Based on interview and review of pertinent facility documents, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) an allegation of neglect for a Certified Nursing Aide who was discovered sleeping during a shift in a resident's room who reported they were under the influence of a substance. This deficient practice was identified for 1 of 6 terminated employee files reviewed, and was evidenced by the following: During entrance conference on 5/20/24 at 9:54 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide the survey team with a list of all employees hired since last standard survey who were still employed by the facility or terminated. The surveyor requested the facility provide the reason for termination. On 5/24/24 at 9:35 AM, the surveyor requested from the DON ten employee files including personal and medical from the provided list. A review of CNA #1's files revealed the following: The employee was hired on 11/16/23, with an Employee Termination form dated effective 1/17/24, with a termination summary for staff was observed to be under the influence of a substance. According to her, she stated she took too much of her anxiety [medications] and never brought in a script. A review of the New Employee Physical Examination signed by CNA #1 on 11/16/23, indicated for list of medical conditions was left blank, and the list of all medications you are currently using and indication of use did not include anxiety medication. On 5/28/24 at 11:40 AM, the surveyor interviewed the DON regarding CNA #1's termination, and the DON stated she received a phone call from the Supervisor that aide was very sleepy and she was sleeping in a chair in a resident's room. Staff woke CNA #1 up and she stated she was tired and went back to work, but was found sleeping again so she was sent home. The DON stated she spoke to CNA #1 the next day who stated she said had been under a lot of stress, and she took too much of her anxiety medication. The DON requested a copy of the prescription, and the CNA stated she would provide the medication bottle, but she never did. The DON stated when the facility suspected an employee being under the influence, they were sent out to the hospital for drug testing, but the facility did not drug test CNA #1 because the aide stated she had a prescription that was never confirmed and the CNA could not provide the name of the prescribed medication. The DON stated CNA #1 never brought in the prescription so she never worked again, and the DON confirmed she did not report the CNA's condition to any agency or licensing boards since the CNA was just sleepy. The DON stated she was unsure who in the state would be notified. At that time, the surveyor requested a copy of CNA #1's assignment sheet for the day, as well as their time card, and the facility's policy regarding an employee under the influence. A review of CNA #1's time card revealed the last day she worked was 12/12/23 from 4:49 PM until 10:45 PM. A review of the CNA Assignment sheet for the 3:00 PM to 11:00 PM shift on 12/12/23, revealed CNA #1 was assigned fourteen residents, which included twelve residents who needed assistance with transferring from bed to chair or chair to bed with five of the residents using a hoyer lift (an assistive device that uses a sling to lift the resident in the air to be transferred between a bed and chair). On 5/28/24 at 2:05 PM, the DON in the presence of the LNHA, Assistant Director of Nursing (ADON), Regional LNHA, Regional Nurse, and survey team, stated the incident with CNA #1 occurred on 12/12/23, and the CNA returned to the facility the next day to speak with the DON. The DON stated CNA #1 stated she was on an antianxiety medication that the aide was unsure of the name, and never provided the prescription. The DON could still not speak to who the incident should have been reported to. On 5/29/24 at 10:13 AM, the LNHA in the presence of the DON, Regional LNHA, Regional Nurse, and survey team stated the facility would report the incident to the NJDOH. The DON stated that CNA #1 at the beginning of her shift was fine, and staff noticed at the end of the shift she was very sleepy. The DON confirmed she was found sleeping in a resident's room, and that the Supervisor had called her that evening because she was concerned with the CNA. The DON confirmed the CNA had a full assignment of residents, and someone impaired by a substance should not be operating a hoyer lift because it was a safety concern. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated reviewed January 2024, included protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff .identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; investigate and report any allegations within the timeframes required by federal requirements . A review of the facility's Substance Abuse in the Workplace policy dated 2020, included the facility is committed to ensuring a drug and alcohol-free workplace in order to maintain the safety of its residents .being under the influence of alcohol or illegal drugs while at the facility poses a serious health and safety risk to all residents .staff may not present in the Facility .conduct any Facility-sanctioned task while impaired on a substance .this policy does not prohibit appropriate use of over the counter and legal prescription medication when used to treat a disability .nothing in this policy is meant to prohibit the appropriate use of over-the-counter medication or other medication that can legally be prescribed under both federal and state law, to the extent that it does not impair a staff member's job performance or safety or safety of others .a violation of this policy is subject to disciplinary action, up to and including termination of employment. NJAC 8:39-4.1(a)5

Based on interview and review of pertinent facility documents, it was determined that the facility failed to investigate an allegation of neglect when a Certified Nursing Aide was discovered sleeping during shift in a resident's room who reported they were under the influence of a substance. This deficient practice was identified for 1 of 6 terminated employee files reviewed, and was evidenced by the following: During entrance conference on 5/20/24 at 9:54 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide the survey team with a list of all employees hired since last standard survey who were still employed by the facility or terminated. The surveyor requested the facility provide the reason for termination. On 5/24/24 at 9:35 AM, the surveyor requested from the DON ten current and terminated employee files including personal and medical from the provided list. A review of CNA #1's files revealed the following: The employee was hired on 11/16/23, with an Employee Termination form dated effective 1/17/24, with a termination summary for staff was observed to be under the influence of a substance. According to her, she stated she took too much of her anxiety [medications] and never brought in a script. A review of the New Employee Physical Examination signed by CNA #1 on 11/16/23, indicated for list of medical conditions was left blank, and the list of all medications you are currently using and indication of use did not include anxiety medication. On 5/28/24 at 11:40 AM, the surveyor interviewed the DON regarding CNA #1's termination, and the DON stated she received a phone call from the Supervisor that aide was very sleepy and she was sleeping in a chair in a resident's room. Staff woke CNA #1 up and she stated she was tired and went back to work, but was found sleeping again so she was sent home. The DON stated she spoke to CNA #1 the next day who stated she said had been under a lot of stress, and she took too much of her anxiety medication. The DON requested a copy of the prescription, and the CNA stated she would provide the medication bottle, but she never did. The DON stated when the facility suspected an employee being under the influence, they were sent out to the hospital for drug testing, but the facility did not drug test CNA #1 because the aide stated she had a prescription that was never confirmed and the CNA could not provide the name of the prescribed medication. The DON stated CNA #1 never brought in the prescription so she never worked again, and the DON confirmed she never took any statements from employees or conducted an investigation. At that time, the surveyor requested a copy of CNA #1's assignment sheet for the day, as well as their time card, and the facility's policy regarding an employee under the influence. A review of CNA #1's time card revealed the last day she worked was 12/12/23 from 4:49 PM until 10:45 PM. A review of the CNA Assignment sheet for 12/12/23, revealed CNA #1 was assigned fourteen residents, which included twelve residents who needed assistance with transferring from bed to chair or chair to bed with five of the residents using a hoyer lift (an assistive device that uses a sling to lift the resident in the air to be transferred between a bed and chair). On 5/28/24 at 2:05 PM, the DON in the presence of the LNHA, Assistant Director of Nursing (ADON), Regional LNHA, Regional Nurse, and survey team, stated the incident with CNA #1 occurred on 12/12/23, and the CNA returned to the facility the next day to speak with the DON. The DON stated CNA #1 stated she was on an antianxiety medication that the aide was unsure of the name, and never provided the prescription. The DON confirmed she obtained no written statements from any staff. On 5/29/24 at 10:13 AM, the DON in the presence of the DON, Regional LNHA, Regional Nurse, and survey team stated that CNA #1 at the beginning of her shift was fine, and staff noticed at the end of the shift she was very sleepy. The DON confirmed she was found sleeping in a resident's room, and that the Supervisor had called her that evening because she was concerned with CNA. The DON confirmed the CNA had a full assignment of residents, and someone impaired by a substance should not be operating a hoyer lift because it was a safety concern. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated reviewed January 2024, included protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff .identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; investigate and report any allegations within the timeframes required by federal requirements . A review of the facility's Substance Abuse in the Workplace policy dated 2020, included the facility is committed to ensuring a drug and alcohol-free workplace in order to maintain the safety of its residents .being under the influence of alcohol or illegal drugs while at the facility poses a serious health and safety risk to all residents .staff may not present in the Facility .conduct any Facility-sanctioned task while impaired on a substance .this policy does not prohibit appropriate use of over the counter and legal prescription medication when used to treat a disability .nothing in this policy is meant to prohibit the appropriate use of over-the-counter medication or other medication that can legally be prescribed under both federal and state law, to the extent that it does not impair a staff member's job performance or safety or safety of others .a violation of this policy is subject to disciplinary action, up to and including termination of employment. NJAC 8:39-4.1(a)5

Complaint NJ #: 161027 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident's primary physician wrote and signed their Physician's Progress Notes at the time of each visit. This deficient practice was identified for 1 of 3 residents reviewed for closed records (Resident #147) , and evidenced by the following: The surveyor reviewed the closed medical record for Resident #147. A review of the admission Record face sheet (an admission summary) reflected that Resident #147 was admitted to the facility with diagnosis that included, but not limited to, aftercare following joint replacement surgery, and infection/inflammation reaction due to internal right knee prosthesis. A review of the Physician's Progress Notes (PPN) in the electronic medical record (eMR) revealed the following had a LATE ENTRY, a designation which indicated the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 2/15/24, but with a created date of 2/19/24. 2. PPN with an effective date of 2/16/24, but with a created date of 2/19/24. 3. PPN with an effective date of 2/19/24, but with a created date of 3/22/24 at 12:33:29. 4. PPN with an effective date of 2/20/24, but with a created date of 3/22/24 at 12:32:56. 5. PPN with an effective date of 2/21/24, but with a created date of 3/22/24 at 12:32:20. On 5/28/24 at 10:16 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who reviewed the resident's eMR and confirmed the above entries were not entered at the time of visit. On 5/28/24 at 1:58 PM, in the presence of the survey team, the surveyor informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, Regional Nurse, and Regional LNHA the concern that physician progress notes were entered days after the patient visit. On 5/29/24 at 11:23 AM, the DON, in the presence of the LNHA, Regional Nurse, and Regional LNHA confirmed that the physician did not document and sign the PPN at the time of the physician visit. A review of the facility's Physician Visits policy, last reviewed January 2024, included [ .] 5. The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. NJAC 8:39-23.2(b)

Complaint NJ #: 161027 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every 30 days. This deficient practice was identified for 1 of 3 residents reviewed for closed records (Resident #151) and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #151. A review of the admission Record face sheet (an admission summary) reflected that Resident #151 was admitted to the facility with diagnosis that included, but not limited to dementia and polyosteoarthritis (inflammation of one or more joints). According to the admission Record, Resident #151 was in the facility for a total of 66 days. Upon review of Resident #151's electronic medical record (eMR), the surveyor located Nurse Practitioner (NP) handwritten physical assessments; however, the surveyor was not able to locate any physician assessments for Resident #151. On 5/28/24 at 10:16 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that it was the facility's expectation that a physician examined all residents upon admission and every 30 days. The ADON reviewed the resident's eMR and confirmed that there was no physician assessment entries. On 5/28/24 at 1:58 PM, in the presence of the survey team, the surveyor informed the Licensed Nursing Home Administrator (LHNA), Director of Nursing (DON), ADON, Regional Nurse and Regional LNHA the concern that Resident #151 did not have any documented physician visits or admission assessment. On 5/29/24 at 11:123 AM, the DON confirmed that there were no physician assessments on record. A review of the facility's Physician Visits policy, last reviewed January 2024, included [ .] 2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter [ .]. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ#: 160630; 169902; 170619; 172027 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents for 5 of 8 residents observed during incontinence rounds (Residents #94, #16, #8, #109 and #137) on 1 of 2 nursing units (Applewood), and b.) provide activities of daily living (ADL) care for 4 of 7 residents reviewed for ADL care (# 95, #94, #109 and #16). This deficient practice was evidenced by the following: 1. On 5/20/24 at 11:41 AM, the surveyor observed Resident #94 in bed. The Resident's Representative (RR #1) informed the surveyor that Resident #94 had not received care that morning, which included incontinence care, and was still wearing the same jeans from last night. At that time, Resident #94 nodded in agreement. On 5/20/24 at 11:52 AM, the surveyor found Resident #94's Certified Nursing Assistant (CNA #1) who confirmed she was the resident's aide for the day, and stated she had provided incontinence care earlier that shift. The surveyor accompanied by CNA #1, entered the resident's room and pulled back the resident's blanket. It was revealed that the resident was wet with urine that saturated through their jeans and bed sheets. At that time, the surveyor observed a strong unpleasant odor. CNA #1 stated she had not provided care yet for that resident, and was previously mistaken. CNA #1 further stated that she had ten residents on her assignment that day and had not provided care. Review of the CNA assignment sheet revealed the unit had a census of 51 Residents with five assigned aides. CNA #1 had an assignment of ten residents on that shift. The surveyor reviewed the medical record for Resident #94. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic kidney disease, Alzheimer's Disease, and a urinary tract infection. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/25/24, reflected the resident had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. A further review revealed the resident required assistance from staff for personal hygiene and toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. A review of the individualized comprehensive care plan (ICCP) dated 10/21/22, included a focus area that the resident was at risk for skin breakdown related to incontinence and immobility. Interventions included to change incontinent product as soon as possible (ASAP) after voiding or bowel movement; keep bed linen clean and dry; keep skin clean and dry. An additional focus area dated 10/21/22, included ADL self-care performance with interventions that included to provide assistance with personal hygiene and assistance with transfers from bed to wheelchair and wheelchair to the toilet. On 5/22/24 at 7:23 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that incontinence rounds should be completed every two hours. On 5/24/24 at 10:17 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that incontinence care should be done every two hours on the day shift. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours. 2. On 5/22/24 at 7:45 AM, the surveyor performed incontinence rounds with the UM/LPN on the Applewood Unit and observed Resident #16 in bed with an incontinence brief that was saturated with urine. The surveyor and UM/LPN observed a strong unpleasant odor. At that time, the UM/LPN confirmed that the brief should have been changed every two hours and agreed that, given the extent of the saturation, the resident's brief could not have been changed at 5:00 AM. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides on the 11:00 PM to 7:00 AM (11-7) shift. The resident's assigned CNA (CNA #2) had an assignment of 18 residents on that shift. The surveyor reviewed the medical record of Resident #16. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included gastronomy status (surgical procedure to insert a tube into the stomach for nutrition), chenille (paralysis of one side of the body), and empress (muscle weakness on one side of the body) following cerebral infarction (stroke), and diabetes mellitus. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had severely impaired cognition and was incontinent of bowel and bladder. A review of the ICCP dated included a focus area dated 2/19/21, that the resident has a history of and was at risk for pressure ulcer development due to decline in mobility and bowel and bladder incontinence. Interventions included to change incontinent product ASAP after voiding or bowel movement; keep bed linen clean, dry and free of wrinkles; keep nails short and filed; and keep skin clean and dry. On 5/23/23 at 9:24 AM, the surveyor attempted a phone interview with the CNA #2 with no answer. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours. 3. On 5/20/24 at 12:13 PM, the surveyor observed Resident #8 in their room seated in a wheelchair. The Resident's Representative (RR #2) stated that on Saturday, he/she observed the resident's clothing was saturated with urine and observed a puddle of urine on the floor under their wheelchair. On 5/21/24 at 10:44 AM, the surveyor observed Resident #8 in his/her room seated in a wheelchair with CNA #3 in the room. The surveyor observed a strong unpleasant odor in the room. CNA #3 acknowledged the odor, and confirmed that the resident's incontinence brief, bed clothing, and bed sheets were all saturated with urine. Upon making this observation, CNA #3 stated, not sure what night shift does. CNA #3 further acknowledged that it was her first incontinence care provided for Resident #8 for that day. On 5/22/24 at 7:41 AM, during the incontinence rounds, the surveyor observed the resident with an incontinence brief with two bladder pads that were wet with urine and inserted inside the adult brief. At that time, the surveyor interviewed the UM/LPN who stated that placing two incontinence pads inside a diaper was unacceptable and that it could cause skin breakdown. Review of the 11-7 CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #4 had an assignment of 18 residents on that shift. The surveyor reviewed the medical record of Resident #8. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included dementia, chronic obstructive pulmonary disease and non-Hodgkin lymphoma. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a BIMS score of 3 out of 15, which indicated a severely impaired cognition. A further review reflected the resident required the assistance of staff for toileting and personal hygiene. A review of the ICCP included a focus area dated 1/24/23, that the resident had the potential for skin breakdown with regards to incontinence and immobility. Interventions included to change incontinent product ASAP after voiding or bowel movement; keep bed linen clean, dry and free of wrinkles; keep skin clean and dry. An additional focus area dated 1/24/23, included ADL with interventions that included assistance of staff member for personal hygiene and transfers. On 5/23/23 at 9:30 AM, the surveyor attempted a phone interview with the CNA #4 with no answer. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours and that bladder pads should not be placed inside incontinence brief unless requested by the family or the resident. The DON acknowledged that inserting bladder pads inside incontinence briefs increased the chance of skin breakdown. 4. On 5/22/24 at 7:32 AM, during incontinence rounds with the UM/LPN on the Applewood Unit, Resident #109 was observed in bed wearing an incontinence brief with a wet bladder pad inside. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #4 had an assignment of 18 residents on that shift which included Resident #109. The surveyor reviewed the medical record for Resident #109. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included dementia, seizure disorder and facial weakness following cerebral infarction (stroke). A review of the most recent comprehensive MDS dated [DATE], reflected the resident had severely impaired cognition and required staff assistance for personal hygiene and toileting. A further review reflected that the resident was incontinent of bowel and bladder. A review of the ICCP included a focus area dated 1/3/22, that the resident was at risk for pressure ulcer development due to a decline in mobility. Interventions included to keep nails short and filed and change incontinence product ASAP after voiding or bowel movement. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours and that bladder pads should not be placed inside incontinence briefs unless requested by the family or the resident. The DON acknowledged that inserting bladder pads inside incontinence briefs increased the chance of skin breakdown. 5. On 5/22/24 at 7:36 AM, during incontinence rounds, the surveyor and UM/LPN observed Resident #137 in bed with an incontinence brief and a bladder pad inside the diaper. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #4 had an assignment of 18 residents on that shift which included Resident #137. The surveyor reviewed the medical record of Resident #137. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included Alzheimer's Disease and urinary retention. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a BIMS score of 3 out of 15, which indicated severely impaired cognition. A further review revealed the resident required staff assistance with toileting and dressing. A review of the ICCP included a focus area dated 2/8/24, that the resident required assistance with ADLs with interventions that included to assist with bathing, dressing, and personal hygiene. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours and that bladder pads should not be placed inside incontinence briefs unless requested by the family or the resident. The DON acknowledged that inserting bladder pads inside incontinence briefs increased the chance of skin breakdown. 6. On 5/20/24 at 11:41 AM, the surveyor interviewed Resident #95 who stated that he/she did not receive their scheduled shower on Friday 5/17/24, and their last reported shower was on Tuesday 5/14/24. Resident #95 stated that their showers were scheduled weekly for Tuesdays and Fridays, but the facility was often short-staffed, and he/she was lucky if they even get one shower per week. The surveyor reviewed the medical record for Resident #95. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included chronic atria fibrillation, heart failure and chronic kidney disease. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 14 out of 15, which indicated a fully intact cognition. A further review revealed the resident required staff assistance for showers. A review of the ICCP included a focus area dated 10/21/22, that the resident needed assistance with ADLs with interventions that included to provide staff assistance to complete a shower or bed bath. On 5/28/24 at 10:10 AM, the surveyor interviewed CNA #5 who informed the surveyor that resident shower days were listed on each of the CNA's assignments. CNA #5 further stated that when a shower was done, the CNAs signed the Applewood Shower Sheet which was kept in a notebook. On 5/28/24 at 10:15 AM, the surveyor interviewed the UM/LPN who provided the surveyor with copies of Resident #95's Shower Sheets. A review of the shower sheets revealed that Resident #95 had not received their scheduled showers on 5/3, 5/7, 5/10, 5/17, or 5/24/24. At that time, the UM/LPN confirmed that Resident #95 had not had his/her scheduled showers on those scheduled days, and that she was responsible for ensuring that showers were done. On 5/29/24 at 9:19 AM, the surveyor interviewed CNA #3 who stated that she was not always able to give the residents showers on their assigned shower days because sometimes she had too many residents and it gets too hectic. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged showers should be given on the resident's assigned days. The DON further stated if the shower was not given on the assigned day, it should be given the following day. 7. On 5/20/24 at 11:41 AM, Resident #94's Representative (RR #1) informed the surveyor that Resident #94 had not received their scheduled shower on Friday 5/17/24, and that their last shower was on Tuesday 5/14/24. RR #1 further stated that Resident #94's showers were scheduled weekly for Tuesdays and Fridays, but that the facility was often short-staffed, and he/she was lucky if they even get one shower per week. The surveyor reviewed the medical record of Resident Resident #94. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included chronic kidney disease, Alzheimer's Disease, and a urinary tract infection. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/25/24, reflected the resident had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. A further review revealed the resident required assistance from staff for personal hygiene and toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. A review of the ICCP included a focus area dated 10/21/22, that the resident was at risk for skin breakdown related to incontinence and immobility. Interventions included to change incontinent product ASAP after voiding or bowel movement; keep bed linen clean and dry; keep skin clean and dry. An additional focus area included ADL self-care performance with interventions that included to provide staff assistance with shower, bed bath, personal hygiene and assistance with transfers from bed to wheelchair and wheelchair to the toilet. On 5/28/24 at 10:10 AM, the surveyor interviewed CNA #5 who informed the surveyor that the resident's shower days were listed on each of the CNA's assignments. CNA #5 further stated that when a shower was done, the CNAs signed the Applewood Shower Sheet which was kept in a notebook. On 5/28/24 at 10:15 AM, the surveyor interviewed the UM/LPN who provided the surveyor with copies of Resident #94's Shower Sheets. A review of the shower sheets revealed that Resident #94 had not received their scheduled showers on 5/3, 5/7, 5/10, 5/17, or 5/24/24. At that time, the UM/LPN confirmed that Resident #94 had not had his/her scheduled showers on those days and stated that she was responsible for ensuring that showers were done. On 5/29/24 at 9:19 AM, the surveyor interviewed CNA #3 who stated that she was not always able to give the residents showers on their assigned shower days because sometimes she had too many residents and it gets too hectic. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged showers should be given on the resident's assigned days. The DON further stated if the showers were not given on the assigned day, they should be given the following day. 8. On 5/20/24 at 11:06 AM, the surveyor observed Resident #109 in bed and observed his/her fingernails were long, jagged, and soiled with a brown material underneath. On 5/22/24 at 7:32 AM, the surveyor accompanied by the UM/LPN entered Resident #109's room. The UM/LPN confirmed the fingernails were long, jagged and soiled. The UM/LPN stated that the nurses were responsible for clipping the nails and the CNAs were responsible for cleaning them and that they should be checked and cleaned daily. The surveyor reviewed the medical record for Resident #109. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included dementia, seizure disorder and facial weakness following cerebral infarction (stroke). A review of the most recent comprehensive MDS dated [DATE], reflected the resident had severely impaired cognition and required staff assistance for personal hygiene and toileting. A review of the ICCP included a focus area dated 1/3/22, that the resident was at risk for pressure ulcer development due to a decline in mobility. Interventions included to keep nails short and filed and change incontinence products ASAP after voiding or bowel movement. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse stated that fingernail care was part of grooming and that CNAs should be checking, clipping, filing and cleaning the residents fingernails. The DON further stated that if a resident had a diagnoses of diabetes, the CNAs should not clip nails, but should still file and clean them. 9. On 5/21/24 at 11:45 AM, the surveyor observed Resident #16 seated in a geriatric chair and observed the resident had a hand splint in place to their left hand. The surveyor observed that Resident #16's fingernails on both their left and right hands were long, jagged soiled. The surveyor reviewed the medical record of Resident #16. A review of the admission Record face sheet, reflected that the resident was admitted to the facility with diagnoses that included gastrostomy status (a surgical procedure inserting a tube into the stomach for nutrition), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) and diabetes mellitus. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had severely impaired cognition and was dependent on staff for eating and toileting. A review of the ICCP included a focus area dated 3/9/23, that included ADLs with interventions that included to provide staff assistance with personal hygiene, bathing and bed mobility. On 5/23/24 at 12:51 PM, the surveyor interviewed the LPN assigned to Resident #16's care who acknowledged that the resident's nails were long, jagged, and soiled and stated that both the nurse and CNA were responsibility for providing nail care for the residents. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse stated that fingernail care was part of grooming and that CNAs should be checking, clipping, filing and cleaning the residents fingernails. The DON further stated that if a resident had a diagnoses of diabetes, the CNAs should not clip nails, but should still file and clean them. A review of the facility's Activities of Daily Living (ADLs) Supporting policy dated revised March 2018, included resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living . NJAC 8:39-27.1(a), 27.2(h)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a residents who received hemodialysis were being assessed in accordance to their hemodialysis access site and professional standards of practice every shift and b.) ensure a resident who received hemodialysis services was care planned for. This deficient practice was identified for 2 of 2 residents reviewed for hemodialysis (Resident #62 and #84), and was evidenced by the following: 1. On 5/21/24 at 11:39 AM, the surveyor observed Resident #62 in their room watching television. The resident informed the surveyor that he/she received dialysis treatments (removes waste products and excess fluid from the blood when the kidneys no longer function properly). The surveyor reviewed the medical record for Resident #62. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included end stage renal disease, chronic kidney disease stage 3 unspecified, and heart failure. A review of the Order Summary Report included the following physician's orders (PO): A PO dated 1/30/24, for dialysis three times a week on Mondays, Wednesdays, and Fridays. A PO dated 1/30/24, to monitor right subclavian permacatheter (temporary or permanent tunneled or connected port under the skin into the subclavian vein in the chest which can be used for a dialysis access point) for signs and symptoms of bleeding. A PO dated 3/12/24, to elevate right arm on pillows every shift for post surgery right arm arteriovenous (AV) fistula (surgically placed shunt that connects an artery to a vein in preparation for dialysis). A review of the comprehensive care plan did not include a focus area with interventions for dialysis. On 5/23/24 at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated the resident was on dialysis and was cleared to use the AV shunt as an access point two to three weeks ago. The LPN stated the resident also had a permacatheter in their chest that was covered. The LPN stated there were no assessments that she needed to do for the AV shunt or permacatheter; no dressings that were done either. The resident had a communication record that went with him/her to dialysis, and dialysis obtained pre and post weights. The LPN stated the Unit Manager/LPN (UM/LPN) completed the care plans. On 5/23/24 at 10:54 AM, the surveyor interviewed the UM/LPN who stated for a resident who went to dialysis, the facility obtained vital signs prior to leaving and the dialysis center obtained pre and post weights. The facility used a communication record to communicate with the dialysis center anything that occurred at dialysis, or anything that the facility needed to follow-up on. The UM/LPN stated if a resident had a permacatheter, professional standards of practice was to monitor the site, keep clean and dry, and make sure no trauma or bleeding every shift. The UM/LPN stated professional standards of practice for an AV shunt was to check bruit and thrill every shift; which was an assessment done by feeling their AV fistula for electric pulse that can be done with fingers or stethoscope done every shift to make sure functioning, no deep vein thrombosis or clogged. If there was any issues, the nurse notified the physician immediately. The UM/LPN confirmed there should be a physician's order to check bruit and thrill as well as a care plan. At that time, the UM/LPN review Resident #62's medical record, and confirmed the resident was using the AV shunt since 5/3/24, and there was no physician's order to check bruit and thrill every shift as well as no care plan. The UM/LPN stated there should also be an arm precaution order; no blood pressure or blood drawn from that arm. On 5/23/24 at 11:22 AM, the UM/LPN in the presence of the surveyor checked Resident #62's bruit and thrill, which the UM/LPN confirmed there was one. The UM/LPN stated as long as the resident had an AV shunt, whether it was in use or not, the nurses should have checked for bruit and thrill every shift. The surveyor continued to review the resident's medical record. A review of the Progress Notes since March did not include a Nurse's Note every shift that the bruit and thrill was monitored. On 5/24/24 at 8:12 AM, the surveyor interviewed the Director of Nursing (DON) who stated if a resident had a permacatheter, there should be orders to check it, and if the resident had an AV shunt, there should be orders to check bruit and thrill every shift. The DON acknowledged that she was aware there was no physician's order to check the resident's bruit and thrill every shift as well as dialysis care plan prior to surveyor inquiry. On 5/29/24 at 10:13 AM, the DON in the presence of the Licensed Nursing Home (LNHA), Regional LNHA, Regional Nurse, and survey team stated Resident #62 had an AV shunt created on 3/12/24, that was cleared for use on 5/3/24. The DON confirmed that the nurse should be assessing for bruit and thrill every shift regardless if the AV shunt was in use or not. 2. The surveyor reviewed the medical record for Resident #84. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included chronic kidney disease, end stage renal disease, and hypertension (high blood pressure). A review of the Order Summary Report included the following physician's Orders (PO): A PO dated 5/15/24, for dialysis three times a week on Mondays, Wednesdays, and Fridays. A PO dated 3/13/24, monitor right fistula (shunt) for excessive bleeding redness, swelling, pain, fever greater than 101 Fahrenheit, signs and symptoms of infection post surgery every shift. A PO dated 5/15/24, for no blood pressure or vein puncture to the right arm every shift. A review of the comprehensive care plan included a focus area dated 9/16/2020 for I need dialysis due to renal failure; no blood pressure to upper extremities; I require blood transfusions related to low hemoglobin and hematocrit levels (iron levels). Interventions included to not draw blood or draw blood pressure in right arm with graft; I may need encouragement to go to scheduled dialysis appointments on Mondays, Wednesdays, Fridays; monitor for signs and symptoms of infection to access site; monitor for dry skin and apply lotion as needed; monitor for peripheral edema; monitor for signs and symptoms of renal insufficiency; monitor for signs and symptoms of bleeding, hemorrhage, bacteremia, septic shock; monitor labs; obtain vital signs and weights. On 5/23/24 at 10:54 AM, the surveyor interviewed the UM/LPN who stated for a resident who went to dialysis, the professional standards of practice for an AV shunt was to check bruit and thrill every shift; which was an assessment done by feeling their AV fistula for electric pulse that can be done with fingers or stethoscope done every shift to make sure functioning, no deep vein thrombosis or clogged. If there was any issues, the nurse notified the physician immediately. The UM/LPN confirmed there should be a physician's order to check bruit and thrill every shift. On 5/23/24 at 11:25 AM, the surveyor re-interviewed the UM/LPN who confirmed Resident #84 did not have a PO to check bruit and thrill every shift, and she was putting one in now. The UM/LPN stated the resident's shunt was revised multiple times, and the resident had developed a blood clot. The dialysis center is looking into a permacatheter at this point. The surveyor continued to review the resident's medical record. A review of the Progress Notes since March did not include a Nurse's Note every shift that the bruit and thrill was monitored. On 5/24/24 at 8:12 AM, the surveyor interviewed the DON who stated if a resident had an AV shunt, there should be orders to check bruit and thrill every shift. The DON acknowledged that she was aware there was no physician's order to check the resident's bruit and thrill every shift prior to surveyor inquiry. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, Regional Nurse, and survey team stated Resident #84 had a PO to check bruit and thrill until they were re-admitted from a hospitalization on 3/13/24, and the PO was never put in. The DON stated from 4/12/24 through 5/22/24, there was twelve documented times on the dialysis communication record that bruit and thrill was checked, as well as the Progress Notes contained twenty-seven times nurses documented bruit and thrill was checked from 3/13/24 to 5/17/24. The DON acknowledged that bruit and thrill needed to be checked every shift, every day. A review of the facility's Hemodialysis Access Care policy dated reviewed January 2024, included .care involves the primary goal of preventing infection and maintaining patency of the catheter (preventing clots); to prevent infection and/or clotting: keep access site clean and dry at all times; do not use the access site to take blood samples, administer intravenous fluids or give injections; needle access for hemodialysis should be rotated; check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing care and at regular intervals; do not access arm to take blood pressure; advise resident not to sleep on, wear tight jewelry or lift heavy objects with access arm; check color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals; and check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of the blood flow through the access site .the general medical nurse should document in the resident's medical record every shift as follows: location of the catheter; condition of the dressing (interventions if needed); if dialysis was done during shift; any part of report from dialysis nurse post-dialysis being given; observations post-dialysis. A review of the facility's Care Plans, Comprehensive Person-Centered policy dated reviewed January 2024, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .the comprehensive, person-centered care plan will: .describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being . NJAC 8:39-27.1 (a)

Complaint NJ #: 157735; 160630; 164199; 170619; 172027 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to a.) provide appropriate incontinence care to dependent residents for 5 of 8 residents (Resident # 94, #16, #8, #109, and #137) and b.) ensure residents received showers as scheduled for 2 of 2 residents (Resident #95 and #94) reviewed for sufficient staffing, and was evidenced by the following: Refer to F677 1. On 5/20/24 at 11:41 AM, the surveyor observed Resident #94 in bed with their eyes open, very soft-spoken. The Resident's Representative (RR #1) informed the surveyor that Resident #94 had not received care that morning which included incontinence care, and that they were still wearing the same jeans from last night. At that time, Resident #94 nodded in agreement. On 5/20/24 at 11:52 AM, the surveyor found Resident #94's Certified Nursing Assistant (CNA #1) who confirmed she was the resident's aide for the day, and stated she had provided incontinence care earlier that shift. The surveyor accompanied by CNA #1, entered Resident #94's room and pulled back the resident's blanket which revealed the resident was saturated with urine through their jeans and bed sheets, and the surveyor observed a strong unpleasant odor. CNA #1 stated she had not provided care yet for that resident, she was mistaken. CNA #1 further stated that she had ten residents on her assignment that day and had not provided care. Review of the CNA assignment sheet revealed the unit had a census of 51 Residents with five assigned aides. CNA #1 had an assignment of ten residents on that shift. On 5/22/24 at 7:23 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that incontinence rounds should be completed every two hours. On 5/24/24 at 10:17 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that incontinence care should be done every two hours on the day shift. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours. 2. On 5/22/24 at 7:45 AM, the surveyor did incontinence rounds with the UM/LPN on the Applewood Unit and observed Resident #16 in bed with an incontinence brief saturated with urine. The surveyor and UM/LPN observed a strong unpleasant odor. At that time, the UM/LPN confirmed that the brief should have been changed every two hours, and that the resident's brief could not have been changed at 5:00 AM. On 5/23/24 at 9:24 AM, the surveyor attempted a phone interview with the CNA #2 who was assigned to Resident #16 on the 5/21/24 11:00 PM to 7:00 AM (11-7) shift with no answer. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #2 had an assignment of 18 residents on that shift. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours. 3. On 5/20/24 at 12:13 PM, the surveyor observed Resident #8 in their room seated in a wheelchair. The Resident's Representative (RR #2) stated that on Saturday he/she observed the resident's clothing was saturated with urine, and observed a puddle of urine on the floor under their wheelchair. On 5/21/24 at 10:44 AM, the surveyor observed Resident #8 in his/her room seated in a wheelchair with CNA #3 in the room. The surveyor observed a strong unpleasant odor in the room. CNA #3 acknowledged the odor and stated that the resident's incontinence brief, bed clothing, and bed sheets were all saturated with urine and stated, not sure what night shift does. CNA #3 confirmed that was her first incontinence care provided for Resident #8 for that day. On 5/22/24 at 7:41 AM, during incontinence rounds, the surveyor observed the resident with an incontinence brief with two bladder pads wet with urine inserted inside the adult brief. At that time, the surveyor interviewed the UM/LPN who stated that placing two bladder pads inside an incontinence brief was unacceptable, and that it could cause skin breakdown. On 5/23/23 at 9:30 AM, the surveyor attempted a phone interview with CNA #4 who was assigned to Resident #8 on the 5/21/24 11-7 shift with no answer. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #4 had an assignment of 18 residents on that shift. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours and that bladder pads should not be placed inside incontinence briefs unless requested by the family or the resident. The DON acknowledged that inserting bladder pads inside an incontinence brief increased the chance of skin breakdown. 4. On 5/22/24 at 7:32 AM the surveyor did incontinence rounds with the UM/LPN on the Applewood Unit and observed Resident #109 in bed wearing an incontinence brief with a wet bladder pad inside their incontinence brief. On the same date at 7:36 AM, the surveyor and UM/LPN observed Resident #137 in bed with an incontinence brief and a bladder pad inside the brief. On 5/23/23 at 9:30 AM, the surveyor attempted to interview CNA #4 who was assigned to Resident #109 and #137 on the 5/21/24 11-7 shift with no answer. Review of the CNA assignment sheet revealed the unit had a census of 52 Residents with three assigned aides. CNA #4 had an assignment of 18 residents on that shift which included Resident #109 and #137. On 5/24/24 at 10:17 AM, the surveyor interviewed the DON who confirmed that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be done between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged incontinence care should be provided every two hours and that bladder pads should not be placed inside incontinence briefs unless requested by the family or the resident. The DON acknowledged that inserting bladder pads inside an incontinence brief increased the chance of skin breakdown. 5. On 5/20/24 at 11:41 AM, the surveyor interviewed Resident #95 who stated that he/she did not receive their scheduled shower on Friday 5/17/24, and that their last shower was on Tuesday 5/14/24. Resident #95 stated that their showers were scheduled weekly for Tuesdays and Fridays, but that the facility was often short-staffed, and he/she was lucky if they even received one shower per week. On 5/28/24 at 10:10 AM, the surveyor interviewed CNA #5 who informed the surveyor that resident shower days were listed on each of the CNA's assignments. CNA #5 further stated that when a shower was done, the CNAs signed the Applewood Shower Sheet which was kept in a notebook. A review of the Applewood Shower Sheet revealed that Resident #95 had not received their shower on 5/17/24. On 5/28/24 at 10:15 AM, the surveyor interviewed the UM/LPN who confirmed that the shower sheet had not been signed indicating that Resident #95 had not received their shower. The UM/LPN further stated that she was responsible for ensuring all residents received their showers on the assigned shower days. On 5/29/24 at 9:19 AM, the surveyor interviewed CNA #3 who stated that she was not always able to give the residents showers on their assigned shower days because sometimes she had too many residents and it gets too hectic. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged showers should be given on the resident's assigned days. The DON further stated if the shower was not given on the assigned day, it should be given the following day. 6. On 5/20/24 at 11:41 AM, Resident #94's representative (RR #1) informed the surveyor that the resident had not received their scheduled shower on Friday 5/17/24, and that their last shower was on Tuesday 5/14/24. RR #1 further stated that Resident #94's showers were scheduled weekly for Tuesdays and Fridays, but that the facility was often short-staffed, and he/she was lucky if they even received one shower per week. On 5/28/24 at 10:10 AM, the surveyor interviewed CNA #5 who informed the surveyor that the resident shower days were listed on each of the CNA's assignments. CNA #5 further stated that when a shower was done, the CNAs signed the Applewood Shower Sheet which was kept in a notebook. A review of the Applewood Shower Sheet revealed that Resident #94 had not received their shower on 5/17/24. On 5/28/24 at 10:15 AM, the surveyor interviewed the UM/LPN who confirmed that the shower sheet for Resident #94 had not been signed indicating that Resident #94 had not received their shower. The UM/LPN further stated that she was responsible for ensuring all residents received their showers on their assigned shower days. On 5/29/24 at 9:19 AM, the surveyor interviewed CNA #3 who stated that she was not always able to give residents showers on their assigned shower days because sometimes she had too many residents and it gets too hectic. On 5/29/24 at 10:13 AM, the DON in the presence of the LNHA, Regional LNHA, and Regional Nurse acknowledged showers should be given on the resident's assigned days. The DON further stated if the showers were not given on the assigned day, they should be given the following day. A review of the facility's Staffing policy updated September 2023, included our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care and facility assessment .staffing numbers and skills requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . A review of the facility's Activities of Daily Living (ADLs) Supporting policy dated revised March 2018, included resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living . NJAC 8:39-5.1(a)

Based on observation and interview, it was determined that the facility failed to a.) store potentially hazardous foods to prevent food-borne illness; b.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; c.) ensure washed cookware was dried in a manner to prevent microbial growth; d.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 5/21/24 at 8:40 AM, the surveyor toured the kitchen with the Dining Service Director (DSD) and observed the following: 1. In front on the walk-in freezer unit, stored directly on the floor, five stacks of twenty-four cases in total of ice cream cups, and a stack of frozen vegetables with a box of oriental blend vegetables directly on the floor. The DSD stated the frozen items were just delivered and the Dietary Aide was labeling the boxes before transferring them into the freezer. The DSD acknowledged food should not be stored or come in direct contact with the floor. 2. In the walk-in freezer, the vinyl strip curtains located in the entrance to the freezer, two curtain strips were missing in the middle of the doorway. These curtains protect the inside of the freezer from outside dust particles as well as keep the cold air from escaping the freezer when the door was opened. The freezer was currently at 25 degrees Fahrenheit. The DSD stated the temperature had increased from the door being opened for the deliveries. 3. On the shelves in the walk-in freezer, the boxes were covered in a thick layer of frost which included the following items that the DSD identified for the surveyor: a case of beef hamburger patties; three liquid coffee containers; broccoli florets; broccoli spears; health shakes; cheese blintz; and stuffed cabbage. The DSD confirmed frost and ice should not be covering the food, and was caused by the door being opened for deliveries. 4. In the walk-in freezer, the condenser unit had a build-up of ice, and the top shelf under the condenser unit contained rods of ice approximately four to six inches in length. The DSD acknowledged the unit and shelves should not have ice buildup. 5. The ice cream chest had a build up of ice on the inside. 6. In dry storage ,one six-pound four-ounce can of cut sweet potatoes dented was in active inventory. 7. On a storage shelf, one large brown cutting board deeply pitted with black discoloration; one large light blue cutting board pitted and yellowish discoloration in grooves; one large brown cutting board pitted; one large yellow cutting board pitted and discolored black; two large red cutting boards pitted; and one large green cutting board pitted with yellow discoloration in the grooves. The DSD stated cutting boards were replaced every quarter or six months and acknowledged those cutting boards needed to be replaced. The DSD stated the grooves could cause bacterial growth. 8. On the storage rack, two four-inch half pans were wet nesting and five four-inch plastic half pans were wet nesting. One of the plastic half pans had brownish debris in it and was missing a corner of the plastic. The DSD confirmed the broken plastic half pan should not be in use, and pans should not be wet nested. On 5/22/24 at 8:30 AM, the Licensed Nursing Home Administrator (LNHA) stated the walk-in freezer repair company was at the facility yesterday afternoon who replaced the motor on the freezer unit which was now operating properly. On 5/29/24 at 10:13 AM, the LNHA in the presence of the Director of Nursing (DON), Regional LNHA, and Regional Nurse, acknowledged the surveyor's concerns. A review of the facility provided undated Dish Washing and Pot Washing policy included .all items must be air dried. This will allow the sanitizer to break down any biofilms and avoid nesting. Note: nesting is when two or more wet pans are placed together. This causes moisture to become trapped and does not allow it to dry. This can cause bacterial growth and contaminate clean pans . A review of the facility provided undated Kitchen Equipment policy included all kitchen equipment is inspected daily by food service director, by maintenance during rounds and with recommendations from outside service companies during visits . A review of the facility provided undated Receiving and Inspecting Guidelines policy included .product placement .store items away from the walls and at least six inches off the floor . A review of the undated facility provided policy Cutting Board Policy included .replace when needed. A review of the undated facility provided policy Dented Can Policy included .the Food Service Director or designee will spot check all cans upon delivery to ensure there are no dents, bulges, or punctures; all cans identified to not be in good condition will be moved to the designated dented can area . NJAC 8:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to properly dispose and maintain cardboard waste in dumpster areas. This deficient practice was identified for 1 of 3 garbage dumpsters, and was evidenced by the following: During a tour of the kitchen on 5/21/24 at 8:40 AM, the surveyor accompanied by the Dining Service Director (DSD) observed the facility's garbage compactor and cardboard dumpster. The surveyor observed the cardboard dumpster to be overfilled with intact cardboard boxes that prevented the lid from closing. The area surrounding the dumpster had piles of intact cardboxes surrounding the side walk of the dumpster area approximately four to five feet in height, as well as intact cardboard boxes in the fire zone of the facility parking lot. The DSD stated the cardboard dumpster was disposed of twice a week, and today was a delivery day. The DSD acknowledged the cardboard boxes should not be around the dumpster area, that it was not being maintained in a sanitary manner. On 5/28/24 at 8:53 AM, the surveyor interviwed the Maintenance Director (MD) who stated the garbage compactor was collected every other Tuesday, and cardboard was collected every Monday and Friday. The MD stated he did not see the cardboard dumpster area until after the surveyor observed it with the DSD, and staff had already cleaned the area. At that time, the surveyor showed the MD a picture of the area at the time of observation, and the MD confirmed the condition of the area was unacceptable. The MD stated the boxes that were identified still intact were both from the nursing department as well as dietary, and the boxes should have been broken down and not left intact. On 5/29/24 at 10:13 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional LNHA, Regional Nurse, and survey team stated it was the facility's policy if the cardboard dumpster was filled, the cardboard boxes could be stored next to the dumpster. At that time, the surveyor showed the LNHA a picture of the dumpster area at the time of observation and asked if the area was maintained in acceptable condition, and the LNHA did not respond. A review of the undated facility provided Garbage and Trash Disposal Policy included the Dining Services Director coordinates with the Directors of Maintenance and Housekeeping to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris .cardboard and other recycling dumpsters should be properly maintained: dumpster door or lid must be closed at all times when not in use; all staff is responsible to breakdown cardboard boxes after each use; and all boxes should be placed in the recycling dumpster flattened as to not take up additional space. If cardboard dumpster is full, stack cardboard on concrete next to dumpster until emptied; area around dumpster should remain clean and free from refuse; report any dumpster or trash compactor issues to maintenance immediately. NJAC 8:39-19.3(a); 19.7(a)(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards of practice and procedures to a.) ensure appropriate hand hygiene was performed during lunch meal in 2 of 5 dining areas; b.) ensure appropriate infection control practices were maintained for 1 of 1 Resident (Resident #16) observed during wound treatments and c.) follow appropriate hand hygiene practices during resident care for 1 of 7 residents (Resident #8) reviewed for Activities of Daily Living (ADLs). The evidence was as follows: 1. On 5/20/24 from 11:35 AM to 11:48 AM, the surveyor observed dining in the Meadows Unit. Prior to handing out lunch trays, the Unit Manager/Licensed Practical Nurse (UM/LPN #1) was observed placing alcohol based hand rub (ABHR) on top of the food truck that contained resident lunch trays. During tray pass, a Licensed Practical Nurse (LPN #1) and Activity Aide (AA #1) were each observed being handed a tray by UM/LPN #1. LPN #1 and AA #1 were observed placing the tray in front their designated resident. LPN #1 and AA #1 proceeded to uncover each resident's plate, use the resident's utensils to cut food, then immediately proceeded to obtain another resident's tray without performing hand hygiene. During the course of the meal observation, staff was not observed performing hand hygiene in between each tray pass. On 5/20/24 from 11:52 AM to 12:21 PM, the surveyor observed dining in the Main Dining Room prior to meal service, hand hygiene was not performed to the residents seated in the room. Meals were delivered to the residents by waitress style to each table. The surveyor observed Restorative Aide (RA #1) assist a resident and used their utensils to cut their meal, and then proceeded to pour coffee and open sweetener packages. RA #1 continued to additional residents performing the same process of cutting residents' meals and serving coffee without performing hand hygiene. On 5/20/24 at 12:27 PM, the surveyor interviewed AA #1 who stated that hand hygiene was required as needed between every couple residents or deemed necessary. When asked if hand hygiene was required after tray contact AA #1 responded, not necessarily. On 5/20/24 at 12:34 PM, the surveyor interviewed LPN #1 who confirmed that hand hygiene was required after every couple residents and was not necessary after every tray contact. On 5/20/24 at 12:39 PM, the surveyor interviewed UM/LPN #1 who stated that there was no expectation of hand hygiene in between residents since the staff was not touching food. When asked if hand sanitation should be expected after touching resident utensils, UM/LPN #1 stated that they were not sure. On 5/20/24 at 12:49 PM, the surveyor interviewed RA #1 regarding hand hygiene who explained hand sanitation was to be completed as necessary or when hands were visibly dirty. RA #1 confirmed it was not expected between every resident contact. When asked how hand sanitation was completed with the residents, RA #1 explained that it would be completed by floor staff before the residents are brought to the dining room. RA #1 confirmed that hand hygiene was not completed with residents in the dining room. On 5/21/24 at 10:32 AM, the surveyor re-interviewed UM/LPN #1 who stated that they spoke with the Regional Infection Preventionist and was instructed that hand hygiene was required between each resident when food was cut up and in between tray pass. UM/LPN #1 confirmed that hand hygiene was not performed the day prior in between each tray pass and after assisting residents with their meal set up. On 5/28/34 at 10:16 PM, the surveyor interviewed Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated that it was expected that staff was to perform hand hygiene in between any interaction with lunch trays that included use of resident utensils for meal set up. When asked regarding the hand sanitation of residents in the main dining room, the ADON/IP confirmed that handwipes were to be handed out by the person overseeing the dining room prior to meal service. On 5/29/24 at 10:13 AM, the Director of Nursing (DON), in the presence of the LNHA, Regional Nurse, and Regional LNHA confirmed handwashing was expected between passing out trays and cutting up food. A review of the facility's Hand Washing policy last revised January 2024, included 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .o. before and after eating or handling food; before and after assisting a resident with meals . 2. On 5/22/24 at 7:45 AM, the surveyor observed Resident #16 in bed. The surveyor reviewed the medical record of Resident #16. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included gastrostomy status (a surgical procedure to insert a tube into the stomach for nutrition), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) and diabetes mellitus. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/28/24, reflected the resident had severely impaired cognition and was incontinent of bowel and bladder. A further review revealed the resident had one stage 4 pressure ulcer and two unstageable pressure ulcers. A review of the May 2024 Physician Order Summary (POS) which was transcribed onto the Treatment Administration Record (TAR) included a physician's order dated 5/7/24, to cleanse the left heel wound with Vashe (a wound cleanser), apply Santyl ointment (wound debridement) and calcium alginate cover (absorbs wound moisture/exudate), with abdominal (ABD) pad (used to absorb heavy drainage); wrap with rolled gauze daily and when needed (prn); cleanse left lateral lower leg wound with Vashe wound cleanser and apply Santyl and calcium alginate, cover with ABD pad and wrap with rolled gauze daily and prn; soak right medial foot with moistened gauze for 3-5 minutes, apply Santyl and calcium alginate, cover with ABD pad and wrap with rolled gauze daily and prn. On 5/22/24 at 10:55 AM, the surveyor observed LPN #2 perform a treatment to Resident #16's wounds with UM/LPN #2 who assisted with the resident's positioning. The surveyor observed the following: LPN #2 disinfected the over-bed table (OBT) with sanitizing wipes and applied a clean barrier. LPN #2 then assembled the needed supplies from the treatment cart and placed them on the OBT in the resident's room. Among the supplies were a bottle of wound cleanser, a tube of Santyl ointment, calcium alginate, gauze sponges, ABD pads, scissors, and a marker. The LPN put small amounts of the Santyl ointment into two separate medicine cups. LPN #2 provided the treatment for Resident #16's wounds according to the physician's orders, and after the treatment, the LPN put the scissors she used to remove the soiled dressings and the pen she used to initial and date the dressings into her pocket without first sanitizing them. The LPN then placed the tube of Santyl ointment and wound cleanser back into the treatment cart without sanitizing them. The LPN did not sanitize the overbed table after she completed the treatment. On 5/22/24 at 11:49 AM, the surveyor interviewed LPN #2 regarding the wound treatment observation who acknowledged that she should not have brought the tube of Santyl ointment and bottle of wound cleanser into the resident's room; she should have taken only what she needed. She further confirmed that she should not have put the contaminated scissors and marker into her pocket but rather should have sanitized them and then returned them to the treatment cart. On 5/24/24, at 11:47 AM, the surveyor interviewed the DON who confirmed that anything used in a resident's room should be disinfected before being placed in the treatment cart. On 5/24/24 at 12:06 PM, the surveyor interviewed the ADON/IP, who confirmed that LPN #2 should not have brought the tube of Santyl and bottle of wound cleanser into the room, but only the amounts needed for the treatment. The ADON/IP further stated that the scissors and marker should have been disinfected and returned to the treatment. A review of the facility's Clinical Competency Validation Wound Dressing-Aseptic checklist reflected discarding materials and PPE according to infection control policy. 3. On 5/23/24 at 10:32 AM, the surveyor observed Resident #8 in bed and observed CNA #3 providing ADL care. The surveyor observed that CNA #3 handled Resident #8's soiled adult brief, then wet her hands with water, applied soap, and immediately placed her hands under the stream of running water. On 5/23/24 at 12:30 PM, the surveyor interviewed CNA #3, who confirmed that she should have washed her hands outside the stream of water for 20 seconds. On 5/24/24 at 11:47 AM, the surveyor interviewed the DON, who confirmed that staff should lather their hands with soap for 20 seconds outside the stream of water. On 5/24/24 at 12:06 PM, the surveyor interviewed the ADON/IP, who confirmed that staff should apply soap to their hands and lather for 30 seconds before placing them under running water. A review of the facility's Hand Washing policy last revised January 2024, included 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .before and after eating or handling food; before and after assisting a resident .Washing Hands 1. vigorously lather hands with soap and rub them together, creating friction for a minimum of 20 seconds . NJAC 8:39-19.4 (a) 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to respond to a resident call light in a timely manner to provide assistance to a resident who required toileting assistance. This deficient practice was identified for 1 of 25 residents reviewed (Resident #34) and was evidenced by the following: On 04/25/22 at 9:35 AM, two surveyors were at the nursing station on the Long Term Care Unit (LTC) when we heard screaming in the hallway. The call light for Resident #34's room was activated and sounded at the nursing station. The surveyors proceeded down the hallway and observed Resident #34 was sitting on the bed and appeared visibly upset. At that time, Resident #34 summoned the surveyors to come into the room. The surveyors entered the room and asked Resident #34 if he/she needed something. Resident #34 stated, I have been here for one and one-half years had never had two (staff) assist with the Sit to Stand. The resident stated that [his/her] call light had been on since 8:00 AM because he/she needed to use the bathroom. and the CNA turned off the light at 8:30 AM, and the Certified Nursing Assistant (CNA) entered the room and indicated that she was waiting for another staff to assist and [The CNA] was still not here to assist. On 04/25/22 at 9:40 AM, the surveyor interviewed the Temporary Nursing Assistant (TNA) assigned to Resident #34. The TNA revealed that she was aware that Resident #34 needed to use the bathroom and the TNA stated she had informed the resident that she would return to assist after she had collected the breakfast trays, and that she could not locate the Sit to Stand (STS) Lift to transfer the resident. The TNA informed the surveyor that she had returned to the room at 9:30 AM and had apologized to the resident. The TNA stated the resident was very upset and was unable to understand why he/she had to wait that long to use the bathroom. The TNA added that there was only one STS Lift for the unit and she could not locate it. The surveyor inquired to the TNA what other approaches could have been used to assist Resident#34, and the TNA indicated that she could have offered Resident #34 a bedpan since Resident #34 was still in bed. On 04/25/22 at 12:00 PM, the surveyor interviewed Resident #34 while Resident #34 was sitting in a wheelchair in the room. When asked if the facility staff answered the call light promptly when he/she needed assistance, Resident #34 stated, Sometimes it seems like it takes forever for staff to come. Resident #34 stated that he/she needed help with being transferred and called for assistance. Resident #34 informed the surveyor that one time he/she alerted 911 because he/she needed to be changed and could not get the staff to assist in a timely manner. Resident #34 stated that this morning he/she activated the call light around 8:00 AM and was not assisted until 9:45 AM. When asked about the time, he/she pointed to the clock in the room to indicate that was how he/she knew the time. On 04/25/22 at 12:25 PM, the surveyor interviewed the Food Service Director (FSD) and requested any logs for the meal cart delivery. The FSD indicated that the Units do not sign when the trays arrived on the unit. However, he provided a log for the time that the trays left the kitchen. According to the log provided, the first cart left the kitchen for the 200's Unit at 7:20 AM, and the last cart scheduled at 7:40 AM. Resident #34's tray was on the second delivery and arrived on the Unit around 7:45 AM. Resident #34 stated to the surveyor that he/she activated the call light around 8:00 AM. Subsequent observations on 04/27/22 and 05/03/22 at 7:50 AM confirmed that Resident #34 received the breakfast tray around 8:00 AM. On 04/25/22 at 12:54 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), regarding the incident with the call light. The LPN/UM stated that her expectation was for call light to be answered in a timely manner. When asked to elaborate she indicated a reasonable time would be within 15 minutes. She added that staff could have been in other rooms providing care or they forgot to turn off the call light. The surveyor asked the LPN/UM if Resident #34 had prior issues with the call light or expressed concerns over his/her needs not being met in a timely manner and the LPN/UM stated, No. On 04/25/22 at 2:55 PM, the surveyor interviewed the Director of Nursing (DON) regarding if any call light audits completed. The DON stated that the system at the facility was not programmed to register when call lights were activated and deactivated by staff. The DON added that the call light was visible on the panel at the nursing station. On 04/26/22 at 11:15 AM, the surveyor reviewed the paper call light audits for the prior two months that were provided by the DON. The DON stated that on a daily basis she asked the Unit Managers to document call lights responses and the Unit Managers provided these logs. The facility did not have the ability to confirm the time call lights were activated or when the requested care was provided. On 04/26/22 at 11:45 AM, the surveyor reviewed Resident #34's electronic medical record which revealed the following: Resident #34 was admitted to the facility with diagnoses which included but, was not limited to, wedge compression Fracture of T [Thoracic] T 11-T 12 vertebra, subsequent encounter for fractures with routine healing, unspecified osteoarthritis, retention of urine and anxiety disorder. The admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 07/31/21, revealed that Resident #34 scored 15/15 on the Brief Interview for Mental Status which indicated the resident was cognitively intact. The MDS further revealed the functional status for bed mobility, dressing, and personal hygiene was coded as the resident required extensive assistance from staff. Resident #34 also required the use of a Sit to Stand Lift (a mechanical lift used for transfer from the bed to a chair) for transfer to the bathroom. The following Progress Notes entries revealed: 11/21/21 at 15:43:15 [3:43 PM] Note Text: This writer was informed of resident calling 911 for assistance. On arrival to resident's room, observed resident seated at edge of bed and c/o [complained] not being attended to in a timely fashion. [He/She] mentioned that [he/she] was wet and needed to be changed right away and that is why [he/she] called police. This writer informed [him/her] that 911 is for emergency calls only and that we are here to assist in every way possible. This writer, nurse, & CNA immediately performed care and safely transferred [him/her] to the bathroom with use of sit to stand equipment. Kept clean and dry with day clothes on; then transferred into [him/her] w/c [wheelchair]. Resident was content afterwards. 12/08/21 at 17:09 [5:09 PM] Health Status Note Note Text: Resident propelled self to nurses station and informed this writer that the CNAs are not being mean or saying thing to [him/her] that are negative but that they are being breezy to [him/her]. Writer asked [him/her] what that meant and [he/she] replied they are just not as talkative to me as they could be. When writer was re assuring resident that the CNAs were busy and that they did say hello to [him/her] when [he/she] came out of [his/her] room, resident then became angry, yelling and screaming at this [NAME] let's talk about general. Resident then went to activities. At 3:10 PM resident came to this writer and stated I need to go to the bathroom. This writer informed resident that we will send a CNA to [him/her] as soon as we can. Resident was informed that [his/her] CNA was on a break and would be back in a few minutes. Resident then stated I can wait a few minutes. Resident waited about 10 minutes and began screaming for [his/her] aid. Writer informed [his/her] that her CNA had just come back from break and that she was getting her supplies to take resident to the bathroom. Resident then screamed I have been sitting here for 40 minutes. Writer informed [him/her] of the time and that it was 10 minutes. At that time resident stopped yelling and CNA assisted resident into the bathroom. 12/13/21 at 14:59 [2:59 PM] Behavior Note Note Text: Resident continues on prednisone, last dose given, 10 (milligram) mg. Respirations even and unlabored. No cough or shortness of breath noted. No wheezing noted. Increased anxiety noted after lunch, Wanted to be toileted Immediately upon returning from MDR. Resident was made aware aware that the CNAs were toileting other residents and will assist [him/her] when care was completed, that [he/she] should go to [him/her] room to be toileted. Resident #34 began to raise [his/her] voice and did not want to wait. Two CNAs approached Resident #34 with the STS machine for transfers and took [him/her] to her room to be toileted. No further episodes noted. The surveyor could not locate the incident that occurred in the presence of the surveyor on 04/25/22 in the Electronic Progress Notes. On 04/27/22 at 12:15 PM, after surveyor inquiry to the DON, the DON provided the surveyor a grievance form dated 04/25/22. The form revealed that the LPN/UM reported that Resident #34 was upset about waiting to be toileted and get care. On 05/03/22 at 12:53 PM, the administrator provided an individual Education Record for the TNA who was assigned to Resident #34 which addressed Residents care and preferences. A review of the Agency-Self Study Orientation Packet for the TNA provided by the facility on 04/27/22 at 2:39 PM, revealed the following under Customer Service/Culture of Caring/ Effective Communication: If you cannot help, ask a supervisor or another person to help. (The TNA acknowledged that she could not assist Resident #34 at 8:30 AM when she collected the breakfast tray and that she did not report to the Unit Manager her conversation with Resident #34 who mentioned that he/she had been waiting for awhile to use the bathroom.) A review of the facility's CNA/TNA main duty was to carry out assignments for resident care including but not limited to answer call light promptly. On 05/03/22 at 10:30 AM, the surveyor interviewed the DON regarding any entries into the medical record regarding Resident #34's concerns regarding a delay in care. The DON indicated that she was not aware of any prior entries in the clinical record regarding Resident #34 concerns with delay in services. (Resident #34 had 3 prior documented incidents with the call lights/ needed assistance to use the bathroom: 11/21/21 at 15:43, 12/08/21 at 15:10 PM and 12/13/21 at 14:59 PM. The facility did not initiate a care plan to assist the direct staff to meet Resident #34's toileting needs in a timely manner. Resident #34 had a BIMS of 15, there was no documentation in the medical record to indicate that the Interdisciplinary Team met with Resident #34 and addressed the above issues). On 05/03/2022 at 11:00 AM, the DON provided a copy of the call lights policy. The listed procedures documented, Answer all call lights in a prompt, calm, courteous manner. All staff, regardless of assignment must answer call lights. Turn off call light. Call-light should not be turned off until request is met. Respond to request or, if unable to do so, refer request to appropriate staff member immediately. On 05/04/2022 at 10:27 AM, the DON indicated that she met with Resident #34 to discuss the concerns and a care plan was developed. The DON stated, I was surprised there was no care plan in place. Our expectations would be to put a care plan to address the issues. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and review of facility documentation, it was determined the facility failed to ensure a comprehensive person-centered care plan was developed with measurable objectives and individualized interventions for 2 of 25 sampled residents (Residents #34, #62) and was evidenced by the following: 1. On 04/21/22 at 9:30 AM, the surveyor observed Resident #34 sitting in a wheelchair in the room watching television. On 04/25/22 at 9:35 AM, two surveyors were at the nursing station and heard screaming from the hallway. The surveyors proceeded to the hallway and we both observed Resident #34 sitting on the bed and was upset. Resident #34 asked the surveyors to come to to the room. The surveyors entered the room and asked Resident #34 if he/she needed something. Resident #34 stated, I have been here for one and one-half years had never had two (staff) assist with the Sit to Stand. The resident stated that [his/her] call light had been on since 8:00 AM because he/she needed to use the bathroom. Staff then turned off the light at 8:30 AM and the Certified Nursing Assistant (CNA) entered the room and indicated that she was waiting for another staff to assist. [The CNA] was still not here to assist. On 04/25/22 at 9:40 AM, the surveyor interviewed the Temporary Nurse Assistant (TNA) assigned to Resident #34. The TNA confirmed that the Sit to Stand Lift (STS) was not available to assist Resident #34 to the bathroom in a timely manner. The surveyor reviewed the medical record for Resident #34 which revealed the following: Resident #34 was admitted to the facility with diagnoses which included, but were not limited to, Wedge compression Fracture of T [Thoracic Spine] T 11-T 12 vertebra, subsequent encounter for fractures with routine healing, unspecified osteoarthritis, retention of urine and anxiety disorder. The admission Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, revealed that Resident #34 scored 15/15 on the Brief Interview for Mental Status which indicated an cognition. Functional status for bed mobility, transfer were coded as requiring extensive assistance from staff. Resident #34 also required a Sit to Stand Lift (mechanical lift to facilitate transfer from the bed/chair) to the bathroom. On 04/25/22 at 9:45 AM, two surveyors observed the Licensed Practical Nurse/Unit Manager (LPN/UM) enter Resident #34's room with the STS Lift to assist the resident. On 04/25/22 at 10:12 AM, the surveyor interviewed the LPN/UM and inquired about the process for the call bell response. The LPN/UM stated that the call bell should be answered in a timely manner and resident's needs should be met promptly. The surveyor inquired regarding what promptly meant, and the LPN/UM stated 15 minutes. The LPN/UM further stated that she had only one STS Lift because the other one was broken. She stated there were three residents on the unit who required the STS Lift. She stated that she was not aware that Resident #34 had the light on since 8:00 AM this morning and she acknowledged that she observed the call light after breakfast but was unsure of the time. On 04/25/22 at 11:22 AM, the surveyor conducted a second interview with the TNA who cared for Resident #34 that day. The TNA stated that Resident #34 did not exhibit behaviors and she confirmed that Resident #34 requested to use the bathroom when she delivered the breakfast tray. She stated she informed Resident #34 that she would return after breakfast to assist him/her. Resident #34 informed then the TNA that he/she had been waiting for a little while. The TNA stated that another staff was using the STS Lift, and that there was only one STS Lift, so she could not assist Resident #34 in a timely manner. On 04/25/22 at 12:25 PM, during an interview with the Food Service Director (FSD), the FSD revealed that the units did not have signed acknowledge receipts of the meals carts. The FSD then provided the log when the meal carts left the kitchen. According to the log, The 200's Unit received the first breakfast cart at 7:20 AM and the second cart left the kitchen at 7:40 AM. Resident #34's breakfast tray was on the second cart and observations on 04/27/22 and 05/03/22 at 7:50 AM, confirmed that Resident #34 received the breakfast tray close to 8:00 AM. On 04/25/22 at 12:45 PM, the surveyor conducted another interview with the TNA. She indicated that Resident #34 informed her that she needed to use the bathroom when she collected the breakfast tray. The TNA stated that she was aware that he/she needed to use the STS Lift but the TNA could not locate the STS Lift. She stated she would have to use the hoyer Lift instead. When asked if there was any other approach that could have been used, she stated clearly, the fact that [he/she] was in bed, I could have offered the bedpan. The TNA indicated that she was assisting with breakfast trays and could not assist Resident #34 when he/she requested to use the bathroom. On 04/25/22 at 12:54 PM, during an interview with the LPN/UM regarding other approaches that could have been used to assist the resident with his/her needs, she indicated the following: The TNA could have borrowed a Sit and Stand Lift from another unit. Could have ask a Physical Therapy staff to assist with transfer. The LPN/UM told the surveyor that the TNA could have offered the bedpan and stated I don't know why she did not offer the bedpan. The LPN/UM stated that she was not made aware of the resident request to use the bathroom earlier. The LPN/UM stated that she had an open door policy, if she was aware she would assist or could have advise the TNA of other approaches that could have been used to assist Resident #34. The surveyor then asked the LPN/UM if delivering/collecting meals trays took precedence over toileting needs. The LPN/UM stated No, however, as a CNA we were trained that when we start passing breakfast tray we had to continue. It is not norm [normal] and we are not trained that way. The LPN/UM added that the TNA took an online course and was not sure if they trained for the State certification yet. They do get trained here. They get a sign in sheet. The surveyor asked the LPN/UM if Resident #34 had prior incidents regarding delay in answering the call light or meeting his/her toileting needs and she stated, No. On 04/26/22 at 10:30 AM, the surveyor conducted a review of Resident #34's electronic clinical record. A review of the Progress Notes from 11/21 to present revealed the following entries: 11/21/21 at 14:31 [2:31 PM] Behavior Note, Note Text: Resident continues on med [medication] changed for dc' d [discontinued ] Buspar. No ill effect noted. Fair appetite. Compliant with meds. CNA came to resident's room this morning for care and since she's a new one, resident stated, I don't want somebody to do me that's new. Another CNA was in the room and stated that she's gonna [going ] to help the other staff. Resident refused and stated that the other aid is doing another resident's flower. This writer explained to the resident that we will try to get somebody to help her. In the meantime, lunch tray came in and resident agreed to wait after lunch. When this writer went to the room after lunch, resident stated that [he/she] called the police and they are coming. Supervisor made aware and came to the unit and talked to the resident. Resident stated [he/she] called the police because [he/she] is wet. Care rendered to resident this time with the supervisor and this writer helping. 12/8/21 at 17:09 [5:09 PM], Health Status Note, Note Text: Resident propelled self to nurses station and informed this writer that the CNAs were not being mean or saying thing to [him/her] that are negative but that they are being breezy to [him/her]. Writer asked [him/her] what that meant and [he/she] replied they are just not as talkative to me as they could be. When writer was re assuring resident that the CNAs were busy and that they did say hello to [him/her] when [he/she] came out of [his/her] room, resident then became angry, yelling and screaming at this writer let's talk about general. Resident then went to activities. At 3:10 PM resident came to this writer and stated I need to go to the bathroom. This writer informed resident that we will send a CNA to [him/her] as soon as we can. Resident was informed that [his/her] CNA was on a break and would be back in a few minutes. Resident then stated I can wait a few minutes. Resident waited about 10 minutes and began screaming for [his/her] aid. Writer informed [him/her] that [his/her] CNA had just come back from break and that she was getting her supplies to take resident to the bathroom. Resident then screamed I have been sitting here for 40 minutes. Writer informed her of the time and that it was 10 minutes. At that time resident stopped yelling and CNA assisted resident into the bathroom. 12/13/21 at 14:59 [2:59PM], Behavior Note, Note Text: Resident continues on prednisone, last dose given, 10 (milligram) mg. Respirations even and unlabored. No cough or shortness of breath noted. No wheezing noted. Increased anxiety noted after lunch, Wanted to be toileted Immediately upon returning from MDR. Resident was made aware aware that the CNAs were toileting other residents and will assist [him/her] when care was completed, that [he/she] should go to [his/her] room to be toileted. Resident #34 began to raise [his/her] voice and did not want to wait. 2 CNAs approached Resident #34 with the STS machine for transfers and took [him/her] to [his/her] room to be toileted. No further episodes noted. The surveyor could not locate the incident that occurred in the presence of the surveyor on 04/25/22 in the Electronic Progress Notes. On 04/27/22 at 12:15 PM, after surveyor inquiry to the DON, the DON provided the surveyor a grievance form dated 04/25/22. The form revealed that the LPN/UM reported that Resident #34 was upset about waiting to be toileted and get care. On 05/03/22 at 12:53 PM, the administrator provided an individual Education Record for the TNA who was assigned to Resident #34 which addressed Residents care and preferences. On 04/25/22 at 2:45 PM, the surveyor reviewed Resident #34's plan of care. There was no care plan in place regarding a toileting program, or any approaches that could assist the direct care staff to better meet Resident #34's toileting needs. On 04/29/22 at 8:59 AM, the surveyor reviewed Resident #34's [NAME]. After surveyor inquiry interventions to toilet Resident prior to breakfast was added on 04/27/22. 2. On 04/22/22 at 7:43 AM, the surveyor observed Resident #62 in bed. Resident #62 reported that he/she had a horrible night, and stated I dreamed all night. On 04/25/22 at 10:15 AM, the surveyor observed Resident #62 in activity holding a doll. During the tour on 04/20/22 at 10:30 AM, the surveyor observed Resident #62 in bed. The bed was in a low position and a tab alarm was noted on the chair. A record review of Resident #62 clinical record was conducted on 04/22/22 which revealed the following: According to the admission Face Sheet, Resident #62 was admitted to the facility with diagnoses which included but not limited to unspecified dementia without behavioral disturbances, anxiety disorder, and low back pain. 02/19/22 at 19:41 [7:41 PM], a Behavior Note revealed: Resident (referring to Resident #62) noted to self propel in w/c [wheelchair] in and out of other resident rooms easy to redirect safety alarm in place. Another entry dated 03/04/22 at 19:50 [7:50 PM], indicated the following: Resident #62 is on OT [Occupational Therapy] and received responsive and noted propelling self to and from the unit. Resident #62 is alert with confusion. Was redirected several times resident wheeled [him/herself] at the front lobby looking for [his/her] room. Resident requires x 1 assist with care and x 1 with transfers. Resident is able to feed self with set-up help . At this time resident is in bed with eyes close. Bed alarm in place. Will continue to monitor. On 03/05/22 at 18:56 [6:56 PM], Behavior Note: Note Text: Resident wandering in wheelchair throughout unit since beginning of shift. Resident propelled self down 40 hallway pushed on exit door alarm sounded. Able to redirect without difficulty. Staff assist to bed. On 04/01/22 at 18:19 [6:19 PM], Behavior Note: Note Text: Resident was wandering around on and off the unit. Also found in one of other resident bathroom using the toilet, alarm going off. Resident is confused and required constant redirecting. At this time resident is being monitored. Will continue to monitor. On 04/04/22 at 16:41 [4:16 PM], Note Text: Observed this resident wandering, found pt [Patient ], in another room using someone bathroom. Toileting [his/herself]. Redirection given. Shower given . No apparent distress noted. will monitor . A review of Resident #62's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/22, indicated some moderate cognitive deficit. Resident #62 scored 10/15 on the Brief Interview for Mental Status (BIMS) which indicated a moderately impaired cognition. A review of Resident #62's comprehensive care plan initiated 11/24/21 with no revision date, documented there was no care plan of individualized interventions for the wandering behavior. There was no documentation regarding assessments and the facility's rationale for not proceeding with care planning for the documented wandering behavior. A review of Resident #62's admission MDS with an ARD of 11/30/21, Section V. CAA (Care Area Assessment) Summary, documented cognition loss/dementia, mood and behavior, psychotropic meds (medications) were triggered in the CAA and the interdisciplinary team (IDT) indicated a care plan for those areas was developed. On 04/26/22 at 9:13 AM, during an interview with the surveyor, the LPN/UM regarding indicated that she was not aware of any behaviors for Resident #62 exhibited. On 05/03/22 at 9:56 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #62. The CNA confirmed the resident wandered. The CNA added that Resident #62 wandered at times but was easily redirected. On 05/03/22 at 1:03 PM, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) was made aware of the above concerns. The DON stated that she was not aware of any wandering behavior. The surveyor referred to the nursing entries in the resident's medical record, and the DON stated that a care plan should have been in place to address the wandering behavior. On 05/04/22 at 10:32 AM, the DON provided a care plan for the wandering behavior developed on 05/03/22, after surveyor inquiry, with directives for the direct care staff to follow. The facility policy entitled, Care Planning updated 10/21 provided by the LNHA on 05/03/22 at 11:37 AM, included but was not limited to the policy statement, Our facility's Care Planning/ Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy was not being followed. NJAC:8:39-11.2 (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and review of facility documentation, it was determined that the facility failed to: 1.) immediately conduct contact tracing to identify residents and staff who had close contact with a COVID-19 positive staff member, 2.) conduct contact tracing to identify residents and staff who had close contact with a symptomatic COVID-19 positive resident, 3.) ensure an unvaccinated symptomatic Certified Nurses Aide (CNA) #1 notified a supervisor of symptoms prior to her shift on 04/08/22, when she proceeded to deliver direct care for nine of 27 residents on the Dementia unit, and assisted with care for other residents, 4.) ensure that unvaccinated staff, CNA #1 was tested prior to the start of their shift per facility policy, and 5.) follow the Centers for Disease Control and Prevention (CDC), Federal, State, and County guidance to prevent exposure and mitigate the spread of COVID-19, a deadly virus. This deficient practice was identified on 2 of 3 resident units (Dementia and Subacute) and was evidenced by the following: Reference F 886L 1.) On 04/20/22 at 9:24 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) had informed the survey team that the facility was currently experiencing an outbreak of COVID-19. The survey team was informed there were six positive COVID-19 cases, four cases on the Dementia unit and two cases on the Subacute unit. On 04/20/22 at 3:00 PM, the DON provided the survey team with the facility line listing which included nine names. The first name listed was a staff CNA #1, assigned to the Dementia unit. The line listing indicated CNA #1 had a TMAX (temperature) of 101.0 degrees Fahrenheit, symptoms that included congestion and fatigue, the symptom onset was 04/08/22, and the COVID-19 antigen (a rapid COVID-19 test) was collected on 04/08/22, with a Positive result. The line listing further revealed five residents who resided on the Dementia unit, and two residents who resided on the Subacute unit as all having tested COVID-19 positive. The line listing revealed the following: One staff member on the Dementia unit tested 04/08/22, with positive results. Resident #56, on the Dementia unit tested 04/10/22, with positive results. Resident #16, on the Dementia unit tested 04/12/22, with positive results. Resident, unsampled, on the Dementia unit tested 04/17/22, with positive results. Resident #78, on the Dementia unit tested 04/18/22, with positive results. Resident, #27, on the Dementia unit tested 04/18/22, with positive results. Resident #260 on the Subacute unit tested 04/18/22, with positive results. Resident, unsampled, on the Subacute unit tested 04/19/22, with positive results. On 04/21/22 at 9:30 AM, the DON provided the surveyor with nine contact tracing documents associated with the facility outbreak. A review of the contact tracing documents revealed there were no staff members identified and listed as exposed to an already identified COVID-19 + (positive) employee or resident. There was a blank contact tracing document provided for Resident #56 who resided on the Dementia unit who had tested positive on 04/10/22, per the facility line listing. The contact tracing document indicated the Date of Exposure was 04/11/22, per the facility, with a notation that Resident Sits by [him/herself] in a Private Room with no staff or residents listed as being exposed. 2.) On 04/21/22 at 11:52 AM, the surveyors interviewed the DON who stated that Resident #56 had been symptomatic, that he/she had no contacts, that he/she was in a private room, and the facility did not conduct contact tracing. On 04/26/22 at 2:16 PM, the surveyors interviewed the DON who stated that Resident #56 required staff assistance. The DON stated that [NAME] who had provided care for Resident #56 was tested for COVID-19. The surveyor observed Resident #56 in the common areas on the following date/times: On 04/21/22 at 12:46 PM, the surveyor observed Resident #56 unmasked and was singing in the Dementia unit activity area with other residents while in close proximity, less than 6 feet. On 04/25/22 at 9:51 AM, the surveyor observed Resident #56 unmasked and singing in the Dementia unit activity area with other residents in close proximity, less than 6 feet. On 04/27/22 at 8:37 AM, the surveyor observed Resident #56 in a chair on the Dementia unit by the nurse's station. Resident #56 was not wearing a mask and was within 6 feet of an activity aide who was feeding another resident. On 04/28/22 at 8:29 AM, the surveyor observed Resident #56 on the Dementia unit by the nurse's station, without a mask and was within 6 feet of two other residents. On 04/29/22 at 7:46 AM, the surveyor observed an activity aide transporting Resident #56 via wheelchair into a common area on the Dementia unit. Resident #56 had been seated within 6 feet of two other residents. In total, the facility provided nine contact tracing documents that included two staff and seven residents. The contact tracing documents provided by the facility revealed that the facility failed to completely document the staff and residents who may have been identified as a close contact, and as exposed to a COVID-19 positive staff and resident. On 04/25/22 at 1:53 PM, the surveyor interviewed the DON regarding what the process would be to identify close contacts, including residents and staff, for COVID-19 exposure. The DON stated that the process to identify residents exposed to a positive staff member would be to review the staff assignment for residents the staff had provided care for. The DON further stated that the process to identify staff exposed to a positive resident would be to review the resident's staff assigned to provide care. The DON further stated that the facility would also rely on the screening process upon entry to help monitor staff, and that the unvaccinated staff would be tested for COVID-19 twice weekly. 3.) On 04/26/22 at 9:31 AM, during an interview with two surveyors, CNA #1 who had tested positive for COVID-19 on 04/08/22, stated she had felt ill about 5:00 AM on 04/08/22. CNA #1 stated she was not sure what her temperature read because she did not take her temperature, but she knew she had a fever because she was warm. CNA #1 stated she took Tylenol prior to coming to work and that she had told the receptionist at the front desk that she didn't feel well. CNA #1 further stated that 04/08/22 was her day to be administered the COVID-19 test, and that she was tested about 3:00 PM after the end of her shift. CNA #1 stated she had not been vaccinated for COVID-19. On 04/26/22 at 9:37 AM, during an interview with two surveyors, the Registered Nurse Unit Manager (RN UM) on the Dementia unit stated she had not worked on 04/08/22. The RN UM stated if a staff member did not feel well, they must report it to the front desk, be swabbed (administered a rapid COVID-19 test) and have their temperature taken again. The RN UM further stated if an employee felt sick or the employee knew they weren't OK, the employee should tell us (facility). The RN UM stated if an employee tested positive for COVID-19, she inform the DON and Assistant Director of Nursing (ADON). The RN UM also stated if an employee took Tylenol prior to their shift, the employee probably would not register as having a temperature upon screening. On 04/26/22 at 9:53 AM, during an interview with two surveyors, the front desk Receptionist was asked about to explain the screening process. The Receptionist stated she had worked on 04/08/22. She stated she was educated on the process regarding if a staff member went to check in on the electronic kiosk used for screening, and then mentioned they were sick prior to the start of their shift, she would not let the staff member pass the lobby and she would immediately contact the supervisor. The receptionist further stated that no staff had reported to her they felt sick on 04/08/22. On 04/26/22 at 10:35 AM, during an interview with the survey team, CNA #1 stated she had been a CNA since 2007 and had worked part time at the facility for 11 years. CNA #1 stated she had been educated on the signs and symptoms of COVID-19 such as a fever, no taste, and no smell. CNA #1 further stated she was educated and knew to inform the supervisor before entering the facility if she had any symptoms. CNA #1 stated that on 04/08/22, she woke up, did not feel well, took Tylenol, went back to sleep, and felt fine. She stated she then reported to work. CNA #1 stated her duties included resident care, assisting (other staff) with two person (resident) transfers, and that she would assist residents with eating. CNA #1 further stated that 04/08/22 was her regularly scheduled day to be COVID-19 tested, and that the ADON RN Infection Preventionist (ADON RN IP) was the one who tested her at the end of her shift. CNA #1 stated she informed the ADON RN IP that she was not feeling well that morning and felt ok now. CNA #1 stated nobody inquired to her regarding any questions about her day on 04/08/22, or who she had contact with during her shift at any time, after she had tested positive for COVID-19. On 04/26/22 at 12:55 PM, during an interview with the surveyors, the ADON RN IP and DON were asked about contact tracing. The DON replied that a review would be completed to find out who any identified close contacts would be, and that would be completed as a team with the unit managers. The DON stated then interviews would be completed with the staff and the residents. The DON continued to state that if the COVID-19 positive person was a staff member, that they would find out when the staff member had worked last, ask for their assignment, and also inquire if they helped on another assignment. She stated that information would determine who would be need to be tested for COVID-19 and on contact tracing. The DON added that the facility would use the CDC algorithm related to COVID-19 exposure. On 04/26/22 at 1:47 PM, during a follow up interview with the surveyors, the DON and ADON RN IP presented their copy of QSO-20-38-NH revised 03/10/22 to review. The DON stated the facility referred to and used that directive, and that it was important to identify close contacts quickly and to test for COVID-19 immediately. The DON stated she was aware CNA #1 was sick on 04/08/22 but could not explain why the identified close contacts were not tested until 04/11/22 (three days later), and not on 04/08/22. The DON stated she did not identify, or test staff because she was not aware if CNA #1 had been with any staff for 15 minutes. The DON stated she interviewed the RN UM and other aides on the floor (Dementia unit) and that she did not document the conversations with staff. The ADON RN IP stated that when she administered the COVID-19 rapid test to CNA #1 at the end of her shift, CNA #1 informed her at that time that she wasn't feeling well earlier in the day. The ADON RN IP next stated she informed the DON of CNA #1's positive COVID-19 result, and informed CNA #1 not to return back to work. The DON stated that on Monday 04/11/22, CNA #1's assignment was reviewed as a team, all staff and family were alerted of a positive COVID-19 test result on 04/08/22, and residents were routinely monitored for signs and symptoms of COVID-19 as normal on each shift. The DON stated that she could not answer if testing should have been done immediately because she had utilized a different directive to complete testing at 24 hours. The DON could not speak to why testing was not completed at 24 hours either. 4.) On 04/27/22 at 9:14 AM, the surveyor interviewed the ADON RN IP, in the presence of the survey team, regarding the facility testing prior to the outbreak of 04/08/22. The ADON RN IP stated the facility was testing un-vaccinated employees twice weekly and the employees would be swabbed prior to the start of their shift using a rapid test. The ADON RN IP stated that if she was not there to do the swabbing, then another nurse would test the unvaccinated employees prior to their shift. The ADON RN IP stated the importance of testing prior to the shift was because the employee may not have been symptomatic, may have COVID-19, and it would prevent the spread of the virus. The ADON RN IP stated that if a staff member tested positive prior to their shift, she would send the employee home. The ADON RN IP stated the unvaccinated employees knew that they needed to contact the supervisor to be tested prior to the start of their shift. The surveyor inquired as to how the 04/08/22 outbreak started, and the ADON RN IP stated it started with the unvaccinated employee who tested COVID-19 positive. The ADON RN IP further stated that CNA #1 was running late on 04/08/22, that CNA #1 wanted to start her assignment and that was the reason she (CNA #1) was not tested prior to the start of her shift. The surveyor inquired as to what should have been done after CNA #1 tested COVID-19 positive. The ADON RN IP stated that when an employee tested positive for COVID-19, we should start testing the residents that he/she had close contact with. She further stated I notified the DON that CNA #1 tested positive for COVID-19. The ADON RN IP stated testing should be completed immediately and was regardless of the vaccination status of the residents. The ADON RN IP stated the exposed employees were not tested immediately. On 04/27/22 at 9:57 AM, the surveyors interviewed the ADON RN IP who stated that when an employee was due for testing, they were supposed to report before the shift started and that the employees knew to do that. The ADON RN IP stated CNA #1 had been running late that day (04/08/22) so CNA #1 came in and started working. The ADON RN IP further stated there was no documented disciplinary action with CNA #1. CNA #1 left at the end of her shift that day after. On 04/29/22 at 10:23 AM, during an interview with the surveyors, the DON and ADON RN IP informed the survey team they had completed recent contact tracing. The DON stated when someone tested COVID-19 positive, the facility would look back 48 hours prior to identify residents and staff on the unit who may have had a close contact exposure. The DON acknowledged that no doctors or therapist were listed on the original contact tracing documents, and stated they should have been. The DON stated contact tracing should begin immediately, and completed within 24 hours. The DON further stated the supervisors would be responsible to begin the contact tracing, when either she or the ADON RN IP were not at the facility. The DON stated the supervisors were educated, however, she was not sure to what extent of the process they were aware of. On 04/29/22 at 10:34 AM, the DON further stated a date completed or started was not required on the contact tracing documents because (I) just know I (DON) did the contact tracing. The DON also revealed that since the facility had been following a prior regulation that referred to source control, staff including doctors and therapists were not included in the contact tracing. On 04/29/22 at 10:41 AM, during an interview with the surveyors, the DON stated the facility was on day 28 of an outbreak from January 2022 and she was unaware that the outbreak of 04/08/22 should be considered a new outbreak. The DON acknowledged she had been in contact with the local health department for guidance, and had been instructed to reference the new directive. The DON stated that since she had already started the contact tracing the prior way, she decided to keep following the prior directive. 5.) On 04/26/22 at 1:26 PM, the DON and IP provided the surveyor with the Executive Directive No. 21-012, dated November 24, 2021, The New Jersey Department of Health (NJDOH) Guidance for COVID-19 Diagnosed and/or Exposed Healthcare Personnel, dated February 17, 2022, and Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities, dated February 25, 2022. At that time, the surveyor inquired to the DON regarding using the QSO-20-38-NH guidance from CMS, that was referenced in the DOH email. The DON stated the facility used what they had and she stated she was not sure of the CMS QSO-20-38-NH, Revised 03/10/22. On 04/28/22 at 12:34 PM, the surveyor conducted a telephone interview with the Public Health Epidemiologist for the county the facility resided in. The surveyor inquired to the Epidemiologist regarding what the facility guidance should the facility followed for contact tracing and testing regarding the 04/08/22 outbreak. The surveyor referenced the email between the epidemiologist and the facility dated 04/14/22. The epidemiologist stated that the QSO 20-38-NH guidance was what was referenced in the email and that should have been followed by the facility. The epidemiologist stated the facility should have identified using a broad based or close contact method, and the facility was responsible to complete COVID-19 testing immediately. The email also provided references for updates and resources with the link to CDC Releases Emergency Guidance for Healthcare Facilities to Prepare for Potential Omicron (a variant of COVID-19) surge. Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, Revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. A review of the facility provided, Policy and Procedure COVID-19 Pandemic Case Investigation and Contact Tracing, updated 3/2022, included but was not limited to: Objective - case investigation and contact tracing, by local and state health department, is a key strategy for preventing further spread of COVID-19. 3. Contact tracing Procedures - those who were exposed such as staff and residents who are in close contact 48 hours prior will be identified as close contacts and will be monitored closely. Contact tracing is generally recommended for anyone (e.g. HCP, patient, visitor) who had prolonged close contact with the COVID-19 case. A review of the facility provided, Policy for Emergent Infectious Disease (COVID-19) updated 03/01/22, included but was not limited to: Assumption - the local, state, and federal health authorities will be the source of the latest information and most up to date guidance on prevention, case definition, surveillance, treatment, and skilled nursing center response related to a specific disease threat. This document contains recommendations .Modifications should be made based upon the regulatory requirements. Testing of Residents 1. If testing capacity allows, facility-wide testing of all residents should be considered in facilities with suspected or confirmed cases of COVID-19. 3. If testing capacity is not sufficient for facility-wide testing, perform testing on units with symptomatic residents should be prioritized. Testing of nursing home HCP (staff) - 1. If testing capacity allows, all HCP should be considered in facilities with suspected or confirmed cases of COVID-19. Early experience suggests that, despite HCP symptom screening, when COVID-19 cases are identified in a nursing home, there are often HCP with asymptomatic SARS-CoV-2 infection present as well. Testing related to (+) COVID-19 exposure and/or symptoms associated with SARS-CoV-2 1. Contact tracing approach - identifies all resident close contacts and staff high-risk exposures. All individuals with close contact and/or high-risk exposure should be tested. If testing reveals additional cases, contact tracing will continue to be performed. Testing of Residents and Staff as follows: 4. Routing testing: all staff testing must be completed prior to entering the facility and units to decrease exposure to the residents and staff. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 03/10/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed -that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing - that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. A review of the Policies and Practices- Infection Control Revised/Reviewed: 1/2019 revealed: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and mange transmission of diseases and infections; 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infection in the facility, b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public, 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed . A review of the Infection Prevention and Control Program Reviewed 3/2021 revealed: Policy Statement: 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program, 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety, 1. Coordination and Oversight, a. the infection prevention and control program is coordinated and overseen by and infection prevention specialist (infection preventionist), 3. Surveillance, a. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications, 6. Outbreak Management, a. Outbreak Management, Outbreak management is a process that consists of: 1. determining the presence of an outbreak; 2. determining the presence of an outbreak, 3. preventing the spread to other residents, 4. documenting information about the outbreak, 5. reporting the information to appropriate public health authorities, 6. educating the staff and the public, 7. monitoring for recurrences, 8. reviewing the care after the outbreak has subsided; and recommending new or revised policies to handle similar events in the future, 9. Monitoring Employee Health and Safety, a. The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors, and volunteers, including: 1. situations when these individuals should report their infections or avoid the facility (for example, the draining skin wounds, active respiratory infections with considerable coughing and sneezing, or frequent diarrhea stools) . A review of the undated Job Description: Infection Control Preventionist revealed: Broad Function: The infection preventionist is responsible for the facility infection prevention and control program (IPCP), which is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. CMS definition: Infection preventionist: term used for the person (s) designated by the facility to be responsible for the infection prevention and control program .Management of Nursing Department: Oversight of the IPCP, which included, at a minimum, the following elements, A system from preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangements based upon the facility assessment .and following accepted national standards, Establish a facility-wide system for the prevention, identification, investigation, and control of infections of residents, staff, and visitors, including surveillance designed to identify possible communicable diseases or infections before they spres, Conduct outbreak investigations, Maintain current knowledge of federal, state, and local regulations and ensure that the facility leaders are informed of appropriate issues, understand and comply with infection, control . A review of the Certified Nursing Assistant job description revealed the following: Job Summary, The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine.; C. Carry out assignments for resident care including (but not limited to): a. Bathing, b. Dressing, c. Grooming, d. Shaving, e. Feeding, f. Restorative nursing procedures, g. retraining; M. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty; Z. Follow established fire, disaster, safety, infection control, and evacuation policies and procedures . NJAC 8:39-19.2(a); 19.4(a); 19.4(d)(f)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other pertinent facility document, it was determined that the facility failed to ensure that medication was administered in accordance with the physician's order. This deficient practice was identified for 1 of 29 residents reviewed for medication (Resident #119), and was evidenced by the following: During the initial tour of the [NAME] Unit on 12/03/19 from 10:00 AM to 11:30 AM, the surveyor observed Resident #119 awake and seated in a chair in his/her room. When interviewed, the resident stated that he/she was watching television. On 12/05/19 at 10:30 AM, the surveyor observed Resident #119 again seated in the chair. When interviewed by the surveyor, the resident stated that a few weeks ago, he/she did not receive his/her Pradaxa (medication used to treat irregular heart rhythm) for a few days because the medication was unavailable. Review of the admission Record revealed that Resident #119 was admitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar), atrial fibrillation (irregular heart rhythm) and heart failure. Review of an Order Summary Report, with active orders as of 12/09/19, revealed a physician's order, dated 08/15/17, for Pradaxa Capsule 75 milligram (mg) to be given twice daily. According to the order, the medication was to be administered for the treatment of Atrial Fibrillation. Review of a Progress Note (PN), dated 11/21/19 at 11:37 AM, revealed that the Pradaxa was not available for administration to the resident and that staff were waiting for the medication to be delivered from the pharmacy. Review of subsequent PNs, from 11/22/19 through 11/25/19, revealed that the pharmacy was not notified again and that the Pradaxa was not administered to the resident from 11/21/19 to 11/25/19. Further review of the PNs revealed that there was no documentation to show that Resident #119's physician was notified that the medication was not available to the resident. Review of the corresponding Medication Administration Record (MAR), dated November 2019, revealed that the Pradaxa was scheduled for admisinistration at 09:00 AM and 05:00 PM daily. The documentation found on the MAR reflected that Resident #119 did not receive the medication on the following dates: 11/20/19; 11/21/19; 11/23/19; 11/24/19; and 11/25/19, which reflected a total of 10 missed doses. On 12/05/19 at 10:45 AM, the surveyor interviewed the Licensed Practical Nursing (LPN #1). LPN #1 stated that she called the pharmacy on 11/22/19 regarding Resident #119's missing medication. LPN #1 stated that she did not realize the medication was missing until she went to administer the medication to the resident and that she was not informed of the missing medication during shift report. LPN #1 confirmed that she did not notify the resident's physician, the Unit Manager nor the Supervisor on duty about the missing medication. On 12/05/19 at 11:00 AM, the surveyor interviewed LPN #2 who stated that she called the pharmacy to inquire about when the medication was to be delivered to the facility. LPN #2 also stated that she did not inform the Unit Manager nor the Supervisor about the missing medication and that she could not remember if she notified the doctor. On 12/05/19 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that she was not made aware of Resident #119's missing medication until surveyor inquiry. LPN/UM #1 stated that the nurses should have informed her about the missing medication. LPN/UM #1 also stated that it was the facility's policy that nurses notify the doctor after a resident missed two doses of a medication. LPN/UM #1 stated that nurses should have notified Resident #119's physician or Nurse Practitioner (NP). On 12/05/19 at 11:25 AM, the surveyor interviewed the resident's Nurse Practioner (NP). The NP stated that he was responsible for Resident #119 and that the nurses had not notified him about the missing Pradaxa medication. The NP stated that he was in the building every day and that nurses could have notified him at any time. The NP stated that if he had been made aware, he would have assessed the resident and maybe switched the medication or ordered the same medication from a local pharmacy. During an interview with the Director of Nursing (DON) on 12/10/19 at 10:00 AM, the DON stated that the nurses should have notified the NP and that it was unacceptable to not notify the doctor or the NP. The surveyor reviewed the facility's medication administration policy in the presence of the DON. The policy did not contain information regarding what nurses should do when medications were not available for a resident. NJAC: 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that the resident's environment was as free from hazards as possible by failing to ensure that medical equipment was plugged directly into an electrical receptacle without the use of power strips or adapters. This deficient practice was identified for Resident # 79, 1 of 29 residents reviewed and was evidenced by the following: During a tour of the Applewood Unit on 12/03/19 at 10:31 AM, the surveyor observed the Resident #76's room which revealed the bed and air mattress were plugged into a power strip. On 12/03/19 at 12:27 PM, the surveyor observed Resident #76 in the unit's dining room eating lunch. The resident was seated in a high back wheelchair, wearing nasal oxygen tubing that was connected to an oxygen concentrator set at 2 liters/min. On 12/03/19 at 2:13 PM, the surveyor showed the Licensed Practical Nurse Unit Manager (LPN/UM) the power strip and she stated she did not know the policy of the use of power strips and she would have to get the Maintenance Director. On 12/03/19 at 2:30 PM, the surveyor showed the Maintenance Director the power strip and he stated that the bed and air mattress were not supposed to be plugged into the power strip. He then unplugged the bed and the mattress from the power strip. He stated that the facility does not supply power strips and that no medical equipment should be plugged into a power strip. He also stated that the facility had an in-service about a month ago on the topic of power strips. The Maintenance Director stated he performed random room checks to ensure that the power strips are being used correctly. On 12/10/19 at 9:00 AM, the surveyor informed the Administrator of the finding. The Administrator stated that the facility did not have a policy for the use of power strips. The surveyor reviewed a document titled, In-service Education for General Housekeeping, dated 11/20/19, which indicated medical equipment such as the bed, oxygen concentrators and air mattresses could not be plugged into power strips and must be plugged directly into the wall. Further review revealed the LPN/UM signed the she had attended the in-service. NJAC 8:39-31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to identify and remove expired medication and medical supplies from the emergency cart (Crash cart). This deficient practice was identified in 1 of 2 emergency carts inspected and was evidenced by the following: On [DATE] at 11:21 AM, the surveyor inspected the Meadow Unit emergency cart, and observed two unopened tubes of blood glucose control solution (insta-glucose- used to resuscitate residents with extremely low blood sugar) with an expiration date of 09/2016. There was also one pack of vent suction items that expired on 10/2017. On [DATE] at 11:30 AM, the surveyor showed the expired items to the unit Licensed Practical Nurse (LPN #3) who inspected the items and confirmed that they were expired. LPN #3 collected the expired items and stated that she would give them to the Unit Manager to discard. Upon further interview, LPN #3 stated that the 11 PM-7 AM shift nurses were responsible for checking the crash cart and removing expired item. On [DATE] at 12:20 PM, the surveyor interviewed the DON regarding the maintenance of medications and medical supplies in the emergency cart. The DON stated that the night shift was responsible for checking the crash cart and removing expired items and that they did not have a policy regarding the maintenance of items in the emergency crash cart. NJAC 8:39-29.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of other pertinent facility documents, it was determined that the facility failed to ensure that residents' call lights sound was audible and was answered in a timely manner. This deficient practice was identified for 8 of 10 residents (Residents #9, #12, #38, #55, #62, #66, #105, and #130), who attended the group meeting and for 1 of 1 resident representative (Resident #19) interviewed and was evidenced by the following: On 12/05/19, the surveyor reviewed the Resident Council Meeting minutes for September 2019, October 2019 and November 2019. The 09/27/19 meeting minutes reflected that the facility was recruiting Certified Nursing Assistance to help in answering call lights and tending to the resident needs. On 12/05/19 at 10:30 AM, the surveyor conducted a group meeting with 10 alert and oriented residents who resided on the [NAME] Unit of the facility. When the residents were asked about staff response to their call bell, 7 of 10 residents (Residents #9, #12, #38, #55, #62, #66, and #130) stated that when they turned their call bells on, they usually waited greater than 30 minutes before they get staff assistance. Both Resident #9 and Resident #105 stated they have been left sitting on the toilet for up to 45 minutes waiting for assistance from staff. All 8 residents stated that they complained about the long call bell wait to the Licensed Practical Nurse/Unit Manager (LPN/UM #1) and that they also had complained during their monthly Resident Council Meetings and that nothing had been done about it. On 12/06/19 at 12:05 PM, while the surveyor was seated at the nurse desk on the [NAME] Unit, the surveyor observed Resident #19 as he/she was being wheeled by a family member from the dining room to the resident's room. On 12/06/19 from 12:10 PM to 12:40 PM, the surveyor observed Resident #19's room call light illuminated outside the door, which indicated the call light was on. As the surveyor was seated at the nurses' desk, the surveyor noticed that the call light sound was barely audible. The surveyor observed that the call light sound was coming from a call system speaker located behind the nurses' desk. Upon further investigation, the surveyor noted that the speaker was covered with a clear tape and that the volume button on the call bell speaker was positioned to low. On 12/06/19 at 12: 55 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) while Resident #19's call bell was on. When CNA #1 was asked if she could hear the call bell, CNA #1 answered that she was unable to hear the resident's call bells. CNA #1 stated that she was assigned to [NAME] Unit and had worked at the facility for about six month. CNA #1 added that the call bell system has always been low. CNA #1 also stated that she usually had to look up towards the ceiling for her to see that a resident's light was on. On 12/06/19 at 1:00 PM, the surveyor interviewed CNA #2 who stated that she had been working at the facility for about a year. CNA #2 stated that the call light system on the [NAME] Unit was not like the other units. CNA #2 stated that on the other units, the call light system was loud. When CNA #2 was asked if she could hear Resident #19's call light at the nurses' desk, CNA #2 answered, no. CNA #2 stated that she usually had to look at the panel on the wall or look down the hallways in order to see that a call light was on. On 12/06/19 at 1:15 PM, the surveyor asked for the Assistant Administrator (AA) to turn on the shower room's nurse call light. After turning on the shower room call light, both the AA and the surveyor went to the nurses' desk. When asked if she could hear the call bell from the desk, the AA stated she could barely hear the nurse call light. The surveyor then showed the AA the call bell speaker box which was covered with tape. The AA removed the tape from the speaker box and the sound became louder. The AA switched the volume from low to high which also increased the sound. The AA stated that the tape on the speaker decreased the sound and might have prevented staff from hearing the resident's call bell. The AA stated that she did not know who applied tape to the call bell speaker. On 12/06/19 at 1:20 PM, the surveyor interviewed Resident #19's family member. She stated that she usually turned the call bell on when the resident returned from lunch because it took very long for staff to answer the call lights. The family member stated that she usually turned the call light on ahead of time, so that by the time staff answered the light, Resident #19 was ready to use the bathroom. On 12/06/19 at 1:30 PM, during an interview with the LPN/UM #1, she stated that she had worked at the facility for five years and that the call bell sound had been the same. LPN/UM #1 stated she did not know who placed the tape over the speaker. On 12/10/19 at 9:30 AM, the Director of Nursing (DON) acknowledged that some residents had complained during their group meeting regarding long waits for call lights response. The DON stated that she did random nurse call light audits and that there had not been any problems. NJAC 8:39-31.8(C)9