COMPLAINT # NJ 172662 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to administer medications within scheduled parameters on various shifts in accordance with professional standards of practice. This deficient practice was identified for 1 of 34 residents reviewed for professional standards of practice (Resident #269). Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: On 5/28/25 at 11:30 AM the surveyor reviewed the closed medical record for Resident #269 who had been discharged from the facility. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included cellulitis (a bacterial infection of the skin) morbid obesity, rheumatoid arthritis, generalized anxiety disorder, and major depressive disorder. A review of the March 2024 Medication Administration Record (MAR) included a physician's order (PO) to be administered for the following: oxycodone hcl oral tablet 30 mg (milligram); give one tablet by mouth every 4 hours for moderate to severe pain, dated 1/17/24. Doses were scheduled to be given at 4:00 AM, 8:00 AM, 12:00 PM (noon), 4:00 PM, 8:00 PM, and 12:00 AM (midnight). A review of the corresponding March 2024 Medication Audit Report reflected the following: On 3/1/24, the 4:00 PM dose was administered at 5:26 PM; the 8:00 PM dose was administered at 9:18 PM. On 3/3/24, the 4:00 AM dose was administered at 5:06 AM; the 4:00 PM dose was administered at 6:46 PM On 3/5/24, the 8:00 PM dose was administered at 9:12 PM. On 3/7/24, the 8:00 PM dose was administered at 9:34 PM; the 8:00 PM dose was administered at 9:18 PM. On 3/8/24, the 4:00 AM dose was administered at 5:20 AM; the 8:00 PM dose was administered at 10:25 PM. On 3/10/24, the 4:00 AM dose was administered at 5:44 AM; the 12:00 AM dose was administered at 5:35 AM. On 3/11/24, the 4:00 AM dose was administered at 5:19 AM; the 8:00 PM dose was administered at 9:20 PM. On 3/8/24, the 4:00 AM dose was administered at 5:20 AM; the 8:00 PM dose was administered at 10:25 PM. On 3/12/24, the 4:00 PM dose was administered at 5:04 PM. On 3/13/24, the 12:00 AM dose was administered at 1:05 AM. On 3/14/24, the 4:00 AM dose was administered at 5:47 AM. On 3/16/24, the 8:00 AM dose was administered at 9:44 AM; the 12:00 PM dose was administered at 1:05 PM. On 3/17/24, the 12:00 PM dose was administered at 2:41 PM; the 4:00 PM dose was administered at 5:33 PM. On 3/21/24, the 12:00 AM dose was administered at 1:06 AM; the 12:00 PM dose was administered at 1:09 PM; the 8:00 PM dose was administered at 9:04 PM. On 3/23/24, the 12:00 AM dose was administered at 1:08 AM; the 8:00 AM dose was administered at 3:27 PM; the 12:00 PM dose was administered at 3:28 PM; the 8:00 PM dose was administered at 9:03 PM. On 3/24/24, the 12:00 AM dose was administered at 1:39 AM; the 8:00 AM dose was administered at 9:52 AM; the 12:00 PM dose was administered at 4:31 PM. On 3/25/24, the 4:00 PM dose was administered at 5:07 PM. On 3/26/24, the 8:00 AM dose was administered at 10:14 AM. On 3/28/24, the 12:00 AM dose was administered at 2:01 AM. On 3/29/24, the 4:00 AM dose was administered at 5:10 AM. On 6/2/25 at 1:05 PM, the surveyor team met with the two Regional Clinical Directors, the Regional Director of Operations and the facility Director of Nursing (DON). The DON stated nurses had one hour before and one hour after the time medications were scheduled to be administered before that medication would be considered given late. On 6/3/25 at 10:53 AM, the survey team again met with the facility administration. The DON and the Regional Clinical Director acknowledged there were multiple dates and times the oxycodone had been administered past the time of scheduled administration. A review of the facility's Medication Administration policy dated implemented 9/1/2024 included .administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . NJAC 8:39-27.1(a)

Based on observation, interview, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to 1.) contain nebulizer (a machine used to administer medication in the form of a mist inhaled into the lungs) delivery systems in protective coverings and 2.) ensure a nebulizer was stored appropriately to prevent the potential spread of infection in accordance with the Center for Disease Control (CDC) guidelines for 2 of 4 residents (Resident #99 and Resident #151) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/28/25 at 9:08 AM, Resident #99 was observed lying in bed and the nurse was present for morning medication administration. An oxygen (O2) concentrator (a medical device that separates nitrogen and oxygen from the air around you so you can breathe up to 95% pure oxygen) with oxygen tubing attached was observed at the side of the bed. The O2 concentrator was off on this observation. Resident #99 was not wearing oxygen via nasal cannula (n/c) (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) and tubing was not bagged. The surveyor was unable to determine if the O2 tubing was dated. On 5/30/25 at 12:49 PM, Resident #99 was observed lying in bed awake and alert. Resident #99 was happy that his/her room was changed. A nebulizer machine was observed on top of the bedside table and plugged into an electrical outlet. The nebulizer machine was not in use and the nebulizer mask was observed lying on top of the table and was exposed to contamination. Resident #99 told the surveyor when asked that he/she had not had a nebulizer treatment today and that he/she received them only at bedtime. Resident #99 confirmed that they last had a nebulizer treatment last night. According to the admission record Resident #99 was admitted to the facility with the following but not limited to diagnoses: Chronic obstructive pulmonary disease (COPD) (lung disease involving long-term poor airflow), major depressive disorder, muscle weakness, need for assistance with personal care, and anxiety disorder. A review of the comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 5/21/25 revealed that Resident #99 had a Brief Interview for Mental Status score of 13/15, indicating intact cognition. According to Section GG, Resident #99 could eat independently. Required supervision/touch assist with oral hygiene, toileting hygiene, upper body dressing, lower body dressing and personal hygiene. Required substantial/maximal assistance to shower/bathe self. Section I indicated that Resident #99 had an active diagnosis of COPD. According to Section O of the MDS, Resident #99 did not receive any respiratory treatments. According to the Order Summary Report with Active Orders As Of: 06/03/2025, Resident #99 had the following physician order: Budesonide Inhalation Suspension 0.5 mg inhale orally two times a day for cough rinse mouth with water after use. When each foil pack opened (sic) is good for 14 days. Store unused capsules in foil packet away from sunlight. Order Date: 06/12/2024. According to the 06/01/2025-06/30/2025 Medication Administration Record (MAR) Resident #99 received Budesonide Inhalation Suspension 0.5 mg/2ml (milligram/milliliter) (budesonide Inhalation) 0.5mg inhale on 06/01/2025 at 2100 (8 PM) and 0900 (9 AM) on 06/02/2025. According to Resident #99's comprehensive care plan, Resident #99 had the following care plan Focus: [resident name] is non-compliant with scheduled nebulizer treatments. The following was observed under Interventions: Nebulizer treatments as ordered by MD. Encourage [resident name] to comply. Date Initiated: 06/06/2024. On 06/02/2025 at 10:10 AM the surveyor observed Resident #99 lying in bed. The surveyor observed a nebulizer mask and tubing lying on top of the air conditioning/heater vent, which was observed to have dust in the vents and a shoe on top of it. The tubing and mask were not attached to a nebulizer machine and the tubing and mask were uncovered and exposed. The tubing and mask were not dated. In addition, the surveyor observed a nebulizer machine with mask and tubing connected on top of Resident #99's bedside table. The nebulizer was plugged in to an outlet but was not in use. The mask and tubing were on top of the bedside table and were uncovered and exposed. The mask and tubing had no dates. The surveyor conducted an interview with the Licensed Practical Nurse (LPN #1) assigned to Resident #99 on this observation. The surveyor asked LPN #1 what the facility practice was for storing nebulizer equipment when not in use. Upon observation of the nebulizer equipment LPN #1 told the surveyor that respiratory equipment should be bagged when not in use and tubing should be dated. LPN #1 removed the two (2) exposed nebulizer tubing/mask setups to the trash in the presence of the surveyor. On 06/02/2025 at 01:08 PM the surveyor conducted an interview with facility administration, which included two (2) Regional Clinical Directors, the facility Director of Nursing (DON) and the Regional Director of Operations. The surveyor asked what the facility policy was for respiratory equipment when not in use, specifically nebulizer equipment. The DON and RCD told the surveyor that nebulizer tubing and mask should be bagged when not in use and should be dated when changed weekly. On 06/03/2025 at 10:54 AM the survey team met with facility administration. The facility DON told the surveyor that it was important to bag respiratory equipment when not in use for infection control purposes. The surveyor reviewed the facility provided policy titled Nebulizer Therapy, date implemented: 9/1/2024. The following was revealed under the heading Care of the Equipment: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing every seventy-two hours pr per facility policy. 9. Periodically disinfect unit per manufacturer's recommendations. N.J.A.C. 8:39- 27.1 (a) 2.) On 5/27/25 at 10:22 AM, during the initial tour of the facility, Surveyor #2 observed Resident #151 in bed connected to an oxygen (O2) concentrator (a device used to deliver oxygen-enriched air to people who have difficulty breathing) via nasal cannula (NC) (a flexible tube with prongs that go inside the nostrils to deliver oxygen). The surveyor also observed a nebulizer machine on the floor plugged into an electrical outlet on the right side of the resident's bed. There was no bedside table on the resident's right side. The resident stated that the machine was used to clear his throat. On 5/28/25 at 8:44 AM, the resident was observed in bed receiving O2 via NC. The nebulizer machine was observed on the floor plugged to the electrical outlet on the right side of the resident's bed. On 5/29/25 at 9:21 AM, the surveyor observed the resident's nebulizer machine on the floor in the same area of the room. On 5/28/25 at 10:45 AM, a review of the hybrid (electronic and paper) medical record revealed the following: A review of the admission Record reflected the resident had diagnoses that included but not limited to malignant neoplasm (cancer) of unspecified part of lung and dependence on supplemental oxygen. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 3/11/25 reflected that the resident was cognitively intact and received continuous oxygen therapy. A review of the Order Summary Report (OSR) active as of 5/28/2025 revealed an order for albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083% (Albuterol Sulfate) 1 vial inhaled orally via nebulizer every 6 hours as needed for shortness of breath started on 9/5/24. The OSR also included an order for nebulizer tubing to be change weekly every Wednesday night shift and to label each component with date and initials every night shift started on 5/28/25. A review of the Medication Administration Record (MAR) for the month of January 2025 reflected the resident was last administered nebulization on 1/3/25. A review of the Treatment Administration Record (TAR) for the month of May 2025 reflected the nebulizer tubing was checked for labeling on 5/28/25, 5/29/2025, 5/30/2025, and 5/31/2025. A review of Resident #151's comprehensive care plan revealed a focus for altered respiratory status related to lung cancer and respiratory infection revised on 10/30/24. Interventions included the following: give medications as ordered by physician, monitor for signs and symptoms of respiratory distress and report to physician, and oxygen settings as per order. On 6/2/25 at 10:03 AM, the surveyor observed the resident's nebulizer machine on the floor plugged to the electrical outlet in the same area of the room. The surveyor showed Licensed Practical Nurse #2 (LPN #2) the nebulizer located on the floor. LPN #2 confirmed that it was a nebulizer and stated that it should not be on the floor. LPN #2 then placed the nebulizer on the dresser located at the foot of the resident's bed and stated that staff would clean the device. On 6/2/25 at 10:33 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that the nebulizer should not be on the floor and should be in a bag with the tubing and dated. The IP further stated that if the resident had behaviors, the staff had to do more frequent rounds to ensure the nebulizer machine was stored properly. On 6/2/25 at 1:14 PM, during an interview with the survey team, the Director of Nursing (DON) confirmed the concerns identified. A review of the facility provided policy titled Nebulizer Therapy date implemented on 9/1/2024 did not include proper storage of a nebulizer machine when not in use. NJAC 8:39-19.4 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the updated nurse staffing report daily. This deficient practice was identified on 5/27/25, and was evidenced by the following: On 5/27/25 at 9:15 AM, upon initial entrance to the facility, the surveyor observed the posted daily staffing in the lobby was dated 5/23/25. While the survey team was in the lobby awaiting the facility administration, the staffing coordinator (SC) entered the lobby and replaced the posted staffing sheet for the current day 5/27/25. At that time, the surveyor interviewed the SC who stated staffing should be posted and updated daily and should have been changed by the weekend nursing supervisors in her absence. She further acknowledged that the posting was four days old for the 5/23/25 staffing. On 6/2/25 at 11:37 AM, the surveyor re-interviewed the SC who stated that staffing should be updated and posted daily in the facility lobby to be visible by everyone. She stated that nursing supervisors should make updates if there are any changes to the expected staffing for their individual respective shifts. On 6/2/25 at 1:37 PM, the surveyor, in the presence of the survey team, the Regional Director of Operations (RDO) confirmed that posted staffing should be updated daily, but stated I don't know of any facility that updates it on the weekends. On 6/3/25 at 9:49 AM, the surveyor interviewed the Regional Clinical Director (RCD) who stated that a reasonable amount of time for posting the updated daily staffing would be within a few hours of the start of the day. On 6/3/25 at 10:51 AM, in the presence of the survey team, the RDO acknowledged that the daily staffing was not updated appropriately as observed by the surveyor upon initial entrance to the facility. A review of the facility's Nurse Staffing Posting Information policy with a revised date of 4/16/25 included but was not limited to: it is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time . the nurse staffing sheet will be posted on a daily basis and will contain the following information: a) facility name b) the current date c) facility's current resident census d) the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift . NJAC 8:39-41.2 (a)

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Complaint # NJ 151052 Based on observation, interview, and review of pertinent facility provided documentation, it was determined that the facility failed to provide meals that were at acceptable temperatures for 5 of 5 residents interviewed and one test tray and ensure palatable food for 6 of 6 residents interviewed. a) On 11/28/23 at 10:27 AM, the surveyor observed Resident #355 sitting at the bedside eating breakfast. When interviewed, Resident # 355 stated the food tastes like prison food. It is bland and has no taste. On 11/29/23 at 12:39 PM, the surveyor observed Resident #355 eating his lunch. Resident # 355 stated the pork chop was a little tough. b) On 11/30/23 at 10:30 AM, Surveyor #4 conducted a resident council meeting with five residents. During the resident council meeting, five of the five residents expressed concerns with the palatability and temperature of the food served at the facility. Examples provided included but were not limited to; the liquid eggs were being baked in a square pan and had no flavor. The resident council participants prefer real eggs. A concern was that when provided with tomato soup, the taste was like someone poured water or milk into spaghetti sauce and served that as tomato soup. The residents expressed the concern that the meals were not being delivered fast enough and were cold or lukewarm when they were finally able to eat. c) On 12/05/23 at 12:40 PM, the surveyor observed the meal cart brought to D wing. The meal trays were being distributed to the residents by the Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN). The survey requested the CNA to save the last tray to check temperatures of the food items. On 12/05/23 at 12:53 PM, the surveyor interviewed the Food Service Director (FSD) who stated the food should be palatable and it depends on the person. The FSD stated the hot food should be above 135 degrees Fahrenheit (F) and cold food should be below 41 degrees F. The surveyor and FSD proceeded to check the temperatures of the food items. The meal tray contained the main entrée that consisted of baked chicken thigh, roasted potatoes, and corn. The meal tray also had a chef salad that contained a hardboiled egg and a dessert cup of peaches. All food items on the tray were checked with a facility thermometer and a surveyor thermometer. The following temperatures were recorded with the facility thermometer. Baked chicken thigh 127 degrees F Roast potatoes 116 degrees F Corn 114 degrees F Chef Salad 46 degrees F Hardboiled Egg 52 degrees F Peaches 64 degrees F A review of the facility provided policy on Food Preparation revised on 9/2017, included but was not limited to; # 4 The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. NJAC 8:39-17.4 (a)(2)

Based on interview and document review, the facility failed to have the Director of Nursing (DON) present for one of four Quality Assurance and Performance Improvement (QAPI) meeting as evidenced by the following: On 12/12/23 at 12:20 PM, the surveyor reviewed the quarterly QAPI sign-in sheets for the last four quarterly QAPI meetings. The second quarter sign in sheet, dated 04/03/23, was missing the attendance signature of the Director of Nursing (DON). At that time, the DON stated she may have taken that day off but handed in her report for the meeting. A review of the Facility Assessment, dated 09/01/23, revealed that the QAPI committee included the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing. Infection Control Preventionist, MDS ( Minimum Data Set), dietary representatives, pharmacy, social service, activities, environmental services, rehab/restorative, human resources, safety and records. NJAC 8:39-23.1(3)

Complaint #NJ 152052, NJ 152420, NJ 153704 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 2 of 3 resident Wings (Wing A & D) and was evidenced by the following: Interviews and observations of Surveyor #2 were as follows: On 11/28/23 at 09:23 AM, upon entrance to the facility, the Director of Nursing (DON) stated that the facility had 3 wings which consisted of Wing A which was the Subacute Unit and had 50 beds, D Wing had 59 beds and E Wing had 50 beds. On 11/28/23 at 9:45 AM, an unsampled resident on D wing informed the surveyor the heat in his/her room had been broken for 4 days. The resident stated that they had been unable to sleep because of the cold. At that time, the Registered Nurse Unit Manager (RN UM) confirmed the head had not been working and that maintenance was made aware. On 11/28/23 at 10:00 AM, a maintenance worker confirmed that the heat had not been working, and he was not the maintenance director, and he did not work on the weekends. On 11/28/23 at 12:19 PM, Surveyor #2 interviewed the housekeeper (HK) for Unit A who stated that she was the only housekeeper for the unit with a census of 37 residents. The HK stated that she would go from room to room to clean but not in any specific order. She stated she would wait until the nurses have completed care in a room and then she would clean it. On 11/28/23 at 12:40 PM, while observing the lunch meal delivery, the surveyor interviewed two unsampled residents in room A5. The unsampled resident in the door bed of Room A5 stated they haven't cleaned our room yet. The unsampled resident near the window bed stated she (the HK) just came in an emptied our trash. I can't remember when our room and bathroom were last cleaned. They empty the trash, but they do not clean the rooms. On 11/29/23 at 11:31 AM, Surveyor #2 interviewed the unsampled resident in the door bed of Room A5 who stated that the HK did clean his/her room yesterday but there was still white debris under her bed. They did not clean under my bed. On 11/29/23 at 11:55 AM, Surveyor #2 observed yellow and black stains on the bottom tiles of the A wing shower. Interviews and Observations of Surveyor #1 were as follows: On 11/29/23 at 11:08 AM, Surveyor #1 observed in Room D9 that the heating /air conditioner (AC) unit had a paper towel wedged inside the unit. On 11/29/23 at 11:54 AM, Surveyor #1 observed that in Rooms D1, D25, and D29, there was peeling molding in the rooms and stained resident privacy curtains. Surveyor #1 observed debris on the floor in the bathroom of D1. The surveyor observed that in rooms D17, D22, and D27, the air conditioner covers were broken . On 11/29/23 at 11:35 AM, Surveyor #1 and Surveyor #4, in the presence of the Unit Manager (UM), went to Rooms D9, D25, and D29. The UM stated that she conducted daily rounds on the residents in their rooms, but was not aware of the conditions of the rooms. The surveyors and the UM observed the following: D29 door bed the wall was crumbling; outside of room D31 the thermostat case was missing; D26 the lower protective covering of the door was broken and peeling away; D9 the AC unit was disassembled in areas and the bed foot board was apart; and D1 resident room floor was visibly soiled. The UM stated that any maintenance requests would be put in the computer system and the Maintenance Director (MD) will then address the issues. The UM was unable to provide the surveyor with any computer maintenance requests for the month of November 2023. On 11/30/23 at 9:13 AM, Surveyor #1 interviewed the housekeeping Director (HD) who stated that he did not have enough staff to clean. He stated that he usually had three (3) housekeepers/porters for day shift, one for each unit (A, D, and E) and one porter for the 3-11 shift. The HD further stated that if the housekeeping staffing was bad, he would then cover for the housekeepers. Surveyor #1 had observed an unsampled resident's wheelchair with large amounts of food debris on the wheelchair. The HD stated that he had a cleaning schedule for the wheelchairs which was completed in November. The housekeepers were to clean seven wheelchairs per unit every day, but the HD stated that it had not been done. The HD further stated that the privacy curtains were to be cleaned during a deep cleaning of the resident rooms which consisted of one room per day. On 11/30/23 at 9:29 AM, the HD stated that he worked for a contracted agency, but the housekeeping staff were employed by the facility. He stated that he had discussed the staffing concerns with the contracted agency and the Licensed Nursing Home Administrator (LNHA). On 11/30/23 at 10:30 AM, Surveyor #4 conducted a resident council meeting with five current residents. Three of five residents expressed concerns that their rooms and the facility in general was not always kept clean. On 12/05/23 at 9:23 AM, Surveyor #2 interviewed the HK on A wing who stated that she was the only housekeeper on the unit and could not get to clean all the resident's rooms every day. The HK stated, I usually will do the worst rooms first. On 12/08/23 at 9:14 AM, Surveyor #2 interviewed the HD who stated that he was responsible for both the housekeeping and the laundry department. He stated that the porters were responsible for taking the trash and the linen out from the units and their focus was primarily on the non-resident areas such as the hallways, dining/day rooms, medication rooms and common areas. The expectations of the housekeepers were to clean every room every day which included removing the trash, sweeping the rooms, and sanitizing the rooms. He further stated that, When we are short staffed like we are today (one housekeeper only for day shift) I would get staff from other building, and I will then clean the rooms too. He stated that he would usually have a housekeeper for each wing (A, D and E) and at least 2 porters per day. I don't expect one housekeeper to be able to clean 60 rooms. We have been doing the best that we can. On 12/08/23 at 9:41 AM, Surveyor #2 interviewed the Infection preventionist (IP) who stated that housekeeping should clean the residents' rooms every day which included the bathrooms, toilet, sink, floor, and high touch areas such as doorknobs, overbed table, bedside table. The IP stated it was important for resident's rooms to be cleaned because this is their home and for infection control purposes. The IP stated she did not follow up to check that the rooms were cleaned and that she would rely on the HD to make sure all the rooms were cleaned. On 12/9/23 at 10:03 AM, the contracted Account Manager (AM) for housekeeping from another building was cleaning rooms on the A wing. The AM stated that he was at the facility helping and was the housekeeper for A wing. The AM stated that when he cleaned a room, he cleaned all the touch points such as the faucet, overbed table, sinks, and remotes. He stated anything that can be touched and that all rooms should be cleaned daily. He further stated at his facility, he used a quality control checklist and made rounds to make sure all the rooms were cleaned every day. On 12/12/23 at 12:20 PM, the survey team reviewed the above findings to the Previous LNHA (PLNHA), the current LNHA, the [NAME] President of Clinical Services and the Director of Nursing. The PLNHA stated that housekeeping had been short staffed. The facility was unable to provide any quality control inspection checklists or audits that were completed to verify that high touch areas and residents' rooms were cleaned daily. A review of the facility's provided procedure titled, Housekeeping Procedures, dated 06/2016, revealed a 5 step daily room cleaning method which included to: 1) empty trash, 2) damp mop floors, 3) horizontal cleaning- disinfect all flat surfaces, 4) spot clean-disinfect all vertical areas, and 5) dust mop the floor. NJAC 8:39-4.1 (a)11; 31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJAC 8:39-27.1 (a) 2 (g) (h) Complaint NJ# 151052, NJ #152112 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) nail care, and b) incontinence care. This deficient practice was identified for 5 of 5 dependent residents (Resident # 20, 76, #101, #106 and Resident #116) reviewed for assistance with activities of daily living. Findings included: On 11/28/23 at 9:40 AM, during the initial tour of the D Unit, a strong urine odor was noted in the hallway. 1. On 11/28/23 at 10:03 AM, the surveyor observed Resident #20 lying in bed in their room. The resident was alert and informed the surveyor that he/she was soiled. He/she could not find the call light to alert the staff, and stated, Please help. The surveyor left the room and informed the nurse of the resident's request. The resident informed the nurse that she needed to be changed. An interview with the resident at 10:15 AM, revealed that staff would take time to answer the call light and sometimes he/she could not locate the call light. The surveyor continued the tour and returned to the nursing station at approximately 12:00 PM. A strong odor of feces was permeated in the hallway at the nursing station adjacent to Resident #20's room. The surveyor attempted to enter the room and was informed by the nurse that Resident #20 was being changed. An interview was conducted on 11/28/23 at 12:23 PM, with the Certified Nursing Assistant (CNA) who cared for Resident #20. The CNA acknowledged that she checked the resident at 7:00 AM, then placed the breakfast tray in the room at 8:30 AM. The CNA failed to check the resident to see if he/she needed incontinence care, or if the incontinence brief needed to be changed prior to providing the resident with the breakfast meal. The CNA stated, I was informed by the nurse that the resident needed help. I was not informed that the resident was soiled with feces. The CNA confirmed she provided incontinence care around 12:00 PM and that the resident was soiled with feces. The CNA explained that she was in another room providing care when the nurse informed her that Resident #20 needed assistance. The nurse did not inform her that Resident #20 needed incontinence care. When inquired regarding the call light that was not accessible, the CNA stated that it was her responsibility to ensure the call light was accessible but this morning she did not check the call light. 2. On 11/28/23 at 12:09 PM, the surveyor observed Resident #76 in bed. The right hand was contracted and an assistive device hand roll was noted inside the resident's right hand. The finger nails were long, discolored, jagged and curling onto the hand roll. On 11/29/23 at 11:21 AM, the surveyor observed Resident #76 in bed. The resident was awake, alert and agreed to be interviewed. The resident's finger nails were still long and jagged. Upon inquiry, the resident stated that he/she would like their finger nails to be trimmed. Resident #76 stated, Feeling much better since I can speak now. The resident acknowledged being provided with incontinence care four times in 24 hours period. The surveyor left the room and asked the Registered Nurse Unit Manager (RN/UM) who was responsible to provide finger nail care. The RN/UM stated that the CNAs were responsible to provide finger nails care. The surveyor then accompanied the RN/UM to the room where we both observed Resident #76 in bed with his/her finger nails jagged, long and discolored. When interviewed by the RN/UM regarding finger nails care, the resident stated that the podiatrist [foot doctor] visited three weeks ago. When asked if the RN/UM made rounds and observed care, the RN/UM informed the surveyor that she made rounds daily to ensure that the residents were safe. The RN/UM stated she was not aware of the resident's finger nails condition. On 11/29/23 at 12:24 PM, the surveyor observed a CNA at Resident #76's bedside providing care. When the surveyor inquired regarding the resident's finger nails, the CNA stated, I was not here yesterday. She declined to comment further. Resident #76's electronic medical record revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; stiffness of unspecified joints, Pneumonia, chronic obstructive pulmonary disease (COPD), and lumbar disc degeneration. A review of Resident #76's most recent quarterly Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 10/01/23, documented the resident required extensive assistance with most activities of daily (ADL) including incontinence care. Resident #76 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) which revealed that Resident #76 had intact cognition. The resident was incontinent of bowel and bladder and required incontinence briefs. Review of Resident #76's care plan dated 07/13/2018, revealed he/she was care planned for ADL/self-care performance deficit related to right lower extremity, wound and limited mobility. The goal was for the resident to improve current level of function in: bathing, grooming/personal hygiene, dressing, and toileting by the next review as evidenced by improved ADL scores. The interventions included: Monitor conditions that may contribute to ADL decline, monitor for decline in ADL function. Provide Resident with total assist for personal hygiene. On 11/30/23 at 10:30 AM, Surveyor #4 conducted a resident council meeting with five residents who reside at the facility. Five of the five residents expressed concern with the amount of time it took staff to answer a call bell for them to get assistance with ADLs or care. Examples included but were not limited to; one resident stated he/she personally waited an hour after ringing the call bell for assistance. A second resident stated he/she witnessed their roommate use the call bell and it took close to an hour for someone to respond. The second resident also added that their roommate was unable to get out of bed his/herself and needed staff assistance. 3. On 12/01/23 at 7:00 AM, the surveyor entered the D Unit to observe medication pass administration. The surveyor observed two residents in the dayroom. Resident #101 was wrapped in a blanket and resting in a recliner chair. The surveyor approached the resident and observed their eyes were closed. A strong urine odor permeated at the corner where the resident was positioned. The surveyor observed a CNA also sitting in the dayroom. The surveyor inquired about the resident being placed in the dayroom and was wrapped in a blanket. The CNA informed the surveyor that she worked the 11:00 PM -7:00 AM shift and was ready to exit the facility and provided not further details On 12/01/23 at 8:25 AM, the surveyor observed a CNA wheel Resident #101 to their room. The surveyor followed the CNA to the room. The CNA used a mechanical lift to transfer Resident #101 to the bed. While on the mechanical lift, the surveyor along with the two CNAs who were executing the transfer, observed urine dripping on the resident's bed during the transfer and while in the mechanical lift over the bed and Resident #101 was wearing two saturated incontinence briefs. Urine continued to drip all over the the resident's blanket. An interview on 12/01/23 at 9:00 AM, with the two CNAs that provided the observed incontinence care, revealed Resident #101's brief was saturated from front to back with urine, and some of the inside material of the incontinent brief balled up and was stuck to the resident's back and a strong odor of urine was observed when the brief was opened. Resident #101 was also soiled with feces. The surveyor summoned the RN/UM to the room where the RN/UM confirmed that incontinence care was not provided to Resident #101 during the 11:00 PM- 7:00 AM shift. The RN/UM observed, who observed the condition of the resident, stated that the resident should not have had been wearing two incontinent briefs. On 12/01/23 at 10:15 AM, the surveyor interviewed the CNA who stated that she was responsible for taking care of Resident #101 during the 7:00 AM to 3:00 PM shift on 12/01/23. The CNA stated her shift began at 7:00 AM, but she had not provided Resident #101 with any care during her shift. She stated she would have to find someone to help her with care for Resident #101 and would change the resident when another staff was available to assist. The CNA stated the resident required total care and required two staff to transfer and provide incontinence care. Review of Resident #101's electronic medical record revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, history of falling, mood disturbance, anxiety, and difficulty in walking. A review of Resident #101's Quarterly MDS assessment dated [DATE], revealed that Resident #101 scored 00/15 on the BIMS and was severely cognitively impaired. Resident #101 was documented as requiring extensive assistance with all ADLs including incontinence care. A review of the resident centered comprehensive care plan revealed that the resident had impaired cognition due to the progression of dementia, and subsequent difficulty communicating and understanding others, even when conversing in his/her native language (Spanish). The goal was for staff to anticipate all needs. Resident #101's Care Plan had a focus area for ADL initiated 12/09/2020, related to impaired balance/dizziness. The goal was for Resident #101 to maintain the highest capable level of ADL ability throughout the next review period. Initiated 12/06/2023 and last revised 12/09/2023. The interventions included: Monitor conditions that may contribute to ADL decline, and monitor for decline in ADL function. Provide Resident with total assist of two (staff) for bed mobility. Provide the resident with total assist of one (staff) for incontinent care. Provide the resident with total assist of one (staff) for personal hygiene. Initiated 04/25/2023. 4. On 12/04/23 at 8:45 AM, the surveyor observed Resident #106 in bed. A care tour completed with the CNA assigned to Resident #101 at that time revealed that Resident #106 was wearing an incontinent brief which was saturated with urine. Inside the incontinent brief the surveyor observed a sanitary-type pad that was also soaked with urine, the incontinent brief was also saturated with urine and was yellow stained. The surveyor inquired regarding the last time that incontinence care had been provided to the Resident. The CNA stated that she had not provided care yet to Resident #106. The CNA further stated that all heavy wetters wore incontinence pads inside the incontinent brief. The CNA added that the facility provided the incontinence pads. Review of Resident #106's electronic medical record revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; Chronic respiratory failure with hypoxia, muscle weakness, and moderate protein caloric malnutrition. A review of the Annual MDS assessment dated [DATE], reflected that Resident #106 was severely cognitively impaired. Resident #106 scored 05 out of 15 on the BIMS. The resident was incontinent of bowel and bladder and required incontinent briefs. A review of the Comprehensive Plan of Care dated 08/30/2021, had a focus for ADL self-care performance deficit related to neurosurgery for aneurysm status post fall. The goal was for Resident #101 to maintain current level of functioning in all ADLs through the review date. Initiated 08/30/2021 and last revised 12/05/2023. Interventions included: The resident required total assistance of one person assist for incontinent care. The care plan did not specify the frequency for incontinence care. 5. On 12/01/23 at 9:00 AM, the surveyor performed a care tour with the CNA who cared for Resident #116. The surveyor observed Resident #116 in bed. Resident #116 was wearing an incontinent brief which was saturated with urine. Inside the incontinent brief the surveyor observed three sanitary-type pads soaked with urine. The incontinent brief was also saturated with urine and yellow stained. The surveyor accompanied the RN/UM to the room where we all observed that Resident #116's incontinent brief along with the three sanitary-type pads soaked with urine and was yellow stained. During an interview with the CNA at 11:30 AM, she stated that the 11:00 PM -7:00 AM shift staff left Resident #116 with three sanitary-type pads inside of the incontinent brief. She stated that Resident #116 was a heavy wetter. On 12/04/23 at 10:30 AM, the surveyor interview the Director of Nursing (DON) regarding the above concerns with incontinent care. The DON stated that incontinent care was to be provided every 2-3 hours and as needed, and heavy wetters were to be changed more frequently. The DON added that double incontinent briefs could be used upon request. When inquired regarding a policy for utilizing double briefs and multiple sanitary- type pads inside of the brief, the DON stated there was no policy. The DON stated that two residents on the unit requested double incontinent briefs and they had been care planned to have double briefs. The DON then clearly stated , This had to do more with skin integrity, and this was not a standard of practice. The DON acknowledge that she had been aware that the staff were placing two incontinent briefs of the residents, and three weeks ago, the staff were in-serviced regarding not placing double briefs on the residents. On 12/04/23 at 10:39 AM, the DON stated that the sanitary-type pads were provided for alert residents and to be used inside of regular underwear and not inside of incontinent briefs. The DON stated it was not the facility protocol to put pads inside of incontinence briefs. The DON stated that the residents must be checked for incontinence care prior to breakfast and she would provide the policy for perineal care. On 12/05/23 the surveyor reviewed Resident #116 medical record. The admission Face Sheet (an admission summary), reflected that Resident #116 was admitted to the facility with diagnoses which included but were not limited to; Unspecified Dementia, mood disturbance, and adjustment disorder with depressive mood. The Quarterly MDS dated [DATE], reflected that Resident #116 was severely cognitively impaired. Resident #116 scored 02 out of 15 on the BIMS). Review of Resident #116's Comprehensive Care plan provided by the facility on 12/06/23, revealed: A focus area for ADL self care performance deficit related to Dementia. Initiated 11/14/2021. The goal was Resident #116 will maintain current level of ADL function in bathing/showering, dressing, eating, personal hygiene and toileting through the review date. The interventions included: Resident #116 required maximum assistance by one staff with personal hygiene. Resident #116 was totally dependent on one staff for toilet use. The Care Plan did not include directive to the direct care staff regarding the frequency of incontinence care. On 12/06/23 at 8:19 AM, the surveyor interviewed the RN assigned to the 11:00 PM-7:00 AM shift. She stated that she was aware, and the night supervisors were also aware that the CNAs were using double incontinent briefs and sanitary-type pads on some of the residents. When asked to comment on how the facility handled the above concerns with incontinence care, the RN stated the CNAs were reminded verbally not to use double incontinent briefs on the residents. Upon further inquiry, the RN informed the surveyor that no formal education was provided to the staff. On 12/13/23 at 9:09 AM, during the exit conference with the survey team, the DON, Liscensed Nursing Home Administrator and Corporate Administation, the DON stated, I don't know what the incontinent pads were. The DON stated that incontinence pads could only be used inside of underwear and not inside of incontinent briefs or diapers. A review of the facility's policy titled, Activities of Daily Living (ADLs) Supporting updated 1/2023,revealed the following: Policy Statement Residents will be provided with care and services as appropriate to maintain or improve their ability carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Policy for Urinary Incontinence -Clinical Protocol revealed under Treatment /Management #4 As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. All 5 residents were assessed to be dependent on staff for ADLs care. The residents were observed with soiled incontinent briefs and did not received the care needed based on their assessments. Since the initial tour of the survey the urine odor was noted on the unit and shared with the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) A review of the hybrid closed medical record revealed that Resident #159 had been admitted with diagnoses which included but were not limited to; fracture of neck of left femur, difficulty walking, unsteadiness on feet, and muscle weakness. A review of the admission MDS dated [DATE], included but was not limited to a BIMS of 15/15 indicating the resident was cognitively intact. Section G Functional Status revealed Resident #159 required the assistance of one staff for transferring between surfaces and bed mobility turning side to side. Section G further documented that the resident required two or more staff physical assistance to walk in the room and there was impairment of one side of the lower extremities. Section GG documented the resident's admission performance as substantial/maximal assistance from staff to roll left and right, sit to lying, lying to sitting on the side of the bed, and sit to stand. Section M documented the only skin problem as being a surgical wound. A review of the resident centered on-going Care Plan included but was not limited to; a focus area of a L [left] hip ORIF [Open Reduction Internal Fixation surgery], there were no goals or interventions to address skin integrity. A focus area of limited physical mobility, with a goal which included to remain free of complications including skin-breakdown, and interventions which included dependent on 1 staff for locomotion/transfer, assistance with mobility as needed. A review of the Order Recap Report included a physician's order dated 1/9/22 for [name redacted] wound gel apply to rt [right] sacral topically every day shift for sacral opening cleanse area with nss [normal saline solution] apply [name redacted] wound gel and cover with a dry dressing. A review of Resident #159's skin assessments included but was not limited to the following; admission assessment dated [DATE], Section C. Skin Integrity documented a right arm IV [intravenous] site, a left hip surgery site, and left hip non-pit [pitting] edema. The assessment failed to document any measurements as indicated on the form. 12. Braden Sensory Perception documented a. ability to respond meaningfully to pressure-related discomfort 1 completely limited: unresponsive to painful stimuli, due to diminished level of consciousness or sedation or limited ability to feel pain over most of body surface. c. activity 3 walks occasionally. d. mobility 3 slightly limited. f. friction and sheet 3 no apparent problem. A Weekly Skin Review dated 12/28/21, documented pre-existing incision to hip dressing intact. A Weekly Skin Review dated 1/3/22, documented skin intact. A Weekly Skin Review dated 1/10/22, documented raised area to sacrum, intact, no drainage, treatment applied (The skin review did not identify sacral opening that necessitated the physician order dated 1/9/22). A Discharge Instruction form dated 1/13/22, documented Nursing treatment instructions [name redacted] wound gel apply to rt [right] sacral topically every day shift for sacral opening cleans area with nss [normal saline solution] apply [name redacted] wound gel and cover with a dry dressing. A review of the electronic Progress Notes (PN) included but were not limited to; an entry dated 1/7/22 by the activities department. The next entry was a PN dated 1/11/22, by the physician. There were no PNs dated 1/10/22 by nursing regarding the raised area to sacrum, intact, no drainage, treatment applied. with any measurements or assessments. The PNs failed to include an assessment of the facility acquired PU. The DON at the time of Resident #159's stay at the facility, no longer worked at the facility and was unable to be interviewed. A review of the facility provided, Skin Integrity Program Policy, updated 10/2020, included but was not limited to; Purpose: to provide information regarding identification of pressure ulcer/injury risk factors. Preparation: Review the resident's care plan and identify the risks factors as well as interventions designed to reduce or eliminate those considered modifiable. Prevention: Keep the skin clean and free of exposure to urine and fecal matter. Mobility/ Repositioning: Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. (The policy was not being followed. Resident #20 was left lying in excrement for 2 hours before being changed on 11/28/23. The care plan was not updated with the development of the pressure ulcers on 11/27/23 and 11/30/23. The care plan for Resident #159 failed to document any goals or interventions to address skin integrity or the facility acquired pressure ulcer. The RD nor the wound care nurse were consulted when the resident developed a wound on 11/27/23.) A review of the facility provided, Care Plans, Comprehensive Person-Centered policy and procedure reviewed 1/2023, included but was not limited to; . includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation. 2. The care plan interventions are derived from a thorough analysis of the information gathered from the comprehensive assessment. 7. The care planning process will: b. include an assessment of the resident's strength and needs. 8. The comprehensive person-centered care plan will: b. describe the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas. k. reflect treatment goals, timetables and objectives in measurable outcomes. k. identify the professional services that are responsible for each element of care. 13. Assessments are ongoing and care plans are revised as information about the resident's conditions change. A review of the facility provided, Charting and Documentation policy and procedure reviewed 1/2023, included but was not limited to; . any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. 2. The following information is to be documented in the resident medical record: c. treatments or services performed. d. changes in the resident's condition. e. events, incidents or accidents involving the resident. f. progress toward or changes in the care plan goals and objectives. 3. documentation in the medical record will be . complete, and accurate. On 12/13/23 during the exit conference, the facility did not provide any documentation to indicate that the pressure sore was avoidable or not and what interventions should have been implemented to prevent recurrence. NJAC 8:39-25.2 (b)(c); 27.1 (a)(e) Complaint # NJ 151052 Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow the facility policy to ensure that residents who were admitted without a pressure ulcer (PU) and was identified at Mild risk for developing pressure ulcers, and a resident admitted without a PU and was identified as completely limited in ability to respond to pressure-related discomfort, were provided with care and services to prevent worsening, or development of a pressure ulcer by failing to ensure: a) comprehensive skin assessments were accurately documented for a pressure ulcer and interventions were implemented to prevent further skin breakdown and promote healing, b) a resident was kept clean and free of exposure to urine and fecal matter, and c) a resident was evaluated for nutritional status to determine if interventions to increase calories and protein were needed to assist with wound healing. This deficient practice occurred for 1 of 3 residents reviewed (Resident #20), and for 1 of 2 closed records reviewed (Resident #159) for pressure ulcers. The deficient practice was evidenced by the following: a) On 11/28/23 at 10:03 AM, Surveyor #1 observed Resident #20 lying in bed in his/her room. The resident's feet were rested directly on the mattress. The resident was alert and informed the surveyor that he/she was soiled. He/she stated he/she could not find the call light to alert the staff and stated to the surveyor please help. Surveyor #1 exited the room and alerted the nurse who was in the hallway of the resident's request. The surveyor followed the nurse to the room and noted that the call light was not attached to the bed. The Licensed Practical Nurse (LPN) could not locate the call light. Upon inquiry, the LPN stated that the call light should be accessible. On 11/28/23 at 10:15 AM, Surveyor #1 interviewed the resident who stated that he/she had been a resident at the facility for a little while, sometimes staff would take time to answer the call light, and that his/her buttocks were burning. The surveyor continued the facility tour and returned to the nursing station around 12:10 PM. A strong odor of feces permeated in the hallway adjacent to the resident's room. The nurse informed the surveyor that staff was in the room assisting Resident #20 with care. The resident stated that he/she needed to be changed at approximately 10:00 AM, and the resident had not been provided with incontinence care until after 12:00 PM [two-hours later]. On 11/28/23 at 12:15 PM, an interview with the Certified Nursing Assistant (CNA) who cared for Resident #20 revealed that she was not informed that Resident #20 needed to be changed. The CNA further stated that while she was providing care to another resident, the nurse informed her that Resident #20 needed assistance. She reported to the room after taking care of the other resident only to observe that Resident #20 was soiled with feces. When asked if she had provided incontinence care to the resident that morning, the CNA stated no. She informed the surveyor that around 8:30 AM, she delivered the breakfast tray and left the room and did not elaborate on why she failed to provide any incontinence care to the resident and could not state if she had provided any incontinent care to the resident. The surveyor reviewed the medical record for Resident #20 which revealed: The admission Record face sheet (an admission summary) reflected that Resident #20 was admitted with diagnoses which included but were not limited to; bilateral osteoarthritis of knee, contracture right knee, unspecified abnormalities of gait and mobility, and the need for assistance with personal care. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/30/23, reflected that the resident had a Brief Interview Mental Status (BIMS) score of 11 out of 15, indicating a moderately impaired cognitive status. The assessment reflected that the resident did not exhibit behaviors of rejecting care that would interfere with treatment goals in the last seven-day look-back period. The resident required two- persons assist with bed mobility and transfers, and that he/she was admitted without any pressure ulcers. (partial thickness tissue loss). There was no evidence that the resident had a PU upon admission per review of the admission Nursing History and Assessment, the individualized Comprehensive Care Plan, the admission Physician's Orders sheet, the admission Skilled Nurses Notes, the Physician progress notes, or the Treatment Administration Record for 08/23/23. A review of the admission Nursing History and Assessment form dated 08/23/23 reflected that Resident #20 was alert and oriented to self and had intact skin. The assessment did not reflect evidence that the resident was admitted with a pressure ulcer. On admission the resident received a score of 15 on the Braden Scale indicated that he/she was at risk. A review of the admission Physician Order's Sheet (POS) dated 08/23/23, reflected an order to perform a weekly skin check by a nurse on Tuesday and Friday. Use the weekly skin assessment to document findings. Schedule on bath day and time ordered was in the morning every Tuesday, and Friday for the skin assessment. A review of the Braden Scale-for Predicting Pressure Sore Risk assessment dated upon admission on [DATE], reflected the resident was at risk for developing a pressure ulcer. The assessment had a total score of 15. A score of 15-18 reflected mild risk for developing a pressure ulcer. The scale further revealed: Moderate risk 13-14 High risk 10-12 Very high risk 9 or below. A review of the resident's individualized, Interdisciplinary Plan of Care dated 09/05/23, reflected that the resident was at risk for pressure ulcers due to a decreased activity. The goal indicated that Resident #20 will not show signs of skin breakdown x 90 days. Interventions included to provide skin care i.e., lotions, barrier creams as ordered, Initiated 09/05/23; Observe skin for signs and symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, Initiated 09/05/23; Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered, Initiated 09/05/23; Weekly skin check by license nurse, Initiated 09/05/23. A review of a Nursing admission Note dated 11/21/23 timed 14:20 [4:20 PM] revealed that Resident #20 was alert and oriented X 1. Verbally appropriate, skin color normal, skin temperature warm. Braden Scale 15.0 skin integrity. The notes revealed that Resident #20 did not have redness or any type of skin breakdown or wound to the right or left buttock. A review of the Nutrition Quarterly review dated 11/29/23 at 20:58 [8:58 PM] revealed: Routine Chemistry blood laboratory report with a collection date of 11/27/23, which reflected the resident had an albumin (blood protein) level of 3.5 grams per deciliter (g/dl) (normal range indicated 3.5 to 5.5 g/dl). The Registered Dietitian (RD) did not make any recommendations. The RD indicated that the left hip hematoma was resolved. The RD did not indicate in his note that Resident #20 had a pressure ulcer to the left and right buttock. On 11/29/23 at 11:30 AM, Surveyor #1 interviewed the RD in the presence of the survey team. The RD revealed that he was not made aware of Resident #20 having a wound. The RD further added that all wounds were to be discussed and addressed in the morning meeting. Surveyor #1 interviewed the RD regarding the wound identified on 11/27/23 to the lower right buttock. The RD confirmed that he was not made aware that Resident #20 had developed a wound to the right buttock on 11/27/23. A review of the chemistry blood laboratory report collected 11/28/23 and reported 12/02/03, reflected some critical lab values. Albumin was 2.8 gm/dl [depleted]. Protein Total 5.9 gm/dl. On 12/08/23, the RD forwarded a note to the physician which revealed that Resident #20 was at risk for malnutrition. A review of the Treatment Administration Record (TAR) for November 2023 reflected weekly skin assessments for 7:00 AM to 12:00 PM shift plotted to be performed on Tuesdays and Fridays on 11/03, 11/07, 11/10 and 11/14, 11/17, 11/21, 11/24, and 11/28, signed by the Registered Nurse/Charge Nurse. Resident #20 had a change in condition for skin impairment identified on 11/13/14, however the weekly skin assessment dated [DATE] indicated that Resident #20 had intact skin. A review of the resident's Interdisciplinary Comprehensive Plan of Care revised on 12/01/23, reflected that the right lower buttock skin tear was resolved on 09/05/23. A review of the TAR reflected that Resident #20 had another skin tear to the right lower buttock identified on 11/13/23 that was resolved on 11/22/23. However, there was a change in condition documented and dated that the change in condition was noted 11/13/23. A review of the change in condition reflected the resident representative was informed of the change in skin condition, but the physician was not notified. On 11/30/23 at 11:20 AM Surveyor #1 interviewed the Charge Nurse regarding the wound treatment dated 11/27/23. The nurse stated that she informed the physician of the wound and suggested that the wound be treated with [name redacted] (a gel wound dressing) and [name redacted] (a debriding agent). The Charge Nurse also stated that she did not review the wound measurements with the physician. The surveyor then asked the Charge Nurse what stage of wound should be treated with [name redacted] gel wound dressing and [name redacted] debriding agent, but she declined to comment. A review of the POS for November 2023 did not reflect a physician order for the skin tear identified on 11/13/23. A review of the Weekly Skin Assessments dated 11/14/23, reflected that Resident #20's skin was intact. On 11/21/23, the Weekly Skin Assessment indicated under skin condition, Pre-existing, but there was no corresponding documentation in the medical record to address what areas of the body had non-intact skin, nor did the assessment address where on the body the non-intact skin was, and if there was a new finding. A review of the wound consult Visit Report dated 11/30/23, and documented by the Advanced Practice Nurse/Wound Consultant (APN/WC) reflected that Resident #20 had a wound to the left buttock and the measurements were 2.5 centimeters (cm) x 1.5 cm x 0.1 cm. A Timeline for the wound, dated 12/04/23 revealed the 11/30/23 consult was completed virtually, and was not in person. The APN/WC recommended to apply a medicated ointment and 1. [name redacted] agent used for skin care Sprinkles Secondary Dressing: 1. [name redacted] cream oxide. There was no documented evidence for a Braden Scale Pressure Ulcer Risk assessment dated upon identification of the pressure ulcer on 11/27/23 and 11/30/23, to determine the resident's new pressure ulcer risk. A review of the POS for November 2023 did not reflect evidence of a new physician order for the treatment of the pressure ulcer in accordance with the APN/WC recommendations made on 11/30/23. The Daily Progress Notes dated 11/27/23 timed 14:50 PM (2:50 PM) as a late entry created on 11/30/23 timed 14:53 PM (2:53 PM), after the surveyor's inquiry, reflected that Resident #20 was noted with a wound which measured 2.5-centimeter (cm) x 1.8 x 0.1 cm. There was no documentation regarding the wound when the facility stated the wound was identified on 11/27/23. A review of the POS for November 30, 2023, reflected a telephone order from the Attending Physician to cleanse right buttock wound with normal saline solution (NSS) and apply a [name redacted] debriding agent, and [name redacted] wound gel, and cover with Silicone foam dressing daily every day shift for wound care. A review of the TAR for November 2023, did not reflect evidence that a treatment to the right lower buttock pressure ulcer was implemented on 11/27/23. The TAR reflected that the Charge Nurse was signing for the wound care for the 7:00 AM -3:00 PM shift. On 11/30/23/23 at 12:15 PM, the surveyor interviewed both the LPN and the CNA assigned to Resident #20. The LPN informed Surveyor #1 that Resident #20 did not have a wound. The CNA confirmed that she did not observe a dressing on the resident's left buttock. The CNA informed the surveyor that she was provided with a cream [not a treatment] to apply to the resident's buttocks. There was no documented evidence in the medical record from the resident's attending physician that addressed the pressure ulcer to the right buttock or evidence that it was examined by the attending physician or the APN/WC prior to 11/30/23. A review of a follow-up APN/WC Visit Report dated 12/06/23, reflected that the left buttock wound was not healed. The left buttock measured 1.0 cm x 0.7 cm x 0.1 cm. A review of a follow-up Nutrition assessment dated [DATE], which was 15 days after the identification of the wound to the right buttock facility-acquired pressure ulcer, which time the RD indicated that Resident #20 was at risk for malnutrition. The RD initiated a dietary care plan. The RD recommended to obtain weight weekly x 4 weeks, change the resident's diet to a regular thin liquid diet with double portions, add an ordered drink for weight maintenance, and an ordered liquid medication for wound healing. On 11/30/23 at approximately 1:10 PM, the surveyor interviewed again the Charge Nurse assigned to do the treatments for the residents on the unit. The Charge Nurse was outside the resident's room with the treatment cart, and she stated that Resident #20 was awake, and she was about to do his/her wound treatment to the left buttock. She stated that it was a newer wound but could not speak to when it developed. The Charge Nurse stated that direct care staff did not report any change in skin condition prior to 11/27/23. On 11/30/23 at 1:30 PM, the surveyor conducted a phone interview with the APN/WC who stated that she comes every Wednesday to the facility and was not made aware of Resident #20's wound identified on 11/27/23. She stated that she was informed on 11/30/23, regarding a wound on the left buttock. The APN/WC stated she did a video call with the facility and changed the wound treatment at that time. The APN/WC stated the process was that she would come to the facility and complete wound rounds and if there was a new wound, or a change in her recommendations that she would write the order for nurses to implement at that time. The APN/WC stated she documented the visit report, and the facility would receive it within a day or so. When inquired about what type of wound should be treated with [name redacted] wound gel and [name redacted] debriding agent, she stated a stage 2 to stage 4 and if the wound had a lot of drainage. The surveyor inquired why she recommended the [name redacted] particles used for skin care for Resident #20, and the APN/WC stated that she recommended it to act as an absorbent dressing so that the drainage of the wound did not macerate the edges of the wound. On 11/30/23 at 2:00 PM, the surveyor interviewed the CNA assigned to care for Resident #20. The CNA stated that she assisted the resident in getting him/her dressed and would apply barrier cream to the buttocks. The CNA was unsure about the wound or any dressing that had been applied. On 12/01/23 at 8:21 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor copies of the facility policies on Prevention of Pressure Ulcers/Injuries updated 11/2018, and the Pressure Ulcer Investigation Form policy updated 2018. The LNHA was unable to provide any additional documentation to the survey team. On 12/01/23 at 8:21 AM, the LNHA provide facility's policy titled, Prevention of Pressure Ulcers/ Injuries, last revised 1/2023. No other document was provided regarding the wound identified on 11/27/23. On 12/01/23 at 9:58 AM, Surveyor #1 interviewed the Unit Manager regarding the wound identified on 11/27/23. The Unit Manager stated she could not speak to or provide any document regarding the resident's wound and that the surveyor would need to speak to the Director of Nursing. On 12/05/23 at approximately 10:00 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process when a wound was identified. The DON stated that the nurse would inform the wound care team who would provide directives on how to proceed with the wound. A change of condition would be completed and documented, and the Interdisciplinary Team would be made aware in the morning meeting. When asked to provide the documents for the wound identified on 11/27/23, the DON stated that she did not have any documentation regarding the wound as she was not made aware. There were no statements from the Primary Nurse, and/or statements from previous shifts from direct care staff. There was no investigation done to rule out if neglect been ruled out as a possible cause for the development of the pressure ulcer on 11/27/23 and again on 11/30/23. The DON added that the Charge Nurse did not follow the facility's protocol. The DON and surveyor reviewed the Progress notes together for Resident #20 and the DON could not speak to the timing, accuracy, and accountability questions the surveyor had regarding the resident's left buttock wound. The DON acknowledged that there were discrepancies. The surveyor inquired how the resident developed a pressure ulcer to the left buttock and the facility was not aware of any skin condition prior to 11/27/23, but the direct care staff had been providing wound care on all 3 shifts. The DON stated she would need to get back to the surveyor. On 12/06/23 at 10:30 AM, the DON stated that Resident #20 was assessed by nursing to only be at risk for developing a pressure ulcer as per the Braden Scale. The facility was unable to provide documented evidence that the resident refused care or medications, had other behaviors that would impact interventions to prevent the pressure ulcer. The facility was unable to speak to why there the care plan was not updated when the pressure ulcer was identified.

Complaint # NJ 149879, NJ 151052, NJ 151398, NJ 152112, Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient staff were available to: a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs) care, b) provide nail care for a resident who was dependent on staff for ADLs, and c) provide colostomy (a surgically created opening in the colon or large intestine) for a resident dependent on staff for colostomy care. This deficient practice was identified for 7 of 9 residents reviewed for ADLs (Resident #20, #76, #101, #106, #116, #354, and closed record #159), and expressed by 5 of 5 residents who attended a resident council meeting and was evidenced by the following: Refer to 677E, 686E, 689G, and 691D. a) On 11/28/23 at 10:03 AM, Surveyor #1 observed Resident #20 lying in bed in his/her room. The resident was alert and informed the surveyor that he/she was soiled. He/she stated he/she could not find the call light to alert the staff, and stated, Please help. Surveyor #1 left the room and alerted the nurse in the hallway that the resident was requesting assistance. The surveyor and the Licensed Practical Nurse (LPN) went to Resident #20's room and the LPN eventually found the call light wrapped and placed on the wall out of the residents reach. On 11/28/23 at 10:15 AM, Surveyor #1 interviewed the resident sometimes staff would take time to answer the call light. At 12:10 PM, the surveyor noticed a strong odor of feces permeated in the hallway adjacent to the resident's room. The resident reported that he/she needed to be changed at approximately 10:03 AM, but the resident was not provided with incontinence care until after 12:00 PM. On 11/28/23 at 12:15 PM, an interview with the Certified Nursing Assistant (CNA) who cared for the resident revealed that she was providing care to another resident. When asked if she provided incontinence care to the resident that morning, the CNA stated, no. She informed the surveyor that around 8:30 AM, she delivered the breakfast tray and left the room. On 12/01/23 at 8:25 AM, Surveyor #1 observed a CNA wheeling Resident #101 to their room. As the CNA transferred the resident to their bed, the surveyor observed Resident #101 was wearing two incontinent briefs and the urine was leaking out. The Unit Manager (UM) was present and acknowledged that the resident had two incontinent briefs on and was soiled with urine and feces. On 12/01/23 at 8:40 AM, Surveyor #1 observed Resident #116 in their room in the presence of the UM. The surveyor and UM observed the resident was wearing one incontinent brief that had three absorbency pads inside. On 12/04/23 at 8:45 AM, during a care tour with the CNA, the surveyor observed Resident #106. The resident was wearing an incontinent brief what was soaked with urine. The surveyor further observed an absorbency pad soaked with urine inside the incontinence brief. A review of a facility provided Grievance Form, dated 01/06/22, included but was not limited to; a grievance filed by Resident #159 documented that on 01/05/22, on the 3 PM to 11 PM shift, the resident rang his/her call bell but no staff arrived. The resident had a family member call the facility to inform the staff that the resident needed assistance to be toileted. b) On 11/28/23 at12:09 PM, the surveyor observed Resident #76 in bed and observed his/her right hand contracted with the fingernails long and jagged. On 11/29/23 at 11:21 AM, a second observation of Resident #76 revealed his/her right-hand fingernails were still long and jagged and had not been addressed. Resident #76 stated that he/she would like to have his/her fingernails trimmed. On 11/29/23 at 12:24 PM, the CNA was at Resident #76's bedside providing nail care. When inquired regarding the resident's nails, the CNA stated, I was not here yesterday. c) On 12/07/23 at 9:33 AM, a surveyor reviewed the closed electronic medical record (EMR) for Resident #354. Resident #354 was documented as having a colostomy with a colostomy appliance. A review of a physician's order dated 12/22/21, included colostomy appliance change every day shift every three days. The surveyor reviewed the Treatment Administration Record (TAR), for January 2022 included but was not limited to the following; a colostomy appliance change was completed on 01/01/22, 01/04/22, and 01/10/22 (6 days later); completed on 01/13/22, 01/16/22, 01/19/22, 01/22/22, and 01/28/22 (6 days later). The surveyor reviewed the nursing Progress Notes which failed to document that the colostomy appliance was changed during the dates of 01/07/22 and 01/25/22. d) On 11/30/23 at 10:30 AM, Surveyor 4 conducted a resident council meeting with five current residents of the facility. During the meeting, five of five residents expressed concerns with the facility being understaffed and having to wait a long time for care. One resident stated he/she had waited an hour for care. A second resident stated that he/she witnessed their roommate use the call bell and waited close to an hour. On 12/07/23 at 8:55 AM, Surveyor 4 interviewed a CNA on the E wing. The CNA stated she had worked at the facility for 2 years and the staff would work short. The CNA gave an example of the day before, 12/6/23, the facility was short, and she had not time to document and less time to spend on resident care. On 12/07/23 at 8:59 AM, a second CNA on E wing stated that when the facility had less than five CNAs on the unit, she found it hard to complete tasks such as resident hygiene and incontinence care. On 12/07/23 at 9:01 AM, a CNA on D win stated that she found it hard to provide quality care if there were less than 5 CNAs. She further stated it was too difficult to care for 15 residents and get basic things done. On 12/07/23 at 9:02 AM, a second CNA on D wing stated that on 12/6/23, there were not enough staff, and it was rough and that things such as showers would suffer. Staffing had been calculated for the following time frames and revealed the following: 1. For the 2 weeks from 11/07/2021 to 11/20/2021, the facility was deficient in CNA staffing for residents on 7 of 14 day shifts as follows: -11/07/21 had 16 CNAs for 139 residents on the day shift, required at least 17 CNAs. -11/10/21 had 16 CNAs for 138 residents on the day shift, required at least 17 CNAs. -11/13/21 had 13 CNAs for 135 residents on the day shift, required at least 17 CNAs. -11/14/21 had 13 CNAs for 135 residents on the day shift, required at least 17 CNAs. -11/15/21 had 13 CNAs for 134 residents on the day shift, required at least 17 CNAs. -11/19/21 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs. -11/20/21 had 15 CNAs for 136 residents on the day shift, required at least 17 CNAs. 2. For the 2 weeks from 01/02/2022 to 01/15/2022, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 1 of 14 evening shifts, deficient in CNAs to total staff on 1 of 14 evening shifts, and deficient in total staff for residents on 2 of 14 overnight shifts as follows: -01/02/22 had 14 CNAs for 151 residents on the day shift, required at least 19 CNAs. -01/02/22 had 14 total staff for 151 residents on the evening shift, required at least 15 total staff. -01/02/22 had 6 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -01/02/22 had 10 total staff for 151 residents on the overnight shift, required at least 11 total staff. -01/03/22 had 14 CNAs for 150 residents on the day shift, required at least 19 CNAs. -01/04/22 had 13 CNAs for 150 residents on the day shift, required at least 19 CNAs. -01/05/22 had 15 CNAs for 150 residents on the day shift, required at least 19 CNAs. -01/06/22 had 16 CNAs for 150 residents on the day shift, required at least 19 CNAs. -01/07/22 had 16 CNAs for 150 residents on the day shift, required at least 19 CNAs. -01/08/22 had 15 CNAs for 149 residents on the day shift, required at least 19 CNAs. -01/08/22 had 9 total staff for 149 residents on the overnight shift, required at least 11 total staff. -01/09/22 had 15 CNAs for 149 residents on the day shift, required at least 19 CNAs. -01/10/22 had 12 CNAs for 148 residents on the day shift, required at least 18 CNAs. -01/11/22 had 12 CNAs for 147 residents on the day shift, required at least 18 CNAs. -01/12/22 had 16 CNAs for 146 residents on the day shift, required at least 18 CNAs. -01/13/22 had 16 CNAs for 146 residents on the day shift, required at least 18 CNAs. -01/14/22 had 13 CNAs for 146 residents on the day shift, required at least 18 CNAs. -01/15/22 had 9 CNAs for 144 residents on the day shift, required at least 18 CNAs. This equated to half of the required CNAs to provide the minimum resident care. 3. For the 2 weeks of staffing prior to survey from 11/12/2023 to 11/25/2023, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts as follows: -11/12/23 had 10 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/13/23 had 13 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/14/23 had 15 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/16/23 had 17 CNAs for 152 residents on the day shift, required at least 19 CNAs. -11/17/23 had 16 CNAs for 152 residents on the day shift, required at least 19 CNAs. -11/18/23 had 15 CNAs for 152 residents on the day shift, required at least 19 CNAs. -11/19/23 had 10 CNAs for 152 residents on the day shift, required at least 19 CNAs. -11/20/23 had 15 CNAs for 155 residents on the day shift, required at least 19 CNAs. -11/21/23 had 18 CNAs for 155 residents on the day shift, required at least 19 CNAs. -11/22/23 had 18 CNAs for 152 residents on the day shift, required at least 19 CNAs. -11/23/23 had 15 CNAs for 148 residents on the day shift, required at least 18 CNAs. -11/24/23 had 13 CNAs for 148 residents on the day shift, required at least 18 CNAs. NJAC 8:39-4.1(a)12; 27.1(a)

Based on observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure that the facility self-identified areas for improvement including environmental concerns, resident care related concerns and significant incidents. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: the D Unit had a strong odor of urine throughout the Unit. -11:35 AM, two surveyors observed the condition of room on the D Unit which included: D1- room and bathroom floor visibly soiled. D9- the air conditioner unit and door appeared to be torn apart, the privacy curtain was stained and there was debris on the floor. On 11/28/23 at 12:40 PM, a surveyor interviewed two residents in their room on the A Unit (Sub-Acute). Lunch was delivered to the Room. The surveyor observed both Unsampled residents sitting in bed were eating lunch. One Unsampled Resident stated, they haven't cleaned our room yet and the other Unsampled Resident stated, she just came in an emptied our trash. Both Unsampled Residents stated they could not remember when their room and bathroom was cleaned last and stated, they empty the trash but do not clean. At that time, the surveyor observed some small pieces of paper on the floor. On 11/29/23 at 11:52 AM, a surveyor toured the E Unit and outside room E 11 observed a handrail was falling off the wall. The handrail across from nurses' station by bathroom had broken end cap, and the handrail by door of unit day room was not secure. On 11/29/23 at 12:38 PM, a surveyor observed Resident #116 in the day room rummaging through books, pacing in the wheelchair and was unsupervised. A subsequent medical record review for Resident #116 revealed that on 06/14/23 the resident was observed in the 2nd floor lounge and was pulling on the change machine located between two vending machines. The change machine tipped over and hit the resident in the head which resulted in a laceration, bruise, and a skin tear. Resident #116 also sustained multiple falls, including a fall with a fracture on 02/14/22. On 11/30/23 at 9:13 AM, a surveyor interviewed the Housekeeper Director (HD) about the cleaning process. The HD stated he had two weeks cleaning schedule. The surveyor asked the HD if he confirmed that the cleaning was being completed and he stated, not often. The HD stated, I do not have enough staff to clean, and I discussed it with the district manager. On 12/5/23 at 8:30 AM, a surveyor along with the Unit Manager for E Wing toured the unit pantry. Various food items that were stored in the refrigerator were either expired or not labeled with a use by date, including gray and a mold-like coated package of deli type meat. The ice scoop was nested in a holder with brown colored water on the bottom. On 12/05/23 at 8:40 AM, a surveyor toured the D Wing unit pantry with the Unit Manager Registered Nurse. Floors were observed as visibly soiled, the ice scoop was nesting in water, many undated items that included, but was not limited to; an undated container of ham, beans and macaroni and cheese in the refrigerator. The UM stated the Housekeeping Department was responsible for cleaning the refrigerator and removing items. On 12/12/23 at 9:48 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, about the facility Quality Assurance and Performance Improvement (QAPI) process. The LNHA stated he was the LNHA of record from September 2022 through December 13, 2023, as he was transferring to another facility. The LNHA stated the facility completed monthly QAPI meetings, and the quarterly QAPI meetings were the meeting that included the Medical Director (MD). 11/30/23 at 9:13 AM, a surveyor interviewed the Housekeeper Director (HD) about the cleaning process. The HD stated he two weeks cleaning schedule. The surveyor asked the HD if he confirmed that the cleaning was being completed and he stated, not often. The HD stated, I do not have enough staff to clean, and I discussed it with the district manager. On 12/12/23 at 9:48 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, about the facility Quality Assurance and Performance Improvement (QAPI) process. The LNHA stated he was the LNHA of record from September 2022 through December 13, 2023, as he was transferring to another facility. The LNHA stated the facility completed monthly QAPI meetings, and the quarterly QAPI meetings were the meeting that included the Medical Director (MD). On 12/12/23 at 9:54 AM, the surveyor asked the LNHA what the QAPI process was. The LNHA stated, it was a way to see how all departments were doing as a building and it was an improvement plan to look at what needed to be focused on. The LNHA stated the quarterly QAPI was a synopsis of what was being reviewed and the MD, along with others were present at that meeting. The LNHA confirmed that he was the facility QAPI Coordinator and he, along with the Director of Nursing was involved with QAPI and was ultimately responsible for the QAPI process. 12/12/23 at 9:56 AM, the surveyor requested the LNHA to list all the current QAPI plans that were in effect prior to the surveyors entering the building. The LNHA stated he did not have any minutes from the July to September 2023 QAPI meetings. The surveyor asked what the policy was for QAPI. The LNHA stated to identify a problem, identify the root cause, who was involved, set up a team, implement interventions and monitor outcomes. The LNHA stated the goal was always 100% On 12/12/23 at 9:58 AM, the LNHA stated the facility's current QAPI's included: 1. The appropriate destruction of narcotics. 2. Antibiotic stewardship- proper use of antibiotics 3. Activity- Smoking appropriately, activity staff, working with nursing on having residents out of bed. 4. The Material Data Set form, section GG with the certified nursing assistants. 5. Therapy- adaptive equipment and splints appropriately. 6. Human Resources-staff retention and recruitment. 7. Central supply- housekeeping and personal protective equipment carts. 8. Maintenance-a lot of peeling bed boards and foot boards. 9. Dietitian-weight loss. 10. Food service- Residents are complaining that food is not hot enough and started 10/01/23 by the new food service director. It is between the kitchen and nursing and was related to a new insulated tray system that was now working and was specific for the temperatures in the kitchen only and to ensure the heating system for the trays was working. 11. Housekeeping- cleaning rooms. The LNHA stated rooms I felt, are not clean the room, and stated the staffing is part of the challenges for housekeeping and maintenance, and other areas. 12. Admissions- involved with housekeeping for new admissions and all items in room. On 12/12/23 at 10:19 AM, the LNHA confirmed the facility did not have any QAPIs on abuse and also there were no QAPI's on significant events. On 12/12/23 at 10:26 AM, the surveyor asked the LNHA if there were any QAPI's in place related to the findings identified by the survey team, which included loose handrails. The LHNA stated, maybe an earlier month and confirmed that the status of the handrails was currently not part of the QAPI. On 12/12/23 at 10:31 AM, the surveyor asked the LNHA about the unsecured cash machine that fell on a resident in June, 2023. The surveyor asked if that incident was reviewed in the QAPI. The LNHA stated, I think it was just installed and wasn't secured, the vendor put it in and Maintenance found out after. The surveyor asked if that would be considered a significant event and the LNHA responded, I would say it was significant, and maybe it should have been a QAPI and stated that Maintenance went around the facility to ensure things were secured, and I don't think Maintenance documented that they went around to ensure things were secured, I would have to ask. The surveyor asked the LNHA stated that Maintenance can QAPI about forty things in this building, however did not provide a rationale for why the identified concerns were not part of the QAPI. On 12/12/23 at 10:42 AM, another surveyor asked the LNHA about what about a QAPI for cleanliness or resident rooms. The LNHA stated, there are a lot of things to be done in the rooms and stated he will speak with maintenance, it is endless what needs to get done. The LNHA confirmed that he was aware of the staffing deficit for the Housekeeping Department and when asked if the decrease in staffing was part of the QAPI, the LNHA stated the staffing concerns with the Housekeeping Department were not included in the QAPI process. A review of the following policies revealed: Quality Assurance and Performance Improvement (QAPI) Program policy reviewed 5/2023 revealed: This facility shall develop, implement, and maintain and ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life., 2. Profice a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurements; c. Identifying and prioritizing quality deficiencies, d. Systematically analyzing underlying causes of systemic quality deficiencies, e. Developing and implementing corrective action or performance improvement activities, f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities. The Quality Assurance Performance Improvement (QAPI) Program Plan, Reviewed 5/2023 revealed: Purpose . Focus areas include all systems, processes and outcomes that affect resident and family satisfaction, the quality of care and services provided, and the quality of life for persons living and working in our organization, as well as visitors to our facility. Scope . The principles of QAPI are taught to all staff, volunteers . Governance & Leadership . Administration fosters a culture of quality within the facility, so staff embrace the principles of QAPI and are comfortable identifying quality problems or areas for improvement. Engagement of staff, residents, families and visitors is a hallmark of the QAPI program. PIP (performance improvement projects) Identification . The QAPI team monitors and analyzes data, and reviews feedback and input from residents, staff, families, volunteers, providers, and stakeholders to identify areas to improve the quality of life and quality of care and services . The Quality Assurance and Performance Improvement (QAPI) Program - Feedback, Data and Monitoring Updated 5/2023 revealed the QAPI programs is based on the collection of information obtained from data, self-assessment and systems of feedback . 1. Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI committee in order to identify problems that are high risk, high volume or problem prone and to guide decisions regarding opportunities for improvement . 2. The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. NJAC 8:39- 33.2 (a)(b)(c)12;13(d); 33.3, 34.1(a)(c)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 2 of 3 resident units. This deficient practice was evidenced by the following: On 11/29/23 at 11:52 AM, Surveyor #4 was on E unit and observed that outside of room [ROOM NUMBER], the handrail was not securely fastened to the wall and was slanting down on the left side. Surveyor #4 was able to physically move the handrail up and down. Surveyor #4 observed another handrail across from the E unit nurses station by the bathroom which had a broken jagged end cap. Surveyor #4 observed a handrail by the entrance door of the E unit day room which was visibly not secured to the wall. On 11/29/23 at 11:55 AM, the Registered Nurse Unit Manager (RN UM) on E wing was shown the handrails. The RN UM stated that handrails were for the safety of someone who ambulates. She stated when handrails were broken or loose, it would be very unsafe. On 12/05/23 at 8:30 AM, Surveyor #1 observed the D unit. The handrails outside of rooms D 7, D 21, and D 23, were observed to be pulling away from the wall and not securely fastened. On 12/05/23 at 9:15 AM, Surveyor #4 observed the handrail leading to the door of the D unit and E unit shared activity room. The handrail was closer to the E unit side and was observed to be pulling away from the wall and not secure. On 12/05/23 at 9:15 AM, the Director of Nursing (DON) stated that the handrails should be secured for resident safety and that maintenance should check them. On 12/05/23 at 9:43 AM, the Maintenance Director (MD) in the presence of the survey team, stated that there was a computer program for handrail audits. The MD pulled out his work phone and showed the survey team the work orders the staff used to report concerns to the MD. The MD stated it would be everyone's responsibility to check and report if handrails were not secure. The MD further stated it was important for the handrails to be secure because residents hold on to them and that someone could be injured if the handrails were not secured. He stated a resident could fall and break something. The MD was unable to provide any handrail audits to the survey team. On 12/05/23 at 10:56 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, stated the handrails may be loose but they can hold 200 pounds. The LNHA further stated it was not acceptable for the handrails to be loose or broken. A review of the facility provided, Handrail Policy, updated 2/2023, included but was not limited to the following; Policy Explanation and Compliance Guidelines 1. All handrails will be firmly secured. 2. Secured handrails means handrails that are firmly affixed to the wall. 3. Routine maintenance on handrails will be completed by the maintenance department. The facility failed to follow their policy. This concern was presented to the facility administration on 12/12/23. The facility had no additional documentation to provide the surveyors. NJAC 8:39-31.2(e)

Based on observation, interview and document review it was determined that the facility failed to ensure: a) potentially hazardous and perishable food items located in the refrigerator were labeled with a use by date and covered. b) staff restrained hair c) resident food storage areas were maintained in a clean and sanitary manner and food was appropriately labeled and dated with a use by date to prevent the potential for food borne illness. This deficient practice occurred in the main kitchen and 2 of 2 remote resident food pantries and was evidenced by the following: On 11/28/23 at 8:54 AM, the surveyor conducted a tour of the kitchen with Food Service Manager FSM and observed the following: 1) The walk-in refrigerator was observed with opened potentially hazardous food items that were not labeled with a used by date and expired dairy products. This included half a case of bacon stored in a box that was uncovered, exposed to air and was not labeled with a use by date, ham that was opened and exposed to the environment, located on a tray without use by date, and a bag of shredded cabbage that was in a box opened and was not labeled with a use by date. The FSM stated that the items in the refrigerator must be covered, labeled, and dated with use by dates. The walk-in refrigerator also included various items of expired dairy products, these items included half a crate of 8 oz of whole milk, 3/4 of a crate of 8oz 2 % milk and half a crate of 32oz of half and half. The expiration dates for these items varied from November 15th, 18th, 19th, and 20th. The milk crates were disorganized, and items were not rotated according to the dates of expiration. The FSM confirmed he was responsible to ensure the items were appropriately rotated and that expired items needed to be removed. 2) On 12/01/23 at 10:24 AM, the surveyor observed a Food Service Worker (FSW) in the kitchen washing and stacking dishes without wearing a hair restraint. When the FSW acknowledge the surveyor she proceeded to the doorway by the exit and obtained a hair net. The surveyor interviewed the FSW and stated that she had been educated on wearing a hair net and wearing proper Personal Protective Equipment (PPE) in the kitchen. The FSW also stated the propose of wearing a hair net is that hair did not get into the food. During this time the FSM was also present. The FSM stated the FSW had an emergency phone call and left the kitchen and upon return forgot to wear a hairnet. The FSM acknowledged that it was not an excuse, and it is the policy and procedure to wear hairnets in the kitchen. 3) On 12/05/23 at 8:30 AM, the surveyor observed the food pantry on E wing with the Registered Nurse Unit Manager (RNUM). The ice scoop holder mounted to the ice machine was noted to have brown murky fluid with particles at the bottom of the scoop holder and the bottom edge of the scoop was in direct contact with the brown murky fluid. The surveyor interviewed the RNUM and she acknowledged the brown water nesting at the bottom of the ice scoop holder and without a means to drain. The resident refrigerator contained packaged lunch meat that was gray and appeared to have mold like cover on it and was dated 11/09/23, a 6 count of bagels that were unopened that contained mold like discolorations and a wrapped sandwich that was undated. The resident refrigerator had signage that was posted on the outside of the refrigerator that stated WHEN PLACING ITEMS IN THE REFRIGERATOR ALL ITMES MUST HAVE: NAME & DATE MAX. HOLD DATE-2 DAYS. EVERY FRIDAY REFRIGERATOR WILL BE CLEANED OUT REMOVE YOUR STUFF!!. On 12/05/23 at 8: 40 AM, the surveyor observed the food pantry on D wing with the RNUM. The floors on D wing pantry were noted to be visibly soiled, the ice scoop holder was visibly soiled with dust and fluid was nesting at the bottom of the ice scoop holder with no means to drain. Upon opening of the refrigerator, a visibly soiled red sticky content on the inner top shelf was observed, there were numerous items undated and expired, which included a container with ham, beans and macaroni and cheese undated, chocolate cake with sell by date of 11/28/23, apple pie with sell by date of 11/24/23, container of rice undated, and completely thawed frozen strawberries undated. The RNUM stated the purpose of dating food is because it could have bacteria. The RNUM also acknowledged the water nesting in the ice scoop holder and said stagnant water can cause bacteria. On 12/05/23 at 9:15 AM, the surveyor interviewed the Director of Nursing (DON) with the concerns of the panties of E and D wing. The DON stated nursing department and housekeeping is to monitor the pantry, and expired items are to be removed daily. The DON stated the ice scoops should be cleaned and should have a means to drain and should not be sitting in stagnant water for infection control purposes. A review of the Food Brought by Family/Visitors Policy updated on 10/2019 number 7.) food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. Part B) perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the us by date. 8.) the nursing staff will discard perishable foods on or before the use by date. 9.) The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). A review of the Staff Attire policy updated on 9/2017 number 1.) All staff members will have their hair off the shoulders, confined in hair net or cap, and facial hair restrained. A review of the Pantry Policy updated on 01/2023 states the facility will ensure Resident Pantries will always be maintained in a sanitary and organized condition. The Policy Explanation and Compliance Guidelines states expired food or food that has been in the refrigerator or freezer for greater than (>) 72 hours will be discarded. Ice Machine is clean and there is no standing water in the bottom of the Ice Scoop holder. NJAC 8:39-17.2 (g)

Based on observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure: a) written policies and procedures were followed to ensure all adverse events were identified and investigated, b) written procedures were followed to ensure the QAPI was consistently data driven and measurable to ensure the effectiveness of the performance improvement initiative, and c) a mechanism was in place and consistently followed to obtain input from staff, residents/ resident representatives. The deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686E, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: the D Unit had a strong odor of urine throughout the Unit. -11:35 AM, two surveyors observed the condition of room on the D Unit which included: D1- room and bathroom floor visibly soiled. D9- the air conditioner unit and door appeared to be torn apart, the privacy curtain was stained and there was debris on the floor. On 11/28/23 at 12:40 PM, a surveyor interviewed two residents in their room on the A Unit (Sub-Acute). Lunch was delivered to Room A005. Observed both Unsampled residents sitting in bed were eating lunch. One Unsampled Resident stated, they haven't cleaned our room yet and the other Unsampled Resident stated, she just came in an emptied our trash. Both Unsampled Residents stated they could not remember when their room and bathroom was cleaned last and stated, they empty the trash but do not clean. At that time, the surveyor observed some small pieces of paper on the floor. On 11/29/23 at 11:52 AM, a surveyor toured the E Unit and outside room E 11 observed a handrail was falling off the wall. The handrail across from nurses' station by bathroom had broken end cap, and the handrail by door of unit day room was not secure. On 11/29/23 at 12:38 PM, a surveyor observed Resident #116 in the day room rummaging through books, pacing in the wheelchair and was unsupervised. A subsequent medical record review for Resident #116 revealed that on 06/14/23 the resident was observed in the 2nd floor lounge and was pulling on the change machine located between two vending machines. The change machine tipped over and hit the resident in the head which resulted in a laceration, bruise, and a skin tear. Resident #116 also sustained multiple falls, including a fall with a fracture on 02/14/22. 11/30/23 at 9:13 AM, a surveyor interviewed the Housekeeper Director (HD) about the cleaning process. The HD stated he had two weeks cleaning schedule. The surveyor asked the HD if he confirmed that the cleaning was being completed and he stated, not often. The HD stated, I do not have enough staff to clean, and I discussed it with the district manager. On 12/12/23 at 9:48 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, about the facility Quality Assurance and Performance Improvement (QAPI) process. The LNHA stated he was the LNHA of record from September 2022 through December 13, 2023, as he was transferring to another facility. The LNHA stated the facility completed monthly QAPI meetings, and the quarterly QAPI meetings were the meeting that included the Medical Director (MD). On 12/12/23 at 9:54 AM, the surveyor asked the LNHA what the QAPI process was. The LNHA stated, it was a way to see how all departments were doing as a building and it was an improvement plan to look at what needed to be focused on. The LNHA stated the quarterly QAPI was a synopsis of what was being reviewed and the MD, along with others were present at that meeting. The LNHA confirmed that he was the facility QAPI Coordinator and he, along with the Director of Nursing was involved with QAPI and was ultimately responsible for the QAPI process. 12/12/23 at 9:56 AM, the surveyor requested the LNHA to list all the current QAPI plans that were in effect prior to the surveyors entering the building. The LNHA stated he did not have any minutes from the July to September 2023 QAPI meetings. The surveyor asked what the policy was for QAPI. The LNHA stated to identify a problem, identify the root cause, who was involved, set up a team, implement interventions and monitor outcomes. The LNHA stated the goal was always 100% On 12/12/23 at 9:58 AM, the LNHA stated the facility's current QAPI's included: 1. The appropriate destruction of narcotics. 2. Antibiotic stewardship- proper use of antibiotics 3. Activity- Smoking appropriately, activity staff, working with nursing on having residents out of bed. 4. The Material Data Set form, section GG with the certified nursing assistants. 5. Therapy- adaptive equipment and splints appropriately. 6. Human Resources-staff retention and recruitment. 7. Central supply- housekeeping and personal protective equipment carts. 8. Maintenance-a lot of peeling bed boards and foot boards. 9. Dietitian-weight loss. 10. Food service- Residents are complaining that food is not hot enough and started 10/01/23 by the new food service director. It is between the kitchen and nursing and was related to a new insulated tray system that was now working and was specific for the temperatures in the kitchen only and to ensure the heating system for the trays was working. 11. Housekeeping- cleaning rooms. The LNHA stated rooms I felt, are not clean the room, and stated the staffing is part of the challenges for housekeeping and maintenance, and other areas. 12. Admissions- involved with housekeeping for new admissions and all items in room. On 12/12/23 at 10:12 AM, the surveyor asked what the mechanism was to identify areas for improvement to bring to the QAPI. The LNHA stated he would get information from the daily morning meeting which included department heads. The surveyor asked if resident families would provide a source of areas to be reviewed in the A from qapi- re: QAPI. The LNHA stated, no, that if a family had a concern, it would be the grievance process. The surveyor asked if the grievances are incorporated into the QAPI process and the LNHA stated, if there is a grievance that stands out, or keeps reappearing, we may QAPI it. The LNHA stated, I am not going to say a specific rule to see that they are part of the QAPI, I typically review every single grievance and sign off. The surveyor asked if there were any QAPI's related to abuse or falls and he stated, no. The surveyor asked how the QAPI monitors significant events. The LNHA stated nursing would be responsible for that. The surveyor asked the LNHA if he could recall the last time a significant event occurred and he stated, it has been discussed but he was not sure when. The surveyor asked the LNHA if any front-line staff, like Certified Nursing Aides (CNA) or housekeeping, attended the QAPI, or were a part of the process. The LNHA stated no the front-line staff, per the policy, were not included in the QAPI. The LNHA stated each department was to themselves and may provide education of the staff and that would be completed with the department managers. The surveyor then referenced the facility QAPI policy regarding Staff members are chosen from staff with direct care and/or service responsibilities, (i.e. other leadership members, nursing assistants, nurse, housekeeping aides, maintenance workers, and dietary aides) to participate in performance improvement projects (PIPs) . The surveyor asked the LNHA if there was a mechanism to report any concerns to the QAPI. The LNHA stated he has an open-door policy and if the staff wanted to be confidential, they could go to Human Resources. The LNHA confirmed he did not have a process to solicit input for the QAPI from all staff. The surveyor asked how the QAPI would monitor improvement. The LNHA stated the next month we would bring up the topic and hopefully see an improvement. The surveyor asked the LNHA if the QAPI process was measurable to determine if improvement occurred. The LNHA stated some of it is data driven. On 12/12/23 at 10:54 AM, the surveyor interviewed the Corporate Nurse (CN) regarding the goals for the QAPI. The CN stated the goal should be specific and measurable and it was part of the QAPI process. On 12/12/23 at 10:56 AM, a surveyor interviewed a CNA #1 who was working on the E Wing and stated she has been employed since September 2021. CAN #1 stated staffing was the biggest issue and she would go to her Union Representative. The surveyor asked CNA #1 about QAPI and she stated, I don't know what QAPI is. On 12/12/23 at 11:09 AM, a surveyor interviewed CNA #2 who stated she has worked at the facility for two years. The surveyor asked about QAPI and she stated, I don't know anything about that. CNA #2 stated staffing was an issue and there were issues with equipment and things get fixed and break again. On 12/12/25 at 11:25 AM, the DON provided the surveyor with a copy of three active QAPI plans which revealed: Problem Statement: Side rail assessments are not initiated quarterly/annually, Goal: All residents side rails assessments much be initiated quarterly/annually, Started 09/24/23. The Metric(s) section of the form was blank; Problem Statement: The injudicious use of antibiotics, Goal: To encourage judicious use of antibiotics, Started 07/21/22, The Metric(s) section of the form was blank; Problem Statement: Antibiotic Stewardship, Goal: To manage the use of and prevent the misuse of antibiotics, The Metric(s) section of the form was blank. A review of the QAPI Meeting Minutes dated 07/10/23 revealed that the DON reported 5 reports of resident to resident abuse and 1 report of drug diversion. There were no documented QAPI plans related to abuse or drug diversion. A review of the following policies revealed: Quality Assurance and Performance Improvement (QAPI) Program policy reviewed 5/2023 revealed: This facility shall develop, implement, and maintain and ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life., 2. Profice a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurements; c. Identifying and prioritizing quality deficiencies, d. Systematically analyzing underlying causes of systemic quality deficiencies, e. Developing and implementing corrective action or performance improvement activities, f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities. The Quality Assurance Performance Improvement (QAPI) Program Plan, Reviewed 5/2023 revealed: Purpose . Focus areas include all systems, processes and outcomes that affect resident and family satisfaction, the quality of care and services provided, and the quality of life for persons living and working in our organization, as well as visitors to our facility. Scope . The principles of QAPI are taught to all staff, volunteers . Governance & Leadership . Administration fosters a culture of quality within the facility, so staff embrace the principles of QAPI and are comfortable identifying quality problems or areas for improvement. Engagement of staff, residents, families and visitors is a hallmark of the QAPI program. PIP (performance improvement projects) Identification . The QAPI team monitors and analyzes data, and reviews feedback and input from residents, staff, families, volunteers, providers, and stakeholders to identify areas to improve the quality of life and quality of care and services . The Quality Assurance and Performance Improvement (QAPI) Program - Feedback, Data and Monitoring Updated 5/2023 revealed the QAPI programs is based on the collection of information obtained from data, self-assessment and systems of feedback . 1. Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI committee in order to identify problems that are high risk, high volume or problem prone and to guide decisions regarding opportunities for improvement . 2. The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. NJAC 8:39- 33.2 (a)(b)(c)12;13(d); 33.3, 34.1(a)(c)(d)

Based on observation, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified in 3 rooms on 2 of 3 nursing units and was evidenced by the following: 1. During the initial tour on 07/20/2021 at 11:14 AM of E wing the following was observed: In Room E10: 1. The wall on the left was missing wallboard leaving an open area above the floor trim and a large area of stripped wallpaper. 2. Further down on the left side there was another area of stripped wallpaper and an open area with a black cable protruding from the hole. 3. The wall between the heater and the window had a large area of stripped wallpaper. 4. The wall to the right of the bed had a large area with stripped wallpaper from around the red emergency outlets to the floor trim. 5. On the left side of the room, there was a dresser with a missing bottom drawer. 6. In the corner on the right side of the bed, there was a dresser with two missing drawers, the first and third drawers. In Room E16: 1. the bathroom door had an open area in the external part of the door with multiple white areas surrounding the open area. During an interview with the surveyor on 07/26/21 at 11:13 AM, a Certified Nurse Aide stated that if a room needed to be repaired, they report it to the charge nurse who would enter the repair into the work order system for the maintenance department. During an interview with the surveyor on 07/26/21 at 01:08 PM, the Registered Nurse/Charge Nurse (RN/CN) stated that maintenance concerns were entered into a work order system and maintenance does the repair. The RN/CN toured rooms E10 and E16 with the surveyor. The RN/CN stated that he had not noticed the holes in the walls, but he was aware of the torn wallpaper. He stated that he should have entered it into the work order system for maintenance for repairs, but he did not. He acknowledged that room E10 should not have the holes in the walls because it could allow vermin to enter the room. He stated that he was not aware of the hole in the bathroom door in room E16. During a tour of room E10 with the Registered Nurse/Unit Manager (RN/UM) on 07/26/21 at 01:23 PM, the RN/UM stated that the room was not homelike one bit. She stated that staff should report repairs as soon as it was noticed. During an interview with the surveyor on 07/26/21 at 01:30 PM, the RN/CN stated that he made rounds every morning on every resident but did not enter the repairs in the work order system for room E10 or room E16. The RN/UM stated that she made rounds on every resident every day but did not check to see if rooms needed repairs. During an interview with the surveyor on 07/26/21 at 01:32 PM, the Maintenance Director (MD) stated that staff enter maintenance repairs into the work order system and then the repairs get assigned to the maintenance staff for repairs. He acknowledged that the repairs for room E10 and E16 were not entered into the computer system. The MD also stated that he made rounds to each unit at least three times a week and asked the nurses if there were any maintenance issues. The MD stated that rooms E10 and E16 were not currently on the list for repairs. Review of the Completed Work Orders for June 2021 revealed no work was completed by the maintenance department for room E10 and E16. Review of the Completed Work Orders for July 2021 revealed that the repair to the bathroom door in room E16 was entered into the work order system on 7/26/2021, after the surveyor had toured with the RN/CN and that the repair was completed on 7/26/2021. There were no work orders for room E10. During an interview with the survey team on 07/29/21 at 09:21 AM, the Director of Nursing (DON), in the presence of the Administrator, stated that licensed staff were expected to report repairs in the work order system upon discovery for maintenance to repair. 2. According to the Facility's admission Record, Resident # 1 was admitted to the facility with diagnoses which included but not limited to; End stage Renal disease, Diabetes with Retinopathy with Macular Edema (eye conditions that causes decrease in vision) . Review of the Minimum Data Set (MDS), an assessment tool dated, 03/27/2021, Resident # 1 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident had severe vision impairment. Review of the resident's care plan dated 10/17/2021 revealed that the resident had vision impairment related to diagnosis of blindness in both eyes with goals for the resident to maintain independence of using electronics. Interventions included to orient resident to his surrounding and to insure privacy and dignity. During an interview with the surveyor on 07/21/2021 at 09:45 AM, Resident #1 stated that he/she had been blind for the past 5 years. The surveyor observed the over bed table had a large area of the laminate missing and the particle board was exposed. The resident stated he/she was not aware of the condition of the table due to his/her blindness. During an interview with the surveyor on 07/23/2021 at 12:45 PM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated she was not aware of the condition of the table and that the table was in disrepair. She stated the nurses usually reported environmental issues but was not aware of the overbed table. During an interview with the surveyor on 07/23/2021 at 2:48 PM, the maintenance staff member showed the surveyor that the table that was removed from the resident's room and placed in a first-floor room for items that were going to be discarded. NJAC 8:39 - 31.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to apply geri sleeves (a protective sleeve that is used on the arms or legs) for a resident who was at high risk for bruising, for 1 of 1 resident reviewed for skin conditions (Resident #16). This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #16 was admitted to the facility in 05/2016 with medical diagnoses which included, but not limited to; Hypertension (high blood pressure), Cerebral infarction (damage in the brain due to a loss of oxygen), hemiplegia (severe paralysis of one side of the body) and hemiparesis (mild or partial paralysis to one side of the body). Review of a Minimum Data Set (MDS), an assessment tool dated 04/22/2021, revealed that Resident #16 had a Brief Interview for Mental Status (BIMS) of 13 which indicated the resident was cognitively intact. The MDS also revealed that the resident required extensive assist of one with dressing. Review of the resident's care plan dated 06/09/2016 revealed that the resident was at risk for bruising/skin tears as evidenced by frail fragile skin, poor safety awareness, impaired sensation, and use of anticoagulants. The goals were that the resident would remain free of skin tear and /or bruising. Interventions included to observe skin condition daily with ADL care and report abnormalities, and remind the resident to wear geri sleeves to protect fragile skin. Review of the Nurse Practitioner Note dated 07/20/2021 at 01:30 PM revealed the resident had bruises on the left hand and arm. During the initial tour of the unit on 07/20/21 at 10:33 AM, the surveyor observed Resident #16 in his/her room, seated in a wheelchair wearing a short-sleeved shirt. The surveyor observed bruising to the resident's left arm. The resident stated he/she usually wore geri sleeves because of bruising, but they were being washed. During the resident council meeting, on 07/23/2021 at 10:00 AM, the surveyor observed Resident #16, not wearing geri sleeves which exposed the bruising on his/her arm. During a follow up interview with the surveyor on 07/26/2021 at 01:00 PM, Resident #16 stated that he/she had not had the geri sleeves for two weeks and have been asking the staff for them. The resident stated that he/she is unable to put them on without assistance. During an interview with the surveyor on 07/26/2021 at 01:00 PM, the Certified Nursing Assistant (CNA) stated if the resident did not have the geri sleeves, the resident would ask for them, but the resident did not. During an interview with the surveyor on 07/26/2021 at 01:10 PM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated if Resident #16 was missing the geri sleeves, the resident would ask for them. On 07/28/21 at 02:30 PM, the surveyor met with the Administrator, Director of Nurses (DON) and the Regional Nurse and informed them of the above observations. On 07/29/2021 at 09:29 AM, during exit meeting, the surveyors met with the Administrator, DON, and Regional Nurse. The DON stated the resident was paralyzed and was unable to apply geri sleeves. She stated that the resident had a diagnosis of Senile Purpura (easily bruising that affect older adults due to fragile skin) and nursing should have ensured the geri sleeves were on to protect the resident's fragile skin. Review of the Activities of Daily Living (ADLs), Supporting policy dated 11/2018 with an update dated 10/2019 included residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. NJAC 8:39-27.1 (a)

Based on observations, interviews, review of clinical records and facility policies and procedures, it was determined that the facility failed to a.) provide a timely and adequate nutritional assessment and/or intervention to impede an unplanned significant weight loss and improve the nutritional parameters for 1 of 6 residents reviewed for nutrition (Resident #132). Resident #132 had a unplanned significant weight as follows: Resident #132 experienced a 14.6 pound (lb.) 6 % weight loss in one week between 6/08/21 to 6/15/21, a 10.5% weight loss of 23.9 lbs. in one month from 6/08/2021 to 7/06/21, and a 31.6 lb. weight loss in seven weeks from 6/08/21 to 7/28/21. This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #132 was admitted to the facility in 6/2021 with medical diagnoses which included, but were not limited to; Hemiplegia (paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength) affecting the right side, Vascular Dementia (brain damage caused from interruption of the blood supply) with behavior Disturbance, Diabetes (too much sugar in the blood) and hypertension (high blood pressure). A review of the Minimum Data Set (MDS), an assessment tool dated 06/14/21, Resident #132 had a Brief Interview for Mental Status (BIMS) of 9, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident required limited assistance of one for eating, and the resident's weight was recorded as 227 lbs. A review of Resident #132 Care Plan (CP) dated 6/14/21 revealed that the resident was nutritionally compromised due to swallowing disorder and need for therapeutic diet for dysphagia (swallowing difficulty), Diabetes and was on a dysphagia advanced diet with nectar thickened liquids and a consistent carbohydrate diet (CCD). The goals included continuing to consume more than 75% of meals. Interventions included: Monitor/document/report signs and symptoms of dysphagia (trouble swallowing). Monitor/document/report to MD signs of significant weight loss: 3 lbs. in one week, more than 5% weight loss in one month or more than 7.5% weight loss in 3 months, and more than 10% weight loss in 6 months. A review of an additional CP dated 6/10/21 revealed that the resident required maximum assistance of one for eating. A review of Resident #132's Order Summary Sheet revealed a physician's order (PO) dated 6/8/21, which included to weigh the resident every Tuesday for 4 weeks, and then weigh the resident the first of the month every month with a start date of 7/1/21. The PO included that the resident was on a CCD with dysphagia advanced texture, and thickened liquid nectar consistency. A review of the resident's Nutritional Assessment, completed by the Registered Dietitian (RD), dated 6/09/21, revealed that the resident's weight was 226.8 lbs. with a usual bodyweight of 215 lbs. The resident consumed 75-100% of most meals per nursing staff, and that the resident had a BMI (Body Mass Index) of 30% obesity class I (low-risk obesity). The RD documented that mild weight loss was beneficial related to comorbidities, increase BMI, and a CCD diet would aid with weight management. Further documentation of the nutrition plan revealed that the RD would monitor and follow oral intake, skin, laboratory values, weights, plan of care, and follow up as appropriate. A review of nurse's Progress Note (PN) dated 6/08/21 at 6:30 PM and on 6/10/21 at 2:35 PM revealed that the resident had +1 bilateral lower extremity edema (swelling caused by excess fluid trapped in the body's tissue when pressure was applied, which left an indent that rebounded immediately). Further review of the nurse's PN revealed no additional documentation of edema. A review of the resident's medical visits by the physician or Nurse Practitioner from 6/10/21 through 7/20/21 revealed the resident did not have any edema, had a satisfactory appetite, and had no significant weight change. A review of the nurse's PN dated between 6/8/21 and 7/24/21 revealed the resident's appetite was excellent or good for breakfast and lunch. There was no documentation for dinner. In addition, there was no evidence that the percentage of consumption for meals was documented. A review of Resident #132's weight records revealed the following: 6/08/21 (admission) weight 226.8 lbs. 6/15/21 weight 212.2 lbs. 6/22/21 weight 210.0 lbs. 6/29/21 weight 204.0 lbs. 7/02/21 weight 204.6 lbs. 7/06/21 weight 202.9 lbs. The above reflected the following weight changes: 6/08/21 to 6/15/21 a 6.4% weight loss of 14.6 lbs. (226.8 lbs. to 212.2 lbs.); 6/15/21 to 6/22/21 a 1.04% weight loss of 2.2 lbs. (212.2 to 210); 6/22/21 to 6/29/21 a 2.86% weight loss of 6 lbs. (210 lbs. to 204 lbs.); 6/29/21 to 7/06/21, a .54% weight loss of 1.1 lbs. (204 lbs. to 202.9 lbs.); 6/08/21 to 7/06/21, an overall 10.5% weight loss of 23.9 lbs. in one month. During an interview with the surveyor on 7/26/21 at 1:00 PM, the Certified Nursing Assistant (CNA) stated the resident fed themselves, was weighed weekly, and currently, it was monthly. During an interview with the surveyor on 7/26/21 at 1:52 PM, the RD stated that new admissions had weekly weights done for four weeks, then are weighed monthly. She said she would reevaluate and intervene if the resident was not eating or there was a significant weight loss of 5% in one month, 7.5% in three months, and 10% in six months. She would then put interventions in based on the resident's diet, write a note, add supplements, and follow up the following month to see if the interventions were effective. Additionally, the weight loss would be discussed during the daily clinical meeting, and the family would be notified. She stated re- weights were done if there was a significant weight loss or if the resident was not eating. She added if there was a discrepancy in the weight, she would typically write a note but would not ask for a re-weight because she would look at the four weekly weights for trends instead. The surveyor asked the RD about Resident #132. The RD stated that the resident had edema on admission, was on diuretics, and ate 75-100% of meals based on staff reports and her observation. She explained that the resident had a high BMI of 30% and should be under 25%. The RD stated that in the resident's assessment that a mild weight loss would be a weight loss that was not significant. The surveyor reviewed Resident #132's weights with the RD. The RD stated that she did not use the admission weight of 226 lbs because she felt that the scale was not accurate and instead went by the second weekly weight of 212 lbs. The RD stated based on the second weekly weight. The resident had a 4.7% weight loss since admission, which was not a concern. The RD confirmed that no re-weights were done for the weight changes that had occurred. During an interview with the surveyor on 07/26/2021 at 03:14 PM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated that the CNA'S would weigh the residents, and the nurses would document the weight in the resident's electronic medical records. She said she usually entered the weights in the computer, and if there were a discrepancy, she would re-weigh the resident. A review of the RD's PN dated 7/26/21 6:39 PM revealed recommendations which included to continue diet as ordered, monitor for any changes from Speech-Language Pathologist, trial 4 ounces of health shake daily for proactive intervention, initiate meal monitoring to confirm the percentage of resident's intake, and initial weekly weights for four weeks. The RD wrote that she would monitor the resident and follow up as needed. During an interview with the surveyor on 7/27/21 at 9:45 AM, the Director of Maintenance stated the facility had a company that would come to the facility to check the medical equipment and calibrates the weight scales. There were no reports from the staff for scales discrepancies. During an interview with the surveyor on 7/27/21 at 9:50 AM, the resident's assigned CNA stated she was in-serviced on how to weigh a resident correctly. The CNA said the resident ate 100 % of meals if the resident was set up correctly and that she would check on the resident during meals. On 7/27/21 at 1:16 PM, the surveyor observed the resident during lunch. The resident was seated in the lounge chair and appeared thin. The CNA set the resident's tray up in their room. The resident was able to feed themselves and consumed 100% of the meal. The CNA was observed going in and out of the room, checking on the resident. On 7/28/21 at 9:38 AM, in the presence of the LPN/UM, the surveyor observed two staff members, a CNA and an LPN, weigh the resident using a lift scale. The resident's weight was 195.2 lbs., which indicated a weight change of 3.79% and a weight loss of 7.7 lbs. (202.9 to 195.2 lbs.) and an overall 13.9% weight loss of 31.6 lbs. since admission. The resident's lower legs were exposed; The surveyor observed no edema on the resident's extremities. During a follow-up interview with the surveyor on 7/28/21 at 9:48 AM, the LPN/UM stated she would verify the accuracy of weights by re-weighing the resident since the resident's last weight was 202 lbs. She added that when the resident was admitted , the initial weight was taken on a different unit (A wing), and the resident's weight was 226 lbs. The resident was then moved to the resident's current unit (D wing) on 6/10/21 and weighed again on 6/15/21 with a weight of 212.2 lbs. She stated she re-weighed the resident, and the weight was the same but did not document the re-weight. She said she felt that maybe the scale was off because the resident moved from one unit to the next. The LPN/UM stated if she thought the scale was not accurate, she would notify maintenance to look at the scale because the scale might need to be calibrated. The LPN confirmed that she did not notify maintenance of a possible scale inaccuracy. The LPN/UM further stated the next weight was on 6/22/21, and the resident's weight was then 210 lbs. They did not document meal monitoring because the resident would eat 100% of meals and snacks. She stated she would notify the RD and physician when there was a weight loss. She stated the resident's weight was discussed during the morning clinical meeting, and it was decided the RD would watch his meals and the team knew the resident was eating 100% of meals with snacks from home. She stated she reviewed the transfer paperwork from the old facility, and she said the supplements were discontinued because of weight gain. The Nurse Practitioner attended the clinical meetings, and they discussed the possibility of a medical issue. She stated they were trying to see if it was due to the facility change, edema, change in supplements, change in snacks, or the diuretic the resident was taking. The LPN/UM confirmed the discussion regarding Resident #132 was not documented. During an interview with the surveyor on 7/28/21 at 10:22 AM, the Director of Nursing (DON) stated when there was a weight loss, they get the RD involved and order blood work to see if other physiological issues or changes were occurring. If the scales were off, they would call the company for re-calibration. The DON stated that Resident #132 had edema and that they were looking for other underlying issues because the resident eats. During an interview with the surveyor on 7/28/21 at 11:17 AM, the Speech Therapist stated she evaluated the resident on 7/27/21 due to weight loss. She also planned to see the resident for a possibility of an upgrade in the diet. During a follow-up interview with the surveyor on 7/28/21 at 11:23 AM, the RD stated that there was a seven-pound weight loss since last weight, and at that point, the resident's weight loss was a concern. She said she asked the resident's family for the usual body weight, which was 215 lbs, and that the resident had a weight gain at the prior facility. She determined the resident's ideal body weight was 178 lbs. The RD further stated that she did not document the change in the weight because she was not confident about the scale accuracy, and she should have documented that. She noted that no triggers popped up to alert her of weight change on her computer, and that's why she did not look into the weights. She stated the resident's weight loss was not discussed during the morning clinical meeting because she did not use the admission weight of 226 lbs, and instead, she used the weight of 212 lbs. She did not notify the physician because she did not think the weight change was an issue since the resident was eating. The surveyor reviewed the resident's care plan with the RD and questioned why the interventions of notifying the physician if there were a weight loss of more than 3 lbs in a week was not followed. She stated she developed the resident's care plan, but that was a default intervention in the computer. She said she instead looked at significant weight losses of 5 % in one month, 7.5% in 3 months, and 10% in 6 months. She stated the care plan was based on concerns and goals for the resident, and the expectation was that it should be followed. The RD added that if the State were not in the facility, she would have continued to use 212 lbs as the resident's weight instead of 226 lbs. However, after the current weight of 195 lbs was obtained, the weight loss was now a concern. During a telephone interview with the surveyor on 7/28/21 at 01:30 PM, the physician stated the resident came into the facility with generalized non-pitting edema, so he adjusted the resident's medication to get rid of fluids. He noted that the resident also had abdominal ascites (fluid accumulation in the peritoneal cavity causing the abdomen to swell). He stated he did not document this because it was something just sensed when he examined the resident. He said he adjusted the medication because he wanted to stop the effects of the vasodilators. He stated he spoke to the family, and they agreed with the treatment, and the residents should stabilize and level out his weight. A review of Resident #132's physician's orders revealed no changes in the resident's medications that would reflect a weight change. During a telephone interview with the surveyor on 7/28/21 at 2:15 PM, the resident's family member stated they would visit the resident once a week. The family member said the RD called the day prior (7/27/21) and spoke about snacks and informed the family member of the resident's current weight, which was around 200's. The family stated they told the RD the weight at the prior facility was around 220 lbs [actual weight 195 lbs]. The family member stated the physician called, today, and he stated he would reassess the medications when he came into the facility to see the resident. A review of PNs from the previous facility revealed a Nutritional/Dietary note dated 5/26/21 at 2:16 PM, which included the resident had a 9% weight gain that month and the current weight was 227.2 lbs. with no edema reported. The recommendations were to discontinue the sugar-free magic cups and boost puddings. A review of the Activity Order Summary report from the previous facility dated active orders as of 5/28/21 revealed the medications were the same as the current standing orders at the current facility. On 7/28/21 at 2:30 PM, the Administrator, the DON, and Regional Nurse were notified of the surveyors' findings. During an interview with the survey team on 7/29/21 at 9:29 AM, the DON stated that they had identified multiple problems with documentation, scale calibrations, and the interdisciplinary approach regarding the resident. She noted the nurse's notes did not consistently document the resident's meal consumption. When there was documentation, it was not based on percentage consumed, but words such as good or excellent. She also stated that the nurses were not astute with documenting the edema the resident had. She noted the resident's weight loss was not a planned weight loss and they should have assumed the weight from the other facility was correct, and re-weights should have been completed. The DON stated that once there was a weight change, the RD should have completed an assessment, notified the family and physician, ordered labs, and look at the interventions that were in place. The DON stated the physician was notified of the weight loss, and labs were ordered the night prior (7/28/21) to see if there were any underlying conditions that could have caused the weight loss after surveyor inquiry. During a follow-up interview with the surveyor on 7/29/21 at 11:07 AM (the day of exit), the DON stated that the resident's bloodwork came back abnormal and that the physician would be notified. A review of Resident #132's laboratory results ordered on 7/28/21 and reported on 7/29/21, revealed that the the resident's albumin (a test to measure malnutrition or liver disease) level was low (3.2 with normal range of 3.5-5.2), and the carcinoembryonic antigen (CEA) (a protein in the blood that could indicate cancer) level was high (6.7 with a normal range of less than 3.8). A review of the Biomedical equipment test results for the facility completed on 6/14/21 revealed that the Hoyer lift scale on A wing was tested and passed for calibration. The Hoyer lift scale on the D wing was tested and passed for calibration. A review of the RD's job description included, but was not limited to; encourage the resident/family to participate in the development and review of the resident's plan of care, maintain an adequate liaison with families and resident as necessary, involve the resident/family in planning dietary objectives and goals for the resident, develop a written dietary plan of care (preliminary and comprehensive) that identifies the dietary problems/needs of the resident and the goals to be accomplished for each dietary problem/need identified, review nurses notes to determine if the care plan is being followed. Discuss problem areas with the Director of Nursing Services. A review of the Change in a Resident's Condition or Status policy dated May 2017 updated 10/2019, revealed the nurse will notify the Physician when there had been a significant change in the resident's physical/emotional/mental condition, and that would require interdisciplinary review and or revision to the care plan. A review of the Care Plans, Comprehensive Person-Centered policy, dated December 2016 updated 10/2019, included that the facility will develop and implement a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs each resident. The interdisciplinary team (IDT), in conjunction with the resident and their family or legal representative, develop and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be developed within seven days after the completion of the MDS assessment. The comprehensive care plan will be prepared by the interdisciplinary team, which includes but is not limited to; a. The attending physician; b. A registered nurse who is responsible for the resident, d. A member of the food and nutrition services staff; f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. The interdisciplinary team must review and update the care plans when there had been a significant change in the resident's condition when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay on at least quarterly, in conjunction with the required quarterly MDS assessment. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatment. Such refusal will be documented in the resident's clinical record in accordance with established policy. A review of the Weight Assessment and Intervention policy, dated 10/2018 updated 10/2019, included that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents; Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the RD in writing; The RD will respond within 24 hours of receipt of written notification; The threshold for significant unplanned and undesired weight loss will be based on the following criteria-One month- 5% weight loss is significant; greater than 5% is severe. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible; The identified causes of weight loss, Goals, and benchmarks for improvement; and Time frames and parameters for monitoring and reassessment. NJAC: 8:39-27.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to a.) maintain an accurate accountability and reconciliation for controlled medications in 1 of 1 automated medication dispensing system storage units and b.) maintain an active Drug Enforcement Agency registration, that was not expired, to order and purchase schedule 1 and 2 controlled substances. This deficient practice was evidenced by the following: On [DATE] at 12:25 PM, the surveyor inspected the automated medication dispensing system storage unit (AMDSSU) in the presence of the Assistant Director of Nursing (ADON). The ADON ran a discrepancy report from the AMDSSU which identified that the medication count was accurate and there were no irregularities identified. At that time, the surveyor interviewed the ADON who stated that a second licensed nurse was required to gain access to controlled medications that were contained within the AMDSSU. He then called for a Licensed Practical Nurse (LPN) to assist and access the controlled medications for the purpose of inspection. The count was determined to be accurate and it was confirmed that no discrepancies were noted. The ADON stated that an inventory of the controlled medications was required to be done daily by two licensed nurses and the records of the inventory were maintained on a log in the Director of Nursing's (DON) office. At 12:53 PM, when the surveyor requested to view the Controlled Substances Log (CSL) the ADON referred the surveyor to the Infection Preventionist Nurse (IPN) who stated that the logs were maintained in a book in the medication storage room beside the AMDSSU. The Surveyor reviewed the CSL which revealed that the shift count was completed most recently on XXX[DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documented evidence that additional Shift Counts were conducted thereafter. The IPN who was present stated that she completed the last shift count of the controlled substance inventory on record with another licensed nurse on [DATE] when she worked as a shift Supervisor. The IPN stated that nursing was required to count the controlled medications every twenty-four hours, sign the Controlled Substances Log (CSL), and generate a printed report from the AMDSSU upon completion to validate the accuracy of the count. She stated that the reports were maintained in the back of the CSL, but it got to be too much, and she just got rid of them. She further stated that sometimes an inventory was conducted via a printed report from the AMDSSU alone as it did not require a second licensed nurse to be present. On [DATE] at 2:12 PM, the ADON provided the surveyor with inventory reports generated from the AMDSSU that were dated [DATE], [DATE], [DATE], and [DATE]. Review of the CSL revealed that there was no documented evidence that two licensed nurses performed an inventory of the controlled substances on the dates that the reports were generated as required as evidenced by a lack of licensed nurse signatures in the CSL. During an interview with the surveyor on [DATE] at 9:45 AM, the DON stated that facility nursing staff were supposed to conduct a controlled substance count every twenty-four hours to ensure the accuracy of the count. She stated that a licensed nurse was not permitted to run an inventory report alone as two licensed nurses were also required to access the AMDSSU and physically count each controlled medication to verify the accuracy of the inventory daily. During an interview with the surveyor on [DATE] at 10:25 AM, the DON explained that the oncoming and outgoing Nurse Supervisors were responsible to count the controlled drugs in the AMDSSU daily and sign the CSL once completed. She further stated that she was responsible to monitor the CSL for completion and lost track of it since COVID. On [DATE] at 1:41 PM, the surveyor reviewed the DEA-222 (Drug Enforcement Agency) Forms (forms used to order class I and II-controlled drugs). The surveyor reviewed the Medical Director's (MD) Controlled Substance Registration Certificate which expired on [DATE]. The surveyor interviewed the DON at that time, and she stated that she would have to investigate it further. On [DATE] at 10:04 AM, the DON provided the surveyor with the MD's current Controlled Substance Registration Certificate for review which expired on [DATE]. When interviewed, the DON stated that it appeared that after [DATE] the MD was not registered and did not have privileges to order any controlled medications for the back-up-controlled medication inventory (controlled medications utilized when the pharmacy was unable to make a routine delivery during off hours) that were stored in the AMDSSU. She stated that the facility had not ordered any controlled medications for the back-up inventory since [DATE] and was not aware that the MD's Controlled Registration Certificate had expired. During an interview with the surveyor on [DATE] at 10:36 AM, the Pharmacy Representative stated that she had worked at the Pharmacy for 15 years and had not previously had an issue with the facility's Controlled Substance Registration Certificate being expired. She stated that if it had expired, the facility would not be able to order back up narcotics for the AMDSSU and would be able to order narcotics for individual residents. During an interview with the surveyor on [DATE] at 10:50 AM, the Pharmacist in Charge (PIC) of the Pharmacy's Narcotic Division stated that the Pharmacy kept a running list of expired Controlled Substance Registration Certificates and reviewed the list before any orders were filled. She confirmed that the facilities Controlled Substance Registration Certificate expired on [DATE]. She stated that the last order that was processed for the facility was on [DATE]. She further stated that the facility would have to fax a copy of the registration to them before they could order any controlled medications for the AMDSSU. During an interview with the surveyor on [DATE] at 11:39 AM, the DON stated that the facility had no issues with drug diversion or missing medications from AMDSSU or otherwise, for at least three years. She stated that occasionally, pharmacy notified that facility that a discrepancy was created and the ADON followed up via a discrepancy report. She stated that discrepancies were easily resolved and were usually caused by data entry errors. During an interview with the surveyor on [DATE] at 9:40 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MD's Controlled Substance Registration for DEA-222 Management was handled by the previous owners, and the reminder for the renewal was sent to them and/or the MD. He stated that the MD's pending renewal request was expected to arrive at the facility within five to seven days. On [DATE] at 11:40 AM, the DON provided the surveyor with the MD's Controlled Substance Registration Certificate renewal which was valid through [DATE]. Reviewed of the facility policy, NSG313 Automated Medication Dispensing System (AMDS) for Interim/Stat/Emergency Supply (Omnicell, Pyxis) (Revision Date [DATE]) revealed the following: 9.1 A reconciliation of controlled drugs (schedule II through V) must be done daily on any medication bin that was accessed in the past 24 hours. 9.1.2 A witness is required for daily reconciliation of controlled drugs and documented as applicable to device in use. 10.1 A designated nurse will check the AMDS device for discrepancy alerts daily and attempt to resolve the dame day. Review of Instructions for DEA FORM 222, that was addressed to the MD and contained within the DEA-222 Book, revealed the following: Purchasers and suppliers who use this form must have an active DEA registration that is not expired, revoked, or suspended. Both parties must be registered to handle the schedule 1 and 2 controlled substance(s) on the order form. NJAC 8:39-29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 7/20/21 at 09:35 AM, the surveyor toured the kitchen in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. The surveyor washed hands at handwashing sink #1 and observed the paper towel dispenser was empty. The [NAME] stated more paper towels were coming from the stock room. The surveyor also observed the foot pedal trash can had no trash bag with trash and debris in the can. The [NAME] acknowledged the debris and stated it usually has a trash bag. 2. In the nourishment/ice cream freezer, there was a box of puff pastry with the inner plastic covering open and the outer cling wrap partially covering the box with the pastry visible and exposed to air. The [NAME] stated it should be covered and removed it from the freezer. 3. In the walk in refrigerator, there were 6 pitchers of liquid with no labels or dates. The [NAME] identified the liquids as water, lemonade and iced tea and stated they should be dated when they are made. There was one box of French [NAME] bread with the inner bag open and the rolls exposed to air. The [NAME] stated the bag should be closed, have a date on it and that we have to toss it. There were three individual plastic bowls with lids stored on a tray with no labels or dates. The [NAME] identified them as salad, removed them and told the staff to throw them away. 4. In the pot/baking supply room on the second shelf of a four tiered silver rack was one large box of confectioner's sugar which contained one individual bag that was opened and wrapped in clear plastic with no open or use by date noted. The [NAME] stated it should have an open and use by date on it and threw it away. On the second shelf of another four tiered silver rack, there were multiple sized serving pans/lids nestled on top of each other. The [NAME] separated two nesting half hotel pans and separated two nesting loaf pans and the surveyor observed moisture between each of them. The [NAME] identified the liquid as water, stated it should not be there and returned the pans to the pot sink. The [NAME] further stated that once the pots are washed and dried on the drying rack then they are stacked in the pot room and that it is important to store them dry to prevent contamination. 5. On the top shelf of a four tiered spice rack the surveyor observed a one gallon container of soy sauce with brown drips on the outside of the container and a one gallon container of light unsulphered molasses with brown drips on the outside of the container. The [NAME] stated it should not be like that and it would be washed. On the second shelf of the spice rack, there was a closed container of ground cumin with a sticky substance on the lid. The [NAME] stated it would be washed. On the third shelf of the spice rack, there was a metal loaf pan half full of white powder covered with clear plastic wrap with a blue scoop sitting on top of the plastic cover. There was no label or date observed. The [NAME] identified it as thickener, stated it was from today, that it should be dated and wrote 7/20/21 on the plastic cover. 6. The meat slicer was observed covered with a clear plastic bag. Upon removal of the plastic bag, the blade was observed to have tan debris. The [NAME] acknowledged it was dirty and it needed to be cleaned, stated it gets cleaned after each use then covered in plastic, and requested a staff member clean the slicer. 7. One white covered bin contained a large opened bag of flour which had a green handled scoop resting on the flour. The [NAME] acknowledged the scoop should not be in the bag, removed the scoop and stated the scoop should be hanging on the side of the bin. 8. In the dry storage room on the top shelf of a four tiered rack in the canned goods section, there were two dented 46 ounce cans of pineapple juice and one dented 50 ounce can of cream of mushroom soup. The [NAME] acknowledged they were dented and stated they should be removed from the shelf and put on the dented can shelf. On the second shelf of the four tiered rack there was one 35 ounce bag of cheerios which was opened and wrapped in clear plastic with no opened or use by date. The [NAME] stated it was used for breakfast today and marked 7/20/21 on it. During an interview with the [NAME] at that time, she stated it was the staff's responsibility to check stock and date food. On 7/21/21 at 09:12 AM, the surveyor toured the kitchen in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. The floor under the dishwash area and handwashing station #1 contained white and rust colored debris. The [NAME] stated they scraped the floors today and were in the process of washing them which they do three times a day. During an interview at that time, the [NAME] stated cleaning was everyone's responsibility and confirmed that it was important to clean regularly, to date and label food when it is opened, pulled or used so people don't get sick and to avoid cross contamination so residents are not in jeopardy. The [NAME] further stated that if food sits out it could develop salmonella or botulism which could cause an outbreak. On 07/23/21 at 11:29 AM, the surveyor was in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. A dietary aide (DA) entered the kitchen, turned on the faucet at handwashing sink #2, wet her hands, lathered with soap for 4 seconds, rinsed hands and attempted to get a paper towel from the dispenser which did not dispense. The DA then went to handwashing sink #1, turned on the water, lathered with soap for 10 seconds, rinsed hands, dried hands with a paper towel and turned off the faucet with the same towel. She then proceeded to the tray prep area to set up trays for the resident's lunch. During an interview with the DA at that time, she stated that staff were to wash hands when they go from one task to another, when they come in the kitchen and when they are dirty. The DA stated they are to wash for two minutes, sing happy birthday twice and thought that was what she did. The DA acknowledged she did not wash that long and stated it was important to handwash correctly to stop the spread of germs. During an interview with the surveyor on 7/23/21 at 11:56 AM, the [NAME] stated the importance of handwashing correctly was to prevent the spread of infection and keep residents from getting sick. Review of the facility's policy Environment, HCSG Policy 028, with a revision date of 9/2017, revealed Procedures 3. All food contact surfaces will be cleaned and sanitized after each use. 6. All trash will be contained in covered, leak-proof containers that prevent cross contamination. Review of the facility's policy Equipment, HCSG Policy 027, with a revision date of 9/2017, revealed Policy statement, All foodservice equipment will be clean, sanitary, and in proper working order. Procedures 3. All food contact equipment will be cleaned and sanitized after every use. Review of the facility's policy Manual Warewashing, HCSG Policy 023, with a revision date of 9/2017, revealed Procedures 3. All serviceware and cookware will be air dried prior to storage. Review of the facility's policy Receiving, HCSG Policy 017, with a revision date of 9/2017, revealed Procedures 4. All canned goods will be appropriately inspected for dents, rust, or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All non-perishable foods and supplies will be stored appropriately. Review of the facility's policy Food storage: dry goods, HCSG Policy 018, with a revision date of 9/2017, revealed Procedures 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility's policy Food storage: cold foods, HCSG Policy 019, with a revision date of 4/2018, revealed Procedures 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy 4.7 Food handling, with a revision date of 6/15/18, revealed Use by dating guidelines 26. Foods in dry storage are in closed, labeled, and dated containers; no open boxes or bags. For products that have been opened but not fully used, a use by date is included on the label. Review of the facility's policy Handwashing/Hand Hygiene, with a reviewed date of 3/2021, revealed Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Procedure, washing hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel NJAC 8:39-17.2(g) NJAC 8:39-19.4 (m,n)