Complaint #: NJ184231 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 21 sampled residents (Resident #178), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #178. A review of the admission Record face sheet (admission summary) revealed the resident was admitted to the facility with diagnoses including; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of the Progress Notes revealed the following: On 1/20/24 at 6:09 AM, the resident was feeling warm and was noted with a non- productive cough. There was no documentation that the family was notified. On 1/22/25 at 5:26 PM, the resident received Tylenol for a temperature of 101 degrees Fahrenheit, was flushed, warm to the touch, and was unable to verbalize symptoms. There was no documentation that the family was notified. On 1/23/25 at 10:38 AM, nursing received a call from the family stating the resident had a visitor that informed the family the resident was sick and questioned why they had not been notified. During an interview with the surveyor on 4/8/25 at 9:47 AM, the Licensed Practical Nurse (LPN #2) said that when there was a change in the resident's condition such as a temperature, a cough, a change in mental status, or any other symptom that would be different from the resident's normal, the family was notified. LPN #2 also said that the notification to the family was documented in the resident's Progress Notes. During and interview with the surveyor on 4/8/25 at 10:01 AM, the Director of Nursing (DON) said when there was a change in a resident's status, the nurse completed an assessment, called the doctor, notified the family, and documented in the Progress Notes. When asked if Resident #178's family was notified of their change in condition in January of 2025, the DON said she could not find any documentation that the family was notified and confirmed they should have been. A review of a facility provided Notification of Change policy dated revised 1/2025, included . The facility must inform the resident, consult with the resident's family and or notify the resident's family member or legal representative when there is a change requiring such notification . NJAC 8:39-13.1(c)

Complaint #: NJ184231 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure there was a physician's order (PO) for oxygen administration and b.) administer nebulizor therapy (a method of delivering medications to the lungs by inhaling a mist created by a nebulizer) consistently according to the physician order. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care and services(Resident #178 and Resident #44), and was evidenced by the following: A review of Resident #178's electronic Medical Record (EMR) revealed two progress notes. On 1/23/2025 at 10:45 AM, and on 1/23/25 at 11:00 AM, which indicated the resident was currently on 2 liters of oxygen. A review of Resident #178's admission Record face sheet (an admission summary) revealed they were admitted to the facility with diagnoses which included; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of Resident #178's Order summary report dated 1/1/2025- 1/24/2025, did not include a PO for oxygen. During an interview with the surveyor on 4/8/25 at 9:47 AM, the Licensed Practical Nurse (LPN #2) said residents on oxygen should have a physician's order. When asked about a resident in respiratory distress LPN #2 said, if they do not already have an order for oxygen, they would used nursing interventions and placed the resident on oxygen at 2 liters per minute then call the doctor for further instructions and placed orders in the computer. During an interview with the surveyor on 4/8/25 at 10:01 AM, the Director of Nursing (DON) said that Resident #178 should have had an order for oxygen. The DON was unsure of when the resident was placed on oxygen and after reviewing the resident's EMR she stated, She didn't have any orders for oxygen but should have. A review of a facility policy titled Oxygen Administration with a revised date of 1/2025, revealed under . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. On 4/7/25 at 10:06 AM, during the initial tour of the facility, the surveyor observed Resident #44's nebulizer on top of their bedside table. The resident stated that they used the nebulizer a couple of times a day. The surveyor reviewed the medical record for Resident #44. A review of the admission Record face sheet revealed Resident #44 was admitted to the facility with diagnoses which included; acute respiratory failure with hypoxia (deficient oxygen in the body) and an abscess of the lung with pneumonia (a collection of pus in the lungs). A review of the resident's most recent Minimum Data Set (MDS), an assessment tool dated 3/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated a mildly impaired cognition. The MDS also reflected that the resident received respiratory treatment which included continuous oxygen therapy. A review of the April 2025 Order Summary Report included the following orders: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) one application inhaled orally every 6 hours for shortness of breath related to acute respiratory failure with hypoxia and bacterial pneumonia ordered on 2/25/2025 and started on 2/26/2025. Oxygen at 4 liters per minute via nasal cannula (a device used to deliver oxygen) as needed for oxygen saturation (level) of 88% or less. A review of the corresponding Medication Administration Record (MAR) in February 2025 revealed that nebulization on the following dates and times was not signed administered: On 2/26/25 at 6:00 PM. On 2/27/25 at 12:00 AM. On 2/28/25 at 12:00 PM. A review of the individualized comprehensive care plan initiated on 2/25/25, reflected a focus for self-care deficit due to recent hospitalization for pneumonia, acute hypoxic respiratory failure, and oxygen use. The interventions included the resident required assistance to complete activities of daily living. On 4/11/25 at 1:36 PM, during an interview with the survey team, the Director of Nursing (DON) stated that if the MAR was not checked then it was basically not done. A review of facility provided policy titled Oxygen Administration revised in January 2025, did not address nebulization therapy. NJAC 8:39 - 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations. This deficient practice was identified for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, and was evidenced by the following: On 4/10/25 at 10:40 AM, the surveyor observed Resident #16 in bed. The resident stated to the surveyor they were taking pain medications because they had three different types of cancer. The resident further explained acetaminophen (Tylenol) usually did not work and after taking it, they would still be in pain. The resident had tried other pain medications like opioids with some success. The surveyor reviewed Resident #16's medical records. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included; depression, rheumatoid arthritis (chronic inflammation of the joints), malignant neoplasm of the isthmus uteri (cancer of the uterus) ,and secondary malignant neoplasm of retroperitoneum and peritoneum (cancer in the abdominal cavity that spread there from a primary cancer in another part of the body). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/26/25, reflected that the resident's Brief Interview for Mental Status (BIMS) score was 11 out of 15, which indicated that the resident's cognition was moderately impaired. A further review of the MDS revealed the resident in the last five days had received as needed pain medication or had been offered and declined. In addition, during the pain assessment interview, the resident revealed they frequently had pain and it occasionally effected their sleep. A review of the Medications section of the MDS revealed the resident was taking opioid pain medication during the last seven days or since admission. A review of the Order Summary Report (OSR) (physician's order sheet) with order date range of 3/1/24 to 12/31/24, revealed multiple orders for pain medications. A physician's order (PO) dated 3/18/24, for acetaminophen 325 milligrams(mg); give 2 tablets by mouth every six hours as needed for pain. A PO dated 3/23/24, for ibuprofen 600 mg; give 1 tablet by mouth every six hours as needed for mild pain. A PO dated 3/23/24, for oxycodone 5 mg; give 1 tablet by mouth every four hours as needed for moderate-severe pain related to unspecified osteoarthritis; pain in unspecified knee. A review of the August 2024, September 2024, October 2024, and November 2024 electronic Medication Administration Records (eMAR) revealed an order dated 3/18/24, for acetaminophen 325 mg; give 2 tablets by mouth every six hours as needed for pain with a discontinued date of 11/10/24. An order dated 3/23/24, for ibuprofen 600 mg; give 1 tablet by mouth every six hours as needed for mild pain with a discontinued date of 11/10/24. An order dated 3/23/24, for oxycodone 5 mg; give 1 tablet by mouth every four hours as needed for moderate-severe pain related to unspecified osteoarthritis; pain in unspecified knee with a discontinue date of 11/28/24. A review of the Consultant Pharmacist's (CP) Pharmacist's Consult to Physician revealed the following recommendations: On 8/27/24, the CP recommended multiple as needed (PRN) medications were noted for the same or overlapping indications. Please sequence the following medication: Tylenol, ibuprofen, oxycodone, and change to mild, moderate, and severe pain respectively. On 4/11/25 at 12:46 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated she received the monthly CP's recommendations from the Director of Nursing (DON) and she was responsible to ensure the recommendations were addressed. LPN/UM #1 stated if they were nursing recommendations, she addressed them, and if they were for the physician, she contacted the physician for their response. On 4/11/25 at 2:07 PM, the survey team met with the facility's Administration. The DON stated the time it took to respond to the CP recommendations was about ten days, but should definitely be addressed prior to the next CP review. The DON acknowledged the pain medication sequencing should have been addressed immediately after the CP identified the issue and made their recommendation. A review of the facility's undated Pharmacy Consultant Policy and Procedure policy revealed . The pharmacist will report any irregularities to the attending physician and the DON, and these reports must be acted upon . The pharmacist will provide the DON with pharmacy recommendation reports on an on-going basis each month. The DON will act upon these recommendations by bringing them to the attention of the attending physician and ensuring any changes are implemented in a timely manner. NJAC 8:39-29.3

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage rooms (East wing) inspected and was evidenced by the following: On 4/7/25 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), inspected the East Unit Medication Room. Observed on the counter was two one-liter opened and removed from the protective packaging Intravenous (IV) solutions for dextrose 5% with 0.45% normal saline (D5/1/2 NS). LPN/UM #1 stated they were for a resident who had been discharged and she was unsure how long the solutions were good for once removed from the protective overwrap. During inspection of the medication room refrigerator, an opened bottle of Tuberculin Purified protein derivative (PPD) 5 TU/0.1 ml (5 tuberculin units/0.1 milliliter) labeled house stock was dated opened 2/26/25. There was also an open bottle of Patient's own insulin aspart dated opened 1/18/25. When asked how long the bottles were good for once opened, LPN/UM #1 stated she believed the opened PPD and insulin should be discarded after 30 days. On 4/14/25 at 10:24 AM, the surveyor interviewed the Director of Nursing (DON), who stated the insulin bottle should have been discarded after 28 days, and the PPD solution should be discarded after 30 days. On 4/14/25 at 12:22 PM, the surveyor interviewed the Registered Nurse for Regional Staff Development (RN/RSD), who stated that IV bags that were resident specific must be used by the date printed on the pharmacy label, and any IV bag without a label and not in the overwrap must be discarded. The RN/RSD acknowledged the IV bags and the opened vials found by the surveyor should have been removed from active inventory. A review of the facility's undated Storage of Medications policy included . the facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed . NJAC 8:39-29.4(h)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (designed to reduce transmission of multidrug-resistant organisms in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This was observed for 1 of 2 unsampled resident (Resident #39) reviewed for EBP. This deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html On 4/9/25 at 10:59 AM, the surveyor observed a sign by the door of Resident #39 that the resident was on EBP, and a PPE bin was outside the room by the doorway. The sign had instructions for staff to wear gown and gloves during high-contact resident care activities that included dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, and wound care. The surveyor went inside the room to interview a sampled resident and noted the roommate, Resident #39 being changed. The surveyor asked Resident #39 if surveyor can observe them being changed which the resident agreed to. The surveyor observed Certified Nursing Assistant (CNA) #1 cleansed the body and changed the resident's incontinence brief. CNA #1 wore gloves but did not wear gown. When the resident was about to be turned to their side still unclothed but wearing incontinence brief, CNA #2 entered the room wearing gloves with no gown. CNA #2 assisted CNA #1 turn the resident to their side and finish putting on their clothing. A review of the admission Record face sheet (an admission summary) revealed Resident #39 was admitted to the facility with diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness of one side of the body following stroke) and neurogenic bladder (nerve damage causing lack of bladder control). A review of Resident #39's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/9/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS further revealed that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) active as of 4/9/25 included the following physician's orders: - Enhanced barrier precautions related to catheter every shift. - Foley/ 16Fr for urinary retention, neurogenic bladder, and/or wound healing secondary to incontinence. - Foley catheter care every shift. A review of the comprehensive care plans revised on 12/13/24, included a focus for the resident being at risk for infection requiring enhanced barrier precautions for indwelling urinary catheter. The goal was for the resident to be free from signs and symptoms of active infection. The interventions included the following: Enhanced barrier precautions, use of gown and glove during high-contact activities such as dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, wound care, and therapy. On 4/9/25 at 11:40 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that staff had to wear gowns and gloves during high-contact activities when residents are on EBP to protect the residents with catheters from infection. The IP further stated that high-contact activities include incontinence care, dressing, showering, washing, transferring, and during feeding assistance in the resident's room. A review of the facility-provided policy titled Enhanced Barrier Precautions revised in March 2024, reflected under Policy Statement the following: To minimize the transmission of germs transferring from residents to staff hands and clothing, staff will wear gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading Multidrug-Resistant Organisms (MDRO). NJAC 8:39 - 19.4 (a)(5)

2. On 4/8/25 at 12:20 PM, the surveyor observed Resident #72 in the rehabilitation room. Resident #72 was observed to have their large Foley catheter bag suspended beneath the seat of their wheelchair. The Foley bag was observed to be inside of a blue privacy bag. The surveyor reviewed the medical record for Resident #72. According to the admission Record, Resident #72 was admitted to the facility with the following diagnoses: displaced fracture of base of neck of right femur, urinary tract infection, retention of urine, and presence of urogenital implants. According to the Minimum Data Set (MDS), an assessment tool dated 3/16/25, Resident #72 had a Brief Interview for Mental Status score of 3 out of 15, which indicated severe cognitive impairment. A review of Section GG revealed that Resident #72 was dependent on staff for activities of daily living. A review Section H of the MDS revealed that Resident #72 had an indwelling catheter. A review of Section I revealed that Resident #72 had active diagnoses of a urinary tract infection and retention of urine. A review of the Order Summary with an order date range of 1/1/25-4/30/25, revealed the following physician's order (PO) for Resident #72: A PO dated 3/10/25, to change drainage bag to leg bag every day shift when out of bed (OOB) and change back to large drainage bag at night, every shift. A review of the ICCP included a focus area that the resident had an indwelling urinary catheter related to urinary retention. Interventions included to: change urinary collection bag as needed/ordered, and report if there was a change in amount, color, or odor of urine. On 4/10/25 at 10:38 AM, Resident #72 was observed seated in a high back wheelchair in the [NAME] Solarium attending an activity after completing physical therapy. Resident #72 had their large catheter bag suspended from the frame under the seat of their wheelchair and enclosed in a large privacy bag. Resident #72 did not have a catheter leg bag as ordered on this observation when out of bed. On 4/10/25 at 1:39 PM, the surveyor observed Resident #72 seated in their wheelchair in the [NAME] Solarium. Resident #72 had a large urinary catheter bag within a privacy bag suspended under the seat of their wheelchair. Resident #72 did not have a leg bag when out of bed as per physician order on this observation. On 4/11/25 at 11:22 AM, the surveyor observed Resident #72 seated in their wheelchair in the [NAME] Solarium. Resident #72 was doing an activity. The surveyor observed Resident #72's large catheter bag inside of a privacy bag and suspended from the seat of their wheelchair. No leg bag was observed. On 4/11/25 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #72. LPN #1 told the surveyor that she had worked with Resident #72 a couple of times. The surveyor asked Resident #72 if they were supposed to have a leg bag when out of bed. LPN #1 told the surveyor I assume it would be done by the nurse. I will check the order and see if it should be changed to a leg bag. LPN #1 then went into the computer and checked the order for Resident #72. LPN #1 then told the surveyor, Yes, they should have a leg bag when out of bed. On 4/11/25 at 1:39 PM the surveyor conducted an interview with facility's Administration which included the Licensed Nursing Home Administrator (LNHA), the Regional Staff Development Nurse, the Director of Nursing (DON), and the Administrator in training. The surveyor asked the Administration if Resident #72 was to have a urinary leg bag when out of bed. The DON told the surveyor, Yes, they should have had a leg bag if that was what the physician ordered. 3. On 4/8/25 at 9:26 AM, the surveyor conducted a record review for Resident #72. Resident #72 had the following active physician order: Document urine output every shift. Start date: 3/10/2025. On 4/8/25 at 1:25 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #72. A review of the 3/1/2025-3/31/2025 Treatment Administration Record (TAR) revealed that the facility failed to document urine output for Resident #72 on the following days and shifts: 3/12/25 day, 3/14/25 night, 3/16/25 evening, 3/17/25 day, 3/20/25 day, and 3/26/25 day shift. A review of the 4/1/2025-4/30/2025 TAR revealed the facility failed to document urine output on the following days/shifts: 4/3/25 night and 4/5/25 evening. On 4/11/25 at 11:25 AM, the surveyor conducted an interview with LPN #1. LPN #1 told the surveyor she had worked with Resident #72 a couple of times. The surveyor told LPN #1 that Resident #72 had a physician's order to document urine output every shift. The surveyor then asked LPN #1 when urine output should be documented. LPN #1 told the surveyor, It should be documented every shift. LPN #1 further explained that she usually does it at the end of her shift. The surveyor asked LPN #1 if the TAR should have any blanks and LPN #1 responded, No. On 4/11/25 at 1:39 PM, the surveyor conducted an interview with facility's Administration which included the Licensed Nursing Home Administrator (LNHA), the Regional Staff Development Nurse, the Director of Nursing (DON), and the Administrator in training. The surveyor asked what a blank on the TAR would indicate? The DON told the surveyor a blank on the TAR indicated that the nurse did not document it. The surveyor then asked the DON if a blank would mean it was not completed as ordered. The DON stated, Yes. The surveyor then asked the DON why it was important to monitor urine output. The DON replied to make sure whatever was going in was coming out, and that it was adequate. On 4/14/25 12:28 PM, the surveyor reviewed the 4/1-4/30/2025 TAR. The TAR revealed that Resident #72 did not have urine output documented by nursing staff on the following shifts: 4/11/25 evening shift and 4/12/25 day shift. A review of the facility's Management of Indwelling Catheter policy dated revised 1/2025. The policy did not include urinary leg bags or monitoring urinary output. NJAC 8:39-19.4(a)5; 27.1(a) Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a.) nephrostomy (a type of urinary catheter inserted through the skin into the kidney to drain urine when there is blockage) care was consistently performed and documented in accordance with a physician order; b.) nephrostomy flushing was consistently performed and documented in accordance with a physician order; c.) urine output from nephrostomy tube was consistently monitored and documented according to physician orders; d.) urine output from Foley catheter was consistently monitored and documented according to a physician order; and e.) large catheter bag (a bag used to collect urine) was consistently changed to a leg bag when the resident was out of bed according to a physician order. This deficient practice was identified for 2 of 3 residents reviewed for urinary catheter (Resident #1 and Resident #72), and was evidenced by the following: 1. On 4/8/25 at 8:30 AM, the surveyor observed Resident #1 in bed during an incontinence round with a Certified Nursing Assistant (CNA). The CNA exposed the brief which was noted to be well-fitted and dry. A nephrostomy tube was noted on the right flank side of the resident's back. The tube was labeled and dated appropriately. There was no dressing noted covering the incision site. The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included; obstructive and reflux uropathy (a condition where normal flow of urine is blocked or flows backward from the bladder anywhere in the urinary tract) and calculus (stone) of the kidney. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/22/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated a moderately impaired cognition. The MDS further included that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) revealed the following active orders as of 4/8/25: - Cleanse around right nephrostomy catheter incision site with NSS (normal saline solution), pat dry, and apply a slit 4 x 4 gauze dressing daily on day shift for wound care started on 10/15/24. - Flush nephrostomy tube daily with 10 milliliters (ml) flush on 7:00 AM to 3:00 PM shift. Apply border gauze to nephrostomy site with daily flush every day shift for nephrostomy tube care started on 12/9/24. - Monitor output and empty bag every shift from right nephrostomy tube every shift started on 8/22/24. - Document urine output every shift started on 8/22/24 and revised on 2/27/25. A review of the monthly Treatment Administration Record (TAR) for the months of October 2024 through April 2025, revealed blanks in the documentation portion for the corresponding orders from the OSR and were not addressed in the progress notes: - 10/30/24, day shift had blanks on order for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 11/8/24, day shift had a blank on order for cleansing of catheter. - 11/13/24, day shift had blanks on order for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 11/29/24, day shift had a blank on order for cleansing of catheter. - 11/30/24, day shift had a blank on order for cleansing of catheter. - 12/10/2024 day shift had blanks on order for cleansing of catheter, order for flushing, and order to document urine output. - 1/13/25, evening shift had a blank on order to document urine output. - 1/16/25, day shift had blanks on order for cleansing of catheter, order for flushing, and order to document urine output. - 1/22/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 2/2/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 2/26/25, day shift had a blank on orders to document urine output. - 3/11/25, evening shift had a blank on order to document urine output. - 3/29/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 4/2/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. A review of the individualized comprehensive care plan (ICCP) dated revised on 12/12/24, included a focus for risk of urinary retention related to kidney stone, benign prostatic hyperplasia (prostate gland enlargement), right nephrostomy tube, bladder outlet obstruction, and chronic obstructive pyelonephritis (kidney infection with blockage of the urinary tract). The goal was for the resident to be free from signs and symptoms of retention. Interventions included to administer the resident's medications per physician orders and to obtain laboratory tests as ordered and notify the physician. Another focus area the resident was at risk for infection due to the nephrostomy catheter that requires Enhanced Barrier Precaution (EBP) (an infection control strategy to reduce transmission of multidrug-resistant organisms in nursing homes). The goal for this focus was for the resident to be free from signs and symptoms of active infections. Interventions included EBP, laboratory tests as ordered, and hand hygiene prior to and after care. On 4/11/25 at 1:39 PM, during an interview with the survey team, the Director of Nursing (DON) was asked by the surveyor what a blank in the administration record would indicate. The DON stated that a blank in the administration records indicated that the nurse did not document it. The surveyor asked the DON if a blank meant the order was not completed as ordered. The DON stated, Yes. The DON was asked by the surveyor why it was important to do catheter care and catheter flushing. The DON replied that catheter care was important to monitor for infection. The DON also stated that flushing was important to make sure the catheter was functioning properly. The DON was asked why it was important to monitor urine output, and the DON replied to make sure whatever was going in was coming out; that it was adequate. A review of facility provided policy titled Management of Indwelling Catheter revised in January 2025, did not address nephrostomy care, nephrostomy flushing, and monitoring of urine output.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to implement Care Plan interventions to reduce the risk for injury for a resident with a known history of skin tears. This deficient practice was identified for Resident #78, 1 of 3 residents reviewed for accidents, and was evidenced by the following: The resident's Face Sheet (FS) indicated that Resident #78 was admitted to the facility with diagnoses that included but were not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission Minimum Data Set (MDS) an assessment tool utilized to facilitate care, dated 08/30/23, indicated that the resident had severe cognitive deficits and required extensive assistance with activities of daily living (ADLs). On 11/03/23 at 10:55 AM, during tour of the [NAME] Unit, the surveyor observed Resident #78 sitting up in a reclining chair. The resident's eyes were closed, and he/she was not able to be interviewed due to severe cognitive deficits. A bandage was observed on the bridge of the resident's nose. The Certified Nursing Assistant (CNA) was tending to the resident at this time and was interviewed. The CNA stated that the resident had fallen last week. The surveyor reviewed the resident's medical records which indicated the following: The Progress Note (PN) dated 11/03/2023 at 22:30 (10:30 PM) indicated that Resident #78 was found with a skin tear to the right forearm and posterior left shin. The PN also indicated that a treatment was ordered, and the physician and supervisor were made aware. The PN dated 11/04/2023 at 02:52 PM, indicated that a CNA identified that Resident #78 had a skin tear with some bleeding on the resident's left outer lower leg while the resident was in the recliner outside of the nurse's station. The skin tear measured 3.5 centimeters (cm) by 3 cm and a treatment was provided with NSS (saline) and steri strips (skin closure strips). A clean, dry dressing (CDD) was also applied. The PN indicated that the resident was agitated, anxious and restless in the recliner before the skin tear was found and may have bumped his/her leg against the recliner. The PN also indicated that the resident had leg sleeves on, but the left one was pulled up on the leg towards the thigh and was put back on his/her lower leg. The Treatment Administration Record (TAR), dated 11/03/23, reflected a physician's order to cleanse skin tear on the left forearm with NSS and appy triple antibiotic ointment and cover with a dry clean dressing twice a day for seven days. Resident #78's CNA [NAME] (gives a overview of each resident's care) indicated that the resident required moderate assistance of one (1) staff member for ambulation and moderate assistance of one (1) staff member for transfers. Resident #78's Care Plan (CP) did not reflect interventions regarding preventative/protective measures for Resident #78's fragile skin on the resident's bilateral arms. On 11/06/23 at 10:23 AM, the surveyor observed Resident #78 in a low bed with a mattress on the floor next to the bed. The resident was noted to be confused, had garbled speech, and was agitated. The resident had protective sleeves on the lower extremities. The surveyor observed that the resident had bruised knees and bruised fragile, thin skin on both upper arms. The surveyor also observed a dressing on the left forearm. The CNA entered the room and that time and was interviewed. The CNA stated indicated that the resident had a skin tear on the left arm but did not wear protective sleeves on upper arms, just lower legs. On 11/06/23 at 10:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she had been employed through the agency and had been coming to the facility for 22 years. The LPN described Resident #78 as anxious, restless, and required complete care with ADLs. The LPN stated that the resident's medications were changed last week for the anxiety. She also explained that the resident was non-ambulatory and required one (1) staff member to transfer. She stated that the resident utilized the wheelchair (w/c) or the reclining chair when he/she got out of bed. She stated that the resident was at risk for falls and that preventative fall precautions were in place which included: bed alarm, chair alarm, low bed, and a mattress on the floor next to her bed (crash pads). The LPN stated that the resident's skin was very fragile, and it did not take much for his/her skin to bruise or develop a skin tear. The LPN stated that the protective preventive measures to protect the resident's skin included protective sleeves on the resident's bilateral legs and moisturizer. The LPN stated that the resident did not wear any protective devices on his/her bilateral arms and did not have any response as to why there were no protective measures for Resident #78's fragile skin on the bilateral arms. The LPN stated that she was not sure if an incident or accident report was completed when the resident developed the skin tears on 11/03/23 and 11/04/23. On 11/08/23 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) who admitted that she was not aware that Resident #78 had developed skin tears on the left forearm and posterior left shin on 11/03/23 and on the resident's left outer lower leg on 11/04/23. The DON explained that she did not think that any incident or accident reports were completed when Resident #78 developed the skin tears on 11/03/23 and 11/04/23. She stated that she would find out what happened and that maybe the incident reports were on the unit. The DON indicated that it would have been important to ensure that preventive/protective measures were put in place to prevent the reoccurrence of skin tears on the resident's upper arms. She stated that protective or preventive measure should have been documented on the CNA [NAME] and the CP. The DON confirmed that the resident's CP and CNA [NAME] were not updated with any new interventions to prevent the reoccurrence of skin tears on Resident #78's arms. On 11/13/23 at 12:36 PM, the DON provided the surveyor with incident reports for Resident #78's skin tears that were found on 11/03/23 and 11/04/23. She stated that the incident reports were sitting on the Units Manager's desk and have not yet been investigated. She stated that the acting Unit Manager told her that she did not know what to do with the incident reports and was going to give them to the DON during the morning meeting but never did. The DON admitted that interventions were not implemented to protect the resident from further injury after the discovery of the skin tear on the left forearm and the back of the left shin on 11/03/23, and after the discovery of the skin tear on the left lower leg on 11/04/23. On 11/17/23 at 09:49 AM, in the presence of the survey team, the DON stated that she tried to investigate the skin tears after the fact and that the information she had received was that the incident report did not make it to a supervisor or unit manager for review. She stated that there was oversite related to a communication breakdown. The DON also stated that there was not a policy regarding Care Plan or updating Care Plans. The surveyor reviewed the facility policy titled, Skin Report Worksheet, dated 04/2013, that indicated any preventative devices such as a wheelchair or geri-chair cushions, wedge cushions, boots, extra pillows, etc. will be ordered to relieve pressure to the area. The surveyor reviewed the facility policy titled, [NAME], with a revised date of 01/15, that indicated the purpose of this tool was to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the [NAME] would be changed, as Resident care needs change. N.J.A.C 8:39-33.1 (d)

Complaint NJ #: 157448, 158079, 162538, 162579, 163502 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 of 13 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Report completed by the facility for the week of 08/21/22 to 08/27/22 revealed the facility had no RN coverage for all shifts on 08/24/22 and 08/26/22. Review of the PBJ Staffing Data Report for Quarter 3 2023 (April 1 - June 30) revealed the facility had no RN hours for the following dates: -04/08/23 (Saturday) -04/09/23 (Sunday) -04/22/23 (Saturday) -05/21/23 (Sunday) -06/03/23 (Saturday) -06/07/23 (Sunday) Review of the Employee Daily Schedule By Shift, provided by the facility, for the aforementioned dates verified that there was no RN scheduled to work 8 consecutive hours on the following days: -08/24/22 -08/26/22 -04/08/23 -04/22/23 -05/21/23 -06/03/23 During an interview with the surveyor on 11/14/23 at 10:51 AM, the Staffing Coordinator stated there should be a RN in the facility daily for 8 consecutive hours. During an interview with the surveyor on 11/15/23 at 11:06 AM, the Director of Nursing (DON) stated there should be a RN in the facility for 8 consecutive hours daily. The DON further stated that there had been times when there is no RN for 8 consecutive hours when there are call outs. During an interview with the surveyor on 11/15/23 at 11:23 AM, the Licensed Nursing Home Administrator (LNHA) stated that there should be a RN in the facility daily for 8 consecutive hours. Review of the facility's Nursing Policy and Procedure Staffing Guidelines policy, revied 08/2022, included, The minimum staffing needed for each skill level (RN, LPN, CNA, and Unit Clerk) is determined by the nurse-patient ratio guidelines and the patient/resident care needs, i.e., level of acuity and based on New Jersey state minimum requirements. NJAC 8:39-25.2(h)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to properly label and date opened multidose medications for 2 of 3 medication carts (West Side 1 and East Side 1) inspected. This deficient practice was evidenced by the following: On 11/09/23 at 10:16 AM, the surveyor inspected the [NAME] Side 1 medication cart in the presence of Licensed Practical Nurse (LPN) #1. Inside the medication cart, the surveyor observed the following: -1 insulin lispro pen which was opened but not labeled with an opened date -1 insulin glargine pen which was opened but not labeled with an opened date At that time, the Assistant Director of Nursing (ADON) verified the insulin pens had been opened but not labeled with an open date. The ADON further stated that the pens should have been dated upon opening and that she would dispose of the insulin pens. On 11/09/23 at 10:30 AM, the surveyor inspected the East Side 1 medication cart in the presence of LPN #2. Inside the medication cart, the surveyor observed the following: -1 Breo Ellipta inhaler which was opened but not labeled with an opened date -1 Trelegy Ellipta inhaler which was opened but not labeled with an opened date At that time, LPN #2 stated the inhalers should have been dated upon opening. During an interview with the surveyor on 11/15/23 at 11:06 AM, the Director of Nursing (DON) stated insulin pens and inhalers should be dated upon opening. The DON explained that opened multidose medications should be labeled with an opened date so that the nurse knows how long the medication is good for based on manufacturer's guidelines. Review of the manufacturer's guidelines for Humalog (insulin lispro), revised 03/2013, included, In-use Humalog vials, cartridges, pens, and Humalog Kwikpen should be stored at room temperature . and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the manufacturer's guidelines for Lantus (insulin glargine), revised 05/2019, included, Do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. Review of the manufacturer's guidelines for Breo Ellipta, revised 05/2023, included, Discard Breo Ellipta 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. Review of the manufacturer's guidelines for Trelegy Ellipta, revised 06/2023, included, Discard Trelegy Ellipta 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles policy, dated 01/2020, included, Once any medication or biological package is opened, the Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. NJAC 8:39-29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 11/09/23 at 11:56 AM, the surveyor observed a Certified Nursing Assistant (CNA #2) with two lunch meal trays on a rolling bedside table (BST) in the [NAME] Wing hallway. CNA #2 entered room [ROOM NUMBER] and placed a meal tray on the resident's BST then returned to the hallway, gathered the second meal tray, and entered room [ROOM NUMBER]. CNA #2 placed the meal tray on the resident's BST, opened the carton of milk and poured the contents into a cup, opened a straw, and placed it into the cup, opened the lid from the ice cream, then removed the plastic food lid and placed it on the BST. CNA #2 then opened the potato chip bag, cut up the food with the fork and knife, opened two sugar packets and poured them into the coffee and mixed it with a spoon. She then moved the BST closer to the resident, collected the trash and placed it into the food lid and left the room with the lid which contained the empty milk container, straw paper, sugar wrappers and ice cream lid and placed them on the rolling BST in the hall. The resident was then observed using her fork to eat her lunch. CNA #2 then moved the rolling BST with the dirty lid, up the hallway to the food cart, where she placed the dirty lid containing the trash, on top of the cart. She moved the BST aside, took a lunch meal tray from the food cart and placed it on the rolling BST, touched the front of her surgical mask to adjust the mask on her nose, rolled the BST down the hallway while stopping to remove an additional BST from the hall and placed it into room [ROOM NUMBER], then stopped at room [ROOM NUMBER], an isolation room. CNA #2 stood at the doorway and removed a disposable isolation gown from the personal protective equipment (PPE) bin and unfolded it. A speech therapist approached and spoke with the CNA, at which time CNA #2 loosely rolled up the isolation gown and placed it on top of the PPE bin and walked up the hallway. CNA #2 touched the right side of her hair while she stopped to speak with another staff member in the hallway, then walked to another hall to retrieve a towel from the linen cart and walked back to room [ROOM NUMBER]. CNA #2 then donned (put on) the rolled-up gown from the top of the PPE bin, donned gloves, knocked and entered room [ROOM NUMBER]. CNA #2 reached down with her right hand and moved the blue mat that was on the floor, she then pulled the privacy curtain partially between the residents, placed the towel over the resident as a clothing protector, moved the resident's BST, adjusted the bed linens, pulled a chair near the resident, moved the resident's bed closer to the wall, removed the food lid, set up the meal tray then sat in the chair and fed the resident lunch. No hand hygiene (HH) was observed during the observation. During an interview at that time, CNA #2 stated that HH should have been performed between each resident and acknowledged she did not clean her hands correctly during the meal tray pass observation. The CNA stated it was important to make sure HH was completed correctly during tray pass so germs were not transferred. On 11/09/23 at 12:18 PM, the surveyor interviewed the assigned Licensed Practical Nurse (LPN #3) who stated that during meal tray pass, hand sanitizing should have been done between residents to prevent cross contamination and spreading of germs. On 11/09/23 at 12:22 PM, the surveyor interviewed LPN #2, who stated she was the Charge Nurse on the unit today, and informed her of CNA #2's meal tray pass observation. LPN #2 acknowledged that CNA #2 did not perform HH correctly and stated that there were several missed opportunities for the CNA to perform HH. LPN#2 stated that HH should have been performed between each resident and that it was important to perform HH correctly to prevent cross contamination. On 11/09/23 at 12:36 PM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that HH should have been performed any time before and after resident care. The surveyor informed the LPN/UM of CNA #2's meal pass observation, and she acknowledged that the CNA did not perform HH correctly. She further stated that it was important to perform HH correctly to prevent the spread of germs. On 11/09/23 at 12:49 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that HH should have been performed by staff: prior to touching meal trays, with any contact with food items, with any personal contact with residents, and performed between residents. The surveyor informed the ADON of CNA #2's meal pass observation. She acknowledged that the CNA did not perform HH correctly and stated that it was important to perform HH correctly to prevent infection. On 11/13/23 at 09:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that HH should have been performed before entering a resident's room, when handling food, and performed between residents. The surveyor informed the DON of CNA #2's meal pass observation from 11/09/23. She acknowledged that the CNA did not perform HH correctly and stated that it was important to perform HH correctly to prevent the transmission of infection. On 11/13/23 at 10:15 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that HH should have been performed before passing meal trays, after providing the resident with their tray and preparing their food and performed in between each resident. The surveyor informed the IP of CNA #2's meal pass observation from 11/09/23. The IP acknowledged that the CNA did not perform HH correctly and stated that HH was the important first step in breaking the chain of transmission to any pathogen. On 11/15/23 at 12:19 PM, the surveyors met with the Administration team and the team was informed of CNA #2's meal pass observation from 11/09/23. The surveyor requested from the LPN/UM, IP, ADON, DON and Licensed Nursing Home Administrator any hand hygiene inservices for CNA #2 prior to 11/09/23. No documentation was provided. The surveyor reviewed the facility policy titled, Isolation-Notices of Transmission-Based Precautions, dated August 2019, that indicated that notices will be used to alert personnel and visitors of TBP while protecting the privacy of the residents. The policy indicated that when TPB are implemented, the IP or designee determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart to that personnel and visitors are aware on the need for and type of precautions. The surveyor reviewed the facility policy titled, Isolation-Initiating Transmission-Based Precautions, dated August 2019, that indicated that if a resident was suspected of, or identified as, having a communicable infectious disease, the charge nurse or nursing supervisor notified the IP and resident's attending physician for evaluation of appropriate TBP. When TPB are implement, the IP clearly identifies the type of precautions, anticipated duration and the PPE that must be used. The policy also indicated that the physicians are involved in decisions related to infection control and residents under their care. The surveyor reviewed the facility policy titled, Physician's Orders, dated 01/13, that indicated the purpose of the policy was to communicate and document the physician's order for care and treatment of residents. The surveyor reviewed the facility policy titled, [NAME], with a revised date of 01/15, that indicated that the purpose of this tool is to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the [NAME] would be changed, as Resident care needs change. The surveyor reviewed the facility policy titled, Hand Hygiene, reviewed 2/14, that indicated, Procedure: 1. Indications for hand washing and hand antisepsis: c. Before having direct contact with Residents. i. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the Resident. The surveyor reviewed the facility policy titled, Personal Protective Equipment-Contingency and Crisis Use of Facemasks, dated April 2020, that indicated, General Procedure for Donning and Doffing Masks. 1. D. After touching a facemask or before changing a face mask, perform hand hygiene. f. Handle a mask only by the elastic ear loops. g. Refrain from touching the mask while it is in use. 2.a. Front of mask is contaminated-DO NOT TOUCH. The surveyor reviewed the facility policy titled, Personal Protective Equipment-Using Face Masks, revised September 2010, that indicated, Miscellaneous. 8. Handle mask only by the strings (ties). 9. Never touch the mask while it is in use. NJAC 8:39-19.4 (a)(m)(n) Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to a.) provide a safe environment to prevent the potential spread of infection by not following standards of infection control procedures for 1 of 6 residents reviewed for infection control (Resident #82) from 10/24/23 until 11/06/23, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units (West Wing) observed. The deficient practice was evidenced by the following: 1.) The surveyor reviewed Resident #82's Face Sheet (FS) which indicated that the resident had the diagnoses which included but was not limited to dementia and aphasia (a disorder that affects how you communicate). The admission Minimum Data Set (MDS) an assessment tool that facilitates a resident's care, dated 08/07/2023, reflected that the resident had severe cognitive deficits and required limited to extensive assistance with activities of daily living (ADLs). On 11/03/23 at 12:06 PM, the surveyor observed the resident sitting up in the chair in his/her room. The resident's responsible party (RP) was present in the room and was interviewed at the time. The RP stated that the resident had a rash located on the groin area and was not sure what the rash was but was being treated with a cream that appeared to be helping. The RP stated that she had no complaints regarding the care the resident received and that she was very happy with the care. The surveyor observed an isolation cart (cart containing personal protective equipment (PPE) such as gloves, isolation gowns, gloves and face masks) located in the front of the resident's doorway, however the surveyor did not observe any signage on the resident's door to indicate that the resident was on isolation. The surveyor interviewed the RP who stated that the isolation cart was in front of the door because the resident had a rash on the groin area and that you had to wear a gown and gloves when you provided care to Resident #82. The surveyor reviewed the nursing Progress Notes (PN) that indicated that following information: The PN dated 10/24/2023 at 08:00 AM [Recorded as Late Entry on 10/24/2023 08:08] for 10/23/23, indicated that the Nurse Practitioner (NP) was told by the Resident's spouse that Resident #82 had spots on his/her upper inner thighs. The PN indicated that the resident was assessed by the NP and it had appeared that there were more red spots with raised hard centers and that some red spots seemed to have flattened out and appeared smooth. The PN also indicated that the spots had no drainage and that the resident stated that the areas were not itching, however there was some stinging or burning. A dermatology consult was ordered, and the resident was put on contact precautions (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient had handled). The PN dated 10/24/2023 at 22:29 (10:29 PM), indicated that the resident was seen by dermatology and the reddened area on the resident's groin were biopsied. The PN dated 10/30/2023 at 04:27 AM, indicated that the resident was on contact isolation. The PN dated 11/01/2023 22:33 (10:33 PM), indicated that the resident was on contact isolation. The PN dated 11/02/2023 at 14:57 (02:57 PM) indicated that Resident #82 was on contact isolation precautions related to red spots on the inner thigh and isolation precautions were maintained during the shift. The surveyor reviewed the Care Plan and there was no documentation that the resident was on contact isolation. The surveyor reviewed the Certified Nursing Assistant [NAME] (provides an overview of each patient and what care that was to be provided) and there was no documentation the resident was on contact isolation. The surveyor reviewed the Physicians Orders (PO) and there was no PO that the resident was to be on contact isolation. On 11/06/23 at 11:57 AM, the surveyor interviewed the primary care Certified Nursing Assistant (CNA #1) who stated that he was assigned to provide care for Resident #82. CNA #1 explained to the surveyor that the resident required extensive assistance with activities of daily living (ADLs). The surveyor asked CNA #1 why there was an isolation cart placed outside Resident #82's doorway and the CNA stated that Resident #82 was not on contact isolation and that the isolation cart in front of the resident's room was for another resident that had COVID. He stated that the resident's RP came in daily to wash and dress the resident. CNA #1 added that he was not aware that the resident was on contact isolation for a rash on the inner thighs and was not aware that he was supposed to don (put on) PPE when caring for the resident. He also stated that there was no signage on the door that indicated that the resident was on contact isolation. He stated that he did not get report this morning because he was there early before every other staff member. On 11/06/23 at 11:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that it was written on the 24-hour report that Resident #82 was on contact isolation for red spots on the inner thighs. She stated that she was not sure what the rash was and that she had not looked at it yet and was going to do the treatment this afternoon. She stated that it was documented on the 24 report that the resident was on contact isolation. She stated that contact isolation consisted of wearing gloves, gown, and mask when in contact with the resident or when performing care. The surveyor questioned LPN #1 regarding why the CNA was not informed that the resident was on contact isolation and LPN #1 stated that this was her first day and that she did not give the CNA report this morning. LPN #1 then proceeded to ask CNA #1, in the presence of the surveyor, why he did not know that the resident was on contact isolation, and CNA #1 responded, Because nobody told me. On 11/06/23 at 12:16 PM, the surveyor interviewed a nurse who identified herself as the acting LPN Unit Manager (LPN/UM). The acting LPN/UM stated that if any resident had a contagious infection that the nurse would have had to obtain a PO for the resident to be on transmission-based precautions (TBP). She stated that she was not positive that you had to get a PO and would have to check with management. She continued to explain that that if a nurse found out that a resident had a contagious infection that the nurse would have been responsible to notify the physician and the resident's family. She explained that if a resident was on TPB then signs would have been posted on the door to see the nurse and isolation carts would have been placed in the front of the resident's room. She also added that all staff would have been notified regarding the resident condition and that the family would also have been notified. She confirmed that it would have been important for staff to know if the resident had a contagious infection and what PPE the staff were required to wear when they cared for or came in contact with the resident. She stated that it was important that the appropriate PPE was worn, hand hygiene was performed and that specific medical equipment was assigned to that resident to both contain, and prevent, the spread of infection. She stated that it would have been documented in the 24 hour report and also documented on the resident's CNA [NAME] and Care plan. She stated that Resident #82 had a biopsy and that it was determined that it was dermatitis, however the resident was put on contact isolation just in case because they did not know what the rash was. The acting LPN/UM stated that CNA #1 should have known that the resident was on contact isolation so that he could have worn the appropriate PPE when in the resident's room or when caring for the resident. She also reviewed Resident #82's medical record with the surveyor and confirmed that there was not a PO for the resident to be on contact isolation and it was not documented on the Care Plan, the resident's CNA [NAME], nor on the Treatment Administration Record (TAR). She stated that the resident's [NAME] was something that the CNAs utilized to find out what type of care a resident required. On 11/06/23 at 12:23 PM, the surveyor interviewed LPN #2 who stated that you would not have to obtain a PO to put a resident on isolation and that it was nursing judgment. On 11/06/23 12:34 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that stated that a PO was required to put a resident on isolation or transmission-based precautions (TBP). She stated that the PO should have been obtained for whatever type of TBP the resident was to be on. She also explained that signage should have been posted on the resident's door to see nurse. She stated the sign posted on the door was a notification to visitors or staff that something was going on with the resident and that they should see the nurse to obtain additional information before entering the resident's room. She continued to explain that an isolation cart was placed outside the room with the appropriate PPE, and that it should have been documented on the 24- hour report (24-hour communication form for each shift) that the resident was put on isolation. She stated that she told the nurse last week to put Resident #82 on contact isolation for the groin rash because she was not sure what the rash was. She admitted that she did not follow-up to make sure that the staff obtained a physician's order for the isolation. She stated that it should also have been documented in the TAR, on the CNA [NAME], and on the CP that the resident was on contact isolation. The IP admitted that she did not follow-up with Resident #82 to assure that this was implemented and stated that it was hard for her to follow-up because the administration had her performing other duties instead of focusing on her role as the facility's IP. The IP stated that the importance of ensuring that staff adhered to the contact isolation policy was to prevent the spread of infection. The surveyor reviewed the PN dated 11/06/2023 at 13:51 (01:51 PM) that the biopsy results came back from the dermatologist office and the rash was not contagious. The note also reflected that the resident was removed from contact isolation. On 11/08/23 at 10:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when the resident was put on TBP the nurse should have called the physician to obtain an order for the resident to be on TBP. She continued to explain that the nurse would also have been responsible to get an isolation set up outside the resident's room which contained isolation gowns, masks, gloves, facial shields (PPE), and that signage was supposed to be placed outside the resident's door. The signage indicated that the visitor should stop and come to the nurse's station to find out what type of PPE and isolation was required to visit that resident. The notification that the resident was on contact isolation was written on the 24-hour report and the nurse would communicate this information to the CNA. She continued to explain that the IP usually would notify administration by way of phone and email. She stated that this all should have been documented in the progress notes, resident Care Plan and CNA [NAME]. The DON confirmed that all these infection control processes should have been implemented. The DON also stated that these processes were required to be put into place to prevent the potential spread of infection. On 11/14/23 at 11:20 AM, the surveyor interviewed the DON who stated that the CNA [NAME] was the most easily accessed piece of information regarding resident care and that it needed to be updated to assure that the CNA knew how to care for the resident. She stated that it would have been important to document in the [NAME] that the resident was on contact isolation so that the CNA knew. The DON stated that the facility did not have a policy regarding Care Planning. On 11/15/23 01:20 PM, the surveyor interviewed the IP and the Medical Director who stated that a physician's order was required to put a resident on isolation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an accident/incident for 3 of 6 residents (Resident #22, #55, and #78) reviewed for accident/incidents. This deficient practice was evidenced by the following: 1.) On 11/03/23 at 10:23 AM, during the initial tour, the surveyor observed Resident #22 sitting in a wheelchair in their room. Resident #22 stated that he/she did not have any complaints about the facility. The surveyor reviewed the medical records for Resident #22. According to the Resident Face Sheet, Resident #22 was admitted with diagnoses that included dementia, high blood pressure, muscle weakness, and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body.) A review of the quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate care, dated 09/26/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident's cognition was moderately impaired. A review of the Care Plan (CP), start date on 03/25/2022, included the resident was at risk for skin breakdown r/t [related to] decreased mobility, poor safety awareness with an approach to conduct a systematic skin inspection per protocol. A review of the Progress Notes (PN) from August 2023 revealed the following: -08/09/23 10:34, the Registered Nurse (RN) was called into the resident's room for assessment due to crying out in pain. The RN noted a negative x-ray result from right hip earlier in the week. The RN was unable to remove the resident's pants to assess, due to the resident's refusal. Pain medication was administered. The Certified Nursing Assistant (CNA) assisted the resident with activities of daily living (ADLs) and noticed a large bruise on the resident's right posterior leg. The RN was called back in the resident's room and noted right posterior knee area had a large bruise colored blue, purple, and yellow approximately 16 inches (in.) x 10 in. with a round hard edema (swelling) noted in entire bruised area. Resident #22 was sent out to the emergency room to rule out (r/o) right leg fracture or deep vein thrombosis (DVT - a blood clot that forms in a deep vein). - 08/09/23 18:46 (6:46pm), Resident #22 returned to the facility, included bruising to the right leg remains the same. -08/11/23 12:16, large hematoma (bruise) noted to lower extremity, excessive bruising noted. -08/13/23 06:33, bruising to back of right knee continues. -08/13/23 06:15, observed bruise at the right inner thigh down to joint. On 11/06/23 at 10:48 AM, the surveyor requested any accident and incident reports for Resident #22. On 11/08/23 at 10:07 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), again, any accident and incident reports for Resident #22. On 11/08/23 at 10:51 AM, the surveyor observed Resident #22 in his/her room sitting in a wheelchair watching tv. Resident #22 stated that he/she did not remember having any bruises on their leg but that they were doing okay. Resident #22 stated that the care was good and that anything he/she needed that the staff assisted. On 11/08/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that Resident #22 was on aspirin (ASA) 81mg daily. LPN #1 stated that skin assessments were documented on the paper chart on the resident's shower days which were twice a week. The surveyor asked LPN #1 what the process was if a resident obtained a bruise from an unknown origin and LPN #1 stated that for an unknown bruise they would have completed an incident report that went back for 72 hours. She further stated they obtained statements from the staff within the past 72 hours that cared for or had seen the resident. She then stated that the statements went to the Unit Manager (UM) which were then discussed during the morning meeting with the administrative team, and that the physician and the family were notified. LPN #1 reiterated the protocol for an unknown bruise included to write up an incident report to investigate on how it occurred. On 11/08/23 at 12:25 PM, the Director of Nursing (DON) stated that the incident report was completed but that she was still trying to find it. On 11/09/23 at 10:03 AM, the DON stated that she still had not found the incident report. At that time, the surveyor inquired about the bruise that was documented in the PN. The DON stated that she could not recall at that time about the bruise. On 11/09/23 at 10:29 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that if she observed a bruise on the resident or it was something new, she would inform the nurse. She stated that she would have had to write a statement on what she saw or what the resident was doing during the last time she saw the resident, and if it was witnessed or not. CNA #1 stated that once the statement was completed she gave it to the nurse. On 11/13/23 at 12:03 PM, the surveyor interviewed LPN #2 who stated that the skin assessments were in the medication administration record (MAR) and treatment administration record (TAR) which was signed on the shower days. LPN #2 stated that if there was something new then a progress note would have been written. The surveyor asked what the process for injuries of unknown origins such as bruises were and LPN #2 stated that if there was a bruise of an unknown origin then they would investigate and complete written statements that would go back three (3) days. She further stated that in the 3 day look back period, it included statements from whomever cared for the resident such as the aide, the nurses, as well as any staff member that may have seen the resident. LPN #2 stated that once the statements were completed that they were then given to the supervisor to be reviewed. LPN #2 stated it was important that a thorough investigation was completed so that the cause of the bruise would have been identified and then it would have been determined how to fix the problem based on what happened. LPN #2 stated that she cared for Resident #22 a few times but was not aware of any bruises back in August. On 11/13/23 at 12:13 PM, LPN #2 and the surveyor reviewed the PN in the electronic medical record (EMR) from 8/9/23 10:34, which reflected the bruising. She stated that an incident report should have been completed because we don't know what caused it and it looked unwitnessed. On 11/13/23 at 12:25 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she did recall the incident but did not know if there were statements. She stated that the statements should have been completed as the nurse normally completed them, but again reiterated, she was not sure if it was done since she could not find them. The ADON stated that a completed incident report was important because it ensured the resident was being taken care of and for the health and safety of the resident. She explained it was a communication tool for our staff to discuss what occurred and to brainstorm new interventions. The ADON stated that she knew the DON had looked to see if the incident reports were done but would look for the incident report and the 24-hour report related to the bruise. On 11/13/23 at 12:44 PM, in the presence of the survey team, the ADON confirmed that if the bruise was of an unknown origin, then an incident report should have been completed and that she would continue to look for the incident report. On 11/14/23 at 09:00 AM, in the presence of the survey team, the DON stated that an investigation was not completed and acknowledged it should have been done. She further stated that it was a learning experience and a good opportunity to educate the staff. On 11/14/23 at 01:05 PM, in the presence of the survey team, the DON stated the incident report should have been completed because it was important to know what happened and how an injury occurred. She further stated that after surveyor inquiry she educated the staff to ensure that an investigation was completed each time. On 11/15/23 at 10:12 AM, in the presence of the survey team, the ADON stated that during the assessment she looked at various reasons as to what may have caused the incident, which was the reason for completing an investigation. She further stated that Resident #22 tried to be independent as much as possible and liked to do things for themselves and would not always ask for help. The ADON stated that she asked if an incident reporting sheet was done but further stated that she did not follow up to see if it was completed. The ADON stated that it was protocol to investigate and get statements for any injury of unknown origin and it was my mistake that I did not follow up with making sure an incident report was completed. On 11/17/23 at 09:42 AM, in the presence of the survey team, the DON stated that it was important to investigate an injury of unknown origin to make sure abuse and neglect did not occur. She further stated that the only way to rule out abuse was to investigate it. The DON stated that it was important because it helped them track and care for the resident according to their needs. 2.) According to Resident #55's Face Sheet, the resident was admitted to the facility with the diagnoses which included but were not limited to dementia, osteoporosis, and coronary artery bypass graft. A review of the quarterly MDS, dated [DATE], indicated that Resident #55 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs). On 11/08/23 at 11:29 AM, the surveyor observed Resident #55 sitting in a reclining chair with his/her legs hanging over the arm of the chair. The surveyor observed that the resident had multiple small skin tears and openings on the right lower extremity. The surveyor observed that one (1) skin tear on the right lower leg had a steri-strip (wound closure tape that keep wound edges together) intact. There was another small opening on the right upper leg near the knee that was undressed and a skin tear on the right bicep that was undressed. The surveyor observed that the resident had a band aide intact to the left elbow area. The resident was unable to be interviewed due to cognitive loss. The surveyor reviewed the Treatment Administration Record (TAR) for November 2023 and there were no treatment orders for the skin tear openings on the residents right lower extremity, left elbow, right upper leg near the knee and the right bicep area. The surveyor reviewed the physician order sheet dated 11/02/23 and there was a physician's order for a treatment order to the right upper bicep skin tear. The ordered indicated that the skin tear was to be cleansed with NSS (saline solution), gently pat dry, cover with border gauze, leave steri-strips in place until they fall off daily in14 days. The surveyor observed that the physician's order did not get transcribed onto the Treatment Administration Record (TAR) and there was no documentation that the treatment was being done. On 11/08/23 at 11:53 AM, the surveyor interviewed CNA #2 who stated that she had been employed in the facility for five (5) years. CNA #2 stated that Resident #55 required total care with all aspects of ADLs and was non-ambulatory (a person who is unable to walk). CNA #2 stated that the resident required two person assist for transfers and bed mobility. CNA #2 stated that the resident had skin tears on the left upper bicep area. She also added that the resident had scratches and opening on the right lower leg. On 11/08/23 at 01:03 PM, the surveyor, accompanied by the DON and ADON, all observed Resident # 55's skin. Resident #55 was in the dayroom sitting up in the reclining chair. The DON and ADON both confirmed that the resident had skin tears on the right lower leg, the right bicep, and the left elbow. They also confirmed that there were no treatments written in the TAR for any of these skin tears. The DON and ADON also both confirmed that there were no treatment orders for the right shin skin tear, left elbow skin tear and right upper leg. The ADON stated that this was not acceptable and that a full body assessment would be performed and that treatment orders would be obtained for the skin tears. The DON then explained that she received a verbal statement from the LPN, a full-time employee employed for many years, who identified that the resident had a skin tear on the right upper bicep on 11/02/23. The DON also stated that the LPN never initiated the incident/accident report and that the investigation into the cause of the skin tear on the right bicep was not conducted. The DON also confirmed that there was no documentation in the resident's medical record regarding the left elbow skin tear, the skin tear on the right upper leg nor the right bicep. The DON also confirmed that investigations into these skin tears were not conducted for the injuries of unknown origin. The DON explained that when the nurses performed skin checks on 11/01/23, 11/04/23 and 11/08/23 that the nurse did not put in any codes and there was no documentation of any new skin impairment. She admitted that the nurse may have been signing the TAR and not actually looking at the resident's skin. On 11/13/23 at 09:30 AM, the DON approached the surveyor and explained to the surveyor that the wound care practitioner came in to see Resident #55 on 11/08/23 and that treatments were ordered for all the resident's skin tears and that that all the wounds were documented on the resident's medical record. She also stated that investigations would be conducted related to the skin tears that were on the resident's right bicep, left elbow and right medial shin and that the Resident's Care Plan would be updated to include all interventions to prevent further reoccurrence of skin tears. The surveyor reviewed the wound care practitioner's consult, dated 11/13/23, which indicated that the wound care Nurse Practitioner (NP) identified that the resident had skin tears/laceration located on the right medial shin 1cm x 0.8 cm x 0.1 cm, right shin 0.5. x 0.4 x 0.1 cm, right bicep 2.4 cm x 0.3 cm x 0.1 cm and left elbow 0.9 cm x 1.2 cm x 0.1 cm. The NP documented that the resident had a skin tear related to thin, fragile, atrophic skin. Recommended preventing further skin injury by avoiding friction/shear, careful handling during ambulation assistance and transfer, using emollients, long sleeves, and pants when possible. On 11/14/23 at 11:20 AM, the DON explained the process for incident and accidents and conducting investigations. She stated that the incident/accident report was generated by the nurse that discovered the incident and an investigation would then have been conducted. She stated that the UM's responsibility was to review the report and ensure that treatments were in place. The UM was also responsible to review the preventative interventions, update the Care Plan with new interventions, and update the CNA [NAME] with the new interventions. On 11/15/23 at 12:48 PM, the surveyor interviewed the Medical Director who stated that he was employed by the facility for 6 years. He stated that due to staff turnover and use of agency, it could complicate care and follow-through regarding resident care. 3.) A review of the resident Face Sheet (FS) indicated that Resident #78 was admitted to the facility with the diagnoses that included but was not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission MDS, dated [DATE], indicated that the resident had severe cognitive deficits and required extensive assistance with ADLs. On 11/03/23 at 10:55 AM, during tour of the [NAME] Unit, the surveyor observed Resident #78 sitting up in a reclining chair. The resident's eyes were closed, and he/she was not able to be interviewed due to severe cognitive deficits. A bandage was observed on the bridge of the resident's nose. CNA #3 was tending to the resident at this time and was interviewed. CNA #3 stated that the resident had fallen last week. The surveyor reviewed the residents' medical records which indicated the following: The Progress Note (PN) dated 11/03/2023 at 22:30 (10:30 PM) indicated that Resident #78 was found with a skin tear to the right forearm and posterior left shin. The PN also indicated that a treatment was ordered, and the physician and supervisor was made aware. The PN dated 11/04/2023 at 02:52 PM, a CNA identified that Resident #78 had a skin tear with some bleeding on the resident's left outer lower leg while the resident was in the recliner outside of the nurses' station. The skin tear measured 3.5 centimeters (cm) by 3 cm and a treatment was provided with NSS (saline) and steri strips (skin closure strips). A clean, dry dressing (CDD) was also applied. The PN indicated that the resident was agitated, anxious and restless in the recliner before the skin tear was found and may have bumped her leg against the recliner. The PN also indicated that the resident had leg sleeves that were on, but the left one was pulled up on the leg towards the thigh and was put back on her lower leg. The Treatment Administration Record (TAR) dated 11/03/23, reflected a physician's order to cleanse skin tear on the left forearm with NSS and apply triple antibiotic ointment and cover with a dry clean dressing twice a day for seven days. On 11/06/23 at 10:23 AM, the surveyor observed Resident #78 in a low bed with a mattress on the floor next to the bed. The resident was noted to be confused, had garbled speech, and was agitated. The resident had protective sleeves on the lower extremities. The surveyor observed that the resident had bruised knees and bruised fragile, thin skin on both upper arms. The surveyor also observed a dressing on the left forearm. CNA #3 entered the room at that time and was interviewed. CNA #3 stated that the resident had a skin tear on the left arm but did not wear protective sleeves on upper arms, just the lower legs. On 11/06/23 at 10:29 AM, the surveyor interviewed the LPN #3 who stated that she had been employed through the agency and had been coming to the facility for 22 years. The LPN described Resident #78 as anxious, restless, and required complete care ADLs. LPN #3 stated that the resident's medications were changed last week for the anxiety. She also explained that the resident was non-ambulatory and required 1 staff member to transfer. She stated that the resident utilized the wheelchair (w/c) or the reclining chair when he/she got out of bed. She stated that the resident was at risk for falls and that the preventative fall precautions in place which included: bed alarm, chair alarm, low bed, and a mattress on the floor next to her bed (crash pads). LPN #3 stated that the resident's skin was very fragile, and it did not take much for his/her skin to bruise or develop a skin tear. LPN #3 stated that the protective preventive measures to protect the resident's skin included protective sleeves on the resident's bilateral legs and moisturizer. LPN #3 stated that the resident did not wear any protective devices on his/her bilateral arms and did not have any response as to why there were no protective measures for Resident #78's fragile skin on the bilateral arms. The LPN stated that she was not sure if an incident or accident report was completed when the resident developed the skin tears on 11/03/23 and 11/04/23. The DON admitted that she was not aware that Resident #78 had developed skin tears on the left forearm and posterior left shin on 11/03/23 and on the left outer lower leg on 11/04/23. The DON explained that she did not think that any incident or accident reports were completed when Resident #78 developed the skin tears on 11/03/23 and 11/04/23. She stated that she would find out what happened and maybe the incident reports were on the unit. The DON indicated that it would have been important to ensure that preventive/protective measures were put in place to prevent the reoccurrence of skin tears on the resident's upper arms. She stated that protective or preventive measure should have been documented on the CNA [NAME] and the Care Plan. The DON confirmed that the resident's CP and CNA [NAME] were not updated with any new interventions to prevent the reoccurrence of skin tears on Resident #78's arms. On 11/13/23 at 12:36 PM, the DON provided the surveyor with incident reports for Resident #78's skin tears that were found on 11/03/23 and 11/04/23. She stated that the incident reports were sitting on the UM's desk and have not yet been investigated. She stated that the acting UM told her that she did not know what to do with the incident reports and that she was going to give them to the DON during the morning meeting but never did. The DON admitted that interventions were not implemented to protect the resident from further injury after the discovery of the skin tear on the left forearm and the back of the left shin on 11/03/23 and after the discovery of the skin tear on the left lower leg on 11/04/23. On 11/17/23 at 09:49 AM, in the presence of the survey team, the DON stated that she tried to investigate the skin tears after the fact and the information she had received was that the incident report did not make it to a supervisor or UM for review. She stated that there was an oversite related to a communication breakdown. A review of the facility's policy titled, Skin Report Worksheet, revised 04/2013, included, 2. The CNA Skin Report Worksheet is to be completed by the CNA at the time care is rendered and when that CNA observes a possible skin integrity concern. A review of the facility's policy titled, Skin Integrity Log: Impaired, revised 05/2015, included, To provide documentation and follow up of resident skin impairments such as bruises. 1. An Impaired Skin Integrity Log is to be initiated whenever new skin impairment is noted, other than a pressure sore. 7. Bruises will be assessed weekly for 2 weeks. A review of the facility's policy titled, Accident/Incident - Residents, Employees, Visitors and Agency Staff, revised 10/2021, included, 1. Reporting of Accident or Incidents: a. Regardless of how minor an accident or incident may be, it must be reported to the Department Supervisor, and the appropriate Accident/Incident Report form must be completed on the shift that the accident or incident occurred. 4. Investigative Action: a. The Nursing Supervisor or Department Supervisor must conduct an immediate investigation of the accident or incident and thoroughly complete the appropriate Incident/Accident Investigation Report. B. In completing any of the Accident/Injury Reports all witnesses and pertinent person(s) statement's must be obtained and attached. All completed Accident/Injury Reports, along with any documentations obtained, must be forwarded to the Director of Nurses Office as soon as possible. A review of the facility's policy titled, Investigating Unexplained Injuries, revised 09/2015, included, 1. Should a resident be observed with unexplained injuries (injuries of unknown source), the staff nurse must complete an Accident/Incident form and record such information into the resident's clinical record. 3. The Investigation will follow the protocols set for the facility's established investigational guidelines. On 11/15/23 at 12:32 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he could not provide the facility's established investigational guidelines that were stipulated in the policy titled, Investigations of Unexplained Injuries. NJAC-8.39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/06/23 at 11:40 AM, the surveyor observed Resident #195 in the room sitting up in a recliner eating lunch. The resident told the surveyor that staff respond if anything was needed. At that time, the surveyor observed a 2x2 inch band-aid on the resident's upper right side of the resident's forehead. The band-aid was not signed or dated. The surveyor reviewed the hybrid medical record for Resident #195. According to the admission Record (an admission Summary), Resident #195 was admitted with diagnoses that included, but were not limited to, generalized weakness, anemia unspecified, and cellulitis (infection of the skin caused by bacteria) of buttock. A review of the resident's Minimum Data Set (MDS) dated [DATE], had a BIMS of 13/15 which indicated that the resident was cognitively intact. A review of the admission Physical dated 10/22/23, indicated in the Skin Section: No rash or lesions, small sacral decubitus ulcer Stage II. The admission Physical documentation further reflected that there was no identified concern with the resident's forehead. A review of progress note dated 10/20/23 at 15:56 (3:56 PM), indicated, [Resident #195] presents with sacral pressure related to using bedpan at home, scabbed lumplike area on top of head, bruising to bilateral arms, and moist scabbed area to right Achilles. A review of the Physician's Orders reflected an order dated 11/9/23, for the treatment of the scabbed area on the resident's forehead. This Physician's Order was implemented after surveyor inquiry. A review of the November 2023, Treatment Administration Record (TAR) reflected that the nurses were not signing for the care of the scabbed area on the resident's forehead from 11/1/23 - 11/8/23. A review of the Care Plan initiated 10/21/2023, included a focus area that the resident was at risk for impaired skin integrity related to anemia, decreased mobility electrolyte derangement and history of breakdown. Th care plan intervention included that any signs of skin breakdown (sore, tender, red, or broken areas) were to be reported. On 11/09/23 at 08:47 AM, the surveyor observed the resident lying in bed. The resident stated that staff changed his/her bandages every other day. The surveyor observed a 2x2 inch band-aid on the upper right side of the resident's forehead. The band-aid was not signed or dated. On 11/15/23 at 10:49 AM, the surveyor entered the resident's room accompanied by the LPN/UM #2. The resident was awake, lying in bed, and watching television. LPN/UM #2 asked the resident if it was okay to look under the band-aid on forehead and the resident stated it was fine. The surveyor noted that the band-aid was timed, initialed, and dated for that morning. LPN/UM #2 told the surveyor that the treatment nurse had changed it as ordered. LPN/UM #2 removed the band-aid from the resident in the presence of the surveyor. The surveyor observed a light amount of bright red blood, visible on the gauze of the band-aid and a barrier cream appeared to have been applied. The surveyor further observed the opened area as a raised lump with bright red blood at the tip. Upon resealing the band-aid the resident asked how it looked, and LPN/UM #2 stated that compared to what LPN/UM #2 remembered there was no longer a scab and the skin was healing, and they would continue to monitor. On 11/09/23 at 09:25 AM, the surveyor interviewed the LPN/UM #2, who stated that skin assessments were completed for each resident on shower days but also at each time of contact. The LPN/UM #2 said that any new observations or significant changes in current wounds could be reported by any staff member. Each concern should be documented, and the doctor would be notified so that treatment could be recommended if needed. The LPN/UM #2 explained that the facility contracts for wound care services. There was also a wound care nurse on staff in case there is an immediate concern. LPN/UM #2 said that if a new wound was identified, or a change in a current one was noted, the in-house doctor was notified as well as the contracted provider. If the concern was not immediate, the contracted provider would assess in-person on their next scheduled day at the facility. On 11/09/23 at 10:59 AM, surveyor interviewed LPN #3, who stated that they could not speak to wound care because those treatments were completed by treatment nurse and LPN #3 was the Medication Nurse for the unit. LPN #3 said that they are aware that Resident #195 had a pressure ulcer on the sacrum and on the right heel. LPN #3 said that any new skin issues were reported to the Unit Manager immediately and if new treatments were implemented, they would be followed. LPN #3 said that care plans were updated by the UM. When asked about the band-aid on the forehead of Resident #195, LPN #3 stated that the resident was admitted to the facility with a scabbed bump on the forehead and, at the request of Resident #195 and the family, the band-aid was placed as a deterrent to prevent the resident from picking at the scab. On 11/14/23 at 11:18 AM, the surveyor interviewed LPN #4 who said that he/she was assigned as the unit's treatment nurse and that treatments were completed as ordered. When asked about wound care, LPN #4 said that they had just completed the wound treatment on the forehead of Resident #195. On 11/14/23 at 12:05 PM, the surveyor interviewed the ADON who said that the resident was admitted to the facility with a scabbed lump and a band-aid had been placed per the request of the family to deter the resident from picking at the scab. ADON said that on 11/9/23 after the resident's shower, the family requested for the area to be assessed because the band-aid was falling off. ADON said that the doctor was contacted, and a treatment was ordered and implemented on 11/9/23. On 11/15/23 at 10:45 AM, the surveyor interviewed the LPN/UM #2 who said that Resident #195 was admitted to the facility with a scabbed bump and the original band-aid was placed as a preventative measure, per the resident and family's request because the resident would pick at it at home. The family expressed concern on 11/9/23 that the band-aid fell off after the shower and Resident #195 started picking at it again. LPN/UM #2 said that the doctor was contacted and a treatment was ordered. The surveyor asked how long the previous band-aid had been on for and LPN/UM #2 said it was changed daily but there was no documentation noting that. LPN/UM #2 stated that a treatment should have been ordered upon admission. LPN/UM #2 said that a request for a wound consult was emailed to the contracted provider. On 11/15/23 at 11:00 AM, the surveyor interviewed NP who was at the nurse's station. The NP said that they had been asked to assess the forehead of Resident #195 that morning. The NP further explained that a treatment was currently in place and that the NP was planning on seeing the resident next week because the resident had already been seen for that week and the concern was not reported as an emergency. The NP further stated that the Resident #195 was under their care, but NP had not been asked to assess the resident's forehead prior to that day (11/15/23). On 11/16/23 at 12:50 PM, the surveyor interviewed the DON who stated that the lump should have been noted on the admission Physical by the doctor. The DON further stated to the surveyor that the area should have been assessed and a treatment should have been implemented by a physician. The DON explained that the resident's care plan should have been updated to reflect the resident's skin care. The facility policy titled, Skin Integrity Log: Impaired dated 05/15 indicated the purpose for the policy was to provide documentation and follow-up of resident skin impairments such as skin tears, abrasions, rashes, bruises, and other types of impaired skin integrity other than pressure ulcers. The policy indicated that weekly assessments of skin tears would continue until the area was resolved. The facilities policy titled, Wound and Skin Care Protocols dated 02/13 indicated that the purpose of the policy was to provide a systematic approach and monitoring process for skin integrity and chronic wound care. The policy purpose also indicated that the facility would maintain the resident's skin integrity and promote wound healing. The facility policy titled, Physician's Orders and dated 01/13 indicated the purpose of the policy was to communicate and document the physician's order for care and treatment of residents. The policy reflected that the licensed nurse would note all orders to indicate that the order has been carried through including notifying the pharmacy, transcribing the orders to the Medication Administration Record (MAR) and the TAR or other documentation as indicated. The policy further indicated that each chart would be reviewed during the twenty-four (24) hour chart check procedure by the night nurse. All orders written since the last chart check will be reviewed to ensure it has been noted and transcribed correctly. The facility policy, [NAME] with a revised date of 01/15 indicated that the purpose of this tool is to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the [NAME] would be changed, as Resident care needs change. NJAC 8:39-27.1 Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to follow professional standards of practice for 2 of 19 residents (Resident #55 and # 195) by not a.) obtaining physicians' orders for treatments for (Resident #55 and #195), b.) providing treatments as ordered by a physician (Resident #55), c.) accurately assessing a resident's skin during weekly skin checks (Resident #55), d.) implementing interventions to protect a resident's skin identified as having frail, fragile skin (Resident #55) and e.) accurately assessing a resident's skin during a admission physical (Resident #195). This deficient practice was evidenced by the following: 1.) According to Resident #55's Face Sheet, the resident was admitted to the facility with the diagnoses which included but was not limited to dementia, osteoporosis (porous bones), and coronary artery bypass graft (CABG) is a procedure used to treat coronary artery disease. The quarterly Minimum Data Set (MDS) an assessment tool that facilitates care dated 10/02/23, indicated that Resident #55 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs). On 11/08/23 at 11:29 AM, the surveyor observed Resident #55 sitting in a reclining chair with his/her legs hanging over the arm of the chair. The surveyor observed that the resident had multiple small skin tears and openings on the right lower extremity. The surveyor observed that one (1) skin tear on the right lower leg had a steri-strip (wound closure tape that keep wound edges together) intact. There was another small opening on the right upper leg near the knee that was undressed and a skin tear on the right bicep that was undressed. The surveyor observed that the resident had a unsigned/undated band-aide intact to the left elbow and the area. The resident was unable to be interviewed due to cognitive loss. The surveyor did not observe any protective device in place to prevent the resident from developing any further skin tears. The surveyor reviewed the Treatment Administration Record (TAR) dated 11/1/23, and observed that there were no treatment orders for the skin tear openings on the residents right lower extremity, left elbow, upper leg near the knee or the right bicep area. The surveyor reviewed the physician order sheet dated 11/02/23 and there was a physician's order for a treatment order to the right upper bicep skin tear. The ordered indicated that the skin tear was to be cleansed with NSS (saline solution), gently pat dry, cover with border gauze, leave steri-strips in place until they fall off daily in14 days. The surveyor observed that the physician's order did not get transcribed onto the Treatment Administration Record (TAR) and there was no documentation that the treatment was being done. The surveyor reviewed the Progress Note (PN) dated 11/02/2023 at 07:18 AM, written by a Licensed Practical Nurse (LPN) that discovered the skin tear on the right upper arm. The progress note indicated that a treatment was applied to the wound, however the note did not contain a description of the wound or measurement of the wound. On 11/08/23 at 11:53 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that she had been employed in the facility for five (5) years. The CNA stated that Resident #55 required total care with all aspects of ADLs and was non-ambulatory (a person who is unable to walk). The CNA stated that the resident required two person assist for transfers and bed mobility. The CNA stated that the resident had skin tears on the left upper bicep area and there was a dressing on the area. She also added that the resident had scratches and opening on the right lower legs but did not wear any protective sleeves or devices on the legs or arms. On 11/08/23 at 12:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she worked for an outside agency. LPN #1 stated that the resident had dementia and was non-verbal and requires total care and two persons assist with transfers and bed mobility. LPN #1 stated that the only treatment that the resident had was for skin protective skin creams and that the resident did not have skin tears and the resident's skin was intact. LPN #1stated that she did not receive any communication a in report about anything new happening with the resident. LPN #1 reviewed the Resident #55's TAR in the presence of the surveyor and confirmed that there were no treatment orders for the resident documented in the TAR. LPN #1 accompanied the surveyor to see the resident and confirmed that the resident had skin tears on the right lower extremity and the right bicep area. She stated that she would get the resident back to bed to examine the resident's skin. LPN #1 reviewed the physician order sheet with the surveyor and confirmed that the treatment order for Resident #55's bicep skin tear should have been transcribed onto the TAR to assure that the treatment was applied. The surveyor reviewed the TAR with LPN #1 who signed the TAR indicating she performed a body assessment for the resident on 11/8/23, however the resident had multiple skin tears. LPN #1 admitted that she signed the TAR that she performed a body assessment check but did not actually look at the resident's entire skin and did not identify that the resident had skin tears on the right upper bicep, right shin, left elbow and the right upper leg. On 11/08/23 at 12:14 PM, the surveyor interviewed LPN #2 who explained that when a nurse performed the weekly resident skin check, the nurse would document a code on the TAR. The codes were as followed: 1=no new skin injury, 2=previously noted skin injury, and 3=new skin injury see skin injury report. The surveyor observed that on the TAR there were only nurses' signature and no codes that indicated the skin was checked. LPN #2 reviewed the TAR with the surveyor and confirmed that the nurses who performed the skin checks for Resident #55 on 11/01/23, 11/03/23 and 11/08/23 failed to document the code and therefore you could not tell by looking at the documentation if the resident developed a new skin condition or not. On 11/08/23 at 12:25 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if the nurse received a treatment order for Resident #55's skin tear of the right bicep, the nurse must assure that the order was transcribed to the TAR so that the treatment got performed. The DON also stated that when the nurse performed the skin assessments on 11/01/23, 11/03/23 and 11/08/23 the nurse should have documented that the resident had multiple skin tears on the right shin, left elbow and right bicep area. The DON did not have a response as to how the nurses did not observe these wounds during their assessments of the resident's skin. On 11/08/23 at 01:03 PM, the surveyor, accompanied by the DON and Assistant Director of Nursing (ADON) to observe Resident # 55 skin. The surveyor observed Resident #55 sitting up in the dayroom sitting in the reclining chair. The DON and ADON both confirmed that the resident had skin tears on the right lower leg, the right bicep, and the left elbow. They also confirmed that there were no treatments written in the TAR for any of these skin tears. The ADON and DON had both reviewed the physician orders and both confirmed that there was a treatment order written for the skin tear on the right bicep, however the treatment order was not transcribed to the TAR and therefore the treatment was never performed. The DON and ADON also both confirmed that there were no treatment orders for the right shin skin tear, right upper leg and left elbow skin tear. The ADON stated that this was not acceptable and that a full body assessment would be performed and that treatment orders will be obtained for the skin tears. The surveyor reviewed the progress notes (PN) dated 10/29/2023 at 21:17 (09:17PM) which indicated that the nurse observed 5 (five) small skin tears on the right shin area. The note reflected that the physician was notified, and the family was notified. The surveyor reviewed the physician' orders for October 29, 2023, and could not find a treatment order for the 5 skin tears that were located on the right lower shin area. The surveyor reviewed the PN dated 10/30/2023 at 07:55 AM, which reflected that Resident #55 would receive treatments to skin tears as ordered and would be given skin protectors sleeves for the bilateral shins and that the resident's recliner arms would be padded to prevent further skin tears. The surveyor observed the resident on 11/08/23, and the resident was not wearing protective skin sleeves on the bilateral lower legs and the surveyor did not observe that the resident's reclining chair arms were padded. The surveyor also reviewed the resident's medical records and there were no treatments ordered for the skin tears that were observed on the right shin. The surveyor reviewed a facility Incident and Accident report (IR) dated 10/29/23 at 20:00 (8:00 PM) which indicated that the resident was noted to have 5 small skin tears on the right shin. The IR indicated that the possible cause of the skin tears was that the resident swings his/her legs over the side of the recliner and there were metal sides to the reclining chair. The interventions were to pad the arms of the reclining chair. The surveyor did not observe the resident's reclining arms of the chair to be padded. The IR also indicated that protective leg sleeves would be applied to the residents' bilateral lower extremities, however the surveyor did not observe the resident wearing protective leg sleeves to the bilateral lower extremities. There also was not a physician's order for the protective leg sleeves to the lower legs and the resident's Care Plan did not reflect that these interventions were put in place to prevent further skin tears from occurring. On 11/09/23 at 09:40 AM, the surveyor interviewed the DON who confirmed that the preventive interventions that were to be put in place to protect the resident from further development of lower extremity skin tears were not implemented as indicated on the IR investigation dated 10/29/23 at 08:00 PM. The DON also confirmed that the nurse did not put verbal physician orders in for treatments to be performed to the right lower extremities skin tears, therefore treatment was not rendered from 11/01/223 until 11/08/23 after surveyor inquiry. The DON then explained that she received a verbal statement from the LPN a full-time employee employed for many years who identified that the resident had a skin tear on the right upper bicep on 11/02/23 and had written verbal treatment order for the skin tear however she forgot to transcribe the order to the TAR. The DON stated that as a result of not transcribing the order to the TAR, the treatment was never done to the skin tear on the right bicep from 11/03/23 until 11/08/23 after surveyor inquiry. The DON also stated that the LPN never initiated the incident/accident report and that the investigation into the cause of the skin tear was not conducted. The DON also confirmed that there was no documentation in the resident's medical record regarding the left elbow skin tear or right upper leg and that treatment orders were not obtained and no investigation was conducted for the injuries of unknown origin. The DON explained that when the nurses performed skin checks on 11/1/23, 11/4/23 and 11/8/23 the nurse did not put in any codes and there was no documentation of any new skin impairment. She admitted that the nurse may have been signing the TAR and not actually looking at the resident's skin. On 11/13/23 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse acting Unit Manager (LPN/UM #1) who documented the Progress Notes (PN) on 10/30/2023 at 07:55 AM, that she would obtain treatment orders for 5 small skin tears that were located on the right shin area. The acting LPN/UM #1 stated that she must have asked another nurse to obtain the treatment orders for the residents' right shin skin tears and the other nurse did not obtain the orders. She continued to explain that would have been important to assure that these treatments were done to prevent infection and to promote healing of the skin. The acting LPN/UM #1 continued to admit that she also failed to assure that the interventions such as skin sleeves or padding of the chair was done. She stated that the interventions would have been important to put in place at the time to prevent skin tears from reoccurring. On 11/13/23 at 09:30 AM, the DON approached the surveyor and explained to the surveyor that the wound care practitioner came in to see Resident #55 on 11/08/23 and that treatments were ordered for all the resident's skin tears and that that all the wounds were documented on the resident's medical record. She also stated that investigations will be conducted and that the Resident's Care Plan would be updated to include all interventions to prevent further reoccurrence of skin tears. The surveyor reviewed the wound care practitioners consult dated 11/13/23, which indicated that the wound care Nurse Practitioner (NP) identified that the resident had skin tears/laceration located on the right medial shin 1cm x 0.8 cm x 0.1 cm, right shin 0.5. x 0.4 x 0.1 cm, right bicep 2.4 cm x 0.3 cm x 0.1 cm and left elbow 0.9 cm x 1.2 cm x 0.1 cm. The NP documented that the resident had a skin tear related to thin, fragile, atrophic skin. Recommended preventing further skin injury by avoiding friction/shear, carful handling during ambulation assistance and transfer, using emollients, long sleeves, and pants when possible. On 11/14/23 at 11:20 AM, the DON explained the process for incident and accidents and conducting investigations. She stated that the incident/accident report was generated on the unit by the nurse that discovered the incident. The unit manager was then responsible to review the report and assured that treatments were in place. The Unit Manager was also responsible to review the preventative interventions, update the Care Plan with new interventions, and update the CNA [NAME] with the new interventions. The DON stated that the CNA [NAME] was the most easily accessed piece of information regarding resident care and the needed to be updated to assure that the CNA knew how to care for the resident. On 11/15/23 at 12:48 PM, the surveyor interviewed the Medical Director who stated that he was employed by the facility for 6 years. He stated that due to staff turnover and use of agency, it could complicate care and follow-through regarding resident care. On 11/16/23 at 11:03 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she could not provide a policy regarding the weekly skin checks that were done on shower days. The ADON also confirmed that when then skin tears were identified that a weekly skin log should have been implemented so that the wounds could be monitored weekly. She stated that this process was never implemented for Resident #55's skin tears.

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide in-service education at least once every 12 months for 2 out of 5 Certified Nursing Aides (CNA)s personnel files reviewed, (CNA#1 and CNA#4) and b.) complete annual performance reviews for 5 out of 5 CNA personnel files reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). This deficient practice was evidenced by the following: On 11/16/23 at 9:09 AM, the surveyor reviewed the five CNA personnel files which revealed the following: - CNA#1 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#2 did not receive a performance evaluation. - CNA#3 did not receive a performance evaluation. - CNA#4 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#5 did not receive a performance evaluation. On 11/16/23 at 09:20 AM, the surveyor interviewed the Director of Human Resources for the county who stated that she oversaw the Human Resource Department for the entire county which consisted of over 40 different departments and she was solely responsible for holding the employee files. The Director of Human Resources told the surveyor that the facility had always been responsible for providing in-service education for the staff working at the county facility as well as conducting annual performance evaluations for staff. On 11/16/23 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that the facility did not have a Staff Educator who was the previous staff member responsible for providing in-service education. The LPN/IP further stated that the Staff Educator had stopped working at the facility in April or May of 2023 and was also the person who was responsible for completing the performance evaluations for the CNAs. On 11/16/23 at 11:12 AM, the surveyor interviewed the facility's Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) who stated that the Staff Educator had stopped working at the facility in late spring of 2023 and since then herself, the Assistant Director of Nursing (ADON), and LPN/IP had been fulfilling that job responsibility at the facility. The DON explained that the Staff Educator was a flexible position, the former staff member was available to work all shifts and was responsible for completing the CNAs performance evaluations which were not done. On 11/16/23 at 11:16 AM, the surveyor interviewed the facility's LNHA in the presence of the DON who agreed with the DON that the previous Staff Educator was formally responsible for providing annual in-service education to all staff working at the facility and was also responsible for performing the performance evaluations. The LNHA stated that process changed due to the fact the county implemented a hiring freeze upon the facility. On 11/17/23 at 09:58 AM, the surveyor conducted a follow up interview with the DON who stated that she did not recall the name of CNA#1 and CNA#4 had not worked at the facility for more than a year, however they were county employees. The DON told the surveyor that the facility did not have a policy and procedure for annual in-service education or a policy and procedure for annual performance evaluations. NJAC 8:39-43.17(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility documentation it was determined that the facility failed to: a.) ensure that food items were labeled, dated, and stored properly, b.) ensure that ice machines were cleaned and in safe operating condition, and c.) ensure that equipment was cleaned and maintained to prevent foodborne illnesses. This deficient practice was evidenced by the following: On 11/03/23 at 9:56 AM, the surveyor met with the Food Service Director (FSD) to begin the kitchen tour. 1. One gallon opened container of lemon juice was on the shelf on the seasoning rack. The FSD stated that the container did not belong there and it should have been refrigerated. The FSD immediately disposed of the container. 2. On the Salad Dressing Rack, located next to seasoning rack across from 3 compartment sink in the main kitchen, the surveyor observed a 2.5 feet by 1.5 feet sheet pan that contained food particles and stains. Two knives, a cardboard box, and an unknown kitchen appliance were on top. The FSD stated, I am not sure why it is there, then removed the tray and all items from the area to be washed. The FSD said that the purpose of keeping clean and dirty areas separate was, You don't want any areas where bacteria could be growing mixed with clean items. 3. At the time of the observation, the surveyor asked the FSD if the area was a clean area and the FSD explained that it was where clean items were kept after they were dry. The surveyor observed a red cutting board, 3 feet by 2 feet, which contained a black substance streaked across both sides. The surveyor observed a yellow cutting board, 3 feet by 2 feet, that had a black substance streaked across one side. The surveyor also observed a blue cutting board, 3 feet by 2 feet which contained food particles throughout the cutting board. The FSD immediately removed the cutting boards and stated that all cutting boards should be clean and free of particles and substances to prevent the spread of bacteria. 4. No log was noted on the ice machine in the main kitchen. The surveyor asked the FSD if there was a log and the FSD said, no. The surveyor wiped a clean paper towel across the inside cover and a black substance adhered to the paper towel. The surveyor observed the FSD do the same, and she obtained the same results. The FSD stated that there should not be black substance on the ice machine to prevent the growth of bacteria. 5. The surveyor and the FSD entered the walk-in refrigerator in the main kitchen. The surveyor observed nine, 10-pound unknown meats sealed in plastic wrap with no identifying information. The surveyor asked the FSD what they were, and the FSD explained that they were roast beefs that had previously been cooked. The FSD further stated that the meat should have a label identifying what it is and when it was opened, so that others can be aware of how long the meat is good for. 6. The surveyor and the FSD entered the walk-in freezer in the main kitchen. The surveyor observed a tray of biscuits that were open to air and not labeled. The FSD stated that they had served beef stew last night and that it should have been wrapped and labeled after use. The FSD further stated that food needed to be covered, labeled, and dated. The FSD removed the item to be disposed of in the presence of the surveyor. 7. On the bread rack, the surveyor observed: - 4 bags of hoagie rolls dated 10/26/23. - a loaf of sliced rye bread with no label and no expiration date. - a loaf of club wheat bread dated 10/30/23. - a loaf of marble rye, no date, no label, with greenish brown patches. At the time of the observations, the FSD disposed of each item and stated that each item should have been dated and anything that had expired should have been disposed of. 8. One gallon of [NAME] Cooking Wine on a shelf with a Best Buy date of 8/9/23. The bottle was open. The FSD disposed of the bottle. A review of the undated facility's, Dietary Orientation: Safe Food Handling,, revealed 1. Cutting boards in good condition . 3. Cleaned and sanitized in dish machine after each use . A review of the undated facility policy, Proper storage and labeling of food in the refrigerator, indicated within the policy statement that: All food is to be stored and labeled in a safe and sanitary manner. Procedures: Food is to be labeled with what is inside the container . and Food is to be labeled with the use by date . Open items stored in freezer will be dated for a 6 month use by date . NJAC 8:39-17.2(g)

Based on interviews and record review, the facility failed to provide mail delivery services on Saturdays for residents who resided in the facility. The deficient practice was identified for 5 of 5 residents, (Resident #12, #39, #41, #63, and #72) interviewed during the Resident Council Facility Task (a meeting with residents). The deficient practice was evidenced by the following: On 11/08/2023 at 10:33 AM, during the Resident Council Meeting, the surveyor interviewed Residents #12, #39, #41, #63, and #72 regarding mail delivery services. The five residents reported that the mail was not delivered on Saturdays. On 11/08/2023 at 12:45 PM, during an interview with the surveyor, the Director of Activities stated that residents' mail was delivered to the administrative building (building at a different location from the facility) where it got sorted. Then, an activity person picked up the mail and delivered it to the residents. During the same interview, the Activity Aide who was also present in the room, stated that letters were not delivered on Saturdays and Sundays because the administrative building was only opened from Monday through Friday. On 11/09/2023 at 11:34 AM, during an interview with the surveyor, the Administrator stated that residents' mail was delivered and sorted at another county building (the administrative building), and that they did not work on the weekends. A review of the facility policy titled, Opening Facility Mail, dated 10/14, did not address residents' mail delivery on Saturdays. N.J.A.C. 8:39-4.1(a)(19)