Crystal Lake Hlthcare & Rehab

F-F600 was removed as of 4/16/25. Level of Harm - Immediate jeopardy to resident health or After the IJ removal, the non-compliance continued from 4/16/25 for no actual harm with the potential for safety more than minimal harm that is not an immediate jeopardy.

Residents Affected - Few This deficient practice was identified for 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse and was evidenced by the following: Note: The nursing home is disputing this citation. According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2.

According to the facility's Summary of Investigation with an event date of 4/3/25 revealed under Summary, Staff knocked on the door and entered the room to complete her work assignment. The staff member observed Resident #1 and #2 involved in a sexual act between each other. The staff member exited the room and reported what she witnessed to the nurse. The residents were immediately separated and placed

on 1:1. The residents expressed consent to their actions without anyone being taken advantage of by the other. Abuse is unsubstantiated as both residents were consenting to their sexual action.

1. According to the Admission Record (AR), Resident #1 was admitted to the facility in April 2021 with diagnoses which included but were not limited to: major depressive disorder, alcohol abuse, and toxic encephalopathy (a neurologic disorder caused by exposure to toxins).

According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/26/25, Resident #1 had a BIMS score of 3, which indicated the resident had severe cognitive impairment.

2. According to the AR, Resident #2 was admitted to the facility in September 2020 with diagnoses which included but were not limited to: schizoaffective disorder (a mental health condition with hallucinations, delusions, and mood disorder symptoms), bipolar disorder, and major depressive disorder.

According to the Quarterly MDS, an assessment tool dated 2/21/25, Resident #2 had a BIMS score of 8, which indicated the resident's cognition was moderately impaired.

A review of Resident #2's care plan (CP) revealed under Focus, Resident #2 has an alteration in thought process related to cognitive loss associated with mental illness. History of asking for pornography and fixating on females. Under Interventions, Monitor for sexually inappropriate behaviors.

On 4/10/25 at 11:03 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN#1), who stated that

on 4/3/25 she was informed by the CSC that the HK walked into the room and witnessed both residents in a sexual act. LPN #1 stated she immediately reported the incident to the ADON and the LNHA. LPN #1 stated Resident #2 told me he had been involved with another guy before, but I never seen [sic] anything. LPN #1 further stated that even though both residents were able to make their own decisions, she did not know if

they were able to have sex.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 4/10/25 at 11:46 A.M., the surveyor interviewed the HK, who stated last week she was collecting hangers, and she went to both residents' room and knocked on the door. She further stated when she Level of Harm - Immediate entered the room, she observed Resident #1 on the bed performing oral sex on Resident #2, who had jeopardy to resident health or his/her pants partially down. The HK stated that both residents stopped when they saw her. She stated she safety finished collecting the hangers, then left the room and observed Resident #2 come out of the room behind her. The HK indicated she could not remember the exact date and time the incident had occurred. The HK Residents Affected - Few further stated she went to lunch for 30 minutes and when she returned, she told her co-worker who reported

it to the CSC. The HK stated I did not tell my supervisor because he was off. I was scared to report it to a Note: The nursing home is supervisor because my English is not always understood. The HK indicated Yes, I should have reported it disputing this citation. sooner. I knew I had to report it, but I did not at that moment. The surveyor asked the HK why she wrote in her statement that she immediately told a staff member. The HK did not respond to the surveyor's question.

On 4/10/25 at 12:20 P.M., the surveyor interviewed the CSC who stated she could not remember the actual date and time of the incident, but her daughter, who was the HK's co-worker reported to her that the HK told her she witnessed two residents on the fifth floor having sexual intercourse. The CSC further stated she immediately reported what was told to her to the fifth-floor nurse, the abuse coordinator, the LNHA, and the ADON. The CSC stated after she reported the incident, she called the HK to find out what she had observed.

The CSC stated, The HK should have went [sic] straight to a department head and reported it.

On 4/10/25 at 2:23 P.M., the surveyor interviewed the Social Worker (SW), who stated she was made aware by the LNHA that both residents were involved in a sexual interaction with each other. The SW stated she interviewed both residents and that Resident #2 told her that he had oral sex with Resident #1. The SW stated that the facility residents were allowed to engage in sexual activity under certain circumstances such as having the capacity to give consent. The SW stated that capacity to consent meant that the residents understood the consequences of their actions. The SW stated the BIMS score determined the resident's ability to give consent. The SW further stated No, I would not consider a resident having a BIMs score of 3, that they have the capacity to make a decision regarding having sex. The SW further indicated I think a BIMS score of 8 is too low for giving consent as well.

On 4/10/25 at 3:20 P.M., the surveyor interviewed the ADON who stated that the CSC reported to her that her daughter informed her that the HK stated Resident #1 was lying on the side of the bed, Resident #2 had his/her pants partially down and Resident #1 was performing oral sex on Resident #2. She further stated that once she was made aware by the CSC she immediately placed both residents on 1:1 and conducted an investigation. The ADON stated the local police came to the facility and Resident #1 denied what occurred but Resident #2 confirmed what the HK stated she observed. The ADON stated Yes, I wrote that both residents were consenting to their sexual action. Neither of them said they were raped in front of the police.

The ADON further stated Every resident has a right to make a decision, whether good, bad, or indifferent.

They all have rights. I don't have the right to tell them not to do it. The ADON further indicated she did not have the right to tell the residents not to have sex. She further stated, I don't think they can consent to sexual acts with a BIMS score of 3 and 8. The ADON stated that if the staff had seen any residents having sex, they must immediately report it to the abuse coordinator and separate both residents to ensure their safety. She further indicated that any sexual activity should be reported immediately because it could be abuse. The ADON further indicated she was not aware of any sexually inappropriate behaviors from Resident #1 and Resident #2 prior to the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 4/10/25 at 4:10 P.M., the surveyor interviewed the LNHA in the presence of the Director of Nursing (DON). The LNHA stated that the CSC reported the sexual act between Resident #1 and #2 to the abuse Level of Harm - Immediate coordinator and the abuse coordinator reported it to her. The LNHA stated Yes, correct it was jeopardy to resident health or unsubstantiated because both residents said in front of the police that they consented to having sex. The safety LNHA stated the HK told her that she reported the incident to her co-worker who reported it immediately to

the CSC. The LNHA indicated she was not aware that the HK went to lunch prior to reporting the incident. Residents Affected - Few The LNHA stated Yes, she (HK) should have reported it immediately to the nurse and the abuse coordinator, so it could have been addressed and the safety of all residents could have been assured. Note: The nursing home is disputing this citation. A review of the undated facility policy titled Sexual Intimacy revealed It is the policy of [NAME] Lake Health Care and Rehabilitation Center that residents who wish to engage in sexual intimacy with one another, are permitted to do so, contingent upon they are both consenting adults and have been deemed capable to make decisions according to guidelines of the MDS.

A review of the undated facility policy titled Resident Abuse/Neglect' revealed under Policy, An employee witnessing any form of abuse or neglect is also required to report the incident promptly to the charge nurse.

NJAC 8:39-4.1 (a) (5)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0728 Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Level of Harm - Minimal harm or potential for actual harm 50919

Residents Affected - Few Complaint #: NJ182091

Based on interviews and review of other pertinent facility documentation on 4/10/25, it was determined that

the facility failed to ensure that a staff member assigned the position of Monitor was not performing direct resident care. This deficient practice was identified for 1 of 3 monitors reviewed and was evidenced by the following:

According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 1/1/25 revealed the Physical Therapist Aide (PTA) was approached by Resident #4 who stated the aide hit Resident #3. The PTA went to the residents' room, where the aide (Monitor #1) was performing Activities of Daily Living (ADLS) with Resident #3.

According to the Admission Record (AR), Resident #3 was admitted to the facility in July 2024 with diagnoses which included but were not limited to: dementia, schizoaffective disorder, and major depressive disorder.

According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/25/24, Resident #3 had a BIMs score of 9, which indicated the resident's cognition was moderately impaired. The MDS further revealed the resident required partial to moderate assistance with personal hygiene and supervision for toileting hygiene.

A review of Monitor #1's personnel file revealed a facility form titled Master Payroll Form, under Job Title, Monitor with an effective date of 5/23/24. The surveyor did not observe a CNA license in the personnel file.

On 4/10/25 at 2:47 P.M., the surveyor interviewed the PTA who stated that on 1/1/2025 she went to Resident #3's room to check on the resident and observed a staff member cleaning the resident and a diaper on the bed. The PTA stated she could not remember the staff member's name.

On 4/10/25 at 3:00 P.M., the surveyor interviewed Monitor #1 utilizing the Language Link translator service. Monitor #1 stated Yes, I am a CNA. I do not have a license yet. I have certification in skills. I took the test, but I failed. Monitor #1 further stated the last test she took was in February of last year. Monitor #1 further indicated Yes, I change diapers, bathe them, and transfer them. I do everything. She further stated that she took care of Resident #3 and had changed his/her brief on 1/1/25.

On 4/10/25 at 3:58 P.M., the surveyor interviewed the Human Resources Director (HRD) who stated, No a monitor cannot bathe a resident, change a diaper, or transfer a resident out of bed. The HRD confirmed that Monitor #1 was not a CNA but had been to CNA school. The HRD further indicated that Monitor #1 could not give direct care to the residents. She stated that she was not aware that Monitor #1 was giving direct resident care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0728 On 4/10/25 at 4:10 P.M., the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) stated that a monitor could pass trays and make beds. The LNHA Level of Harm - Minimal harm or further indicated that the monitor could not provide care or transfer a resident. The LNHA confirmed Monitor potential for actual harm #1 was not an CNA. The LNHA stated Yes, it could be a safety issue, but my understanding was that monitors don't do CNA responsibilities. Residents Affected - Few

The facility was unable to provide the surveyor with the assignment sheet for 1/1/25 on 4/10/25.

A review of the facility's job description titled Monitor revealed under Function, Monitor residents while smoking to ensure safe environment and safe smoking. Provide assistance with transportation of residents within facility. Provide safety devices as needed. Make beds. Keep room clean and safe. Encourage activities during leisure times. Monitor inside and outside. Assist with dining room as needed. Help with transportation during smoking hours. Monitor day rooms. Assist with mealtimes. Offer water and/or juice. Encourage hydration. Offer snacks. Will attend in-service sessions relating to the care of the residents in the facility. Make frequent rounds on the residents.

NJAC 8:39-43.2 (a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate 50919 jeopardy to resident health or safety Complaint # NJ185153

Residents Affected - Few Based on interviews, medical record review, and review of other pertinent facility documentation on 4/10/25 and 4/23/2025, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to a) Note: The nursing home is ensure that the staff implemented the facility's policies and procedures for a witnessed sexual abuse that disputing this citation. occurred between two residents, and b) ensure that residents were provided with the care and services to achieve their highest practical wellbeing.

On 4/3/25 at approximately 12:00 P.M., the Housekeeper (HK) stated she went to Resident #1 and Resident #2's room and knocked on the door. The HK entered the room and observed Resident #1 on the bed performing oral sex on Resident #2. The HK finished collecting hangers from out of the room and then went

on her lunch break for approximately 30 minutes. When the HK returned from lunch, she reported it to her co-worker. Her co-worker then reported the sexual encounter that the HK observed to the Central Supply Coordinator (CSC). The CSC reported it to the 5th floor nurse, the abuse coordinator, the LNHA, and the Assistant Director of Nursing (ADON).

The LNHA's failure to ensure that the facility staff implemented the facility's policies and procedures for a witnessed sexual abuse that occurred between two residents placed all residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 4/23/2025 at 1:37 P.M. and was reported to the LNHA. The LNHA was presented with the IJ template. The IJ began on 4/3/25.

An acceptable removal plan was electronically mailed to the surveyor on 4/24/2025 at 4:26 P.M., indicating

the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The co-founder/ Chief Executive Officer (CEO) educated the LNHA on the Administrator's job description. The CEO educated the LNHA and the facility's department heads on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident. The Corporate Consultant/designee educated the governing body on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.

The surveyor verified the removal plan on site on 4/29/2025 and determined the IJ for

F-F835 J was removed as of 4/29/2025.

After the IJ removal, the non-compliance continued from 4/29/2025 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy.

According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 According to the facility's Summary of Investigation with an event date of 4/3/25 revealed under Summary, Staff knocked on the door and entered the room to complete her work assignment. The staff member Level of Harm - Immediate observed Resident #1 and #2 involved in a sexual act between each other. The staff member exited the jeopardy to resident health or room and reported what she witnessed to the nurse. The residents were immediately separated and placed safety on 1:1. The residents expressed consent to their actions without anyone being taken advantage of by the other. Abuse is unsubstantiated as both residents were consenting to their sexual action. Residents Affected - Few 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in April 2021 with Note: The nursing home is diagnoses which included but were not limited to: major depressive disorder, alcohol abuse, and toxic disputing this citation. encephalopathy (a neurological disorder caused by exposure to toxins).

According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/26/25, Resident #1 had a BIMS score of 3, which indicated the resident's cognition was severely impaired.

2. According to the AR, Resident #2 was admitted to the facility in September 2020 with diagnoses which included but were not limited to: Schizoaffective disorder (a mental health condition with hallucinations, delusions, and mood disorder symptoms), bipolar disorder, and major depressive disorder.

According to the Quarterly MDS, an assessment tool dated 2/21/25, Resident #2 had a BIMS score of 8, which indicated the resident's cognition was moderately impaired.

A review of Resident #2's care plan (CP) revealed under Focus, Resident #2 has an alteration in thought process related to cognitive loss associated with mental illness. History of asking for pornography and fixating on females. Under Interventions, Monitor for sexually inappropriate behaviors.

On 4/10/25 at 11:46 A.M., the surveyor interviewed the HK, who stated last week she was collecting hangers, and she went to both residents' room and knocked on the door. She further stated when she entered the room, she observed Resident #1 on the bed performing oral sex on Resident #2, who had his/her pants partially down. The HK stated that both residents stopped when they saw her. She stated she finished collecting the hangers, then left the room and observed Resident #2 come out of the room behind her. The HK indicated she could not remember the exact date and time the incident had occurred. The HK further stated she went to lunch for 30 minutes and when she returned, she told her co-worker who reported

it to the CSC. The HK stated I did not tell my supervisor because he was off. I was scared to report it to a supervisor because my English is not always understood. The HK indicated Yes, I should have reported it sooner. I knew I had to report it, but I did not at that moment. The surveyor asked the HK why she wrote in her statement that she immediately told a staff member. The HK did not respond to the surveyor's question.

On 4/10/25 at 2:23 P.M., the surveyor interviewed the Social Worker (SW), who stated that the facility residents were allowed to engage in sexual activity under certain circumstances such as having the capacity to give consent. The SW stated that capacity to consent meant that the residents understood the consequences of their actions. The SW stated the BIMS score determined the resident's ability to give consent. The SW further stated No, I would not consider a resident having a BIMs score of 3, that they have

the capacity to make a decision regarding having sex. The SW further indicated I think a BIMS score of 8 is too low for giving consent as well.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 On 4/10/25 at 3:20 P.M., the surveyor interviewed the ADON who stated that the local police came to the facility and Resident #1 denied what occurred but Resident #2 confirmed what the HK stated she observed. Level of Harm - Immediate The ADON stated Yes, I wrote that both residents were consenting to their sexual action. Neither of them jeopardy to resident health or said they were raped in front of the police. The ADON further stated Every resident has a right to make a safety decision, whether good, bad, or indifferent. They all have rights. I don't have the right to tell them not to do it.

The ADON further indicated she did not have the right to tell the residents not to have sex. She further Residents Affected - Few stated, I don't think they can consent to sexual acts with a BIMS score of 3 and 8. The ADON stated that if

the staff had seen any residents having sex, they must immediately report it to the abuse coordinator and Note: The nursing home is separate both residents to ensure their safety. She further indicated that any sexual activity should be disputing this citation. reported immediately because it could be abuse.

On 4/10/25 at 4:10 P.M., the surveyor interviewed the LNHA in the presence of the Director of Nursing (DON). The LNHA stated that the CSC reported the sexual act between Resident #1 and #2 to the abuse coordinator and the abuse coordinator reported it to her. The LNHA stated Yes, correct it was unsubstantiated because both residents said in front of the police that they consented to having sex. The LNHA stated the HK told her that she reported the incident to her co-worker who reported it immediately to

the CSC. The LNHA indicated she was not aware that the HK went to lunch prior to reporting the incident.

The LNHA stated Yes, she (HK) should have reported it immediately to the nurse and the abuse coordinator, so it could have been addressed and the safety of all residents could have been assured.

On 4/23/25 at 12:06 P.M., the surveyor conducted a follow up interview with the LNHA who stated, I oversee everything in the building as the Administrator. The LNHA further indicated she reviewed the completed investigation for the incident between the two residents. She stated, Based on everything in the investigation, I agreed abuse was unsubstantiated. The LNHA indicated that she did not know why the HK did not report

the incident immediately.

A review of the facility's undated job description titled Facility Administrator revealed This role is responsible for ensuring compliance with regulatory standards, maintaining a high standard of care, managing staff, and fostering a supportive environment for residents and employees. Under Miscellaneous, Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of the residents. Assure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan.

NJAC 8:39-9.2 (a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 315125 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315125 B. Wing 04/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 50919 potential for actual harm Complaint #: NJ185153 Residents Affected - Many Based on interviews and review of other pertinent facility documentation on 4/23/25, it was determined that Note: The nursing home is the facility failed to maintain documentation and demonstrate evidence of its Quality Assurance and disputing this citation. Performance Improvement (QAPI) program.

On 4/23/25 at 10:47 AM, the surveyor requested the facility's QAPI plan and most recent meeting minutes from the Licensed Nursing Home Administrator (LNHA).

On 4/23/25 at 11:05 AM, the surveyor interviewed the LNHA who stated she was unable to retrieve the QAPI plan and meeting minutes due to not having internet access. The LNHA stated she kept the QAPI plan and meeting minutes on her computer. She further stated she would try to email the surveyor the QAPI plan and meeting minutes.

On 4/23/25 at 12:06 PM, the surveyor conducted a follow up interview with the LNHA who stated No, I am unable to print my QAPI meeting minutes. Since we don't have internet, I am unable to access it. The LNHA further indicated that the QAPI should have been readily accessible to the surveyors when requested.

A review of the facility's policy titled Facility Quality Improvement Plan revealed under Authority and Responsibility, Record minutes of all meetings according to Lineage policy. Maintain documentation according to Lineage policy.

NJAC 8:39-33.1 (b) (c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 315125