Bridgeway Care And Rehab Center At Hillsborough

F-F609 Residents Affected - Some Based on observation, interview and record review, it was determined that the facility failed to conduct a timely and thorough investigation for three (3) of nine (9) residents, (Resident #6 and unsampled Residents #25 and #54), reviewed for alleged violation investigations. The deficient practice was evidenced by the following:

On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at

a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time.

On 8/6/18 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#2). The form indicated Resident does not feel safe when CNA#1 and CNA#2 are caring for him/her and does not want them on his/her assignment. Resident stated they are mean and rude. The form was referred to nursing and signed by the Director of SW (DOSW), who was the Grievance Official (GO), on 5/24/24. According to the form, the corrective action taken to rectify the concern indicated that Education provided to CNAs regarding: abuse prevention, resident's rights, customer service and was signed by the Director of Nursing (DON). The form had a Final Review by Grievance Official: Nature of Concern/Grievance: CNA interaction signed by the LNHA and DOSW/GO and dated 5/28/24.

Further review, revealed an attached Investigation Statement Form revealed that the date of the incident was 5/18-5/19 (reported 5/23/24) and the type of investigation was issues with CNA #1 and CNA #2. The SW documented follow up interviews with two alert and oriented residents under the care of CNA #1 and CNA #2. The SW spoke with two unsampled Residents #25 and #54 on 5/23/24. The SW indicated that the unsampled Resident #54 made a statement that CNA #2 is just not compassionate. He/She doesn't want CNA #2 on his/her assignment as he/she does not feel good with CNA #2. The unsampled Resident #54 made a statement that the CNA #2 took soda and chips from the resident's tray and the resident had to ask for them back. In addition, the Investigation Statement Form revealed a follow up interview with unsampled Resident #25 who according to the statement indicated that CNA #1 made him/her feel humiliated by being exposed during care. The form reflected that the unsampled Resident #25 had requested that CNA #1 not be

on their assignment.

Additionally, attached with the form was another Investigation Statement Form, dated 5/25/24, completed by CNA #2 which indicated that whenever CNA #2 was assigned to Resident #6 they were rude and cursed at CNA #2. The CNA #2 included that the resident had accused her of not paying attention to them.

Also attached to the Grievance/Complaint Form was an In-service: Customer Service/Resident Dignity and

an In-Service: Abuse Prevention dated 5/25/24 and signed by both CNA#1 and CNA #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0610 On 8/6/24 at 10:17 AM, the surveyor interviewed the LNHA regarding the Complaint/Grievance Form dated 5/23/24 for Resident #6. The LNHA confirmed that there was no report to the NJDOH and that the Level of Harm - Minimal harm or Complaint/Grievance Form was complete and there was no further follow up investigation documented. The potential for actual harm LNHA stated that the incident was treated as a grievance and not reported because Resident #6 had a history of fixating on their care and saying that the CNAs were rude and mean and unsure what that meant. Residents Affected - Some The LNHA stated that both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents. The LNHA acknowledged that after reading the wording on the form, that

she should have completed a report to the NJDOH. The LNHA stated that the DOSW/GO and SW had done

the statements and acknowledged that further investigation documentation was needed. The LNHA stated that the Director of Nursing (DON) was currently not available and the DOSW/GO was currently on leave.

The LNHA added that she could not recall why a report was not done and needed to do a review.

On 8/6/24 at 10:49 AM, the LNHA returned to discuss Resident #6 in the presence of the survey team. The LNHA stated that she had not reported because Resident #6 was usually very selective with CNAs and had asked for reassignments in the past. The LNHA added that in general the alert and oriented residents on that floor were particular about who they want to care for them, and it was not unusual for the residents to request certain CNAs and/or request not to have certain CNAs. The LNHA stated that none of the three residents had initiated an issue and Resident #6 had been told in the past to immediately report any issues and in general was a very vocal resident. The LNHA acknowledged that according to the wording on the grievance form, the incidents should have been reported to the NJDOH and further investigation documentation should have been done. The LNHA also stated that she was very familiar with Resident #25, who was a very private person, and the resident was educated to report any issues immediately. The LNHA added that Resident #54 was fairly new to the facility and was also educated to report any issues immediately. The LNHA stated that when there were reports regarding CNAs that part of the process was to investigate what had occurred.

The LNHA added that it was handled as a grievance because the residents were not in danger and that the residents were not satisfied with the care that they received. The LNHA stated that both CNAs were reassigned immediately as per the request of the residents. The LNHA further explained that the grievance process was used for anything not considered abuse such as a CNA that was rushing them or the CNA was task oriented, and more customer service was needed. The LNHA acknowledged that the way the grievance report read that, there should have been further documentation of the investigation completed.

On 8/6/24 at 12:34 PM, the surveyor interviewed the LNHA and the SW regarding the Complaint/Grievance Form. The SW stated that she was the covering DOSW as of 7/8/24. The SW added that she had completed

the form and remembered the discussion clearly. The SW stated that she was performing a quarterly care plan discussion with Resident #6 when the resident voiced a concern about the 2 CNAs. The SW stated that

she remembered Resident #6 just had not wanted the CNAs to be assigned to them and had not thought that was odd because Resident #6 had asked in the past for certain CNAs to be assigned to them. The SW stated that she completed the form and as a follow up, randomly selected two alert and oriented residents, (unsampled Residents #35 and #54), to interview regarding the 2 CNAs. The SW was unable to speak to whether there were more alert and oriented residents on the CNA's assignments. The SW stated that she always asks the residents if they feel safe and when the answer was no, then she reports that to the LNHA.

The SW added that Resident #25 had said she felt humiliated because they were a very private person and does not like having to be cared for and the resident felt strongly that they had not wanted to get anyone in trouble. The SW added that besides not wanting CNA #1, Resident #25 felt safe. The SW added that she should have documented more. The LNHA stated that the DON was also part of the investigation and was returning the next day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0610 The surveyor reviewed the medical record for Resident #6.

Level of Harm - Minimal harm or According to the quarterly Minimum Data Set (MDS) (an assessment tool), dated 5/8/24, reflected that the potential for actual harm resident had diagnoses which included but were not limited to; depression, morbid obesity and heart failure.

The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 Residents Affected - Some out of 15, which indicated an intact cognition.

On 8/6/24 at 1:46 PM, the surveyor interviewed Resident #6 who stated that they were able to make their needs known and told the nurses which aides they wanted and which aides they did not want. The resident was able to identify two CNAs that they felt were very good and would want all the time. The resident stated that CNA #1 gives them anxiety but was unable to speak to a specific incident or occurrence and stated that

they just felt that CNA #1 was reluctant to help them. The resident then added that CNA #1 was friends with CNA #2 and that together they were not good. The resident added that as long as they did not have the aides that they did not want, then they were fine. The resident was not specific as to what the aides that they did not want had done. The resident stated, I can just tell which aides are not good. The resident then stated that he/she has a tendency to get anxious over everything. The resident added that they felt comfortable and was very vocal with the staff. The resident added that they had no recollection of any discussion with the SW.

The surveyor reviewed the medical record for Resident #25.

According to the quarterly MDS (an assessment tool) dated 5/24/24 reflected that the resident had diagnoses which included but were not limited to; hypertension (high blood pressure) and diabetes (high blood sugar).

The MDS assessment reflected that the resident had a BIMS score of 15 out of 15 which indicated an intact cognition.

On 8/6/24 at 2:05 PM, the surveyor interviewed the unsampled Resident #25, who stated that she had nothing to say and had no concerns. The resident added that she felt comfortable and could tell the staff their needs.

The surveyor reviewed the medical record for Resident #54.

According to the quarterly MDS (an assessment tool) dated 7/8/24 reflected that the resident had diagnoses which included but were not limited to; heart failure and pressure ulcers of the right and left heels. The MDS assessment reflected that the resident had a BIMS score of 13 out of 15, which indicated an intact cognition.

A review of the medical record for the unsampled Resident #54 revealed that the resident had been sent to

the hospital after an outside physician's appointment on 7/30/24 and had not returned to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0610 On 8/9/24 at 10:53 AM , the surveyor interviewed the LNHA and DON regarding the Complaint/Grievance Form. The DON stated that when CNAs were reassigned, the staffing coordinator was informed, and Level of Harm - Minimal harm or assignment sheets were updated, and all supervisors were made aware and the CNA themselves were potential for actual harm aware. The DON added that there were no changes to the assignments allowed unless approved by a supervisor. The DON added that CNA#2 was moved to the second floor. The DON confirmed that both Residents Affected - Some CNAs were inserviced prior to returning to work. The DON acknowledged that there should have been more documentation and statements included when the concerns were reported. The DON and LNHA stated that

they had been working on completing the investigations after surveyor inquiry. The LNHA stated that Resident #25 had not wanted to discuss anything further and felt there were too many people in their room looking at them on 5/19/24 but had not wanted to report the issue. The DON added that Resident #25 understood the reason was that the CNA #3 was being helped by CNA #1 because CNA #3 was very new, and CNA #1 noticed some redness on their sacrum and asked CNA #3 to get the nurse who verified the redness. The LNHA added that Resident #25 understood that there was 2 CNAs and a nurse trying to provide care for a medical reason and just preferred not to have CNA #1 assigned to them. The LNHA and DON acknowledged that there was no documentation provided in the Grievance/Complaint form.

On 8/9/24 at 11:00 AM, the surveyor was provided investigations for Resident #6 and unsampled Residents #25 and #54 by the LNHA. The LNHA stated that CNA #2 removed a finished meal tray from Resident #54 containing the chips and soda. Then, when the resident expressed wanting the items they were provided.

The LNHA acknowledged that the Grievance/Complaint Form had not explained the above.

A review of the investigations for Residents #6 and unsampled Residents #25 and #54 were completed and thorough after surveyor inquiry.

On 8/9/24 at 12:33 PM, the survey team met with the LNHA and DON. The LNHA stated that she felt that

they had made sure all residents were safe, that the identified CNAs were reassigned as per resident requests. The DON added that CNA #2 was assigned to a different floor to separate the 2 CNAs.

On 8/13/24 at 9:13 AM, the survey team met with the LNHA and DON. The LNHA stated Based on the wording of the report and no further documentation of statements that there should have been a documented further investigation.

A review of the facility policy for Grievances/Complaints, Filing dated 6/21/24 provided by the LNHA included Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. In addition, The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under the guidelines for reporting abuse, neglect and misappropriation of property, as per state law.

A review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/4/23 provided by the LNHA included to investigate and report any allegations within timeframes required by federal and state requirements.

NJAC 8:39-4.1(a)(5), 9.3(d), 13.4(c)2(i-vi)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 34033 potential for actual harm Based on observation, interview, and record review, it was determined that the facility failed to ensure that all Residents Affected - Few medications were administered without error of 5% or more. During the medication observation on 8/6/24,

the surveyor observed two (2) nurses administer medications to four (4) residents. There were 26 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.69 %. This deficient practice was identified for one (1) of four (4) residents, (Resident # 268), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows:

On 8/6/24 at 8:57 AM, the surveyor observed the Registered Nurse (RN) preparing to administer the morning medications to Resident #268. The RN stated that according to the electronic medication administration

record (EMAR), the resident had two insulin (a medication used to lower blood sugar) pens (medication provided in the form of an injector pen) to prepare. The RN explained that the pens had to be primed with two (2) units to see the function of the needle. The RN removed the resident's Glargine (Lantus) (a long-acting insulin) 100 units (U)/milliliter (ML) solution pen-injector (a disposable single-patient-use prefilled insulin pen) from the medication cart and removed the pen cap and replaced the cap with a needle cap and placed the Lantus on top of the medication cart in a horizontal position. The RN then removed the Lispro (a short-actin insulin) Kwikpen (a disposable single-patient-use prefilled insulin pen) 100 U/ML solution pen-injector and removed the pen cap and replaced it with a needle cap and placed the Lispro on top of the medication cart in a horizontal position. The RN explained that the pens had to be primed with 2 units to see

the function of the needle. The RN then explained to the surveyor that she was not going to be administering all the morning medications at this time because there was an intravenous medication and a Voltaren gel (topical medication to relieve joint pain) until after the resident had finished breakfast. The surveyor observed

the RN preparing a total of seven (7) medications for the resident which included the Lispro pen-injector and

the Lantus pen-injector. The RN then showed the surveyor that she was dialing a dose of 36 U for the Lantus insulin pen according to the physician's order (PO) on the EMAR. Next, the RN showed the surveyor that she was dialing a total of seven (7) U of the Lispro insulin pen according to a standing PO for five (5) U plus another 2 U according to a sliding scale PO for a blood sugar result of 161.

On 8/6/24 at 8:40 AM, the surveyor observed the RN inject the resident's left arm subcutaneously (SC) with

the Lispro insulin pen injector that was dialed to 7 U and then the Lantus insulin pen injector that was dialed to 36 U.

The surveyor had not observed the RN prime the Lantus and the Lispro insulin pens before administration. (ERROR #1 and #2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0759 Upon returning to the medication cart, the surveyor asked the RN when she had primed the insulin pens. The RN stated that she primed the insulin pens when she removed them from the medication cart and after she Level of Harm - Minimal harm or put on the needle cap. The RN stated that she dialed the pens to 2 U and pushed the plunger and the potential for actual harm plunger went back to zero 0. The RN acknowledged that she had not shown the surveyor the priming of the 2 U and thought that she had done the priming quickly. The RN added that she had primed the insulin pens Residents Affected - Few when they were horizontal on top of the medication cart and with the needle cap on. The RN stated that the only time she removed the needle cap was just before she injected the resident in their room. The RN explained that when she primed the insulin pens by dialing the 2 U and pressing the plunger, the injector pen returned to zero 0 and that meant the pen was working properly. The RN added if there was resistance, or

the pen had not returned to 0 then she would have to change the needle. The RN added that she had shown

the surveyor that the plunger was at zero 0 before dialing to the doses needed for each insulin pen injector.

The RN added that she had training on the technique for insulin pen use but was unsure who had performed

the training.

On 8/6/24 at 11:24 AM, the surveyor interviewed the Staff Development/Advanced Practice Nurse (SD/APN) who stated that she was employed less than two (2) months at the facility. The SD/APN explained that she would be involved in training the nurses the proper techniques for the medication pass. The SD/APN stated that she was familiar with the proper technique for using an insulin pen injector. The SD/APN explained that

the pen injector had to be primed before injecting the dose to make sure the needle was working, and air bubbles were out of the needle. The SD/APN further explained that the pen was primed by dialing two (2) to five (5) units, then taking the needle cap off and holding the pen injector in the vertical position and pushing

the plunger. The SD/APN added that this would allow visualizing the insulin liquid come out of the needle.

The SD/APN added that all insulin pen injectors were to be primed in the same method. The SD/APN stated that seeing the insulin pen injector plunger return to zero was not an indication that the needle was working and you would have to visualize the insulin liquid.

On 8/6/24 at 2:20 PM, the surveyor interviewed the RN who stated that she had spoken with the SD/APN.

The RN also stated that she was unaware of needing to hold the insulin pen injector vertically and removing

the needle cap to see the insulin liquid when priming. The RN added that she thought the needle was working because the plunger went back to zero.

On 8/6/24 at 2:45 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that he had done a medication pass inservice in March but was unsure if the inservice included insulin pen technique. The CP also stated that he was aware that priming a pen injector had to be done prior to injecting the dose. The CP also stated that it would be obvious to see the insulin liquid if the needle cap was off but thought leaving the cap on would be acceptable. The CP added that he thought if there was an issue while priming then there would be resistance from the plunger and the plunger would not go back to zero.

The CP was unable to speak to whether the instructions indicated that when the plunger returns to zero the priming was completed and would have to check.

An inservice titled Med Pass and Expiring meds dated 3/5/24 was performed by the CP was provided by the SD/APN. The inservice included a handout titled Medication Pass and reflected for Injectable Administration to Prime insulin pen prior to each dose.

The surveyor reviewed the medical records for Resident #268.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0759 A review of the resident's Admission Record reflected that the resident had diagnoses which included but not limited to: type 2 Diabetes (high blood sugar). Level of Harm - Minimal harm or potential for actual harm A review of the resident's Order Summary Report reflected the following:

Residents Affected - Few - a PO with a start date of 7/30/24 for Insulin Glargine (Lantus) 100 U/ML solution, inject 36 units SC in the morning for diabetes.

-a PO with a start date of 7/29/24 for Insulin Lispro (1 unit dial) subcutaneous solution Pen Injector 100 U/ML (Insulin Lispro), inject 5 units SC with meals for diabetes in addition to sliding scale coverage.

-a PO with a start date of 7/29/24 for Insulin Lispro (1 unit dial) subcutaneous solution Pen Injector 100 U/ML (Insulin Lispro), inject as per sliding scale: if 150-199 (blood sugar) = 2 u; 200-249=4 u; 250-299=6 u; 300-349=8 u;350-400=10 u; Call MD for blood sugar greater than 400 or less than 70, SC before meals and at bedtime for diabetes.

On 8/7/24 at 1:13 PM, the surveyor interviewed the SD/APN who stated that she had completed a step-by-step safe administration of insulin via insulin pen administration inservice with the RN. The SD/APN had used a manufacturer's specification handout for the Instructions For Use Humalog KwikPen (insulin lispro).

On 8/7/24 at 1:46 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and the DON acknowledged that by not following the manufacturer's specifications for priming an insulin pen injector or incorrectly priming an insulin pen injector could affect the dosage of the insulin. (ERROR #1 and #2)

On 8/8/24 at 10:36 AM, the surveyor interviewed the CP, who stated that he had looked into the priming of

the insulin pen injector and that the needle cap was clear, and that the RN was able to see the insulin liquid

in the cap.

At that time, the surveyor with the CP interviewed the RN who demonstrated that when the two (2) U were pushed with the plunger and the needle cap was on there was liquid that was able to be seen through the needle cap. The RN acknowledged that during the medication pass, neither insulin pen was held upright and that she had not shown the surveyor the priming.

Upon finishing the demonstration, the surveyor and the CP left the medication cart. The CP stated that he thought resistance of the plunger went hand in hand with visualizing insulin and thought there would be resistance when priming the insulin pen if the 2 U had not come out. The CP was unsure if there was documentation regarding the resistance if the 2 U was not visualized. The CP added that he felt the dosage disparity was not significant by not holding the insulin pen vertical and was unsure if there was documentation supporting that. The CP acknowledged that there were specific manufacturer instructions for

the use of insulin pen injectors that included instructions on priming and provided the surveyor with a handout on the instructions for the Insulin Lispro KwikPen. The surveyor, with the CP, reviewed the handout and the CP acknowledged that the instructions were specific to hold the pen injector upright (vertically) when visualizing the two (2) U of insulin liquid. The CP was unable to provide any further documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0759 A review of the Insulin Pen Injections handout of information provided by the CP reflected that the steps required to properly administer an insulin pen included Prime before each injection. Priming your pen means Level of Harm - Minimal harm or removing the air from the needle and cartridge that may collect during normal use and ensures that the pen potential for actual harm is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The handout also revealed Step 6: To prime your pen, turn the dose knob to select 2 units. Step 7: Hold your pen Residents Affected - Few with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the Dose Knob in and count to 5 slowly, You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8.

A review of the facility policy Medication Administration Guidelines: Insulin Pens, dated as effective 2/2/22, provided by the LNHA reflected that Insulin will be administered in a safe and accurate manner. In addition,

the policy reflected for Insulin administration: .j) Remove outer then inner needle caps, k) Prime pen by dialing 2 units or units recommended by manufacturer, with needle pointing up, press injection button with thumb. Look for drops of insulin to come out of tip of needle.

A review of Patient & Caregiver Education specifications for How to use an insulin pen revealed Do a safety test (prime the pen). Priming the insulin pen will help you make sure your pen and needle are working like

they should. This will also help you make sure that the needle fills with insulin, so you get your full dose. It's important to do a safety test before every insulin injection.

NJAC 8:39-11.2(b), 29.2(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48964

Residents Affected - Some Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:

On 08/05/2024 from 09:30 AM to 10:01 AM, the surveyor, accompanied by the Food Service Director (FSD) of another facility, toured the kitchen, and observed the following:

In the walk-in freezer, the surveyor observed two opened packages of biscuits with no dates or labels. The surveyor also noted a tied shut, clear plastic bag of spinach lasagna rolls with no label or dates when opened. The FSD stated there should be opened and use by labels and dates on all opened food in the freezer.

On a storage rack, the surveyor observed a stack of three 3rd pans wet nested and a stack of four 6th pans wet nested. The FSD stated they should not be stacked wet.

A review of facility provided undated policy titled Food Receiving and Storage revealed under Refrigerated/Frozen Storage:

1.All food stored in the refrigerator or freezer are covered, labeled and dated (use by date)

8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Frozen foods will be used by the manufacturer expiration date. If an item has been opened, and open date label will be placed, and the item will follow the manufacturer's expiration date or discarded after 6 months of the open date.

A review of facility provided policy titled Sanitization, revised 7/23/2023 revealed:

12. Observe for wet nesting (accumulation of moisture) when pots, pans, and other kitchen products are put to dry.

N.J.A.C. 8:39-17.2(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 41858 potential for actual harm Based on interview and review of pertinent facility documentation, the facility failed to ensure the required Residents Affected - Few committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following:

A review of the facility provided QAA (Quality Assessment and Assurance) Committee Information updated 06/07/24 revealed: Name: Vacant; Title: Infection Preventionist.

A review of the the facility provided In-Service Attendance; Date: 7/12/24; Topic: Q 2024 QAPI Meeting sign

in sheet had not revealed the IP attended the meeting.

On 08/13/24 at 09:52 AM, during an interview with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated that the required members of the QAPI committee were the administrator, the DON, the IP, the Medical Director, and 2 other staff members. The LNHA acknowledged that the IP had not attended the July 2024 meeting.

A review of the facility's Job Description and Performance Standards, Position Title Infection Preventionist RN (Registered Nurse) revealed: The primary functions and responsibilities of this position are as follows: . 40. Provide monthly, quarterly, and annual; reports for the Quality Assurance and Performance Improvement Committee to the Administrator.

A review of the facility policy 2024 Quality Assurance Performance Improvement Plan revealed: Governance and Leadership .The QAA Committee and its members provide the framework or structure for QAPI. Committee members include the administrator, director of nursing, medical director, infection preventionist .

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 41858

Residents Affected - Few Based on interviews and review of pertinent facility documents, it was determined that the facility failed to 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 (ICP) from 06/08/24 to present.

This deficient practice was evidenced by the following:

Reference:

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.

08/05/24 at 10:50 AM, during entrance conference, the Licensed Nursing Home Administrator (LNHA) stated

the facility does not have an Infection Preventionist (IP) at the moment. She further stated that there was no one certified in ICP.

On 08/06/24 at 08:53 AM, in the presence of the survey team, the LNHA confirmed that the last day of work for the IP was 06/07/24.

On 08/09/24 at 08:57 AM, during an interview with the surveyor, the LNHA stated, I believe the Nursing Supervisor (NS), who does staff education for Personal Protective Equipment (PPE), COVID surveillance and testing, is ICP certified.

On 08/09/24 at 12:33 PM, in the presence of the survey team, the LNHA and the Director of Nursing (DON) were made aware of the concerns of no IP since 06/08/24.

On 08/13/24 at 08:45 AM, the LNHA provided the surveyor with the NS Center for Disease Control and Prevention (CDC) certification dated 5/16/23. At that time, she confirmed that the NS was not the designated IP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0882 A review of the facility's job description for the Infection Preventionist RN (Registered Nurse) revealed: Purpose of this position: The Infection Preventionist (IP) shall be responsible for contributing to the Level of Harm - Minimal harm or development of policies, procedures, and training curriculum for the long-term care facility staff based on potential for actual harm best practices and clinical expertise. They shall monitor the implementation of infection prevention and control policies and recommending disciplinary measure for staff who routinely violate those policies. The IP Residents Affected - Few will assess the facility's infection prevention and control program by conducting internal quality improvement audits.

A review of the facility's policy, Surveillance for Infections reviewed on 01/10/24, revealed: Policy Statement: Surveillance is an essential component of an effective Infection Prevention Control Program. The facility performs surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection.

NJAC 8:39-19.1 (b), 19.4(d) (e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 315510

F-F610

Based on observations, interviews and record review, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting for a) allegations of abuse (Sampled Resident #6, unsampled Resident #25 and #54), and b) a missing wallet with

a resdient's identification (Resident #15). The deficient practice was identified for four (4) of nine (9) residents reviewed for investigations and was evidenced by the following:

1. On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time.

The surveyor reviewed the medical record for Resident #6.

According to the quarterly Minimum Data Set (MDS) (an assessment tool) dated 5/8/24, reflected that the resident had diagnoses which included but not limited to; depression, morbid obesity and heart failure. The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated an intact cognition.

On 8/6/24 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#2). The form indicated Resident does not feel safe when CNA#1 and CNA#2 were caring for him/her and does not want them on his/her assignment. Resident stated they are mean and rude. The form was referred to nursing and signed by the Director of Social Work (DOS), who was the Grievance Official (GO), on 5/24/24.

According to the form, the corrective action taken to rectify the concern, indicated that Education provided to CNAs regarding: abuse prevention, resident's rights, customer service and reassignment. It was signed by

the Director of Nursing (DON). The form had a Final Review by Grievance Official: Nature of Concern/Grievance: CNA interaction signed by the LNHA and GO and dated 5/28/24.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0609 There was no indication that a report was sent to the NJDOH.

Level of Harm - Minimal harm or Further review of the attached Investigation Statement Form revealed that the date of the incident was potential for actual harm 5/18-5/19 (reported 5/23/24) and the type of investigation was issues with CNA #1 and CNA #2. The SW documented follow up interviews with two alert and oriented residents, unsampled Residents #25 and #54 on Residents Affected - Some 5/23/24, that were under the care of CNA #1 and CNA #2. The SW indicated on the form that unsampled Resident #54 made a statement that CNA #2 is just not compassionate. He/She doesn't want CNA #2 on his/her assignment as he/she does not feel good with CNA #2. The unsampled Resident #54 made a statement that CNA #2 took soda and chips from the resident's tray and the resident had to ask for them back.

In addition, the Investigation Statement Form revealed a follow up interview with unsampled Resident #25 who, according to the statement, indicated that CNA #1 made him/her feel humiliated by being exposed

during care. The form reflected that the unsampled Resident #25 had requested that CNA #1 not be on their assignment.

There was no indication that a report was sent to the NJDOH.

On 8/6/24 at 10:17 AM, the surveyor interviewed the LNHA regarding the Complaint/Grievance Form dated 5/23/24 for Resident #6. The LNHA confirmed that there was no report to the NJDOH. The LNHA stated that

the incident was treated as a grievance and not reported because Resident #6 had a history of fixating on their care and was saying that the CNAs were rude and mean and unsure what that meant because the resident had requested specific CNAs in the past. The LNHA stated that both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents. The LNHA acknowledged that after reading the wording on the form, that she should have completed a report to the NJDOH. The LNHA stated that the DOSW/GO and SW had done the statements. The LNHA stated that the Director of Nursing (DON) was currently not available and the DOSW/GO was currently on leave. The LNHA added that

she could not recall why a report was not done and needed to do a review.

On 8/6/24 at 10:49 AM, the LNHA returned to discuss Resident #6 in the presence of the survey team. The LNHA stated that she had not reported because Resident #6 is usually very selective with CNAs and had asked for reassignments of CNAs in the past. The LNHA added that in general the alert and oriented residents on the floor were particular about who they want to care for them and it is not unusual for the residents to request certain CNAs. The LNHA stated that none of the three residents had initiated a concern and Resident #6 had been told in the past to immediately report any issues. The LNHA acknowledged that according to the wording on the form, the incidents should have been reported to the NJDOH.

On 8/6/24 at 11:09 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA stated that the required timeframes referred to in the facility Abuse Policy were to report any allegation of abuse immediately within 2 hours to the NJDOH and complete a NJDOH reportable form within 24 hours.

On 8/13/24 at 9:13 AM, the survey team met with the LNHA and DON, the LNHA stated that she was responsible for reporting to the NJDOH. The LNHA also stated that she could not remember back in May why the incident was not reported and stated based on the wording of the report that she should have reported it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0609 48964

Level of Harm - Minimal harm or 2. The surveyor reviewed the medical record for Resident #15. potential for actual harm According to the Annual MDS, dated [DATE REDACTED], the resident had diagnosis including but not limited to; arthritis Residents Affected - Some and hypertension. The MDS reflected a BIMS score of 11, indicating moderate cognitive impairment.

On 08/06/24 at 01:38 PM, the surveyor reviewed the facility's investigation report which indicated that the resident's daughter reported Resident #15's wallet was missing on 03/10/24. The wallet did not contain any money, but did contain Resident #15's driver's license, social security card, and insurance cards. A police report was filed on 03/13/24.

After inquiry to the NJDOH by the facility on 03/13/24, the facility reported the above incident.

A review of the facility policy for Grievances/Complaints, Filing dated 6/21/24 provided by the LNHA included Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. In addition, The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under the guidelines for reporting abuse, neglect and misappropriation of property, as per state law.

A review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/4/23 provided by the LNHA included to investigate and report any allegations within timeframes required by federal and state requirements.

N.J.A.C. 8:39-4.1(a)(15), 9.4(f)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 15 315510 Department of Health & Human Services Printed: 09/12/2025 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 315510 B. Wing 08/19/2024

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

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 34033 potential for actual harm REFER to