bed in the dorsal recumbent position (a reclining position with both knees flexed, hips rotated outward, and both soles kept flat on the bed), the resident informed the surveyor that she/he had not been changed.
On 01/04/22 at 10:30 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that she/he had not been changed. The surveyor observed the resident had not been provided mouth care yet.
On 01/04/23 at 10:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #19 on her assignment. The CNA revealed that she reported to work late and was just informed by the UM to care for the resident. She had not yet provided care to Resident #19.
On 01/05/22 at 8:15 AM, the surveyor observed Resident #19 in bed. Upon inquiry, the resident stated that he/she had not received care yet.
On 01/05/22 at 11:15 AM, the surveyor observed Resident #19 laying on the dorsal recumbent position, the head of the bed was elevated. Resident #19 had a suprapubic catheter hung on the bed frame on the left side. When asked if he/she had been turned and changed, the resident stated, No. The surveyor informed the Unit Manager (UM).
At 11:30 AM, the surveyor entered the room with the UM and the CNA. At the surveyor's request, the resident's incontinent brief was checked by staff. The resident was observed to be covered with feces from the waist to the upper thighs. Resident #19 had a sacral wound which was also covered with feces. There was no dressing in place to protect the wound.
Further observation revealed that Resident #19 had two incontinent briefs on.
The surveyor interviewed the resident in the the presence of the staff, and he/she indicated that he/she had not been changed since the previous night. At 11:45 AM, the Director of Nursing (DON) entered the room and we all observed that Resident #19 had two incontinent briefs on, was soiled with feces from the waist to the upper thighs, the sacral wound was covered with feces and was not protected with a dressing.
On 01/05/23 at 11:55 AM, the surveyor interviewed the DON who stated that Resident #19 should not have had two incontinence briefs on as the resident was on a Low Air Loss (LAL) mattress and that would defeat the purpose of the LAL mattress. The DON acknowledged that Resident #19 needed maximum assist with grooming, hygiene, transferring and toileting, was incontinent of bowel, and had a Supra pubic catheter in place for wound healing. The DON further stated that she would address the above concerns.
On 01/05/23 at 1:30 PM, the surveyor interviewed the CNA who cared for Resident #19. The CNA stated that she reported to work at 8:30 AM, and Resident #19 was not on her assignment.
Resident #19's admission Record (AR) revealed, Resident #19 was admitted to the facility with diagnoses which included but were not limited to: Severe sepsis, chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction.
The quarterly Minimum Data Set (MDS) assessment tool dated 09/16/22, revealed that Resident #19 had some cognitive impairment, Resident #19 received a score of 07 out of 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 #19 was totally dependent on staff for care.
Review of the Care Plan for Resident #19 initiated on 06/07/22, included a Focus for ADL Self Care Performance Deficit related to: [ Rationale was not provided]. The goal was for Resident #19 to improve current level of function in bed mobility, transfers, toilet use and personal hygiene through the review date. The interventions were to converse with the resident during care, praise all efforts at self-care, encourage to participate, monitor/document and report reasons for self-care deficit, expected course and declines in function. The care plan did not indicate when staff were to provide care to the resident and the frequency for staff to turn and reposition the resident.
2. On 01/04/23 at 9:16 AM, the surveyor observed Resident #45 after morning care had been provided with nails long and jagged, black substance under [NAME] the finger nails, and Resident #45 was unshaven.
On 01/05/23 at 9:18 AM, the surveyor returned to the room and observed that Resident #45 had just completed breakfast. The resident's nails were still long, jagged and not trimmed. Resident #45 had not been shaved.
On 01/05/23 at 9:19 AM, the surveyor interviewed the resident who stated that he/she would like his/her nails to be trimmed and cleaned.
On 01/06/23 at 7:45 AM, the surveyor made a care tour with a random CNA. Resident #45's incontinent brief was soaked with urine.
On 01/09/23 at 9:27 AM, the surveyor observed Resident #45 in bed, nails were trimmed. Resident #45 was still unshaven.
On 01/10/23 at 8:35 AM, the surveyor observed the resident in bed, the resident stated again she/he would like to be shaved.
On 01/11/23 at 7:35 AM, the surveyor entered the room and observed Resident #45 was awake and alert and not shaved. Resident #45 stated, I need everything. The clothing was visibly soiled with yellow substances like feces. A strong feces odor permeated the room and was stronger while approaching the resident's bed. The surveyor left the room to review the daily assignment and identified the CNA assigned to the resident that day. The surveyor returned to the room at 8:30 AM, and noted that the resident had not been changed and was eating breakfast.
On 01/11/23 the surveyor reviewed Resident #45's medical record which revealed the following:
Resident #45 was admitted to the facility with diagnoses which included but were to limited to: Renal disease, peripheral vascular disease, acquired absence of left and right leg above knee amputation.
According to the MDS) dated [DATE], Resident #45 had a BIMS score of 04 out of 15 indicating that Resident #45 was cognitively impaired. The MDS also indicated that Resident #45 required extensive assistance for Activities of Daily Living (ADL) and was always incontinent of urine and stool. However, a conversation with Resident #45 revealed that he/she was awake and alert and able to make his/her needs known. The CNA confirmed that Resident #45 was very alert and able to participate with care.
Review of the Care Plan for Resident #45 initiated on 09/29/22 and last revised 01/06/23, revealed a focus for ADL self care performance deficit related to weakness, bilateral above knee amputation, history of Cerebro-vascular accident with hemiparesis. The goal was for Resident #45 to improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. The interventions included praise all efforts at self care. Encourage to participate to the fullest extent possible with each interaction. Monitor, document report to MD (Medical Doctor) PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
On 01/10/23 at 10:44 AM, the surveyor interviewed the Regional Nurse regarding the care. She stated that staffing was a challenge for the facility. The agency staff did not report to work on time. She was aware that most of the time there was only one CNA to start the 7:00-3:00 PM shift.
On 01/11/23 at 8:30 AM, the surveyor interviewed the CNA who cared mostly for the resident on 01/03, 01/04, 01/05, 01/06, 01/10 and 01/11/23, regarding Resident #45's care. The CNA revealed that Resident #45 was able to feed her/his self after set-up, able to assist with turning and able to make his/her needs known. The CNA went on to state the family brought an electric razor to assist with shaving the resident, however, the razor was not charged and was unable to be used to shave the resident. When asked regarding the resident nails care, the CNA did not have any comments.
The surveyor then inquired about the soiled clothing observed on the resident the morning of 01/11/23. The CNA stated, I dressed the resident yesterday morning with this T-shirt. Two shifts went by and they did not changed the resident. The resident did not have a gown on and had the same T- shirt that he/she was dressed with the morning of 01/10/23. The CNA further stated that the resident would be soiled with urine and feces in the morning. She expressed her concerns to the nurse and nothing had been done. Most of the time there was only one CNA to start the 7:00 AM - 3:00 PM shift. The 11:00 PM - 7:00 AM shift staff were gone and she could not get to all residents in a timely manner as she would like to. The facility was aware of the concerns with staffing.
3. Resident #66 was admitted to the facility with diagnoses which included but were not limited to adult failure to thrive, altered mental status, heart failure and other psychoactive substance abuse.
On 01/03/23 at 10:00 AM, the surveyor observed Resident #66 in bed, and reported having pain on both heels. The surveyor informed the nurse and Resident #66 was medicated for pain immediately.
On 01/04/23 at 10:45 AM, the surveyor observed Resident #66 in bed. Resident #66 had not received care yet. Resident #66 was soaked with urine and had two incontinent briefs on when checked with a random CNA.
On 01/05/23 at 9:15 AM, the surveyor observed in Resident #66 in bed, resting. The surveyor inquired about the resident. The CNA checked the resident and the resident was soaked with urine.
On 01/06/23 at 7:15 AM, the surveyor made a care tour with the CNA who worked the 11:00 PM - 7:00 AM shift. Resident #66 was soaked with urine and had two incontinent briefs on.
An interview with the CNA at 7:30 AM, revealed that all heavy wetters had double briefs on. The CNA also stated that she had 20 residents on her assignment most of the time and could not provide incontinence care to all the residents in the morning.
On 01/06/23 at 10:30 AM, the surveyor interviewed the nurse who revealed that the facility was aware of the workload and she had no control over staffing.
On 01/09/23 at 9:10 AM, the resident was not in bed and the surveyor observed that the sheets including the blanket and the bed were wet and yellow stained.
On 01/09/23 at 11:28 AM, the surveyor interviewed the CNA who revealed that she checked on the resident at 8:00 AM, yet the resident was soaked with urine. The CNA stated that Resident #66's incontinent brief was always soaked with urine and she/he had two incontinent briefs on. According to the CNA, the policy was for applying one incontinent brief only after incontinence care and to check on residents every 2 hours and as needed. The CNA further stated that this morning not only did she have to change one of the residents, but she had to scrub to remove all the dry feces that were left from the 11:00 PM - 07:00 AM shift.
On 01/09/23 at 12:15 PM, an interview with the staffing coordinator revealed that she had been working as a staffing coordinator only for 2 weeks and could not comment on the staffing issue. When asked if she was aware of the regulation for the staffing ratio, she stated that the staffing was based on the census and acuity. She could not comment on the staffing ratio sets forth by the regulation.
4. Resident #75 was admitted to the facility with diagnoses which included but were not limited to heart failure and unspecified cirrhosis of the liver.
The Quarterly MDS dated [DATE], revealed that Resident #75 had intact cognition. Resident #75 scored 12 out of 15 on the BIMS.
On 01/03/23 at 9:50 AM, the surveyor observed Resident #75 in bed, theie eyes closed, and the sheet including the blanket were yellow stained.
On 01/03/23 at 11:30 AM, the surveyor returned to the room, the resident was still in bed and the bedding was still not changed. Resident #75 informed the surveyor that he/she was not changed on the 11:00 PM - 7:00 AM shift.
On 01/04/23 at 9:30 AM, the surveyor returned to the room. Resident #75 was awake and informed the surveyor that he/she was not provided with incontinent care last night and he /she reported it to the nurse. Resident #75 also was not shaved.
On 01/05/23 at 9:09 AM, the surveyor observed the resident in bed, unshaven. Resident #75 informed the surveyor that he/she would like to be shaved again and would like to get out of the bed more often. Resident #75 continued to state that he/she would like to have more therapy. Resident #75 added some days he/she was unable to attend therapy because he/she was in pain. Resident #75 stated clearly, he/she was left in the chair soiled with urine and feces for hours (12:00 PM - 8:00 PM). His/her buttocks were sore and he/she could not get out of the bed for therapy. The staff claimed that he/she refused therapy but the resident stated that he/she did not. The Resident agreed to discuss the above concerns with the surveyor in the presence of the facility's staff.
On 01/05/23 at 12:03 PM, the surveyor interviewed the resident with the DON. Resident #75 stated that he/she needed therapy to be able to get better. Resident #75 also expressed concerns over sitting in the chair from 12:00 PM to 8:00 PM and not being changed. The resident added, Once you get out of the bed, they do not return you to bed until night time, and that The staff always stated they are short handed.
The DON informed the surveyor that she was not aware of the above concerns with incontinence care and would in-serviced the staff. The DON stated that the staffing was a challenge but could not inform the surveyor of any plan to improve resident care.
Resident #75 had a care plan initiated on 08/19/22 and last revised 12/20/22, for bowel and bladder incontinence. The goal was for resident #75 not to decline further. The interventions were to use disposable briefs, change frequently and as needed. Check and change as required for incontinence. Change clothing as needed after incontinence episodes. The care plan was not being followed. Resident #75 was not being changed and the bedding was observed wet and yellow stained with urine. Resident #75 informed the surveyor and the DON that incontinence care had not been provided in a timely manner due to the facility being short handed.
5. On 01/03/23 at 10:30 AM, the surveyor observed Resident #92 in bed facing the wall, and a floor matt was noted next to the bed.
On 01/04/23 at 10:36 AM, the surveyor observed Resident #92 in bed facing the wall. The breakfast tray was on the bedside table untouched. Upon inquiry through the UM, the UM stated that Resident #92 was a late sleeper.
On 01/05/23 at 8 :37 AM, the surveyor observed Resident #92 in bed facing the wall. The surveyor observed the breakfast tray on the bedside table untouched. Resident #92's mouth was covered with a dark brown substance, dry brown food residue was noted between the teeth from the upper lip to the nose. The nails were jagged and a black coated substance was noted underneath the finger nails.
01/05/23 at 9:30 AM, the surveyor entered the room and observed Resident #92 in the same position and observed that oral care had not been provided. Resident #92 had not been turned. The breakfast tray was still on the bedside table untouched.
On 01/05/23 at 9:55 AM, the surveyor inquired regarding tray delivery in the morning. The nurse stated that the breakfast trays arrived between 7:45 AM - 7:55 AM. A review of the meal delivery schedule provided by the nurse on 01/05/23 at 9:55 AM, confirmed that the breakfast tray arrived on the unit between 7:45 AM - 7:55 AM.
On 01/05/23 at 10:15 AM, the surveyor interviewed the UM regarding her responsibilities. The UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignment, and make rounds. The surveyor then asked the UM if she made rounds this morning. The UM replied, YES. The surveyor then asked if she observed any care issues. The UM stated, No.
On 01/05/23 at 10:25 AM, the surveyor escorted the UM to Resident #92's room where we both observed the condition of the resident's mouth, hands and nails. The nails were jagged and a black coated substance was noted underneath the finger nails. The resident was calling out and stated, help me.
The surveyor asked the UM if she could get a CNA to assist with checking the resident's incontinence brief. The UM asked a CNA to assist. Resident #92's buttocks were observed by all to be covered with dry black tarry stool and loose stool. The incontinent brief was saturated with urine and feces, and Resident #92 was observed to have had a sacral wound. The wound was covered with feces and there was no dressing in place to protect the wound. The UM stated that she did not make rounds with the night nurse and was not aware that mouth care was not provided after dinner. The UM stated that she would have a meeting with all the staff.
On 01/05/23 AM at 10:35 AM, the surveyor entered the room with the DON and we all observed that Resident #92 was not being fed, not turned and did not receive incontinence care. Resident #92 was calling out in a soft voice, Help me. When asked if he/she was hungry in the presence of the DON and UM he/she stated, Yes.
On 01/05/23 at 11:00 AM, the surveyor interviewed the DON regarding Resident #92's care. The DON stated that she would in-serviced the staff. The DON also added that her expectations were that all residents would be turned and changed every two hours and as needed.
On 01/05/23 at 12:30 PM, the surveyor interviewed the CNA regarding incontinence care. The CNA stated that during incontinence care they would removed the dressing if the dressing was soiled and would inform the nurse. She could not comment on when the dressing to the sacral area was removed as Resident #92 had not receive morning care yet.
On 01/06/23 at 8:00 AM, the surveyor observed Resident #92 in bed facing the wall. A water cup was observed for the first time on the bedside table. Resident #92 could not access the water cup on the bedside table.
On 01/06/23, the surveyor reviewed Resident #92's electronic clinical record. The admission Face Sheet reflected that Resident #92 had diagnoses which included but were not limited to of history of falling, major depression disorder, pressure ulcer of sacral region and anxiety disorder.
Review of the most recent MDS dated [DATE], revealed that Resident #92 was cognitively impaired and had received a score of 03 of 15 on the BIMS whch was indicative of severely impaired cognition.
Review of Resident #92's Comprehensive Care plan provided by the facility on 01/09/23, revealed that Resident #92 did not have a care plan in place for ADLs self care performance deficit. The comprehensive Care Plan dated 10/05/21, addressed falls, skin integrity, respiratory infection, dehydration . The care plan did not address ADL care. Based on the MDS assessment, Resident #92 was totally dependent on staff for care.
On 01/11/23, the surveyor reviewed the grievance book provided by the facility and noted that Resident#92's Representative filed a grievance on 01/11/23, to address dirty hands and nails observed during visitation.
On 01/18/23 at 6:00 PM, the surveyor conducted a telephone interview with Resident #92's Representative. The representative stated she had concerned with the care and was scheduled to meet with the facility on 01/19/23. The Representative stated over the last 4 months she had noticed a decline in the care. Resident #92 would be left in the room and would cry out because he/she was isolated. The Representative further stated that Resident #92 was sent to the hospital on [DATE], and was informed that she was admitted with sepsis and had an unstageable wound that she was not made aware of prior to admission.
On 01/19/23 at 09:30 AM, the surveyor reviewed the facility's in-serviced education binder provided by the facility and noted that in-serviced education regarding over padding, double incontinence brief and incontinence care were addressed on 04/18/22, 07/19/22 and 11/20/22. The facility management indicated that they were not aware of concerns with incontinence care and residents wearing double incontinence brief.
The above concerns with oral and incontinence care were discussed with the facility management during the survey and again on 01/19/23. The DON indicated that the staff were in -serviced. The surveyor then asked the facility what had been done to improve the care, if any investigations were done regarding residents not being fed, changed and turned, adn wound not being cared for after incontinence care was provided. The facility did not have any comment.
According to the Facility Policy titled, Incontinence Care approved 10/04/22 and last revised 10/2022 provided by the facility on 01/06/23, the following were documented:
Policy: The facility shall provide care for all incontinent residents.
Purpose: To cleanse and refresh residents after each incontinent episode.
Under procedure it was noted to check residents at least every two hours.
The policy was not being followed. Staff indicated that they were short-handed almost every day and could not changed all residents every two hours.
6. On 01/03/23 at 11:14 AM, Surveyor #2 observed Resident #179 lying in bed awake. Resident #179 did not respond to the surveyor when spoken to. Surveyor #2 observed the resident's mouth and lips were very dry. There was an intravenous (IV) running which contained Dextrose 5. There was no water cup visible in the room.
On 01/03/23 at 12:37 PM, the surveyor observed through the doorway that Resident #179 was in bed, with the resident meal tray covered on the overbed table next to the resident. The surveyor entered the room, and heard a noise in the resident's bathroom. There were no other residents assigned to the room. At that time, the door to the bathroom opened and a staff member exited the bathroom holding her cell phone. The staff identified herself as a Certified Nurse Aide (CNA #1) assigned to care for Resident #179. CNA #1 proceeded to explain to the surveyor that she was having some filmily issues and that was why she was on the phone. CNA #1 did not engage the resident, or interact with the resident at all, including with the meal tray and proceeded to exit the resident's room.
On 01/04/23 at 8:35 AM, the surveyor observed Resident #179 with eyes closed, lying in bed and the breakfast meal had not yet arrived on the unit. The surveyor observed a brownish tan flaky food like substance on Resident #179's top right shoulder. The surveyor engaged the resident who opened his/her eyes, looked at surveyor and did not verbally respond.
On 01/04/23 at 8:46 AM, Surveyor #2 observed Resident #179 lying in bed. There was no breakfast tray in the room, but there was a brown flaky substance that resembled food on the resident's gown, top right shoulder. There was no water cup visible in the room. Resident #179's mouth and lips were still very dry in appearance.
On 01/04/23 at 10:55 AM, the surveyor observed Resident #179 in bed, with an IV containing Dextrose 5 being infused, dark colored urine was draining in a catheter tube. The resident was alert, however did not respond to questions. The resident was alone in the room, there was no water cup at bedside and the resident's mouth appeared very dry and scaly.
On 01/04/23 at 11:06 AM, the surveyor while the surveyor was in Resident #179's room, a Certified Nurse Aide (CNA) entered and stated that she had to change the resident's position. The CNA left the room and stated she needed someone else to help, returned and stated she could do it her self. She boosted the resident up, and the CNA did not converse with the resident at that time. The surveyor asked the CNA what type of care she provided for the resident and the CNA stated I don't know, I just came in yesterday and stated I change [him/her] and feed [him/her]. The CNA did not mention anything about mouth care or offering the resident a drink and there was no water cup or swabs to clean the resident's mouth observed in the room. The surveyor timed the interaction, which lasted four minutes and the CNA left without saying anythig to the resident.
On 01/04/23 at 11:16 AM, the surveyor interviewed the Unit Manager (UM) about the care that was supposed to be provided for dependent residents. The UM stated bath, feed and report anything that was wrong to the nurse.
On 01/04/23 at 12:14 PM, the surveyor observed Resident #179 lying in bed. There was still no water cup visible in the room, but there was an untouched lunch tray out of reach of the resident on the overbed table.
On 01/04/23 at 12:28 PM, the CNA set Resident #179 up for the meal and proceeded to use the hand wipe that was on the resident's tray to clean her own hands, and not the resident. The surveyor watched as the CNA began to feed the resident. The surveyor asked the CNA if the resident was offered water, as there was no water at the bedside or on the meal tray. The CNA stated, I forgot, when the surveyor asked where the water was. The surveyor asked the CNA if she had offered the resident any water during her shift and the CNA confirmed she had not. The CNA then left the resident in the middle of the meal, and did not say anything to the resident and exited the room.
On 01/04/23 at12:35 PM, the surveyor asked the UM to come into Resident #179's room. The surveyor asked the UM about the mouth care as the resident's mouth looked very dry. The UM stated mouth care should be done and proceeded to look for mouth swabs in resident's drawer. The UM was unable to locate cleaning swabs and confirmed they were not there. The surveyor asked the UM if water should also be available for the resident, and the UM stated yes.
The surveyor reviewed Resident #179's admission Record which revealed diagnoses that included sepsis, anemia and malignant melanoma of the skin. A Physician's Progress note, dated 12/24/2022 at 11:25 AM, revealed a problem list that included: Metastatic Melanoma, presented with recurrence of large mass at left buttock, with probable liver and lung metastatic disease, sacral wound stage 4, Hypernatremia (elevated blood sodium level) due to poor oral water intake, The Care Plan revealed a Focus: Initiated 12/16/2022 and Revision: 12/22/2022, revealed Resident has a nutritional problem or potential nutritiona problem r/t (resulted to) .need for ADL assist .Interventions included: Encourage PO (by mouth) fluids dated 12/22/2022 and Assist resident at meals, dated 02/22/2022.
On 01/04/23 at 1:28 PM, the surveyor observed a black substance under Resident #179's right hand fingernails.
On 01/04/23 at 1:37 PM, the surveyor interviewed the UM, in the presence of another surveyor. The surveyor asked the UM if he checked the care being provided to the residents by his staff and asked if he had checked if Activity of Daily Living (ADL) care had been provided to Resident #179. The UM stated he did not check the care of Resident #179 and stated, I am pretty sure that someone checked it yesterday, and he would have to check the computer for the ADL completion, and stated he had not done that. The surveyor asked the UM if fingernails would be cleaned as part of ADLs and the UM stated, yes of course. At that time, both surveyors asked the UM to accompany them to Resident #179's room and look at the resident hands. The UM opened Resident #179's hands and stated, I see as he observed the black substance under Resident #179's fingernails on the right hand.
On 01/09/23 at 8:55 AM, the surveyor observed an undated, open cup of water in Resident #179's room. There was no ice in the water and the resident's mouth and lips looked dry. The resident was alert and responded to the surveyor. At 8:59 AM, a different CNA then previously brought in the meal tray. The surveyor asked the CNA about the open cup. The CNA stated, it looked like from 11-7 shift, looked like they didn't throw it out, and the cup should be covered with a lid and have a straw inside. The surveyor asked if the cup is usualy dated, and the CNA stated that they don't tell them to date it.
01/10/23 at 9:18 AM, the surveyor interviewed the UM regarding the water policy. The UM stated that every shift must provide fresh water and as needed. The UM stated the water cups were supposed to be dated because it would be a problem if not dated since you would not know what date it was poured.
On 01/01/10/23 at 11:14 AM, the surveyor interviewed the Registered Dietitan (RD) about Resident #179. The RD stated she reviewed the resident's labs and I put in for PO hydration encouragement, which I know they are already doing. The RD stated she had spoken with nursing to encourage water, juices fluid and the resident should have a water cup in the room.
The policy for oral hygiene was reviewed and indicated the following:
Purpose: Regular oral hygiene will help prevent mouth infections, dental decay and gum disease and will promote personal hygiene.
All residents will receive care of the mouth and teeth every morning and night and as needed to maintain good oral hygiene. The policy was not being followed.
The policy for ADL care dated 06/18/24 last revised 12/15/17, indicated: Residents shall receive assistance with activities of daily living (ADL's) every shift, as appropriate, ADLs include: Bathing, Grooming, Dressing, Eating, Oral hygiene, Ambulation, Toilet activities.
The Resident Hydration and Prevention of Dehydration Policy, undated revealed: This facility will endeavor to provide adequate hydration and to prevent and treat dehydration, .4. Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine base as part of daily care, 5. A 16 oz cup of containing ice water will be placed at each residents' bedside within arm's reach .11. Nursing will monitor fluid intake .
A review of the Position Title: Unit Manager job description revealed under responsibilities/accountabilities: 1. Takes an active role in direct resident assessment and care; including but not limite to, ADL care, Personal Hygiene and Pshycho-social support.
N.J.A.C. 8:39-27.2 (h)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to document the administration, or refusal of medications on the Medication Administration Record (MAR). This deficient practice was identified for 1 of 26 residents (Resident #6) reviewed and was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 01/03/23 at 9:51 AM, the surveyor toured the facility Behavioral Health Unit (BHU) and observed Resident #6 sitting in a wheelchair in the hall. Resident #6 stated he/she had neuropathy (nerve pain) and needs cream in the morning on his/her left knee. Resident #6 further stated that the cream doesn't help the pain. Resident #6 showed the surveyor his/her left knee with a scar from surgery.
A review of the hybrid medical record (records on both the electronic medical record and paper chart) revealed that Resident #6 was admitted with diagnoses which included but were not limited to anxiety disorder, opioid dependence, and fibromyalgia (chronic muscle pain). A review of the most recent Quarterly Minimum Data Set (MDS-an assessment tool), dated 11/25/22, included but was not limited to Section C: a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. Section N: Medications of opioid and antianxiety. The Order Summary Report revealed an order dated 11/4/22 for Aspercreme Lidocaine Cream 4% (percent) apply to left knee topically every 8 hours for pain management. Aspercreme Lidocaine Cream 4% apply to left foot topically every 8 hours for pain management. An order dated 9/15/22 for Clonazepam (antianxiety medication) 1 milligram (mg) give one tablet by mouth every 12 hours for anxiety.
A review of the December 2022 MAR revealed a chart codes /follow up codes legend for the staff to use to document if a medication was not administered and the reason. The December 2022 MAR revealed the following blank areas.
Clonazepam 1 mg on 12/23 and 12/29/22 at 2200 (10:00 PM)
Aspercreme Lidocaine Cream 4% apply to left foot topically on 12/4 and 12/13/22 at 0600 (6:00 AM), and 12/23/22 at 2200.
Aspercreme Lidocaine Cream 4% apply to left knee on 12/4 and 12/13/22 at 0600, and 12/23/22 at 2200.
There was no documentation on the December 2022 MAR to indicate if the medications were administered or not and /or the reason.
A review of the January 2023 MAR (up to 01/18/23 when provided) revealed a chart codes / follow up codes legend for the staff to use to document if a medication was not administered and the reason. The January 2023 MAR revealed the following blank areas.
Clonazepam 1 mg on 1/12, 1/13, 1/15, and 1/16/23 at 2200.
Aspercreme Lidocaine Cream 4% apply to left foot topically on 1/7 and 1/8/23 at 0600, and 1/12, 1/15, and 1/16/23 at 2200.
Aspercreme Lidocaine Cream 4% apply to left knee on 1/7, 1/8, and 1/17/23 at 0600, and 1/12, 1/15, and 1/16/23 at 2200.
There was no documentation on the January 2023 MAR to indicate if the medications were administered, or not and/or the reason.
On 01/19/23 at 8:50 AM, during an interview with the surveyor, the Registered Nurse (RN) on the BHU stated that the MARS should be complete with no blanks. She stated that if there were a blank on the MAR, there should be documentation on the back of MAR.
On 01/19/23 at 9:24 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the process of documenting in the MAR would be for the nurses to check the orders and check for the correct resident. The DON stated the Unit Manager (UM) would be responsible to review for any blank areas on MAR before the shift ends. Also it would be the nurses responsibility to ensure they documented in the MAR. The DON stated that there should never be any blank areas on the MAR.
A review of the facility provided, Medication Administration Policy, last reviewed 9/2022, included but was not limited to Policy: medications shall be administered in a safe and timely manner, as prescribed. Procedure: 12. The nurse administering the medication must electronically sign, date and time the MAR by selecting Y (yes) after giving each medication. 15. If a medication is withheld or refused, the individual administering the medication shall select N (no) followed by selecting the appropriate reasoning and documentation.
A review of the facility provided, EMR [electronic medical record] Documentation Policy, reviewed 1/2022, included but was not limited to Policy: Our documentation processes will continue to follow all state and federal requirements, as well as standard professional practice requirements. Procedure: Medication and Treatment Administration Records nurses to document in the facility EMR.
A review of the facility provided, Clinical Charting and Documentation, reviewed 9/2022, included but was not limited to Policy: all services provided to the resident .shall be documented in the resident's EMR. 1. All observations, medications administered, services performed, etc., must be documented in the resident's EMR. 5. Documentation shall include at a minimum a. the date and time provided, b. the name and title of the individual who provided the care, e. whether the resident refused the procedure/treatment, and g. the signature and title of the individual documenting.
The facility failed to follow their policies and Professional Standards of Nursing.
NJAC 8:39-29.2(d)

Based on interview and document review, it was determined that the facility failed to ensure an allegation of abuse was reported timely to the Department of Health. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #182) and was evidenced by the following:
Refer to 600J and 600F
On 01/19/23 at 8:46 AM, the surveyor contacted the family member (FM) of Resident #182 and conducted a telephone interview. The FM stated Resident #182 had an issue with CNA #1 who had walked into Resident #182's room and was nasty to Resident #182 on 01/17/23. The FM stated CNA #1 told the resident that she was not going to have to change (provide incontinence care) the resident again, since Resident #182 was not her only resident. CNA #1 told Resident #182 that she was on her break at the time, and CNA #1 refused to change Resident #182. CNA #1 then proceeded to throw down the food lid with force on Resident#182's over bed table. The FM stated that he/she had made the Director of Social Services (DSS) aware of what happened on the same day, 01/17/23.
On 01/19/23 at 8:46 AM, the surveyor interviewed Resident #182 while the resident was in bed. Resident #182 stated that he/she had a problem with a female Certified Nurse Aide (CNA #1) on Tuesday (01/17/23). Resident #182 stated that CNA #1 told him/her that he/she was not her only resident, and CNA #1 also threw the meal tray down. Resident #182 stated that the CNA #1 had seemed mad at the time because CNA #1 stated she was on her break. Resident #182 stated he/she had informed the DSS what happened on the same day, 01/17/23.
On 01/19/23 at 9:23 AM, the surveyor conducted an interview with the DSS and inquired if there were currently any investigations in progress. The DSS stated that he had received a grievance from Resident #182 on 01/17/23. At that time the DSS provided the surveyor with the copy of the Facility Name, Grievance/Missing Item Report, which revealed: Date: 01/17/23 (untimed), Resident: [#182], Room: [Resident #182's room number]. Complaint Made By: Patient, Complaint Made to: DSS, Statement of Complaint:, On 01/17/23, at about lunch time, the patient stated a CNA threw the lid cover on the food/tray table. A handwritten Addendum documented directly below the 01/17/23 Statement of Complaint revealed On 01/18/23, on the date above, the Patient stated that the same CNA, while on the total lift machine, wanted to be placed in bed .The statement continued on a blank page which revealed . and in need of a change of [his/her] disposable brief, the CNA stated, Your [sic.] not my only patient, there's no way I'm doing this tomorrow. While in bed, [he/she] was not changed by that CNA. After a while, [he/she] was changed by someone else. The DSS stated that he completed his portion on 01/17/23, when the FM of Resident #182 brought him into the resident's room to speak with Resident #182, and he confirmed that he took the statement from Resident #182 and stated, the complaint was made to me. The DSS stated he brought the initial complaint, on 01/17/23, to the Director of Nursing (DON), because when the complaint involved nursing the DON was responsible for getting statements. The DSS stated that the DON was responsible for the investigation, along with the LNHA, who was the facility abuse coordinator. The DSS stated I would imagine the Director of Nursing has followed up on it [the complaint made by Resident #182]. The DSS stated that he conducted a follow-up interview with Resident #182 on 01/18/23, and at that time, the resident provided an additional statement that he also documented on the form. At that time, the surveyor requested and the DSS provided the surveyor with a copy of the facility abuse policy. The surveyor inquired to the DSS if what Resident #182 stated to the DSS would fall under the abuse category. The DSS stated, yes, that it is verbal abuse, neglect, and it touches many bases. The DSS stated, again, he immediately informed the DON of the allegation made by Resident #182 on 01/17/23. The surveyor inquired to the DSS what the process was when an allegation of abuse occurred, and what his involvement was. The DSS stated he was not involved with the abuse investigation, he assisted with grievances, and missing items, and because the allegation received from the FM and Resident #182 was related to abuse. The DSS stated I immediately told the DON and stated, I would imagine that the DON has followed up on it. The surveyor asked the DSS if this allegation would be a priority, and he stated, yes, and the first thing that would be done would be [CNA #1] would be removed from providing care, and stated if it is alleged abuse, then she cannot come to the facility until the investigation is completed, because you would not want someone who was alleged to have performed an abusive act working because it could happen again. The DSS stated when he took the initial complaint from Resident #182, he had initially thought it was an allegation of abuse and neglect because CNA #1 failed to perform care for the resident, and then slammed the lid down which was aggressive and possibly violent. The DSS stated he was instructed by the DON to provide the UM with blank statement forms on 01/17/23, which he had done, and he instructed the UM to get the statements per the DON's instructions. The DSS stated he provided the copy of the grievance form to the UM on 01/18/23. The surveyor asked the DSS what further involvement he had in the abuse investigation process, and had he received any further communication regarding the allegation been provided by the DON/ LNHA, and he stated, no, not to me. An initial review of the Facility Policy/ Procedure, Abuse Prevention Program, Original Issue Date: 2/2014, Revised: 10/21/22, in the presence of the DSS revealed under Part V, Investigation, Procedure: The administrator who is the APP Coordinator, and the DON will initiate investigations of any allegations of abuse, determine necessary response, and report to the office of the Ombudsman and the Department of Health and Senior Services, as necessary. The scope of the investigation shall be determined by the Administrator and/or the DON. The Protection Procedure revealed, When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor, notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary.
On 01/19/23 at 9:50 AM, the surveyor conducted an interview with the UM for the unit that Resident #182 resided on. The surveyor inquired to the UM if he had received any complaints or was currently involved in any investigations regarding any residents. The UM stated that the FM of Resident #182, came to him on 01/17/23 and informed him that CNA #1 had an attitude, and she was not nice to the resident. The UM stated that he informed the DON and the DSS the same day of the FM's complaints. The surveyor inquired if the UM had been instructed to do anything because of the complaint. The UM stated, I was told to take statements, but because the UM found out late in the afternoon on 01/17/23, CNA #1 had already left for the day and he was unable to obtain a statement. The UM confirmed to the surveyor that CNA #1 was the CNA assigned to Resident #182, and then stated he obtained a statement from CNA #1 on 01/18/23, which was the following day after the allegation The UM stated that CNA #1 worked her full resident assignment on 01/17/23 and again on 01/18/23. At that time, the surveyor reviewed the 01/18/23, 7:00 AM-3:30 PM assignment sheet for the CNAs, and CNA #1's assignment included nine residents. Resident #182's room had both beds crossed off, and it was replaced with two other beds in another room. The UM stated that when CNA #1 arrived to work on 01/18/23, that she had started her assignment first, and then he had spoken to her (time not provided by UM) regarding the reason for being removed from providing care to Resident #182. However, the UM confirmed that CNA #1 continued to work and was assigned to a resident care assignment which included nine residents. The assignment was located on the same unit where Resident #182 still resided and had access to Resident #182, and all other residents. The surveyor asked the UM if he had been provided a copy of the grievance from the DSS, and he stated, yes. The surveyor asked the UM if what was written on the form represented abuse and neglect, and the UM stated, yes, and stated CNA #1 told him, it never happened, and that Resident #182 was happy with the care she had provided. The surveyor asked the UM if he had interviewed anyone else regarding the allegation. The UM stated he had interviewed the four CNAs (including CNA #1) that worked on the unit on 01/17/23, the date when the allegation was received, and the surveyor asked if the UM had interviewed anyone in addition to the CNAs. The UM stated, no, and the surveyor then asked if the UM had interviewed any residents. The UM stated, no, and that he provided the statements he collected to the DON. The surveyor inquired to the UM if it was still an ongoing investigation, and the UM stated yes.
On 01/19/23 at 10:46 AM, the surveyor, in the presence of the survey team, interviewed the DON and LNHA. The surveyor asked what the process was if there was an allegation of abuse. The DON stated the process was, if there was an allegation of abuse, an investigation would be started immediately, and stated right away after she received the complaint. The surveyor inquired if there had been any recent complaints, or allegations of abuse. The LNHA stated there was a grievance provided by the DSS, and the DON and LNHA confirmed it was provided to both on 01/17/23, and the LNHA stated she had been made aware by the UM on 01/17/23 at 4:00 PM. The surveyor asked what the process was when a grievance was received. The DON stated as soon as she received it, that she would identify the caregiver and nurse assigned to the patient, and then she would obtain a statement from the staff that were involved with the resident, including the family, doctor, nurses, and other residents assigned to the staff. The DON stated that the assigned aide to the person who had the complaint would be suspended while the investigation was ongoing, because we don't want any incident to happen, we want to protect the resident and any other resident assigned. The surveyor informed the DON and LNHA that CNA #1 worked on 01/18/23, despite the DON stating the staff would be suspended during the investigation, and the surveyor informed the DON and LNHA that the UM had confirmed he was made aware of the allegation on 01/17/23 and CNA #1 was allowed to work and provide resident care the following day. The surveyor asked about Resident #182's allegation that CNA #1 threw the lid cover, and the DON stated, I would say that was an attitude, and the DON stated based on that assumption she took CNA #1 off Resident #182's assignment. The surveyor asked where attitude would fall in the abuse policy and the LNHA stated it was just sensitivity, and the DON stated the employee could have burnout but may not have intended to be insensitive to the resident. The DON stated we would have to investigate to see if there was an intention of abuse. The DON was asked if there had to be intention for abuse and the DON responded to the survey team, no. The DON then stated that we spoke with the aide on 01/17/23 (no time provided), after the complaint was made. When the surveyor inquired to the DON when she was informed about the incident from the UM, the DON stated, I could not even remember what he told me on 01/17/23, because it was late in the afternoon. The surveyor inquired to what time the DON received the statement from CNA #1, and the LNHA stated we found out at 4:00 PM about the allegation, and that was when the statement was written. At that time, the surveyor inquired to the LNHA who had the facility received statements from, and the LNHA confirmed she had a statement from CNA #1, and three other CNAs who worked that day. The DON stated we didn't get statements from the nurses that worked that day and stated that they received statements from the four CNAs that worked on 01/17/23, and the UM. The surveyor inquired to the DON if she had interviewed the resident when she had found out about the allegation on 01/17/23, the DON stated yes, at 3:00 PM, but that was late in the afternoon. The surveyor asked what the DON had asked the resident, and the DON stated, how are you today and no other specific questions per the DON. The DON stated the UM also spoke with the resident on 01/17/23 and confirmed there was no documented evidence when inquired by the surveyor. The DON stated that other alert and oriented residents would still need to be interviewed to obtain statements, and confirmed the investigation was not complete yet, that they cannot just let it go, and we don't tolerate that. The surveyor asked was anything done for residents who were not alert and oriented and the DON stated we would do a body assessment. The surveyor inquired if that was done and the DON stated no, and the LNHA stated we could ask the family members about any concerns with the caretaker. The LNHA stated yesterday was really when the investigation began, and the other day was just a comment. The surveyor inquired if the investigation was completed on 01/18/23, and the DON stated, no. The surveyor then asked if it the investigation was not completed, was CNA #1 supposed to work and have a resident assignment on 01/18/23. The DON stated, this was given to us late, and the DON and LNHA did not offer an explanation as to why CNA #1 worked on 01/18/23 and provided resident care. The surveyor asked why it was important to interview other staff, and the LNHA stated to make sure other residents are safe. The surveyor asked what kind of an allegation the statements made by Resident #182 represent, the DON stated, a complaint. The surveyor asked if the allegation was an allegation of abuse, and the LNHA stated, yes. The surveyor asked is there anything else that should be done when an allegation of abuse was made. The LNHA stated I have to report it to the State and Ombudsman within two hours, and confirmed it was reported to the Stated Department of Health on 01/19/23, two days later, and not within two hours.
A further review of the Policy/Procedure: Abuse Prevention Program, Original Issue Date: 2/2014 revealed Policy: This facility prohibits abuse, neglect, involuntary seclusion, and misappropriation of property from residents and will utilize the abuse prevention program to effectively prevent occurrences, screen and train staff, identify, investigate, report, and respond to any occurrences .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Forms of resident abuse: Active Forms of Abuse: .2. Verbal Abuse: Talking to residents in a demanding manner, shouting, cursing, and name-calling ., Passive Forms of Abuse: 1. Emotional Abuse: Deliberately ignoring a resident's request, denying a resident water, food, a bedpan, a call bell, etc. for a period of time., 2. Neglect: The failure of the facility, it's employees, or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (ex: [example] allowing a resident to lie in urine or feces, ignoring a resident, not providing daily cleanliness, personal hygiene, proper mouth care, shaving, hair washed and combed, dressing a resident inappropriately and or in dirty clothing. Leaving resident exposed during bathing, dressing, changing etc .). Neglect of goods or services may occur when staff are aware of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (Example-suctioning, transfers, use of equipment. Lack of sufficient staffing to be able to provide the services, lack of supplies, or lack of knowledge of the needs of the resident. Abuse Prevention Program-Part VII- Protection, Procedure: When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. Abuse Prevention Program-Part V1- Identification, Procedure: .Any unusual occurrence, which may potentially constitute abuse, neglect, or involuntary seclusion, will be identified as a potential abuse incident and investigated as such .Abuse Prevention Program-Part V11 Reporting/Response .When an incident is reported to the supervisor, the supervisor is responsible for ensuring that the resident is safe and will notify the administrator as well as the DON, or their designees The administrate and DON will initiate the investigation of the potential abuse incident, determine the necessary response and report to the Department of Health and Senior Services and/or the office of the Ombudsman (if applicable) as per regulations including Peggy's Law. Alleged violates involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .The scope of the investigation shall be determined by the administrator and/or the DON .
N.J.A.C. 8:39-9.4(f)

Based on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by failing to provide: a.) oral and incontinence care to a resident assessed to be dependent on staff for activities of daily living (ADL's), and prior to serving the resident meal, b.) a timely clothing change to a resident whose clothing was visibly soiled, and c.) a resident with respect and dignity. This deficient practice was identified 2 of 26 residents reviewed (Resident #45 and #179), on 2 of 4 units, and was evidenced by the following:
1. On 01/04/23 at 9:30 AM, the surveyor observed Resident #45 in bed. The Certified Nursing Assistant (CNA) was at the bedside assisting the resident with care.
On 01/04/23 at 10:37 AM, the surveyor conducted an interview with the CNA who revealed that Resident #45 required extensive assistance with care, could feed his/herself after set up, and was incontinent of bowel and bladder.
On 01/06/23 at 7:45 AM, the surveyor completed a care tour with one of the CNAs assigned to the floor. The surveyor and the CNA observed that Resident #45's incontinence brief was wet and yellow stained with urine. The CNA stated that Resident #45 was a heavy wetter and would be left wearing two incontinence briefs when she had arrived in the morning.
On 01/11/23 at 7:35 AM, the surveyor entered Resident #45's room and observed that the clothing was soiled with yellow brownish feces like substances, and the resident was unshaven. A strong odor of feces permeated the room and became noticeably stronger while approaching the resident's bed. Resident #45 shared the room with two other residents. The resident answered to the surveyor's greetings and stated, I need everything!, pointed at the soiled clothing and stated, I need to be ready.
The surveyor left the room to review the schedule and returned to the room at 8:20 AM only to observe that the resident was eating breakfast and had not been changed.
On 01/11/23 at 8:30 AM, the surveyor interviewed the CNA assigned to Resident #45. The CNA stated that she did not deliver the breakfast tray to Resident #45.
On 01/11/23 at 8:35 AM, the surveyor entered the room with the CNA, and the CNA stated that she provided morning care and dressed Resident #45 on 01/10/23 during the 7:00 AM- to 3:00 PM shift, and dressed him/her with the white T-shirt he/she still had on now. The CNA stated, two shifts went by (referring to the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM) and the resident had still not been changed. The CNA checked the resident in the presence of the surveyor and the resident was soiled with feces.
On 01/11/23 at 8:40 AM, the surveyor conducted an interview with the CNA who delivered the breakfast tray. The CNA stated she was not aware that Resident #45 needed to be changed. She added that the room had the same smell every day. The surveyor escorted the CNA to the room and when asked about the feces odor still present in the room, she replied that the resident was not on her assignment.
On 01/11/23 at 8:45 AM, the surveyor shared the above concerns with the Unit Manager (UM). The UM told the surveyor that any staff regardless if assigned to a resident or not, should change a resident if the resident needed to be changed.
On 01/11/23 at 8:50 AM, the surveyor interviewed the resident who stated, I told you I needed everything. I needed to be changed and get ready. When asked how did he/she feel regarding not being changed prior to breakfast, Resident #45 stated, the girls (referring to the CNAs) they are overworked, I just stay put.
A review of Resident #45's medical record revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Renal Insufficiency, hemiplegia and hypertension.
The most recent Quarterly Minimum Data Set (MDS), a resident assessment tool used by the facility to prioritize care dated 01/03/23, revealed that Resident #45 had some impaired cognition. Resident #45 scored 04 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS reflected that Resident #45 was always incontinent of bladder and bowel and was not on a toileting program. Resident #45 was totally dependent on staff for personal hygiene and toilet use.
The administrative staff was made aware of the above concerns on 01/11/23 at 9:30 AM and again on 01/19/23 at 12:30 PM. On 01/20/23 at 11:30 AM and no additional information was provided.
2. On 01/03/23 at 11:14 AM, the surveyor observed Resident #179 lying in bed, awake, and was on an air mattress. The television was on and the resident did not appear to be engaged. The resident appeared very thin, an intravenous (IV) was infusing, and the resident did not respond to the surveyors greeting. The resident's mouth and lips appeared very dry with a crust like coating on the lips.
On 01/03/23 at 12:37 PM, the surveyor observed through the doorway that Resident #179 was in bed, with the resident meal tray covered on the overbed table next to the resident. The surveyor entered the room, and heard a noise in the resident's bathroom. There were no other residents assigned to the room. At that time, the door to the bathroom opened and a staff member exited the bathroom holding her cell phone. The staff identified herself as a Certified Nurse Aide (CNA #1) assigned to care for Resident #179. CNA #1 proceeded to explain to the surveyor that she was having some filmily issues and that was why she was on the phone. CNA #1 did not engage the resident, or interact with the resident at all, including with the meal tray and proceeded to exit the resident's room.
On 01/04/23 at 8:35 AM, the surveyor observed Resident #179 with eyes closed, lying in bed and the breakfast meal had not yet arrived on the unit. The surveyor observed a brownish tan flaky food like substance on Resident #179's top right shoulder. The surveyor engaged the resident who opened his/her eyes, looked at surveyor and did not verbally respond.
On 01/04/23 at 1:48 PM, the surveyor, in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA) and Corporate Nurse of the observation with CNA #1 talking on the phone in Resident #179's bathroom. The LNHA stated that was not tolerated, and they [staff] were not supposed to be talking on cell phones in a resident's room.
A review of the facility provided policy titled, Quality of life: Dignity, initiated 03/24/12 and revised 12/04/17, revealed, Each resident of the [facility name] shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining his or her self esteem and self-worth., Procedure: 1. Residents shall be treated with dignity and respect at all times, 2. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.), 4. Residents' private space and property shall be respected at all times, a. Staff will knock and request permission before entering residents' rooms.
N.J.A.C.8:39-4.1(a)(12)

Based on interview, and review of pertinent documents it was determined that the facility failed to have written procedures in place to ensure: a.) all residents were protected from abuse when an allegation of staff to resident abuse occurred, b.) a process was in place for identifying other potential victims of abuse, and c.) a process to ensure all potential witnesses/persons aware of the allegation were interviewed. This deficient practice was evidenced for 4 of 4 resident units, and for 1 of 2 residents reviewed for abuse, and occurred when an allegation of abuse by a Certified Nurse Aide (CNA #1) against a resident (Resident #182) was received on 01/17/23 and CNA #1 proceeded to work a resident care shift the following day, 01/18/23, and had access to Resident #182 and other residents who resided at the facility, and was prior to an abuse investigation being completed. The deficient practice was evidenced by the following:
Refer to 600J
On 01/19/23 at 8:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a request to speak with a family member.
On 01/19/23 at 8:46 AM, the surveyor contacted the family member (FM) of Resident #182 and conducted a telephone interview. The FM stated Resident #182 had an issue with CNA #1 who had walked into Resident #182's room and was nasty to Resident #182 on 01/17/23. The FM stated CNA #1 told the resident that she was not going to have to change (provide incontinence care) the resident again, since Resident #182 was not her only resident. CNA #1 told Resident #182 that she was on her break at the time, and CNA #1 refused to change Resident #182. CNA #1 then proceeded to throw down the food lid with force on Resident#182's over bed table. The FM stated that he/she had verbally informed the Director of Social Services (DSS) of what happened on the same day, 01/17/23, and the FM did not complete a written statement.
On 01/19/23 at 8:50 AM, the surveyor reviewed the CNA assignment sheet for 01/19/23, with the Unit Manager (UM). The assignment sheet for 01/19/23 revealed that there were two CNAs listed to care for the residents on the unit. The surveyor inquired to the UM what the current resident census was for the unit. The UM stated thirty-eight residents were on the unit, and the surveyor asked what the staffing typically was, and if any of the CNAs that had worked on 01/17/23 were removed from the schedule for any reason. The UM stated that there was usually five or six CNAs staffed on the unit, and he was not sure who had called out sick. The UM then stated no, CNAs had not been removed from the schedule for any reason and stated there were three CNAs that had scheduled days off (which included CNA #1).
On 01/19/23 at 9:23 AM, the surveyor conducted an interview with the DSS and inquired if there were currently any investigations in progress. The DSS stated that he had received a grievance from Resident #182 on 01/17/23. At that time the DSS provided the surveyor with the copy of the Facility Name, Grievance/Missing Item Report, which revealed: Date: 01/17/23 (untimed), Resident: [#182], Room: [Resident #182's room number]. Complaint Made By: Patient, Complaint Made to: DSS, Statement of Complaint:, On 01/17/23, at about lunch time, the patient stated a CNA threw the lid cover on the food/tray table. A handwritten Addendum documented directly below the 01/17/23 Statement of Complaint revealed On 01/18/23, on the date above, the Patient stated that the same CNA, while on the total lift machine, wanted to be placed in bed .The statement continued on a blank page which revealed . and in need of a change of [his/her] disposable brief, the CNA stated, Your [sic.] not my only patient, there's no way I'm doing this tomorrow. While in bed, [he/she] was not changed by that CNA. After a while, [he/she] was changed by someone else. The DSS stated that he completed his portion on 01/17/23, when the FM of Resident #182 brought him into the resident's room to speak with Resident #182, and he confirmed that he took the statement from Resident #182 and stated, the complaint was made to me. The DSS stated he brought the initial complaint, on 01/17/23, to the Director of Nursing (DON), because when the complaint involved nursing the DON was responsible for getting statements. The DSS stated that the DON was responsible for the investigation, along with the LNHA, who was the facility was abuse coordinator. The DSS stated, I would imagine the Director of Nursing has followed up on it [the complaint made by Resident #182]. The DSS stated that he conducted a follow-up interview with Resident #182 on 01/18/23, and at that time, the resident provided an additional statement that he also documented on the form. At that time, the surveyor requested and the DSS provided the surveyor with a copy of the facility abuse policy. The surveyor inquired to the DSS if what Resident #182 stated to the DSS would fall under the abuse category. The DSS stated, yes, that it is verbal abuse, neglect, and it touches many bases. The DSS stated, again, he immediately informed the DON of the allegation made by Resident #182 on 01/17/23. The surveyor inquired to the DSS what the process was when an allegation of abuse occurred, and what his involvement was. The DSS stated he was not involved with the abuse investigation, he assisted with grievances, and missing items, and because the allegation received from the FM and Resident #182 was related to abuse. The DSS stated, I immediately told the DON and stated, I would imagine that the DON has followed up on it. The surveyor asked the DSS if this allegation would be a priority, and he stated, yes, and the first thing that would be done would be [CNA #1] would be removed from providing care, and stated if it is alleged abuse, then she cannot come to the facility until the investigation is completed, because you would not want someone who was alleged to have performed an abusive act working because it could happen again. The DSS stated when he took the initial complaint from Resident #182, he had initially thought it was an allegation of abuse and neglect because CNA #1 failed to perform care for the resident, and then slammed the lid down, was aggressive and possibly violent. The DSS stated he was instructed by the DON to provide the UM with blank statement forms on 01/17/23, which he had done, and he instructed the UM to get the statements per the DON's instructions. The DSS stated he provided the copy of the grievance form to the UM on 01/18/23. The surveyor asked the DSS what further involvement he had in the abuse investigation process, and has he received any further communication regarding the allegation been provided by the DON/ LNHA, and he stated, no, not to me. An initial review of the Facility Policy/ Procedure, Abuse Prevention Program, Original Issue Date: 2/2014, Revised: 10/21/22, in the presence of the DSS revealed under Part V, Investigation, Procedure: The administrator who is the APP Coordinator, and the DON will initiate investigations of any allegations of abuse, determine necessary response, and report to the office of the Ombudsman and the Department of Health and Senior Services, as necessary. The scope of the investigation shall be determined by the Administrator and/or the DON. The Protection Procedure revealed, When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor, notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. (The policy failed to include a written process to protect the safety of all residents from abuse during an abuse investigation.)
On 01/19/23 at 9:50 AM, the surveyor conducted an interview with the UM for the unit that Resident #182 resided on. The surveyor inquired to the UM if he had received any complaints or was currently involved in any investigations regarding any residents. The UM stated that the FM of Resident #182, came to him on 01/17/23 and informed him that CNA #1 had an attitude, and she was not nice to Resident #182. The UM stated that he informed the DON and the DSS the same day of the FM's complaints. The surveyor inquired if the UM had been instructed to do anything because of the complaint. The UM stated, I was told to take statements, but because the UM found out late in the afternoon on 01/17/23, that CNA #1 had already left for the day, and he was unable to obtain a statement. The UM confirmed to the surveyor that CNA #1 was the CNA assigned to Resident #182, and then stated he obtained a statement from CNA #1 on 01/18/23, which was the following day after the allegation The UM stated that CNA #1 worked her full resident assignment on 01/17/23 and again on 01/18/23. At that time, the surveyor reviewed the 01/18/23, 7:00 AM-3:30 PM assignment sheet for the CNAs, and CNA #1's assignment included nine residents. Resident #182's room had both beds crossed off, and it was replaced with two other beds in another room. The UM stated that when CNA #1 arrived to work on 01/18/23, that she had started her assignment first, and then he had spoken to her (time not provided by UM) regarding the reason for being removed from providing care to Resident #182. However, the UM confirmed that CNA #1 continued to work and was assigned to a resident care assignment on 01/18/23, which included nine residents. The assignment was located on the same unit where Resident #182 still resided and had access to Resident #182, and all other residents. The surveyor asked the UM if he had been provided a copy of the grievance from the DSS, and he stated, yes. The surveyor asked the UM if what was written on the form represented abuse and neglect, and the UM stated, yes, and stated CNA #1 told him, it never happened, and that Resident #182 was happy with the care she had provided. The surveyor asked the UM if he had interviewed anyone else regarding the allegation. The UM stated he had interviewed the four CNAs (including CNA #1) that worked on the unit on 01/17/23, the date when the allegation was received, and the surveyor asked if the UM had interviewed anyone in addition to the CNAs. The UM stated, no, and the surveyor then asked if the UM had interviewed any residents. The UM stated, no, and that he provided the statements he had collected from the CNA's to the DON. The surveyor inquired to the UM if the investigation was still ongoing, and the UM stated yes.
On 01/19/23 at 10:46 AM, the surveyor, in the presence of the survey team, interviewed the DON and LNHA. The surveyor asked to both the DON and LNHA what was supposed to happen if there was an allegation of abuse. The DON stated the process was, if there was an allegation of abuse, an investigation would be started immediately, and stated right away, after she received the complaint. The surveyor inquired if there had been any recent complaints, or allegations of abuse. The LNHA stated there was a grievance provided by the DSS, and the DON and LNHA confirmed it was provided to both on 01/17/23, and the LNHA stated she had been made aware by the UM on 01/17/23 at 4:00 PM. The surveyor asked what the process was when a grievance was received. The DON stated as soon as she received it, that she would identify the caregiver and nurse assigned to the patient, and then she would obtain a statement from the staff that was involved with the resident, including the family, doctor, nurses, and other residents assigned to the staff. The DON stated that the assigned aide to the person who had the complaint would be suspended while the investigation was ongoing, because we don't want any incident to happen, we want to protect the resident and any other resident assigned. The surveyor informed the DON and LNHA that CNA #1 had worked on 01/18/23, which directly contradicted the DON's statement that the staff would be suspended during the investigation. The surveyor then informed the DON and LNHA that the UM had confirmed he was made aware of the allegation on 01/17/23 and CNA #1 was allowed to work and provided resident care the following day. The surveyor asked about Resident #182's allegation that CNA #1 threw the lid cover, and the DON stated, I would say that was an attitude, and the DON stated based on that assumption she took CNA #1 off of Resident #182's assignment. The surveyor asked where attitude would fall in the abuse policy and the LNHA stated it was just sensitivity, and the DON stated the employee could have burnout but may not have intended to be insensitive to the resident. The DON stated we would have to investigate to see if there was an intention of abuse. The DON was asked if there had to be intention for abuse and the DON responded to the survey team, no. The DON then stated that we spoke with the aide on 01/17/23 (no time provided), after the complaint was made. When the surveyor inquired to the DON when she was informed about the incident from the UM, the DON stated, I could not even remember what he told me on 01/17/23, because it was late in the afternoon. The surveyor inquired to what time the DON received the statement from CNA #1, and the LNHA stated we found out at 4:00 PM about the allegation, and that was when the statement was written. At that time, the surveyor inquired to the LNHA who had the facility received statements from, and the LNHA confirmed she had a statement from CNA #1, and three other CNAs who worked that day. The DON stated we didn't get statements from the nurses that worked that day and stated that they received statements from the four CNAs that worked on 01/17/23, and the UM. The surveyor inquired to the DON if she had interviewed the resident when she had found out about the allegation made on 01/17/23, the DON stated yes, at 3:00 PM, but that was late in the afternoon. The surveyor asked what the DON had asked the resident, and the DON stated, how are you today? and no other specific questions were asked per the DON. The DON stated the UM also spoke with the resident on 01/17/23 and then confirmed there was no documented evidence of that interaction when inquired by the surveyor. The DON stated that other alert and oriented residents would still need to be interviewed to obtain statements, and confirmed the investigation was not complete yet, that they cannot just let it go, and we don't tolerate that. The surveyor asked about residents who were not alert and oriented and the DON stated we would do a body assessment. The surveyor inquired if that was done and the DON stated no, and the LNHA stated we could ask the family members about any concerns with the caretaker. The LNHA stated yesterday was really when the investigation began, and the other day was just a comment. The surveyor inquired if the investigation was completed on 01/18/23, and the DON stated, no. The surveyor then asked if it the investigation was not completed, was CNA #1 supposed to work and have a resident assignment on 01/18/23. The DON stated, this was given to us late, and the DON and LNHA did not offer an explanation as to why CNA #1 worked on 01/18/23 and continued to provide resident care. The surveyor asked why it would be important to interview other staff, and the LNHA stated to make sure other residents are safe. The surveyor asked what kind of an allegation the statements made by Resident #182 represented, the DON stated, a complaint. The surveyor asked if the allegation was an allegation of abuse, and the LNHA stated, yes. The surveyor asked is there anything else that should be done when an allegation of abuse was made. The LNHA stated I have to report it to the State and Ombudsman within two hours, and confirmed it was reported to the Stated Department of Health on 01/19/23, two days later, and not within two hours.
On 01/19/23 at 1:02 PM, the surveyor, in the presence of another surveyor, interviewed Resident #182 with the FM present. The surveyor asked Resident #182 about the incident that occurred with CNA #1, and how it made the resident feel. Resident #182 stated it made him/her feel not good, and he/she was upset and shocked, and the resident was concerned for how he/she would receive care the following day after the incident. Resident #182 stated CNA #1 was mad and left the room and then stated there was no one present when the CNA was not nice to the resident. The FM stated they now had to hire private care to ensure Resident #182 would receive care.
On 01/19/23 at 1:30 PM, the DON provided the Time Card Report, for CNA #1 which revealed CNA #1 worked 01/17/23 from 6:55 [AM] to 15:30 [3:30 PM], and on 01/18/23 from 6:53 [AM] to 15:47 [3:47 PM].
On 01/19/23 at 1:36 PM, surveyor #2 conducted an interview with the UM. Surveyor #2 asked the UM when he was first made aware of the allegations made by Resident #182. The UM stated the FM of Resident #182 told the UM on 01/17/23, and the UM immediately informed the LNHA and DON. Surveyor #2 asked the UM if he had interviewed Resident #182, and he stated I just asked how [he/she] was and [he/she] stated fine.
On 01/20/23 at 12:33 PM, the survey team completed an exit conference with the facility administration, which included the LNHA, DON, Regional Quality Assurance Nurse and Corporate Director of Operations (COD). The surveyor asked the facility if the facility quality assurance comittee was aware that the facility abuse policy did not include protection for all residents. The COD stated no.
A further review of the Policy/Procedure: Abuse Prevention Program, Original Issue Date: 2/2014 revealed Policy: This facility prohibits abuse, neglect, involuntary seclusion, and misappropriation of property from residents and will utilize the abuse prevention program to effectively prevent occurrences, screen and train staff, identify, investigate, report, and respond to any occurrences .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Forms of resident abuse: Active Forms of Abuse: .2. Verbal Abuse: Talking to residents in a demanding manner, shouting, cursing, and name-calling ., Passive Forms of Abuse: 1. Emotional Abuse: Deliberately ignoring a resident's request, denying a resident water, food, a bedpan, a call bell, etc. for a period of time., 2. Neglect: The failure of the facility, it's employees, or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (ex: [example] allowing a resident to lie in urine or feces, ignoring a resident, not providing daily cleanliness, personal hygiene, proper mouth care, shaving, hair washed and combed, dressing a resident inappropriately and or in dirty clothing. Leaving resident exposed during bathing, dressing, changing etc .). Neglect of goods or services may occur when staff are aware of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (Example-suctioning, transfers, use of equipment. Lack of sufficient staffing to be able to provide the services, lack of supplies, or lack of knowledge of the needs of the resident. Abuse Prevention Program-Part VII- Protection, Procedure: When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. Abuse Prevention Program-Part V1- Identification, Procedure: .Any unusual occurrence, which may potentially constitute abuse, neglect, or involuntary seclusion, will be identified as a potential abuse incident and investigated as such .Abuse Prevention Program-Part V11 Reporting/Response .When an incident is reported to the supervisor, the supervisor is responsible for ensuring that the resident is safe and will notify the administrator as well as the DON, or their designees. (The facility Abuse Prevention Program did not include a process to protect all other residents from abuse when an allegation of abuse was reported)
N.J.A.C. 8:39-4.1 (a)5,12