Sycamore Living At East Hanover

F-F689. The Immediate Jeopardy Past Noncompliance started on 02/10/2025 and ended on 02/13/2025 when all nursing and non-nursing staff were educated and trained on elopement/missing person, safety measures (including the check-mate system and transport checklist), revised policies on transportation and tracker logs. This deficient practice was identified for 1 of 3 residents (Resident #1) who had Dialysis and/or appointments that required transportation by the facility.

A review of the Facility Reportable Event (FRE), a document submitted by the facilities to report incidents to

the New Jersey Department of Health (NJDOH), with date of event of 02/10/25, included a timeline as follows:

- 1009 [10:09 am] Transfer log indicates [the] time Resident #1 [name] left the facility.

- 1530 [3:30 pm], resident [unsampled resident #1] is transported back to [the] facility (front entrance).

- 1613 [4:13 pm], resident [unsampled resident #2] is transported back to [the] facility (front entrance).

- 1624 [4:24 pm], transporter [name] leaves the facility

- 1700 [5:00 pm], transporter [name] drives the van into [the] parking spot

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 - 1702 [5:02 pm], transporter [name] exits the van and walks to the rear of the building.

Level of Harm - Immediate - 2148 [9:48 pm], the nurse assigned [name], Licensed Practical Nurse (LPN) #1, reached out to the nursing jeopardy to resident health or supervisor to inquire about the Resident's return. safety - 2149 [9:49 pm], [the] nursing supervisor called the dialysis center x 3 [ three times] and the main center x 3, Residents Affected - Few but there was no answer. A building search was initiated, and the transfer log was checked.

- 2202 [10:02 pm], the nursing supervisor called the Resident's [family member]. [The] building search continued.

- 2204 [10:04 pm], the nursing supervisor called the van driver [name] to confirm the Resident [name] returned to [the] facility. Search continued.

- 2221[10:21 pm], the nursing supervisor exited the front of the building to check the van.

- 2222 [10:22 pm], the nursing supervisor checks both sides of the van.

- 2223 [10:23 pm], the nursing supervisor returns to the building to locate the key for the van.

- 2227 [10:27 pm], the nursing supervisor exits the rear of the building, returns to the van, and opens it. Resident [name] was observed lying on the floor with a wheelchair positioned behind her/him. The nursing supervisor runs back to the building to request additional assistance.

- 2231 [10:31 pm], the nursing supervisor starts the van (to warm it).

- 2232 [10:32 pm], additional staff members arrived at the van to help.

- 2234 [10:34 pm], the van's back door opened. The Resident [name] was transferred to the wheelchair.

- 2235 [10:35 pm], staff providing blankets.

- 2237 [10:37 pm], Resident arrived back in [the] building, transferred to [the] bed, and assessed; warm packs and blankets [were] provided.

- 2243 [10:43 pm], the Ambulance was called.

- 2300 [11:00 pm] (Approximately) [the Resident was] transferred to the [Acute Care Hospital] [name] via Ambulance [name] with 2 [emergency medical technicians] EMTs.

- 2331 [11:31 pm], The Resident's niece [name] [was] provided an update.

The facility provided the Surveyor documented evidence of a Plan of Correction (POC) initiated at the time of

the incident on 02/10/2025 and completed before the survey on 02/25/2025 of the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 On 02/10/2025, after the incident, the family and MD (Doctor) were notified; the driver and the nurse were suspended pending investigation and subsequently were terminated. [The] transport van was taken out of Level of Harm - Immediate service until safety measures can be put in place. jeopardy to resident health or safety Safety measures:

Residents Affected - Few a) Purchase of a safety device system (child check-mate system). The Child Check-Mate System is a safety system that reminds drivers to check for children/residents after each route. The alarm system acts as an electronic reminder to drivers.

b) Use of Resident Transport Safety Checklist (for all facility van drivers)- Before departing, upon arrival at [the] destination, upon returning to [the] community, Resident tracking signs off (a second staff member to sign tracker when Resident to confirm that all transported residents have returned safely, Accountability and 2 Signatures. This checklist must be followed for every trip to ensure resident safety.

Education and in-services were provided to all staff as follows:

02/10/2025 - Topic: Elopement/Missing Person.

-On 02/11/2025 - Policy on Resident Transportation dated 04/07/2024 and revised/ updated on 02/11/2025.

- On 02/11/2025 to 02/13/2025 - Policy on Tracker for Residents Leaving the Building dated 04/03/24 with a revised date of 02/11/2025 and 02/13/2025.

- 02/13/2025 - Topics: Resident Transport Safety Checklist; Child Check- Mate in-service; Policy Revision for Tracker for Residents leaving the building.

- On 02/13/2025 - [the] facility completed a Root-Cause-Analysis (RCA) Report [,] which included a conclusion and follow-up with [an] expected compliance date of 02/14/2025; final review date of 02/20/2025 and follow-up actions:

a. conduct [a ] post-implementation review in 3 months to ensure continued adherence.

b. address[es] any ongoing issues with further policy adjustments if necessary.

A review of Resident #1's Electronic Medical Record (EMR) revealed the following:

According to the Admission Record (AR), Resident #1 was admitted to the facility with the following diagnoses, including but not limited to ESRD [End-Stage Renal Disease], nonrheumatic aortic (valve) stenosis [heart problem], hyperkalemia [condition wherein there is a high level of electrolyte potassium in the blood], muscle weakness (generalized), abnormalities in gait and posture, and cerebral ischemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 According to the Minimum Data Set (MDS), an assessment tool that comprehensively assesses a resident's functional capabilities, dated 02/08/2025, Resident #1's Brief Interview for Mental Status (BIMS) Summary Level of Harm - Immediate Score was 10, revealing moderately impaired cognition. The MDS further revealed in Section GG-Functional jeopardy to resident health or Abilities that Resident #1 required supervision or touching assistance to maximal assistance in her/his safety completion of Activities of Daily Living (ADLs).

Residents Affected - Few A review of Resident #1's Care Plan (CP) showed a CP Focus [problem/need area]: [Resident's name] needs hemodialysis r/t (related to) renal failure Monday, Wednesday and Friday at [name of dialysis center] pickup time 10:30 am [morning] chair time [dialysis session starts] 11:15 am.

A review of Resident #1's Progress Notes (PN) with an effective date of 02/10/2025 22:27 [10:27 pm]and documented by the Director of Nursing (DON) revealed, Notified by nursing supervisor .[Resident's name] [was] observed lying on the floor in the transport van. The PN further showed that the Resident stated, I am cold[.] Assistance from additional staff [were]requested. Staff arrived to assist with [the] Transfer to [the] wheelchair and bed. Upon arriving in bed, the Resident was assessed.

The PN further revealed the Resident's initial temp 92.0 (temporal). Skin assessment revealed no new findings. Blankets and warm packs [were] provided. The Resident [was] transferred to [name of hospital] ER for evaluation. [Doctor's name] and [Resident's niece's name] [were] notified. VS [vital signs}: 165/58 [blood pressure], HR [heart rate] 58, R [respiration]18, T [temperature] 97.2, O2 [oxygen] saturation 98% at room air. Resident transferred via stretcher, accompanied by 2 EMTs .

According to the facility's New Jersey Universal Transfer Form (NJUTF) dated 02/10/25 with Time of Transfer: 11 pm [11:00 PM] and Reasons for Transfer: Resident [came] back from (hemodialysis) H.D. Hypothermia (low body temperature) exposed to the cold x 5 hours [for 5 hours].

A review of the facility's Summary of Investigation (SOI) under Description: On Monday, 2/10/25 at approximately 2227 [10:27 pm], [Resident #1's name] was observed lying on the floor in the transport van. She/he was picked up by [van driver's name] from [dialysis center name] and was transported back to [facility's name] parking lot at 1700 [5:00 pm]. The SOI provided the following timeline:

- 1009 [10:09 am] Transfer log indicates [the] time Resident #1 [name] left the facility.

- 2148 [9:48 pm], the nurse assigned [name], Licensed Practical Nurse (LPN) #1, reached out to the nursing supervisor to inquire about the Resident's return.

- 2149 [9:49 pm], [the] nursing supervisor called the dialysis center x 3 [ three times] and the main center x 3, but there was no answer. A building search was initiated, and the transfer log was checked.

- 2202 [10:02 pm], the nursing supervisor called the Resident's [family member]. [The] building search continued.

- 2204 [10:04 pm], the nursing supervisor called the van driver [name] to confirm the Resident [name] returned to [the] facility. Search continued.

- 2221[10:21 pm], the nursing supervisor exited the front of the building to check the van.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 - 2222 [10:22 pm], the nursing supervisor checks both sides of the van.

Level of Harm - Immediate - 2223 [10:23 pm], the nursing supervisor returns to the building to locate the key for the van. jeopardy to resident health or safety - 2227 [10:27 pm], the nursing supervisor exits the rear of the building, returns to the van, and opens it. Resident [name] is observed lying on the floor with a wheelchair positioned behind her/him. The nursing Residents Affected - Few supervisor runs back to the building to request additional assistance.

- 2231 [10:31 pm], the nursing supervisor starts the van (to warm it).

- 2232 [10:32 pm], additional staff members arrived at the van to help.

- 2234 [10:34 pm], the van's back door opened. The Resident [name] was transferred to a wheelchair.

- 2235 [10:35 pm], staff providing blankets.

- 2237 [10:37 pm], Resident arrived back in [the] building, transferred to [the] bed, and assessed; warm packs and blankets [were] provided.

- 2243 [10:43 pm], the Ambulance was called.

- 2300 [11:00 pm] (Approximately) [the Resident was] transferred to the [Acute Care Hospital] [name] via Ambulance [name] with 2 [emergency medical technicians] EMTs.

- 2331 [11:31 pm], The Resident's niece [name] [was] provided an update.

The Surveyor reviewed the facility's video footage of the [location of the camera] parking lot, and real-time surveillance [with time stamped] showed the following:

At 4:24 pm - the van was seen leaving the facility.

At 4:59 pm - the facility van was seen coming back and into the driveway.

At 5:00 pm - the driver drives [the] van on the left side area of the viewed parking lot.

At 5:02 pm, the driver exited the van and walked towards the back of the building [towards the right side of

the parking lot].

At 5:03 pm - the driver appeared to wave at somebody in another van parked on the right side of the viewed parking lot.

At 9:55 pm - the facility van was seen in the viewed parking lot.

At 10:21 pm - the nursing supervisor was seen walking towards the van [coming from the left side of the viewed parking lot].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 At 10:22 pm - the nursing supervisor reached the van, walked around the van with cell phone one in hand [Supervisor turned on light in her cell phone], and was seen walking back towards the left of the camera Level of Harm - Immediate [building] while talking on her cell phone. jeopardy to resident health or safety At 10:26 pm - the nursing supervisor was seen walking back towards the van.

Residents Affected - Few At 10:27 pm - the nursing supervisor was seen opening the van and appeared to turn on the van's ignition.

At 10:28 pm - the Supervisor was seen running back towards the building.

At 10:30 pm - staff were seen running towards the van with the nursing supervisor behind them; they opened

the back.

At 10:36 pm - additional staff were seen running towards the van and noted carrying blankets.

At 10:36:41 pm - the staff took Resident #1 in a wheelchair from the back of the van and towards the building. The Resident was noted with blankets on her/him.

On 02/25/2025, the Surveyor reviewed the statements obtained from staff during the investigation.

According to the receptionist's statement dated 2/11/2025, Around 10:00 pm, the [nursing supervisor] asked if I've seen [Resident #1] return from Dialysis. I checked my log, and her time in was blank, indicating she didn't return. Sometimes, I have to step away from the desk to either use the bathroom, let someone from Memory Care, or find a nurse . so I thought [driver's name] came and brought her to the room. I didn't see so I called him to confirm around 10:08 pm, and he said yes, he had brought her to her room, so I told [nursing supervisor], and she told me [Resident #1's name] was missing. We proceed to look through the building for her, and around 10:39 pm, [the nursing supervisor] finds her in the [facility name] transport bus.

On 02/25/2025 at 1:35 pm, the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated the van is owned by the facility and had been used until after the incident and would not use it until after safety measures were installed. LNHA further stated she reviewed the incident and video footage; immediate actions were taken to prevent recurrence, and the policy on transportation and tracker log were revised.

On 02/26/2025 at 12:47 pm, the Surveyor interviewed the van driver via phone. The van driver stated that, at around 4:30 pm, he had picked up the Resident from the dialysis center. The van driver further stated, She/

He was in her wheelchair, put her in the vestibule, put on her/ his seatbelt, and she was fine and did not complain of any pain or discomfort. At 5:00 pm, we arrived at the facility parking lot; I parked the van where I normally parked. I exited the van and walked to the rear of the building. In my mind, I wanted to go back to

the building to finish some work. When the Supervisor called me that night, it was shocking to me. I was emotional. I drove her [the Resident] on several occasions, and I think I was not focused at that time.

On 02/26/2025 at 1:27 pm, the Surveyor placed a call to LPN #1 but did not receive a return call.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0689 A review of the facility's policy titled: Policy: Elopements and Wandering Residents with review date: 5/15/24, under Policy Explanation and Compliance Guidelines: .5. Procedure for locating missing resident: a.Any staff Level of Harm - Immediate member becoming aware of a missing resident will alert personnel using facility approved protocol (code jeopardy to resident health or grey). b.The designated facility staff will look for the resident . safety

A review of the facility's policy titled: Policy: Tracker for Residents Leaving the Building date revised 2/13/25, Residents Affected - Few Under Procedure: 1. Receptionist will record Resident name, date, room number, name of person/transport company, destination, and time that resident leaves the building; 2. Receptionist will then send out an email to the LIVIA team informing staff that resident has left the building; 3. When the resident returns from the appointment, the receptionist will record the return time on the tracking log. The receptionist will also ask the driver to sign the tracking log to confirm that they brought the resident back into the building; 4. Receptionist will then send out an email to the LIVIA team informing staff that resident has returned; 5. If the resident does not return to the building within the expected duration, the receptionist will alert the nursing supervisor that

the resident has not yet returned; 6. If the resident does not return to the building prior to reception change of shift, the receptionist will report to oncoming receptionist for continued follow up.

A review of the facility's policy titled: Resident Transportation date revised 2/11/25, Under Procedure: .6. Resident Tracking Log is completed by receptionist. Driver signs tracking log upon return of resident. 7. Resident Transport Checklist is completed by [facility name] driver .

N.J.A.C. 8:39-27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 51144

Residents Affected - Few Complaint #: NJ00182762

Based on interviews, medical record review, and review of other pertinent facility documents on 02/25/2025 and 02/26/2025, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for ADL documentation. This deficient practice was evidenced by the following:

According to the Admission Record (AR), Resident #6 was admitted to the facility with diagnoses that included but were not limited to: diverticulitis of large intestine without perforation or abscess without bleeding; gastrointestinal hemorrhage, unspecified; unsteadiness on feet; weakness; need for assistance with personal care; other reduced mobility; dementia in other diseases classified elsewhere, unspecified severity, without other behavioral disturbance; and Alzheimer's Disease with late onset

A review of Resident #6's Minimum Data Set (MDS) dated , an assessment tool, revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated that the resident's cognition was severely impaired. The MDS further revealed that the resident depended on a helper to eat and roll left and right.

A review of Resident #6's Care Plan (CP) initiated on 10/01/2024 revealed that the resident was at risk for malnutrition due to Alzheimer's Disease, dementia, diverticulitis, and skin breakdown. The CP revealed that Resident #6 was at risk for skin impairment due to decreased bed mobility. Further review of the resident's CP revealed a Focus, initiated on 10/17/2024, that the resident was resistive to turning and positioning.

A review of Resident #6's Documentation Survey Report (DSR) and progress notes (PNs) for the months of October and November 2024 revealed no documentation to indicate that the resident's activity of daily living (ADL) care was provided, or that the resident refused care on the following dates and times:

Bed mobility:

7:00 AM- 3:00 PM shift on: 10/01/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/07/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/28/2024, 10/29/2024, 10/30/2024, 10/31/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024,11/17/2024, and 11/18/2024.

3:00 PM - 11:00 PM shift on: 10/01/2024, 10/02/2024, 10/03/2024, 10/05/2024, 10/06/2024, 10/15/2024, 10/18/2024, 10/29/2024, and 11/15/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0842 11:00 PM - 7:00 AM shift on: 10/01/2024, 10/05/2024, 10/08/2024, 10/09/2024, 10/12/2024, 10/13/2024, 10/15/2024, 10/17/2024, 10/18/2024, 10/20/2024, 10/23/2024, 10/20/2024, 10/31/2024, 11/01/2024, Level of Harm - Minimal harm or 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/08/2024, 11/10/2024, 11/11/2024, 11/12/2024, potential for actual harm 11/13/2024, 11/16/2024, and 11/17/2024.

Residents Affected - Few Eating:

9:00 AM on: 10/01/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/07/2024, 10/11/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/28/2024, 10/29/2024, 10/30/2024, 10/31/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, and 11/16/2024.

1:00 PM on: 10/01/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/07/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/28/2024, 10/29/2024, 10/30/2024, 10/31/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, and 11/16/2024.

6:00 PM on: 10/01/2024, 10/02/2024, 10/03/2024, 10/05/2024, 10/06/2024, 10/15/2024, 10/18/2024, 10/29/2024, and 11/15/2024.

Nutrition- amount eaten:

9:00 AM on: 10/01/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/07/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/28/2024, 10/29/2024, 10/30/2024, 10/31/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, and 11/16/2024.

1:00 PM on: 10/01/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/07/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/22/2024, 10/24/2024, 10/25/202410/28/2024, 10/29/2024, 10/30/2024, 10/31/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, and 11/16/2024.

6:00 PM on: 10/01/2024, 10/02/2024, 10/03/2024, 10/05/2024, 10/06/2024, 10/15/2024, 10/18/2024, 10/29/2024, and 11/15/2024

During an interview with the surveyor on 02/25/2025 at 1:40 PM, the Certified Nursing Assistant (CNA) stated that the care provided should have been documented in the facility's electronic record each day by the end of the shift. The CNA further stated that residents who required assistance with bed mobility were repositioned every two hours.

During an interview with the surveyor on 02/26/2025 at 3:20 PM, the Assistant Director of Nursing (ADON) stated that residents who needed repositioning were repositioned multiple times per day. The ADON stated that CNAs were responsible to document repositioning in the facility's electronic medical record. The ADON further stated that it was the expectation that CNAs completed documentation before the end of their shift.

The ADON confirmed the presence of blank spaces on Resident #6's DSR. The ADON stated that if the DSR contained blank spaces, we don't know what care was given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 315529 Department of Health & Human Services Printed: 09/08/2025 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 315529 B. Wing 02/26/2025

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

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

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 0842 During an interview with the surveyor on 02/26/2025 at 4:50 PM, the Director of Nursing (DON) stated that residents who needed repositioning were repositioned at the start and end of each shift, before and after Level of Harm - Minimal harm or meals, and every two hours on the night shift. The DON stated that CNAs were responsible for repositioning, potential for actual harm but no direct care staff was able to do it. The DON further stated that it was the expectation that CNAs completed documentation in the electronic medical record before the end of their shift. The DON confirmed Residents Affected - Few the presence of blank spaces on Resident #6's DSR. The DON stated that if the DSR contained blank spaces, there was no way to know if the care was provided or not.

NJAC 8:39-35.2 (f)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 315529