Complaint #: NJ186030 Based on interviews, review of medical records, and review of pertinent documents, it was determined that the facility failed to a.) conduct a thorough investigation and b.) follow the facility policy Incident/Accident Investigating and Reporting Policy and Procedure, after a resident fell on facility premises on 05/02/2025. This deficient practice was identified for one of three residents (Resident 2) reviewed for accidents and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to chronic diastolic (congestive) heart failure, generalized anxiety disorder, other recurrent depressive disorders, other chronic pain, opioid dependence with other opioid-induced disorder, muscle weakness (generalized), and need for assistance with personal care. Review of Resident #2's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that Resident #2 had a Brief Interview for Mental Status score of 15 out of 15 which indicated that the resident's cognition was intact. The MDS revealed that Resident #2 used a manual wheelchair for mobility. The MDS revealed that Resident #2 required the assistance of a helper prior to or following standing from sitting in a chair, wheelchair, or on the side of the bed. The MDS further revealed that Resident #2 had not had any falls since the prior assessment. Review of a Police Department Incident Report dated 05/02/25, written by Police Officer (PO) #1 was conducted. The report revealed that PO #1 contacted Resident #2 after she/he fell and was injured at another location. PO #1 and police headquarters made several unsuccessful attempts to reach facility staff regarding Resident #2. PO #1 then went to the facility with Resident #2 and went inside to speak with staff including the facility's Director of Nursing (DON). The report revealed that while PO #1 was speaking to facility staff inside, another staff member informed them that Resident #2, had fallen out of [her/his] wheelchair again while right outside of the Canterbury front entrance. The report further revealed that Resident #2 was then transported to the hospital by ambulance. A telephone interview was conducted with PO #1 on 05/21/2025 at 6:18 P.M. PO #1 stated that on 05/02/2025 after returning to the facility with Resident #2, he went inside to speak with facility staff while Resident #2 remained just outside of the facility entrance. PO #1 stated that while discussing the incident with facility staff, including the DON, another staff member informed them that Resident #2 had fallen out of their wheelchair at the facility's entrance. PO #1 further stated that the facility staff went down to the entrance to assist the resident and get her/him into an ambulance. Review of a progress note (PN) written by Registered Nurse (RN) #2 dated 05/02/2025 at 6:20 P.M. revealed that at 6:20 P.M., RN #2 was notified by the police department that Resident #2 was found with abnormalities such as difficulty verbalizing her/his needs and a possible injury to her/his forehead, and refused medical assistance. The PN revealed that the DON was made aware and got an order to transport Resident #2 to the hospital for evaluation. The PN further revealed that the resident did not return from OOP (out on pass). A telephone interview was conducted with RN #2 on 05/13/2025 at 5:17 P.M. RN #2 stated that Resident #2 was assigned to her on the 3:00 P.M. to 11:00 P.M. shift on 05/02/2025. RN#2 stated that Resident #2 informed her that she/he was going outside to get some fresh air at approximately 3:15 P.M. RN #2 stated that a few hours later the DON informed her that Resident #2 had fallen. RN #2 stated that ordinarily, if one of her assigned residents fell, she would have completed the necessary follow up. RN #2 stated that in this case the facility's DON informed her that she would complete the follow up for the incident involving Resident #2. RN #2 further stated that the information included in her 05/02/2025 6:20 P.M. PN was provided to her by the facility's DON. Review of the facility incident report dated 05/03/2025 revealed that Resident #2 returned to the facility at 6:45 A.M. after leaving a hospital emergency department against medical advice. The facility incident report further revealed under Resident Description' That Resident #2 provided a statement that at 4:30 P.M. she/he fell out of her/his wheelchair outside the facility in the patio area. A review of a handwritten statement signed by Resident #2 revealed that the resident wrote that he/she fell out of their wheelchair on 05/02/2025 at approximately 4:30 P.M., outside on the patio. The resident wrote that they were reaching for something and lost their balance. The resident further wrote that she/he was transported to the hospital by ambulance at approximately 5:00 P.M. An interview was conducted with Resident #2 on 05/08/2025 at 12:24 P.M. Resident #2 was observed sitting in her/his room in a wheelchair. The resident had a scabbed area approximately one inch long and half an inch wide above her/his left eyebrow which was surrounded by swelling. There was bruising, discoloration, and swelling to the resident's left cheek and jawline. The resident had a black eye on the left side. Resident #2 stated that on 05/02/2025 she/he signed out of the facility then went to stores close to the facility. The resident stated that she/he fell out of their wheelchair and hit their head on the pavement at around 4:00 P.M. on 05/02/2025. The resident stated that after falling out of her/his wheelchair, facility staff came outside to assist her/him. A follow up interview was conducted with Resident #2 on 05/08/2025 at 4:41 P.M. The resident confirmed that they fell out of their wheelchair just outside of the facility's front door. Review of the facility document with [Resident #2] Incident Summary 5/2/2024, at the top revealed under Summary, that Resident #2 signed out of the facility and went to a liquor store. While at the liquor store the resident fell while trying to reach for something. The facility was alerted to the fall when a police officer came to the facility and spoke to the DON. The facility document further revealed that Resident #2 was sent to the hospital for evaluation prior to ever coming into the facility from police custody. An interview was conducted with Registered Nurse (RN) #1 on 05/08/2025 at 4:18 P.M. RN #1 stated that Resident #2 told him that she/he (Resident #2) fell near the canopy just outside of the facility's door. An interview was conducted with the facility's Licensed Nursing Home Administrator (LNHA) on 05/08/2025 at 5:14 P.M. The LNHA stated that when accidents or incidents occurred facility staff completed a report in PCC (the electronic medical record). The LNHA stated that the staff would not have completed employee statement forms because the incident involving Resident #2 happened offsite. The LNHA stated that the facility's policy, Incident/Accident Investigating and Reporting Policy and Procedure, would have been followed if something happened on the premises. A follow up telephone interview was conducted with the LNHA on 05/21/2025 at 3:04 P.M., The LNHA stated that no additional summary, statements, conclusions, or other documentation were available for the incident involving Resident #2 on 05/02/2025. The facility DON was not available for interview on 05/08/2025 or 05/21/25. Review of the facility policy titled, INCIDENT/ACCIDENT INVESTIGATING AND REPORTING POLICY AND PROCEDURE with an updated date of 6/2024, revealed, POLICY: It is the policy of this facility to provide a system whereby residents' incidents/accidents are investigated, their causes identified when possible, and timely interventions are established to reduce the probability of repeated incidents. Under PROCEDURE the policy revealed, 1. It is the responsibility of the Licensed Nurse who first witnessed the incident/accident to initiate and complete the Incident/Accident Report in its entirety utilizing input from the staff present at the time of the incident/accident. [ .] 5. All employees assigned to the resident involved in an incident/accident will fill out the Employee Statement form [ .] 8. The Unit Manager will investigate, summarize and conclude all incidents/accidents. NJAC 8:39-27.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ00181512, NJ00181513, NJ00181515, NJ00181438, NJ00181567 Based on observation, interview, and review of pertinent facility documents on 12/13/2024, it was determined that the facility failed to maintain a safe and comfortable room temperature levels for residents in a nursing unit [Gardenia Garden]. This deficient practice was identified in 1 of 2 nursing units in third floor and was evidenced by the following: On 12/13/2024 at 9:32 a.m. [morning], the Surveyor in the presence of the Maintenance Person (MP) checked the temperatures on the Third Floor and the following were obtained: room [ROOM NUMBER] - room temperature of 67.6 degrees Fahrenheit; occupied; radiator on with low cool air coming out; resident ambulatory; not in distress. room [ROOM NUMBER] - room temperature of 68.1 degrees Fahrenheit; occupied; resident out of room; radiator on. room [ROOM NUMBER] - room temperature of 69.4 degrees Fahrenheit; occupied; Certified Nursing Assistant (CNA) doing care; radiator on; resident not in distress. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; occupied; radiator on with low cool air coming out; 2 residents not in distress. room [ROOM NUMBER] - room temperature of 66.0 degrees Fahrenheit; occupied; radiator was on; resident not in distress. room [ROOM NUMBER] - room temperature of 65.1 degrees Fahrenheit; occupied; resident not in room; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; residents not in room; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 65.0 degrees Fahrenheit; occupied; radiator on with low cool air coming out; residents dressed warmly with blankets; residents not in distress. room [ROOM NUMBER] - room temperature of 68.3 degrees Fahrenheit; occupied; radiator on with low cool air coming out; residents not in distress. room [ROOM NUMBER] - room temperature of 64.7 degrees Fahrenheit; unoccupied; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 64.0 degrees Fahrenheit; residents out of room; radiator on with low air coming out. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; occupied; radiator on; residents not in distress. room [ROOM NUMBER] - room temperature of 67.6 degrees Fahrenheit; unoccupied; radiator on with warm air started to come out. room [ROOM NUMBER] - room temperature of 66.5 degrees Fahrenheit; occupied; radiator was noted off; resident (in bed 2) stated he turned off radiator; residents not in distress. room [ROOM NUMBER] - room temperature of 70.0 degrees Fahrenheit; occupied; radiator noted off; resident stated was on last night denied turning radiator off; checked radiator working and left on; residents not in distress. Third Floor - Lilac Lane Unit - hallway temperature of 73.5 degrees Fahrenheit Third Floor - Gardenia Garden Unit - hallway temperature of 67.2 degrees Fahrenheit Third Floor Nurses Unit - wall thermometer on the wall showed 77 degrees Fahrenheit. Third Floor Dayroom/Dining Room - has temperature of 68.0 degrees Fahrenheit. On 12/03/2024 at 1:26 p.m. [afternoon], the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated the first complaint for low heat was on 12/2/2024 and we had been monitoring the room temperatures and maintenance and corporate maintenance had been coming in to fix the problem. We had been monitoring the units and then last night there was a complaint from resident in 3rd floor about no heat. I called the maintenance and that was why regional maintenance person [name] was here and the company fixing the radiator units. We are expecting the room temperatures to go up after the maintenance bled the system. Our target was 71 degrees Fahrenheit per room. There was no power outage nor interruption of service occurrence. I am aware of the recommended temperature of 71-81 degrees as per regulations. On 12/03/2024 at 3:42 p.m. [afternoon], the Surveyor interviewed the regional maintenance person (RMP) in the presence of the LNHA. The LNHA and RMP were made aware of the low temperatures obtained in Unit [Gardenia Garden] in third floor. The RMP stated we did a comprehensive check on the boiler, and we were bleeding the boiler. The RMP further stated in bleeding we pushed the cold air out from the pipes by flushing hot water into it from the boiler. With the low temperatures we do not want to increase the boiler temperature to 200 degrees Fahrenheit hot as this will cause the boiler to break so we do the flushing gradually and it takes quite a while for warm temperatures to kick in the PTACH [radiator]. A review of the facility's undated Cold Stress Emergency Plan: Operational Procedures provided by the facility 4. Other duties may be required. A. Maintenance. 1)Check heating system to ensure it is working properly .3) Maintain proper room temperatures. 4) Check water lines to ensure they are adequately protected .7) Make necessary repairs as soon as possible. NJAC 8:39 -31.2(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to provide timely and appropriate incontinence care for Resident #5 who was dependent on staff for their Activities of Daily Living (ADLs) care. This was observed on 09/16/2024 during the surveyor's incontinence rounds on the third floor nursing unit. The deficient practice had the potential to affect all residents and was evidenced by the following: According to the facility's Transfer/Discharge Report (TDR), resident information revealed Resident #5 had diagnoses of but not limited to Cerebral Infarction, Seizures, Heart Failure, Aphasia, and Hypertension. Resident #5's TDR further entailed his/her list of medications which indicated should be administered via [through] a G-tube (gastrostomy tube, a tube inserted through the wall of the abdomen directly into the stomach). According to Resident #5 Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities and helps the facility identify residents' health problems, dated 08/06/2024, revealed that Resident #5 Brief Interview for Mental Status (BIMS) Cognitive Skills is severely impaired. Resident #5's MDS further indicated in Section GG Functional Abilities and Goals that Resident is dependent on staff for the completion of his/her ADLs. On 09/16/2024 at 12:17 pm [afternoon], the surveyor toured the third floor nursing unit in the presence of the Unit Manager (UM) Licensed Practical Nurse (LPN #1). The UM stated her Unit has two wings and the census was 55. The UM further stated there were two nurses and three Certified Nursing Assistants (CNA)s assigned to the residents. The surveyor with the UM observed Resident #5 in bed. UM stated Resident #5 was non-verbal and had a feeding tube. The UM further stated Resident #5 was dependent on staff for his/her ADLs. On 09/16/2024 at 12:43 pm, CNA #1 was observed going in to the Resident's room. The surveyor then asked CNA #1 if she was assigned to Resident #5 to which the CNA affirmed she was. At that point, the surveyor requested to observe CNA #1. CNA #1 proceeded after donning on a gown and putting on a mask and a pair of gloves, lowered the head of bed of the Resident and opened the front of Resident's diaper while Resident was on their back. Surveyor then asked CNA #1 to turn the Resident on their side and pulled down the Resident's diaper. In the presence of the Unit Manager and CNA #1, the surveyor observed the Resident's green diaper to be covered with brown excrement [feces] and was saturated in brown and strong-smelling urine. When asked by the surveyor, CNA #1 stated I have a lot of patients and when asked how often she would change dependent residents assigned to her, CNA #1 stated I would check on them frequently and change at least once a shift. At this point, the UM stated, CNAs would check and change residents at least once a shift. A review of the 7-3 CNA Assignment Sheet for 09/16/2024 on third floor nursing unit, revealed that for the resident census of 55, there were three CNAs assigned. One CNA for Assignment 1 had nineteen residents to care of, CNA with Assignment 2 had nineteen residents to care of, and CNA with Assignment 3 had seventeen residents for care. On 09/16/2024 at 12:53 pm, the surveyor interviewed CNA #2 (who had Assignment 2) stated she had nineteen residents to care of today. She further stated, it is always under staff everyday. On 09/16/2024 at 4:28 pm, surveyor interviewed Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The DON and RCN were made aware of the incontinence observation in third floor nursing unit and the staffing ratio. The DON stated she was fully aware of the staffing deficits and the facility was working on the staffing problems were in progress. The DON acknowledged of the lack of incontinence care and was working on it as well. Review of the facility's policy on INCONTINENCE CARE revised on 09/2024, Policy: Based on the resident's comprehensive assessment, all residents who are incontinent will receive appropriate treatment and services; Policy Explanation and Compliance Guidelines: . (4) Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. NJ 8:39-25.2 (a)

Based on observation and interview, it was determined that the facility failed to maintain the prior year's state of New Jersey inspection results and post the location of those results in an area that was readily accessible to residents, families and the general public. This deficient practice was evidenced by the following: On 6/27/24 at 10:47 AM, the surveyor conducted a group meeting with seven (7) residents in attendance, Resident #5, Resident #20, Resident #43, Resident #96, Resident #118, Resident #128 and Resident #199. When asked if they were aware of the location of the previous year's survey inspection report, 7 residents said no. On 06/27/24 from 10:47 AM until 11:54 AM, the surveyor conducted the resident council meeting with seven (7) facility chosen residents who regularly attend the facility's resident council meetings that were conducted monthly. The surveyor asked if they know where the results of previous Department of Health surveys were available to them if they would like to read them, all 7 of 7 residents (Resident #5, Resident #20, Resident #43, Resident #96, Resident #118, Resident #128, and Resident #199) responded they did not know where the prior survey results were located. The surveyor reviewed the resident council minutes dated 6/3/2024. The seventh item that was reviewed revealed: Residents were reminded that the current Department of Health Survey Results is located in the front lobby. Any questions to be directed to the Administrator. This item was noted to have the Staff Initials RP next to it. The surveyor did not observe any signs regarding the survey results on any of the nursing units or in the elevators. On 06/28/24 at 10:41 AM, the surveyor interviewed the Director of Recreation (DoR), who stated that the survey binder that had the survey results was at the front desk and at each nursing station and should be presented to a resident if the resident would request for it. The DoR further stated that the facility's Licensed Nursing Home Administrator (LNHA) was in charge of the survey binder. On 06/28/24 at 10:53 AM, the surveyor interviewed the Unit Manager of the third floor who stated the survey results were downstairs at the front desk. On 06/28/24 at 10:57, the surveyor interviewed the LNHA who stated there is a book at the front desk with the survey results in it. He further stated that the location of the book was discussed with the residents upon admission. He also stated that there should have been signs at each nurse's station and at the entrance by the front desk. On 06/28/24 at 11:00 AM the surveyor observed a binder at the front desk, spine facing outward. Front of book labeled Survey Book Vol.11. The spine of the binder with the original item/brand sticker. On 6/28/24 at 1:26 PM, the surveyor spoke with the facility's LNHA, Director of Nursing, Regional Clinical Registered Nurse and the Regional Infection Preventionist. The surveyor informed them regarding the concern of the most recent state survey inspection report not being available for residents, families, and the general public in an area that was easily accessible, where they wouldn't have to ask someone for them and signage directing them to the location of said results. On 07/01/24 at 11:08 AM the LNHA stated the facility does not have a policy regarding the survey results. He further stated that signs (indicating location of survey results binder) are now posted at the front reception, in the elevators and at each nurse's station. He also stated that the signs should've been posted all along. No further information was provided. N.J.A.C. 8:39-9.4(b)

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with the federal guidelines for 2 of 29 residents (Resident #16, and Resident #7) reviewed for the accuracy of MDS completion. The deficient practice was evidenced by the following: 1. On 06/25/24, at 10:45 AM, the surveyor observed Resident #16 lying in bed with their eyes closed. On 06/25/24 at 12:45 PM, the surveyor reviewed Resident #16's hybrid (paper and electronic) medical record, which revealed the following information: According to the admission Record (an admission summary) (AR), Resident #16 was admitted to the facility with diagnoses that included but were not limited to Dementia with behavior. A review of the Quarterly MDS (Q/MDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that the resident had severe cognitive impairment. Further review of the Q/MDS Section D Mood under Section D0150 Resident Mood Interview (PHQ-2-9) which reflected that the interview was conducted and signed on 4/21/24, three (3) days before the Assessment Reference Date (ARD) (refers to a specific endpoint for the observation period in the MDS assessment process). A review of the April 2024 electronic Medication Administration Record (eMAR) revealed a physician's order which indicated, Resident is on (Zoloft) for indication of (Hitting striking out, flipping furniture) for (depression) every shift Target behavior observed of flipping furniture, Wandering at night. The listed behaviors were observed on April 22, 23, and 24, 2024, as indicated in the eMAR. A review of the 4/24/24 Q/MDS for Section E Behavior under Section E0200A - Presence and Frequency reflected 0. Behavior not exhibited. which indicated the behaviors that were observed during the look-back period did not reflect in the Q/MDS, which was 7 days before to the ARD. 2. On 06/25/24, at 10:45 AM, the surveyor observed Resident #7 in bed awake, alert, and oriented, able to answer the surveyor's inquiry. On 06/28/24 at 12:20 PM, the surveyor reviewed Resident #7's hybrid (paper and electronic) medical record, which revealed the following information: A review of Resident #7's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (disease of the brain and spinal cord). A review of the Annual MDS (A/MDS), dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, indicating that the resident had intact cognition. Further review of the Q/MDS Section D Mood under Section D0150 Resident Mood Interview (PHQ-2-9), which reflected that the interview was conducted and signed on 4/17/24, three (3) days before the ARD. On 6/28/24 at 9:40 AM, the surveyor interviewed the facility's Social Worker (SW), who was responsible for completing Section D and Section E in the MDS assessments. The SW stated that he had been interviewing the residents for Section D screening at least 2-3 days before the ARD. The SW also confirmed that the lookback period to complete Section D must be 14 days before the ARD. The SW did not provide any further information as to why he was doing the interview before the indicated ARD. The SW added that Resident #16's behavior, documented in the April 2024 eMAR, should have been coded under Section E0200A. On 6/28/24 at 9:06 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated that the Section D Mood interview completed by the SW should have been a 14-day look-back period from the date of the ARD. The MDSC/RN added that they followed the Resident Assessment Instrument (RAI) Manual. The surveyor reviewed the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, updated October 2023. The RAI manual revealed under Chapter 3, page D-2, This interview is conducted during the look-back period of the Assessment Reference Date Further review under Chapter 3 Section E0200 Behavioral Symptom - Presence and Frequency, page E-5 reflected 1. Review the medical record for the 7-day look-back period. On 6/28/24 at 12:30 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse, and Regional Infection Preventionist. No further information was provided. NJAC 8:39-33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CP) to include safe smoking. This deficient practice was identified for 1 of 29 residents reviewed for resident-centered care plans (Resident #350), and was evidenced by the following: The admission Record (AR) indicated that Resident #350 was admitted to the facility with the diagnoses which included but was not limited to Bipolar Disorder and Seizure Disorder. The admission Minimum Data Set (A/MDS), an assessment tool that facilitates resident care, dated 06/06/24 reflected that the resident was cognitively intact and required supervision with activities of daily living. On 06/26/24 at 10:52 AM, the surveyor interviewed Resident #350 who was outside the facility for coffee social. The resident stated that they had been in the facility for approximately three weeks. Resident #350 stated they enjoyed the recreation department and liked to attend the activities that the facility provided. The resident indicated that they had smoked, and that smoking was permitted in a designated areas. The resident stated that the facility had a smoking schedule wherein residents were permitted to smoke at 09:30 AM, 01:15 PM, 04:15 PM, and 05:30 PM. The resident further stated that the staff held the cigarettes, vapes and lighters when not in use. The resident further stated that the staff monitors the smokers during the scheduled smoking times. Resident #350 stated the facility performed a smoking assessment to ensure that the resident was a safe smoker. The resident stated that they started smoking soon after being admitted to the facility. The surveyor reviewed the form titled, Smoking Contact and Smoking Assessment for Resident #350 dated 06/04/24, which revealed that Resident #350 required supervision during smoking and there was a CP initiated for safe smoking. The surveyor reviewed Resident #350's list of CP and there was no documentation that a CP was implemented for safe smoking. Progress notes reflected the following: On 6/25/2024 at 16:52 (04:52 PM) Smoking and Safety status Resident uses vape products and has anxiety and Chain smokes. On 06/27/24 at 09:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who explained that when a resident was admitted to the facility, the nurse was responsible to complete the smoking assessment upon admission. The LPN further stated that it would be important to complete the assessment immediately to ensure that the resident was safe to use a cigarette smoke, and also for the resident to have the right protective equipment such as a smoking apron. The LPN added that it would be important to ensure the CP was implemented to include safe smoking with safety interventions. The LPN added that the CP was a communication tool which provided information on how to care for a resident. On 06/27/24 at 09:45 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on the third floor who explained that when a resident was admitted to the facility and were a smoker, the smoking assessment must be completed upon admission. The LPN/UM stated that the smoking assessment must be completed so that the resident who smoked had the proper interventions in place to ensure safety and to determine if the resident was an independent smoker. The LPN/UM confirmed that a CP must be implemented to include that the resident smoked and had the proper safety interventions. On 06/27/24 at 09:51 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been employed in the facility for 10 years. The CNA stated that Resident #350 went out to smoke with supervision of the staff from activities department. The CNA added that there had been no incidents or accidents reported regarding the resident smoking. On 06/27/24 at 09:55 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) on the first floor who had been employed in the facility for about 7 months. LPN/UM #1 explained that if a resident smoked, a physician's order must be obtained, and a smoking assessment must be completed upon admission to the facility. The LPN/UM#1 further explained that a smoking assessment was a functionality test to ensure that the resident could hold a cigarette safely as well as light the cigarette. She stated that it would be important to complete the assessment at the time the resident indicated that they smoked to ensure safety to the resident. LPN/UM #1 stated that the smoking assessment would be important to complete in order to determine if protective devices such as a protective apron, would be implemented to prevent the resident from being burnt. She confirmed that a CP would also have to be completed with safety smoking interventions. The assessment included what CP interventions must be in place. She confirmed that the CP should have been implemented to include safe smoking for Resident #350. On 06/27/24 at 10:06 AM, the surveyor interviewed the LPN/UM #2 on the second floor. LPN/UM #2 stated that a smoking assessment must be completed to determine if a resident were safe to smoke and if any interventions should be implemented to ensure that the resident was safe during smoking times. She stated that a CP must be initiated for safe smoking with interventions. LPN/UM #2 reviewed Resident 350's CP in the presence of the surveyor and confirmed that a CP was not implemented for safe smoking when the smoking assessment was completed on 06/04/24. On 06/27/24 at 10:17 AM, the surveyor interviewed the Director of Recreation and the Activities Assistant who both agreed that when a safe smoking assessment was completed on 6/4/24 , a CP should have been implemented to include that the resident smoked. A review of the the facility's policy titled, Smoking dated 02/01/2024 indicated that documentation to support decision making will be included in the medical record, including but not limited to: -Resident wishes, or those of the representative. -Assessment of relevant functional and cognitive behaviors affecting ability to smoke safely. -Response to smoking cessation interventions. -Compliance with smoking policy. A review of the facility's policy titled, Comprehensive Care Plans dated 09/2023, indicated that person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The CP's policy reflected that the comprehensive CP would describe any specialized services the nursing would provide and would include measurable objectives and timeframe to meet the resident's needs and identified. The policy also indicated that qualified staff responsible for carrying out interventions specified in the CP would be notified of their roles and responsibilities for carrying out the interventions and when changes were made. On 7/1/24 at 10:44 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse, and Regional Infection Preventionist and discussed the above concern. No further information was provided. NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to maintain professional standards of clinical practice for 3 of 29 residents reviewed by a.) not accurately documenting in the electronic Medication Administration Record (eMAR) according to the physician's order (PO) for Resident #46 b.) not obtaining a PO for a resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) for Resident #101, #146. This deficient practice was evidenced by: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a-1.) On [DATE] at 11:06 AM, the surveyor observed Resident #46 in bed. The resident stated they were missing their left hearing aid (HA) and that staff was aware. The resident further stated It has been missing for about 2 months. The resident told the surveyor that staff was aware and so was the Unit Clerk (UC). The surveyor reviewed the electronic Medical Record for Resident #46. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes Mellitus with other Circulatory complications, Cerebral Ischemic attack, unspecified, and End Stage Renal Disease. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the resident's Care plan revealed a focus titled,: Risk for Impaired Communication r/t (related to) bilateral hearing deficient, Date Initiated: [DATE]. Further review revealed: Intervention: Ensure hearing aides are placed while awake and put to charge at night, Date Initiated: [DATE]. A review of the Physician Order Summary revealed a PO for: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss, dated [DATE]. A review of the facility provided form titled, Grievance Form dated [DATE] for Resident #46 revealed: Summary of Concern: The resident reported that [identifier redacted] left ear hearing aid is missing and that it is the side [identifier redacted] needs the most. Further review revealed: Resolution: The resident and family have been notified of all the facility's attempt to locate the missing left hearing aid. Insurance was contacted for replacement. A review of progress notes revealed a Health Status Note dated [DATE] at 16:35 (4:35 PM) Note Text: Searched for reported missing left ear hearing aid in the resident's room and around roommate's [NAME] as requested, and non-found. [Name redacted] made aware of the comprehensive search. Also, the NP (nurse practitioner) completed another search on her own of the resident's room and the roommate. And was not able to locate. Housekeeping director searched as well of the laundry area and could not find the missing hearing aid. [name redacted] denied taking the hearing aid to her HD facility however, HD center will be contacted to check for the device in their facility. A review of the eMAR revealed a Chart codes/follow up code which indicated, a check symbol =administered; 5 = Hold/see Nurse Notes; 9 = Other/See Nurse notes. A review of the February 2024 eMAR's revealed a check for 2/27 night, a 9 for [DATE] day shift and a x for [DATE] night, [DATE] day and night shift. A review of the [DATE] eMAR's revealed checks for day and night shifts except for [DATE] there was a 9 for day shift; [DATE] and [DATE] there was a 5 for day shift. A review of the progress notes for the above eMAR documentation revealed the following progress notes: -[DATE] 11:14 eMAR - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss -[DATE] 10:30 eMAR - Medication Administration Note Note Text: RESIDENT HAS SURGERY -[DATE] 11:50 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss. Further review of the progress notes for [DATE] did not reveal any additional documentation regarding the HA. A review of [DATE] eMAR's revealed checks for day and night shifts for the entire month. A review of the progress notes for [DATE] did not reveal any documentation regarding the HA. A review of the [DATE] eMAR's revealed checks for day and night shifts except for the [DATE] there was a 5 for the day shift. A review of the progress notes for the above eMAR documentation revealed a note: [DATE] 12:32 eMar - Medication Administration Note, Note Text: Refused meds after x3 attempts. Further review did not reveal any additional documentation regarding the hearing aid. A review of the [DATE] eMAR's revealed checks for day and night shifts except for [DATE] there was a 9 for day shift, [DATE] was blank for day shift, [DATE] & [DATE] there was a 9 for day shifts. A review of the progress notes for the above eMAR documentation revealed the following notes: -[DATE] 11:43 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss no hearing aids, awaiting insurance approval -[DATE] 13:25 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss no hearing aids. Further review did not reveal any additional documentation regarding the HA. On [DATE] at 11:09 AM, the surveyor interviewed the UC who stated she was aware of the missing left HA for Resident #46. The UC stated the facility tried to find the HA but they were unable to find it. She further stated she called the hearing aide company and left voice messages, but no one was returned the call. On [DATE] at 11:11 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated she was aware the left HA was missing. She stated the resident's family and the doctor were made aware at the time. The LPN/UM stated that the insurance company had been called. The LPN/UM reviewed the eMAR in the presence of the surveyor who verified the active PO dated [DATE]: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss. She stated, I would have my nurse put in a progress note if something was not done according to the order. The LPN/UM showed the surveyor the [DATE] progress note regarding the missing HA. She was unable to find additional progress notes regarding the HA at that time. The LPN/UM verified that a check symbol for the HA PO on the eMARs indicated that both hearing were signed as being administered and removed. On [DATE] at 11:31 AM, the surveyor interviewed Resident #46s assigned Registered Nurse (RN) who stated the resident had 2 HA's but one was lost and we tried to call the ENT (ear, nose, and throat physician). She stated the HA had been missing for 2 or 3 months. She verified if a PO was signed it means it was completed as ordered. The RN reviewed the eMAR in the presence of the surveyor. She acknowledged that she had signed that both HA had been administered several times on the day shift. She stated, I signed because it is one order. She further stated that she should have done a progress note because it (the order) was not done as it was ordered. The RN was unable to find any progress notes that she had made regarding the hearing aid at that time. She acknowledged that the doctor should have been called to change the PO. The surveyor asked the RN what's the purpose of accurate documentation was, she stated, to put correct information for what is going on with the patient. On [DATE] at 11:58 AM, the surveyor interviewed the facility's Director of Nursing (DON) who stated she was aware of Resident #46's missing HA. She stated the Assistant Director of Nursing (ADON) was looking into it the day it happened but she was unaware that it was still missing. The DON reviewed the electronic medical records in the presence of the surveyor who verified active PO for both the hearing aids. She reviewed the eMARs for March, April, May and June. She acknowledged that the HA's PO for both right and left ear had been signed as administered and removed. She stated, they (the nurses) signed for it. The check mark means it was done. It means they signed that they did it. She further stated, when you sign something, you need to do it, if you don't it is not happening. The DON stated, 'your (nurses) not allowed to sign for something that never happened, this (signing an order was done) is a something you did not do but you (the nurses) still signed. She stated it was important to put the order on hold until you get what you need and to call the physician to get the correct order. She further stated that she and the administrator should have been made aware that the HA had not been replaced. On [DATE] at 01:12 PM, during a meeting with the survey team, the Regional Registered Nurse (RRN), the Director of Nursing (DON), the Regional Infection Preventionist (RIP), and the Licensed Nursing Home Administrator (LNHA), the surveyor presented the above concerns. The LNHA stated, this is not acceptable to check you are doing it and your not. The regional IP stated, staff was expected to follow standards of practice for documentation. A review of the facility's policy titled, Use of Assistive Devices revealed under #3. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement. and #6. A nurse with responsibility for the resident will monitor of the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed. b-1.) On [DATE] at 10:00 AM, the surveyor observed Resident #101 who was alert and oriented and was in bed watching television. The resident was verbally responsive and had no issues with care. The Surveyor reviewed the hybrid medical record (medical record is a combination of electronic and paper records) of Resident #101 which revealed the following: According to the admission Record (AR), Resident #101 had diagnoses that included but were not limited to, Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood, Ogilvie syndrome (is an acute dilation of the colon in the absence of any mechanical obstruction in severely ill patients), and Hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the quarterly Minimum Data Set (qMDS) assessment, a tool used to facilitate management of care, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #101 scored a 9 out of 15, which indicated the resident was moderately impaired cognition. A review of the [DATE] physician's Order Summary Report (OSR) revealed no PO for a code status. A review of the resident's medical chart that was located on the 4th floor nursing unit revealed no Practitioner Orders for Life-Sustaining Treatment (POLST) (a written medical order from physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) or any readily available documentation indication the resident's code status. On [DATE] at 10:40 AM, the surveyor in the presence of Licensed Practical Nurse (LPN#1), who was responsible of Resident #101, reviewed the resident's hybrid medical chart which included the resident's electronic and paper chart. LPN#1 could not locate any documentation that showed the resident's code status. LPN #1 stated that she will need to verify the resident's code status. LPN #1 further stated that if the resident's does not have any listed code status, the resident will be considered a full code (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat). On [DATE] at 10:45 AM, the surveyor interviewed the 4th floor Registered Nurse (RN#1) who acknowledged that Resident #101 had no POLST. RN #1 also stated that a POLST was only required if the resident had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) code status. All the other residents with no POLST in the medical chart were considered as full code status. On [DATE] at 10:50 AM, the surveyor interviewed the 4th floor Licensed Practical Nurse/Unit Manager (LPN/UM) who acknowledged that there were no code status indicated in Resident #101's medical chart. On [DATE] at 1:10 PM, the surveyor discussed the above concerns with the administration team which included the LNHA, DON, RRN and the RIP. There was no additional information provided. A review of the facility's policy titled Resident's Rights Regarding Treatment and Advanced Directives that was undated and was provided by the DON revealed the following: 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. a-2.) On [DATE] at 10:35 AM, the surveyor observed Resident #45 in bed watching television. The resident was alert and was verbally responsive and had no issues with care. The surveyor reviewed the hybrid medical record of Resident #45 which revealed the following: According to the AR, Resident #45 had diagnoses that included but were not limited to, Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), adjustment disorder with mixed Anxiety and Depressed mood (a condition that combines symptoms of both adjustment disorder with anxiety and adjustment disorder with depressed mood), and Hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the qMDS assessment, a tool used to facilitate management of care, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #45 scored a 11 out of 15, which indicated the resident was moderately impaired cognition. A review of the [DATE] physician's OSR revealed a PO dated [DATE] for Clonazepam oral tablet 0.5 mg give 1 tablet via G-tube (gastrostomy tube) every 8 hours as needed for anxiety/agitation for 2 weeks. A review of the [DATE] eMAR revealed a PO dated [DATE] for Clonazepam oral tablet 0.5 mg give 1 tablet via G-tube every 8 hours as needed for anxiety/agitation for 2 weeks. Further review of the eMAR revealed that a nurse signed indicating that the above medication was administered on [DATE] at 1935 (7:35 PM). A review of the facility progress notes dated [DATE] at 15:57 (3:57 PM) revealed a Health Status Note which documented the following received patient sitting at the nursing station ready for Endoscopy appt (appointment) at [hospital redacted]; patient is alert and verbally responsive with no apparent distress. NPO (nothing by mouth) status maintained as ordered and morning meds (medications) withheld. At 10:02 am, patient left facility via stretcher with transport and nursing staff in stable condition. At 2:10 pm, patient returned to facility, alert and stable. PEG tube(Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) removed; site checked, dressing intact, no excessive bleeding noted with less than 25% saturation. Good appetite noted post tray set up. Staff will continue to monitor patient for further care. On [DATE] at 1:10 PM, the surveyor discussed the above concerns with the administration team which included the LNHA, DON, RRN and the RIP. On [DATE] at 8:50 AM, the surveyor interviewed the 4th floor LPN/UM who stated that Resident #45's G-tube was removed on [DATE]. The LPN/UM further stated that the PO dated [DATE] for Clonazepam had the incorrect route (via G-tube) and the PO should have been verified by a nurse. There was no additional information provided. A review of the facility's policy titled, Medication Administration that was undated and was provided by the DON that revealed the following: 10. Review MAR to identify medication to be administered. b-2.) On [DATE] at 10:00 AM, the surveyor reviewed Resident #146's electronic medical records which revealed the following information: The AR indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to unspecified mood disorder, Diabetes Mellitus (DM) and Dysphasia (swallowing difficulty). The qMDS, an assessment tool that facilitates a resident's care, dated [DATE] indicated that the resident had severe cognitive deficits. A review of the progress notes (PN) documented by the facility's Social Worker, dated [DATE] at 13:05 (01:05 PM), indicated that Resident #146 had a full code status. The surveyor reviewed the nursing PN dated [DATE] at 09:07, which revealed that Resident #124 had a cardiac arrest and the staff performed CPR. The PN also indicated that 911 emergency number was called who then pronounced Resident #124 deceased . The surveyor reviewed the physician OSR which did not include a PO for the resident's code status. On [DATE] at 10:12 AM, the surveyor interviewed the facility's Director of Social Services (DSW) who stated that Resident #146 was a ward of the state (who is under the legal custody of a state or a subdivision of the state) and was considered an automatic full code status. The DSW further explained that Resident #146 had a legal guardian from the state who was making the decisions on the resident's behalf. The DSW reviewed the residents medical record in the presence of the surveyor and stated that she could not find a PO or any documentation in the resident's profile that Resident #146 had full code status. The DSW stated that the only documentation for the resident's a full code status was included the social service progress notes. On [DATE] at 09:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the third floor who explained the process regarding identifying a resident's code status. The LPN stated that if a resident coded (generally refers to cardiac arrest, in such a case, urgent life-saving measures were indicated), the nurse would immediately check the resident's profile section on the EMR to determine if the resident was a full code or if the resident was a DNR. The LPN stated that a PO would not be required for a code status. The LPN reviewed the resident's profile in the presence of the surveyor and confirmed that the code status was not documented on the resident's profile in the EMR. The LPN further confirmed that there was no PO for a code status, however there was a documentation in the PN from the DSW that the resident was a full code secondary to being a ward of the state. On [DATE] at 09:35 AM. the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on the 3rd floor who explained the process of obtaining a code status for a resident. The LPN/UM stated that when a resident was admitted to the facility, the nurse reviewed the Universal Transfer Form (UTF) and the POLST that was found from the hospital records which would usually indicate the residents code status. The LPN/UM stated that a PO was required for a resident's code status and must be documented on the resident's physical chart and on the resident's profile in EMR. The LPN/UM reviewed Resident #146's EMR with the surveyor and confirmed that there was no code status PO for Resident #146 nor was the code status documented on the resident's profile of the EMR. The LPN/UM explained that when a resident was a ward of the state, the resident was automatically considered a full code. The LPN/UM further stated that it would be important for the staff to obtain a PO for a resident's code status and must be documented on the resident's profile because time was of the essence when determining if the resident required CPR or not in the event of an emergency. The LPN/UM added that staff would not have the time to read all the PN to determine a resident's code status, but that if the code status was readily visible in the resident's profile or in the PO where it could be seen right away in an emergency. On [DATE] at 10:44 AM, the surveyor interviewed the DON who explained that a resident's code status should be documented in the resident's profile in the EMR. The DON also stated that a PO was required for a code status. There was no further information provided. A review of the facility's policy titled, Resident Rights Regarding Treatment and Advanced Directives dated 09/2023 indicated that any decision regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. NJAC 8:39-11.2 (b); 29.2(d)

**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 ensure the primary physician (PP) addressed and evaluated the resident's significant weight changes (a weight loss or gain of 5% in 30 days and/or 10% in 180 days) in a timely manner for 2 of 6 residents (Resident #131 and #95) reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted alert and responsive. Resident stated they had weight loss over the past six months and was unable to recall the last time seeing PP#1. The surveyor reviewed the admission Record (AR) (one page summary of important information about a resident) for Resident #131. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Atrial Fibrillation, Parkinson's Disease, Schizoaffective Disorder, and Hypothyroidism. A review of the Quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care), dated 4/6/24, reflected that Resident #131 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS further reflected Resident #131 had a significant weight loss that was not a prescribed weight-loss regimen. On 6/27/24 at 9:55 AM, the surveyor reviewed Resident #131's electronic (EMR) and paper medical record (PMR). The surveyor reviewed the weight record in the EMR, the weights documented were as follows: 3/12/2024: 255.0 pounds (Lbs.) 3/21/2024: 253.9 Lbs. 3/25/2024: 239.2 Lbs. 3/25/2024: 239.2 Lbs. 4/2/2024: 237.9 Lbs. A review of the Registered Dietitian (RD) progress notes (PN), dated 3/12/24 documented that Resident #131 had a significant weight loss of 14.7 lb./5.8% in 30 days. Further review revealed there were no monthly physician's PN. The surveyor interviewed the 2nd Floor Unit Manager (UM#1) who confirmed she was not able to find any physician PN in the EMR and PMR but stated the PP#1 does come in frequently. The UM#1 called PP#1, who stated that all their notes were documented in the EMR. The UM #1 in the presence of the surveyor reviewed both EMR and PMR but could not locate any physician's PN. On 6/28/24 at 10:51 AM and 12:45 PM, the surveyor attempted to contact PP #1 via phone call but was unavailable for interview. 2. On 6/25/24 at 11:37 AM, the surveyor observed Resident #95 at bedside. The surveyor was unable to interview the resident. The surveyor conducted a phone interview with Resident #95's family, who stated the resident had gained weight since being admitted to the facility, but not sure of exact amount. The family further stated, they have not spoken to Resident's PP #2. The surveyor reviewed the AR for Resident #95. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Heart Failure, Cerebrovascular Disease, Cognitive Communication Deficit, and Dysphagia. A review of the Q/MDS, dated [DATE], reflected that Resident #95 had a BIMS score of 00, indicating severe cognitive impairment. On 6/27/24 at 9:59 AM, the surveyor reviewed Resident #95's EMR and PMR chart. The surveyor reviewed the weight record in the EMR, the weights documented were as follows: 3/27/2023: 129.0 Lbs. 5/10/2023: 129.9 Lbs. 7/26/2023: 132.2 Lbs. 8/9/2023: 133.0 Lbs. 9/14/2023: 159.2 Lbs. 9/25/2023: 159.0 Lbs. A review of the RD PN dated, 9/20/23, documented that Resident #95 had a significant weight gain of 26.2 lb./19.7% in 180 days. A review of the EMR revealed there with no monthly physician's PN in the EMR. The surveyor interviewed the UM#1, who stated the PP #2 wrote all their physician PN in the PMR. The surveyor reviewed the PMR which revealed that PP#2 documented their monthly PN, but all the PN were illegible (not clear enough to be read). The UM#1 was unable to read the physician PN and was unable to state if PP #2 addressed Resident #95's significant weight gain, UM#1 stated PP#2 is usually available when called and will decipher (interpret) the PN when needed. On 6/28/24 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON), Regional Infection Preventionist (RIP) and Licensed Nursing Home Administrator (LNHA), all agreed the PP's need to address any significant weight changes in their monthly PN. On 6/28/24 at 12:00 PM, the DON provided the surveyor with a facility policy titled, Weight Monitoring with a revised date 9/2023. Under the policy explanation and compliance guidelines it states, 3. B. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. On 6/28/24 at 1:12 PM, the survey team met with the LNHA, DON, RIP and Regional Clinical Nurse (RCN). The DON stated the PP's need to address any significant weight changes in the monthly PN. No further information was provided. On 7/1/24 at 10:11 AM, the surveyors conducted a phone interview with PP#2, who could not state the Resident #95's significant weight gain was addressed in their monthly PN. NJAC 8:39-23.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/25/24, at 10:45 AM, the surveyor observed Resident #7 in bed awake, alert, and oriented, able to answer the surveyor's inquiry. A review of Resident #7's hybrid (paper and electronic) medical record revealed the following information: According to the AR, Resident #7 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (disease of the brain and spinal cord). The Annual MDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using a BIMS. The resident scored 14 out of 15, which indicates an intact cognition. A review of the hybrid medical record for Resident #7 revealed that the resident's physician had not hand-signed or electronically signed the monthly PO for December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, and June 2024. Furthermore, there were no physician PN in February 2024 and April 2024. On 7/01/24 at 10:31 AM, the surveyor interviewed the physician for Resident #7 over the phone to inform that the monthly PO from December 2023 through June 2024 were not reviewed and signed. Additionally, there were no physician PN for February 2024 and April 2024. The MD stated he was in the facility but the staff did not tell him to sign the monthly PO. The MD added that if he needed to sign something immediately, he can come to the facility to sign them. 3. On 6/25/24 at 10:27 AM, the surveyor observed Resident #77 sitting in bed, alert with eyes open and was able to answer the surveyor's inquiry. The surveyor reviewed the hybrid medical record of Resident #77, which revealed the following: The resident's AR documented that Resident #77 was admitted with diagnoses that included but were not limited to Type 2 Diabetes Mellitus (high-level sugar in the blood). The QMDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. A review of the hybrid medical record for Resident #77 revealed the resident's physician had not hand-signed nor electronically signed the monthly PO for December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, and June 2024. On 7/01/24 at 09:46 AM, the LPN/UM stated that the MD was at the facility but didn't know why the MD missed to review and sign the PO. The UM/LPN from the 3rd floor stated she was unaware that the MD must sign the monthly PO. On 7/01/24 at 10:35 AM, the surveyor interviewed the MD over the phone regarding the above concern. The MD stated that he usually signed his monthly PO on the paper medical chart. The MD was informed that the monthly PO from December 2023 through June 2024 were not signed and the MD could not provide further information. On 7/01/24 at 10:41 AM, the surveyor team met with the LNHA, DON, RCN, and RIP to discuss the above concern. The DON stated that the unit clerk (UC) was in charge of having the MD review and sign the monthly PO's. If the UC were not in the building, the UC would call the MD to sign the monthly PO. A review of the the facility's policy dated 9/2023 provided by the DON titled Physician Visits and Delegation under Policy Explanation and Compliance Guidelines revealed that: b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate as appropriate by State law; c. Review the resident's total program of care, including medications and treatments, at each visit; d. Date, write, and sign a progress note for each visit., e. Sign and date all orders except for the flu and pneumococcal vaccines, which may be administered per physician-approved policy after an assessment for contraindications. NJAC 8:39-23.2 (b), 23.2 (d) Based on observation, interview, record reviews, it was determined that the facility failed to 1. ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days and 2. ensure the physician reviewed and signed the monthly physician orders (PO). This deficient practice was identified for 3 of 32 residents (Resident #131, #7, and #77), reviewed for physician visits, and was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted to be alert and responsive. The resident was unable to recall the last time seeing their Physician (MD). The surveyor reviewed the admission Record (one-page summary of important information about a resident) (AR) for Resident #131. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Atrial Fibrillation, Parkinson's Disease, Schizoaffective Disorder, and Hypothyroidism. A review of the Quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care), dated 4/6/24, reflected that Resident #131 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. On 6/27/24 at 9:55 AM, the surveyor reviewed Resident #131's electronic and paper chart. During the review, it was revealed that there were no monthly physician's PN. The surveyor interviewed the 2nd Floor Unit Manager (UM#1), who confirmed she could not find any physician PN in either chart but stated the MD does come in frequently. The UM#1 called the MD, who stated all their notes were documented in the electronic chart. The surveyor and UM#1 reviewed both the electronic and paper charts but could not locate any MD PN. On 6/28/24 at 10:51 AM and 12:45 PM, the surveyor attempted to contact the MD for Resident #131 via phone call but was unavailable for interview. On 6/28/24 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the MD was required to have monthly PN in the electronic or paper chart but was unable to explain why the MD had not written their monthly physician PN. On 6/28/24 at 1:12 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Nurse (RCN), and Regional Infection Preventionist (RIP). The DON and RCN both stated that the MDs are expected to write a progress note monthly and after each visit. On 7/2/24 at 10:13 AM, the survey team met with the LNHA, DON, RCN, and RIP for an exit meeting. Facility staff made no further comments.

Complaint# NJ00166657 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's food preference were honored. This deficient practice was identified for 1 of 1 resident reviewed for food preferences (Resident #4), and was evidenced by the following: On 06/26/24 at 12:26 PM, the surveyor observed Resident #4's lunch tray. The meal ticket indicated 16 ounces of skim milk and the lunch tray contained 8 ounces of whole milk. On 06/27/24 at 12:12 PM, the surveyor observed Resident #4's lunch tray. The lunch ticket indicated 16 ounces of skim milk and lunch tray contained 8 ounces of whole milk. The surveyor interviewed Certified Nursing Assistant (CNA) #1 and Unit Manager (UM) who stated that they check the contents of the trays against the meal tickets. The Unit Manager stated that Resident #4's lunch tray was correct. On second check, the UM stated that the milk was incorrect and that she should've caught it at the cart before it was brought into the room. A review of the electronic medical record (EMR) indicated that Resident #4 was admitted with diagnosis including but not limited to Type 2 Diabetes Mellitus (high blood glucose levels) and Bipolar Disorder (a mental disorder that causes unusual shift in a person's mood, energy, activity levels and concentration.) A review of the order summary included a physician order for a CCD/NAS (carbohydrate-controlled diet/No Added Salt) diet regular texture, thin consistency, large portions. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. A review of Resident #4's care plan titled, Nutrition indicated an intervention of Provide me with my food/beverage preferences as available. A review of facility's policy titled, Tray Accuracy indicated: Policy: All trays will be properly et up according to the designated tray card ticket, reflecting the individual resident's dietary needs and preferences. Procedure: Each resident's individual meal tray will be set up and made according to the resident's personal meal tray card ticket. All items described on this ticket will be present on the tray. The defined diet and the individual needs and food preferences will be present on the tray. The defined diet and the individual needs and food preferences will be present on the tray including likes and dislikes in accordance with the compliance guidelines. All trays will be checked by the dietary representative calling the tray line and setting up each tray. Each tray will then be checked by a Dietary management team member prior to being sent to the unit. On received on the unit, the healthcare professional will check the tray prior to serving it to the resident. On 06/28/24 01:26 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse and Regional Infection Preventionist to discuss the above concerns. There was no further information provided. NJAC 8:39-17.4(a)1, 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/25/24 at 10:27 AM, the surveyor observed Resident #77 sitting in bed, alert and awake, able to answer the surveyor's inquiry. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #77, which revealed the following: The resident's AR documented that Resident #77 was admitted with diagnoses that included but were not limited to Type 2 Diabetes Mellitus (high-level sugar in the blood). The Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. A review of the paper copy of the handwritten physician PN from December 2023 through June 2024 showed that they were all illegible. On 6/28/24, at 11:35 AM, the surveyors met with the LNHA and DON who both could not read all the monthly physician's PN. On 7/01/24 at 10:35 AM, the surveyor interviewed the MD over the phone. The MD confirmed that he wrote all his PN on the paper and he can be reached anytime if the nurses cannot read or understand his handwriting. On 7/1/24 at 10:47 AM, the survey team met with the LNHA, DON, RIP, RCN and discussed the above concerns. There was no further information provided. A review of the facility policy titled Physician Visits and Delegation with the revised date of 9/2023 did not specify about the physician's illegible handwriting. NJAC 8:39-35.2 (d)(5) 2. On 6/25/24 at 11:37, surveyor observed Resident #95 in bed. The surveyor was unable to interview the resident. The surveyor spoke with resident's family via phone. The resident's family stated they have not spoken to the Physician (MD) about Resident #95's care. The surveyor reviewed the AR for Resident #95. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Heart Failure, Cerebrovascular Disease, Cognitive Communication Deficit, and Dysphagia. A review of the Q/MDS, dated [DATE], reflected that Resident #95 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. On 6/27/24 at 9:59 AM, the surveyor reviewed Resident #95's electronic and paper chart which revealed there with no monthly physician's PN in the electronic chart. The surveyor interviewed the 2nd Floor Unit Manager (UM#1), who stated the MD wrote all their physician PN in the paper chart. The surveyor reviewed the paper chart which revealed the MD monthly PN were handwritten with all the writing noted to be illegible (not clear enough to be read). The UM#1 was unable to read the physician PN, but stated to the surveyor that the MD was usually available to be called and would interpret the notes when needed. On 6/28/24 at 11:35 AM, the surveyor discussed the above concern to the DON, RIP and LNHA. All agreed on the importance for staff to be able to read the physician's PN. The DON, RIP and LNHA were not able to read the physician's PN for Resident #95. On 6/28/24 at 1:12 PM, the survey team met with the LNHA, DON, RIP and Regional Clinical Nurse (RCN). The DON stated the physician's PN if handwritten needed to legible to the facility staff. No further information was provided. On 7/1/24 at 10:11 AM, the surveyors conducted a phone interview with MD, who confirmed all their notes were handwritten and who stated they are always available if the facility staff needed to clarify their notes. Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PN). This deficient practice was identified for 3 of 29 residents reviewed, Resident#121, #95 and #77, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 6/25/24 at 10:30 AM, during initial tour, the surveyor observed the Resident #121 in bed with their eyes closed. A review of the admission Record (an admission summary) (AR) for Resident #121 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), recurrent Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and adjustment disorder with mixed Anxiety and Depressed mood (a condition that combines symptom of both adjustment disorder with anxiety and adjustment disorder with depressed mood). A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 06/19/24, reflected that the resident's cognitive skills for daily decision-making score were a 3 (three) which indicated that Resident #121's cognition was severely impaired. The Q/MDS further indicated that the resident was on Hospice. A review of the June 2024 Order Summary Report revealed a physician's order dated 03/12/24 for Hospice to evaluate and treat. A review of Resident #121's hospice care binder (HCB)which contained all the hospice care documentation for the resident, that was provided by the 4th floor Unit Clerk (UC), revealed a form titled, Hospice Visit Description Log (HVDL) and indicated it was last signed on 4/23/24. The HCB also included an interdisciplinary care plan and admission orders with initial plan of care. Further review of the HCB revealed no hospice nursing PN for June 2024. The last hospice nursing PN that was found was dated 03/13/24. There were no further nursing PN found in the hybrid medical record or in the HCB for Resident #121. On 6/28/24 at 9:30 AM, the surveyor interviewed the 4th floor Licensed Practical Nurse/Unit manager (LPN/UM) who stated that Resident #121 was under hospice care and a hospice aide would visit the resident daily. The LPN/UM further stated that the hospice nurse would visit the resident weekly and any notes from the visit must be placed in the HCB. On 6/28/24 at 11:30 AM, the surveyor interviewed the Hospice Registered Nurse/ Patient Care Coordinator (RN/PCC) who explained the operation and the process of care of the hospice company. The RN/PCC stated that the aide visits will depend on the resident's care plan and whoever would visit the resident from the hospice company would need to fill out the HVDL form that must be dated with description of care. The RN/HVDL further stated that a hospice nurse would visit the resident weekly and every visit they need to leave a care note that must be dated with a description of the visit. The surveyor informed the RN/PCC that the last hospice nursing PN found in the resident's medical record was a supplemental interdisciplinary note dated on 4/20/24 and the last entry in the form HVDL was on 4/23/24, the RN/PCC stated that the copy of the nursing PN were at the hospice company and there was no copy left at HCB for Resident #121. On 6/28/24 at 1:00 PM, the surveyor presented the above concerns to the facility administrative staff which included the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), Regional Clinical Nurse, and Regional Infection Preventionist. No additional information provided. A review of the facility's Coordination of Hospice Services policy that was undated and provided by the DON revealed the following: 7. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 3 of 3 nursing units on multiple dates of observation and was evidence by the following: 1. On 6/27/24 at 12:05 PM, this surveyor observed the lunch meal on the 4th floor. The main dining room had 18 residents. 18 of 18 residents were served their meal on Styrofoam plates and cups, with plastic utensils. The surveyor further observed the residents who were eating in their rooms also having Styrofoam plates and cups, with plastic utensils. The surveyor interviewed Certified Nursing Assistant (CNA #1), who stated that Styrofoam were used on most meals and it has been ongoing for the past 6 weeks. 2. 0n 6/28/24 at 8:20 AM, the surveyor observed the breakfast meal on the 2nd floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. 3. 0n 6/28/24 at 8:27 AM, the surveyor observed the breakfast meal on the 3rd floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. 4. 0n 6/28/24 at 8:33 AM, the surveyor observed the breakfast meal on the 4th floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. During the resident council meeting conducted during the survey period where 5 residents in the facility attended. There were 5 of 5 residents who stated that the meals were served on Disposable containers, plates, and utensils for a couple months and would prefer regular China and utensils. The same 5 of 5 residents further stated that they were informed by the dietary department the dish machine in the facility was broken. On 6/28/24 at 09:34 AM, the surveyor interviewed the Food Service Director (FSD), who confirmed the dish machine has not worked for the last 5 or 6 weeks. The FSD further stated, he had made frequent requests to the management to have the dish machine fixed. The surveyor further asked why the dietary department was unable to serve meals with non-disposable plates, utensils and glassware while utilizing the three compartment sink (three sink method is the manual procedure for cleaning and sanitizing dishes in commercial settings) for cleaning and sanitizing the dishes, cups utensils and other cookware, the FSD stated, they are trying to use as much non-disposable plates and such but with the size of the resident population, it's very difficult to stay on track with regards to meal preparation. On 6/28/24 at 10:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated he has sent multiple emails to corporate regarding the dish machine repair. Tha LNHA also agreed the residents should not be eating meals off disposable plates and plastic cutlery. A review of the facility's Resident Rights policy with a revised date of 11/2023 stated under the Resident Rights Acknowledgment section, 1. Resident rights, The resident has the right to a dignified existence .5. Respect and dignity; c. The right to side and receive services in the facility with reasonable accommodation of resident needs and preferences 6. Self-determination, b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. On 7/1/24 at 10:40 AM, the survey team met with the LNHA, Director of Nursing, Regional Clinical Registered Nurse, and Regional Infection Preventionist/Registered Nurse. The LNHA provided copies of emails sent to corporate regarding the dish machine. The LNHA further stated the dish machine was being replaced today 7/1/24. No further information was provided. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/25/24 at 9:35 AM, the surveyor in the presence of Food Service Director (FSD) observed the following during the kitchen tour: 1. The dry storage area was noted with a temperature of 80 degrees Fahrenheit (F), the temperature was observed on two different thermometers. FSD stated recent heatwave caused dry storage room to become warmer, and maintenance was aware. 2. In the Walk in freezer, the surveyor observed boxed items being stored on the floor and stacked to ceiling. FSD acknowledged they were not following the 6 inches (in) from the ground and 18 in from the ceiling guidelines. 3. In the cooking area of the kitchen, the surveyor observed dual ovens, both ovens noted with a black colored baked-on debris. 4. In the Chef preparatory area, the surveyor observed on the spice storage rack multiple open seasonings without open or use by dates. The following spices were open: 6 ounce (oz) kosher salt, 6oz cinnamon, 6oz granulated garlic, and 24oz adobe seasoning. The FSD could not state when they had been opened. 5. In the bread storage area, the surveyor observed multiple open bags of sliced white bread (4), hamburger buns (3) and hotdogs buns (2) without open/use by labels. FSD could not state when they had been opened. On 7/1/24 at 10:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Clinical Nurse (RCN), and Regional Infection Preventionist (RIT). The surveyor reviewed the kitchen inspections concerns. On 7/1/24 at 11:00 AM, the LNHA provided the surveyor with multiple facility polices including Food Storage and Dating and Labeling Policy both with revised dates of 2/24/24. The Food Storage policy states under the procedure section, 1. All items with be stored on shelves at least 6 inches above the floor. 3. Items will be stored at least 18 inches of a sprinkler unit. 8. The temperature of the dry storage room for food items will maintain a temperature of 50-70 degrees Fahrenheit at all times. The Dating and Labeling Policy states under the procedure section, 2. Label products in storage with the date the package was opened or the expiration date with no more than 48 hours after opening, whichever is appropriate. 3. Label all dry goods with date received. 7. Foods that are marked with manufactures use by date, once opened and or used, must be marked with the open or use by date and that date must be used. All food items need to be dated with open date once opened. On 7/2/24 at 10:13 AM, the survey team met with the LNHA, DON, RCN, and RIT. There was no additional information provided. NJAC 8:39-17.2(g)

Based on interview and record review, the facility failed to ensure the Practitioner Orders for Life-Sustaining Treatment (POLST-used as directions to emergency health personnel in the event of cardiac or respiratory failure) was complete and code status (to resuscitate or not) orders were in place for one of six residents (Resident (R) 55) reviewed for advanced directives out of a total sample of 35 residents. This failure had the potential to negatively affect the dignity, designated wishes, and physical status of the resident in case of cardiac or respiratory arrest. Findings include: Review of R55's profile, located on the Profile tab of the electronic medical record (EMR), revealed an admission date of 02/09/22 with a diagnosis of syncope and collapse, dementia in other disease classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of R55's significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/09/22 revealed R55's had a Brief Interview for Mental Status (BIMS) score of 06, indicating R55 was severely cognitively impaired. Review of R55's POLST (Practitioner Orders for Life-Sustaining Treatment) form, located under the Miscellaneous tab of the EMR, revealed the following selections: under medical interventions when the person is breathing/has a pulse, limited treatment; under artificially administered nutrition no artificial nutrition was initially selected and then crossed out and defined trial period was selected and dated 05/19/22 (the form was otherwise undated). Further review revealed, under if the person has no pulse/is not breathing, Do not attempt resuscitation/DNAR (Allow Natural Death) and, if the person is in respiratory distress with a pulse, do not intubate, use oxygen were selected. The document revealed R55's daughter and a second surrogate decision were identified. The signatures section was blank, there were no representative signatures indicating they reviewed the form with a practitioner. There was no practitioner signature. Review of R55's EMR Orders tab lacked documentation of a code status for R55. During an interview with the Social Services Assistant (SSA) 07/26/23 at 2:18 PM, confirmed paperwork for the POLST had not been signed and R55 did not have a code status order. The SSA stated she spoke with the daughter yesterday and confirmed the DNAR status and it was now documented in R55's medical record that the resident is DNAR. The POLST and advanced care planning policies were requested, and none were provided. NJAC 8:39-4.1(a)4 NJAC 8:39-9.6(a)(b) NJAC 8:39-35.2(d)14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide privacy during personal care for one (Resident (R)43) of 35 sampled residents. Findings include: Review of R43's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R43 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Review of R43's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/15/23 and located under the MDS tab of the EMR, revealed R43 scored a four out of 15 on her Brief Interview for Mental Status (BIMS), which indicated R43 was severely cognitively impaired. It was recorded, R43 required extensive assistance with bed mobility, transfers, dressing, and toilet use; limited assistance with personal hygiene; and was always incontinent of bladder and bowel. During an observation on 07/23/23 at 11:11 AM, the door to R43 and R65's room was observed to be open. The privacy curtain was pulled to the end of the right side of R43's bed, and the resident was not seen from the hallway. The surveyor knocked on the door, heard someone say, come in, and then entered the room. Certified Nurse Aide (CNA) 1 was standing on the right side of R43's bed providing personal care and helping R43 dress. CNA1 pulled R43's top off, exposing her breasts. The privacy curtain between R43 and R65's bed was fully open. R65 was in her bed, with a full view of R43, and was watching CNA1 provide care to R43. During an interview on 07/25/23 at 10:16 AM, CNA1 stated the purpose of closing the privacy curtain was to provide privacy to residents during care. CNA1 stated she had made a mistake by not pulling the privacy curtain closed. CNA1 stated she did not always close the door to a resident's room during care because some residents did not like their door to be closed. During an interview on 07/25/23 at 10:44 AM, Unit Manager (UM) 1 stated it was her expectation that staff closed the privacy curtains while providing resident care. Review of the facility's undated policy titled, Residents Rights Acknowledgment, revealed, . The resident has a right to personal privacy . Personal privacy includes . personal care . NJAC 8:39-4.1(a)16

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 27) reviewed for hospitalization out of a total sample of 35 residents and their resident representative were provided with a written transfer notice that stated the reason for transfer, the place of transfer, the name and contact information of the Ombudsman, and information concerning the right to appeal the transfer if desired. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of R27's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R27 was admitted to the facility on [DATE] with diagnoses that included history of falling and seizures. Review of R27's Health Status Note, dated 07/22/23 at 3:44 PM and located under the Progress Notes tab of the EMR, revealed, . At 7:26 AM, patient was standing by the elevator pressing its button when all of a sudden I saw patient lost his balance and fall backward and hit the back of his head against the wood of the wall of the nurses station. Patient was alert and confused, talking and blabbing. No physical injury noted. No bruises. No Hematoma. No shortness of breath noted. Patient denies pain . At 8:32 AM, pick up by EMT [emergency medical technician] Personnel . Did transfer hand over to . nurse at [hospital name withheld]. House nurse notified. [Family member] called and notified . Review of R27's Summary for Providers, dated 07/22/23 and located under the Progress Notes tab of the EMR, revealed documentation of R27's vital signs, medical history, a summary of the events that occurred on 07/22/23, and the physician's order to send R27 to the hospital following the fall. The form did not include written notice to R27 or his representative of the reason for the transfer; the place of transfer; appeal rights; or the name, address, and telephone number of the Ombudsman. Review of R27's entire EMR and hard chart revealed no documentation R27 or his representative had been provided a written transfer notice that contained the required information, included the effective date of the transfer, place of transfer, the reason for transfer, the Ombudsman's contact information, and notice of the right to appeal the transfer if desired. During an interview on 07/25/23 at 3:12 PM, Licensed Practical Nurse (LPN) 1 stated that if a resident needed to be transferred to the hospital, the physician was called, orders were placed, documents from the medical record were prepared, vital signs were obtained, and the ambulance was called to pick the resident up. LPN1 stated a universal transfer form was completed listing all the resident's pertinent medical information and the name and contact number of the resident's representative. When asked if a transfer notice, containing all the required information, was provided to the resident and their representative, LPN1 stated he had no knowledge of that information being provided. LPN1 confirmed he did not provide the transfer notice information to R27 or his representative. LPN1 stated he notified R27's family member via telephone of the transfer, and that was all he did. LPN1 stated he did not know the facility's policy on providing the required transfer notice to the resident or representative. During an interview on 07/25/23 at 4:24 PM, Unit Manager (UM) 1 stated if a resident was able to understand at the time of discharge, the facility explained to them where they were going during an emergency transfer. UM1 stated staff would call the physician and the family before the resident left the facility and give report to the hospital where the resident was going. UM1 confirmed the facility did not provide written transfer notices when a resident was transferred to the hospital. As of 07/25/23, R27 had not returned to the facility. Review of the facility's policy titled, Transfer and Discharge (Including AMA [Against Medical Advice], revised 09/2022, revealed, . Provide transfer notice as soon as practicable to resident and representative . The policy did not address what information would be provided in the transfer notice to the resident or representative. NJAC 8:39-4.1(a)31,32

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide one of three residents (Resident (R) 27) reviewed for hospitalization out of a total sample of 35 residents and their representative written notice of the facility's bed-hold policy when the resident was transferred to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: Review of R27's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R27 was admitted to the facility on [DATE] with diagnoses that included seizures, a history of falling, and hypertension. Review of R27's Health Status Note, dated 07/22/23 at 3:44 PM and located under the Progress Notes tab of the EMR, revealed, . At 7:26 AM, patient was standing by the elevator pressing its button when all of a sudden I saw patient lost his balance and fall backward and hit the back of his head against the wood of the wall of the nurses station. Patient was alert and confused, talking and blabbing. No physical injury noted. No bruises. No Hematoma. No shortness of breath noted. Patient denies pain . At 8:32 AM, pick up by EMT [emergency medical technician] Personnel . Did transfer hand over to . nurse at [hospital name withheld]. House nurse notified. [Family member] called and notified . Review of R27's entire EMR and hard chart revealed no documentation R27 or his representative had been provided a written notice of the facility's bed-hold policy at the time of transfer. During an interview on 07/25/23 at 3:12 PM, Licensed Practical Nurse (LPN) 1 confirmed he did not know a resident and their representative had to be provided written notice regarding the facility's bed-hold policy if the resident was sent to the hospital. LPN1 confirmed he did not provide such information when he sent R27 to the hospital. During an interview on 07/25/23 at 4:24 PM, Unit Manager (UM) 1 confirmed she had no knowledge of the requirement to provide written notice of the facility's bed-hold policy at the time of transfer. As of 07/25/23 at 4:00 PM, R27 had not returned to the facility. Review of the facility's policy titled, Transfer and Discharge (Including AMA [Against Medical Advice], revised 09/2022, revealed, . Provide a notice of the resident's bed hold policy to the resident and representative at time of transfer, if possible, but no later than 24 hours of the transfer . NJAC 8:39-4.1(a)31 NJAC 8:39-5.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for one of 35 sampled residents (Resident (R) 119). Failure to code the MDS correctly can lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of R119's admission Record, located under the Profile tab of the EMR, revealed R119 was admitted to the facility on [DATE] with diagnoses that included recurrent major depressive disorder and dementia. Review of R119's Pre-admission Screening and Resident Review (PASRR) Level 1 Screen, dated 11/16/22 and located under the Misc (Miscellaneous) tab of the electronic medical record (EMR), revealed R119 had a major mental illness diagnosis, had significant impairment in function related to the diagnosis, and had a positive mental illness screening. It was recorded a Primary Dementia Exclusion was requested for R119. The form recorded, . For an individual with a Positive Level I Screen for MI [mental illness] with a diagnosis of Dementia and the Dementia is primary or more progressed than the co-occurring MI, a referral to the DMHAS [Division of Mental Health and Addiction Services] for the PASRR Level II evaluation and determination is required prior to NF [nursing facility] admission . Review of R119's PASRR Level II Determination Notification, dated 11/16/22 and located under the Misc tab of the EMR, revealed R119 was to have a psychiatric consult upon admission to the facility, routine follow-up visits with the primary care physician and psychiatrist, medication monitoring, supportive counseling, routine laboratory testing, formulation and implementation of a behavioral modification plant, and the development of a crisis intervention plan. Review of R119's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/22, revealed R119 was coded as not being currently considered by the state level II PASRR process to have a serious mental illness. During an interview on 07/25/23 at 3:54 PM, the Social Services Director (SSD) confirmed R119 did have a positive screening for a serious mental illness. The SSD stated a Level II determination had been completed, and the information was in the EMR. The SSD stated the recommendations from the Level II determination were to be incorporated into R119's plan of care. During an interview on 07/26/23 at 9:09 AM, the Regional MDS Coordinator (RMDSC) confirmed the MDS was coded incorrectly for R119. Review of the RAI Manual, dated October 2019, indicated, The RAI process has multiple regulatory requirements. Federal regulation . require that the assessment accurately reflects the resident's status . A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions . A1510: Level II Preadmission Screening and Resident Review (PASRR) Conditions . Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . NJAC 8:39-11.2(e)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer one (Resident (R) 57) of ten sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) out of a total sample of 35 residents for a Level II resident review after the resident experienced a significant change in status assessment related to new onset mental illnesses. This had the potential to cause R57 to not receive necessary mental health services. Findings include: Review of R57's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R57 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis and hypertension. Review of R57's Preadmission Screening and Resident Review (PASRR) Level I Screening Tool, dated 12/10/18 and located under the Misc (Miscellaneous) tab of the EMR, revealed R57 did not have a diagnosis or evidence of a major mental illness and had no significant impairment in functioning related to a suspected or known diagnosis of mental illness. Review of R57's Diagnoses, listed under the Med Diag (Medical Diagnoses) tab of the EMR, revealed R57 was diagnosed as having adjustment disorder with disturbance of conduct on 02/13/19 and with having unspecified psychosis not due to a substance or known physiological condition on 06/05/19, both during her stay at the facility. Review of R57's entire EMR and hard chart revealed no documentation a new Level 1 PASRR screening had been completed after receiving the mental illness diagnoses or that R57 had been referred for a Level II resident review. On 07/25/23 at 4:03 PM, the Social Services Director (SSD) confirmed the addition of the mental illness diagnoses for R57 were a change in condition for the resident and a new Level I PASRR and Level II resident review should have been completed at that time. NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure two of ten residents (Resident (R) 43 and R95) reviewed for Pre-admission Screening and Resident Review (PASRR) out of a total sample of 35 residents had accurate screenings and/or were referred for a Level II review as required following a positive Level I screening. This had the potential to cause delay in receiving necessary mental health services for R43 and R95. Finding include: 1. Review of R43's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R43 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Review of R43's Pre-admission Screening and Resident Review (PASRR) Level I Screening, dated 09/07/18 and located under the Misc (Miscellaneous) tab of the EMR, revealed documentation R43 did not have a serious mental illness and did not have significant impairment in functioning related to the diagnosis of a mental illness, and had not experienced one psychiatric treatment episode that was more intensive than routine follow-up care in the last two years. Review of R43's Pre-admission Screening and Resident Review (PASRR) Level I, dated 12/05/19 and located under the Misc tab of the EMR, revealed documentation R43 did have a serious mental illness, had significant impairment in functioning, and had experienced one psychiatric treatment that was more intensive than routine follow-up care and had at least one episode of significant disruption to her normal living situation requiring supportive services. It was documented R43's current location was a psychiatric hospital or unit. It was documented R43 had a positive screen for mental illness, and a 30-day exempted hospital discharge for a Level I positive screen was selected. The form recorded, . 30-day Exempted Hospital Discharge - Applies only to INITIAL NF [nursing facility] admission . NOT . NF readmission . Review of R43's entire EMR and hard chart revealed no documentation a Level II resident review had been completed for R43. On 07/25/23 at 3:54 PM, the Social Services Director (SSD) confirmed that neither of the Level I screenings completed for R43 were correct. The SSD confirmed that with the 09/07/18 screening, it should have been coded R43 did have a serious mental illness and had significant impairment in functioning related to the diagnosis. The SSD confirmed that with the 12/05/19 Level I screening, the 30-day Exempted Hospital Discharge request did not apply because R43 had already been admitted to the nursing facility. The SSD confirmed R43's screenings had been completed by people outside the facility but they should have been checked for accuracy by the facility. The SSD confirmed R43 should have had a Level II resident review. 2. Review of R95's admission Record, located under the Profile tab of the EMR, revealed R95 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Review of R95's Pre-admission Screening and Resident Review (PASRR) Level I Screen, dated 10/27/21 and located under the Misc tab of the EMR, revealed R95 was determined to have a diagnosis of schizoaffective disorder, had significant impairments in functioning related to the known mental illness diagnosis, and had experienced one psychiatric treatment episode that was more intensive than routine follow-up care. It was recorded R95 had a Positive Screen MI (Mental Illness) Only. The form documented that for a Positive Screen MI Only, a referral to Division of Mental Health and Addiction Services (DMHAS) was required. There was no documentation that any exceptions or exclusions had been requested. Review of R95's entire EMR and hard chart revealed no documentation that the referral to DMHAS had been completed. On 07/25/23 at 4:07 PM, the SSD reviewed R95's Level I PASRR and confirmed a referral should have been made for a Level II review. The SSD reviewed the EMR and R95's paper file and confirmed she could not find any information showing the referral had been made as required. Review of the facility's policy titled, PASSR Policy and Procedure, reviewed 11/2022, revealed, . The Preadmission screening and Resident Review ensures that individuals are placed in the most appropriate setting for their needs . If the Level I is positive for serious mental illness then a copy of the Level I must be faxed to the Division of Mental Health and Addiction Services . for a Level II Evaluation and Determination . NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure notification was provided for and care plan meetings were conducted routinely for one (Residents (R ) R36) of a total sample of 35 residents. Findings include: R36's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. The document indicated R36 was her own responsible party (RP). R36's quarterly Minimum Data Set assessment with an Assessment Reference Date (ARD) of 06/21/23 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15 indicating R36 was cognitively intact. Review of R36's comprehensive care plan indicated the plan of care was most recently revised with the resident's quarterly MDS assessment dated [DATE]. R36's Interdisciplinary Team (IDT) Notes, dated 03/30/23 and found under the Notes tab in the EMR, indicated a quarterly care planning meeting was held on that date with the resident present. There was no additional documentation in the resident's record to indicate a care planning meeting had been conducted with the resident since that date. Comprehensive review of R36's EMR indicated nothing to show the resident had been invited to a care planning meeting since 03/30/23. During an interview with R36 on 07/23/23 at 1:59 PM, she indicated she was her own RP and stated she did not recall having been invited to a care planning meeting with the Inter-Disciplinary Team (IDT) at any time recently. She indicated she would participate if invited. During an interview with the Social Services Assistant (SS) on 07/25/23 at 7:47 PM, she indicated she was in charge of scheduling care planning meetings for residents. She stated if a care planning meeting had been held recently, documentation of the invitation to the meeting as well as notes from the meeting itself would be found in the progress notes in the EMR. During an interview with the Regional Clinical Director (RCD) on 07/26/23 at 1:20 PM, she confirmed she was unable to locate any documentation to show R36 had been invited to a care planning meeting since 03/30/23, or that a care planning meeting had been held by the IDT for the resident since that date. The RCD stated her expectation was care planning meetings were to be conducted for residents at least quarterly and R36 should have been invited to the meeting and in attendance if she chose to be. The facility's Residents Rights Policy, revised September 2022, read, in pertinent part, The resident has the right to participate in the development and implementation of his or her person-centered plan of care .and has the right to request meetings .and has the right to participate the establishment of expected goals and outcomes of care. NJAC 8:39-4.1(a)3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure broken hearing aids were repaired for one of five residents (Resident (R)6) reviewed for hearing devices in a total sample of 35 residents. Findings include: Review of an undated Face Sheet, found in the Profile tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnoses including unspecified dementia. Review of R6's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/19/23 revealed R6 was assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 of a possible 15 points. On 07/23/23 at 11:30 AM, R6 was observed in his room, sitting on the rollator. When screened in the initial pool portion of the survey R6 stated his main concerns were staffing, and that he had been asking for months for his hearing aids to be repaired. He stated the hearing aids don't work and had been stored on the nursing medication cart for months. When asked if he had alerted staff he said he told the Nurse Practitioner and the Activities staff. He stated the facility hadn't had a full time Social Worker (SW) for months. R6 said there had been some temp staff assisting, but nothing gets done. A review of R6's EMR revealed his current physician orders had specific orders related to R6's bilateral hearing aids: 01/20/2017 .hearing aid accountability each shift .04/11/22 .hearing aids on in a.m. off at bedtime .09/30/22 Hearing aid to (bilateral right and left) ears ON in AM and OFF in PM every day and night shift Put on in AM and Remove in PM (Keep in Nurse's Cart)12/27/22 .Hearing aid to (bilateral) ears ON in AM and OFF in PM every day and night shift for Hearing loss .There were no SW notes to correspond with any of these orders. Review of a Progress Note, found in the Progress Note tab of the EMR, revealed on 07/26/22 a nurse's note identified that R6's hearing aid was not functioning properly and a call was placed to the audiologist and was told .a rep [audiology representative] would be in by the end of the week to repair. R6 stated on 07/23/23 at 11:30 AM, that the hearing aids had never been fixed and were in the nurses' medication cart. Continued review of the EMR revealed R6 had not received any SW assistance with his hearing aids. There were no social service visits in R6's EMR for over a year and none to respond to the multiple orders for his hearing aids to be repaired. On 07/25/23 the Social Services Staff (SS) member was asked about R6's hearing aids and stated the hearing aids needed batteries. When asked if batteries had been provided SS stated as far as she knew they had not, she had been out on medical leave, but she would speak to the resident, and take care of that immediately. When asked if coverage was provided while she was out, she stated the facility had been trying to hire full time SW, but there were only temporary fill-ins while she was out for maternity leave. On 07/26/23 at 3:35 PM the Interim Director of Nursing was asked if she felt the medically appropriate services had been provided to R6 related to his hearing aids. Her response was to shrug her shoulders and say, I guess not - I'm interim until the DON's licensure issues are resolved and I don't know a lot of the things that I'm being asked. Review of a facility policy titled Vision and Hearing Services, revised 09/20/22, revealed It is the policy of this facility to ensure residents have access to and receive proper treatment and assistive devices to maintain hearing and vision abilities .2. Employees should refer any identified need for hearing and vision services/appliances to the Social Worker (SW)or designee .3. The social worker or designee is responsible to assist residents and/or families in locating and utilizing any available resources for the residents hearing and vision needs .Assistive devices to maintain hearing include but are not limited to hearing aids and amplifiers . NJAC 8:39-27.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide routine pain medications as ordered by the physician for one of 35 sampled residents (Resident (R) 61). This had the potential to cause unrelieved pain for R61. Findings include: Review of R61's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R61 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, stage 4 pressure ulcer of the sacral region, and adult failure to thrive. Review of R61's Care Plan, dated 12/23/21 and located under the Care Plan tab of the EMR, revealed R61 had pain related to depression and a pressure ulcer. Interventions included administering pain medication as ordered. Review of R61's Physician Orders, dated 01/17/22 and located under the Orders tab of the EMR, revealed R61 was to receive hydrocodone-acetaminophen (Norco, a narcotic pain medication) 5/325 milligrams (mg) one tablet by mouth four times daily for pain, at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Review of R61's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/04/23 and located under the MDS tab of the EMR, revealed R61 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R61 was moderately cognitively impaired. It was recorded R61 received scheduled pain medications and had received an opioid pain medication on seven of the preceding seven days. Review of R61's Medication Administration Notes, dated 05/08/23 at 5:00 PM through 05/11/23 at 9:34 PM and located under the Progress Notes tab of the EMR, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician. It was documented the medication had not been delivered by the pharmacy and that a total of 14 doses were missed. Review of R61's Medication Administration Notes, dated 05/28/23 at 9:28 AM through 05/28/23 at 9:43 PM and located under the Progress Notes tab of the EMR, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician. It was documented the medication had not been delivered by the pharmacy and that a total of four doses were missed. Review of R61's Medication Administration Notes, dated 06/06/23 at 1:55 PM through 06/06/23 at 9:27 PM and located under the Progress Notes tab of the EMR and Medication Administration Records (MARs), dated 06/06/23 and located under the Orders tab of the EMR, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician. It was documented the medication had not been delivered by the pharmacy and that a total of three doses were missed. Review of R61's MARs, dated 06/14/23 from 5:00 PM through 9:00 PM and located under the Orders tab of the EMR, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician and missed two doses of the medication. Review of R61's Medication Administration Notes, dated 06/14/23 at 9:06 PM and located under the Progress Notes tab of the EMR, revealed, . Medication was re-ordered on 6/12/23, resident receive medication four times a day. Today 6/14/23, when nurse noticed medication was not yet delivered, nurse placed a call to pharmacy regarding medication refill, as per pharmacy tech . a script is needed for the refill. Nurse then placed a call to resident's primary [physician name withheld] to request the script in order to refill the medication, the doctor expressed anger toward nurse and demanded the DON [Director of Nursing] to call him. Unit Manager notified and called DON, unable to leave message . Review of R61's MARs, dated 06/15/23 at 9:00 AM through 9:00 PM, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician. There were a total of four doses that were missed. Review of R61's Medication Administration Notes, dated 07/16/23 at 2:11 PM through 07/17/23 at 9:00 PM and located under the Progress Notes tab of the EMR, revealed documentation R61 did not receive Norco 5/325 mg four times daily as ordered by the physician. There were a total of seven doses that were missed. It was documented that the facility was awaiting delivery of the medication from the pharmacy. During an interview on 07/24/23 at 2:00 PM, R61 confirmed he did have pain and there were times, sometimes days, when he did not receive his pain medication. R61 stated the pain was not unbearable but it would have been better if he had his pain medication. During an interview on 07/25/23 at 9:56 AM, Licensed Practical Nurse (LPN) 1 stated the facility's process for reordering narcotic medications was to take the sticker off of the medication card and either contact the pharmacy through telephone, computer, or fax and reorder the medication. LPN1 stated the pharmacy should be called to see if there was a valid prescription on file if the medication was a narcotic, and if not, the physician should be contacted to send a new prescription to the pharmacy. LPN1 stated staff might have to call the physician for a prescription but the pharmacy could call the physician as well. LPN1 stated if the medications did not arrive, staff should call the pharmacy. LPN1 stated the reason R61 went without his medications was because the pharmacy needed prescriptions for the refills, and they had difficulties in getting the prescriptions. During an interview on 07/25/23 at 10:03 AM, Registered Nurse (RN) 1 stated medications, including narcotics, should be reordered when the supply was down to the last row on the medication card. RN1 stated that with narcotics, staff was supposed to call the pharmacy and ensure there was a refill available. RN1 stated if there was not a refill, the physician was to be called. RN1 stated if the medications did not arrive in time, staff could see if there was a supply in the emergency medication kit located on the fourth floor. During an interview on 07/25/23 at 10:24 AM, the Medical Director confirmed his expectation was for staff to notify him if they were having a problem receiving medications from the pharmacy or with other physicians writing prescriptions for narcotic medications. The Medical Director stated, They could call me, and I would cover and go after the primary [physician]. During an interview on 07/25/23 at 10:29 AM, Unit Manager (UM) 1 stated the process for reordering narcotics consisted of reordering via computer, fax, or phone call when the supply was low. UM1 stated if a prescription was needed for the refill, the nurse might not know unless they called the pharmacy. UM1 stated if medications, including narcotics, were not available for a resident, the policy was for the staff member to check the emergency medication kit located on the fourth floor and then call the physician and let them know if a prescription was needed immediately. UM1 stated her expectation was for the staff to let her know if a medication was not available, and she would call the doctor herself to get a prescription. UM1 confirmed the emergency medication kit should have Norco in it but that R61 had not received any medication from the emergency medication kit. Continuing with the interview on 07/25/23 at 10:29 AM, UM1 reviewed R61's medical record and stated she had called the nurse practitioner herself on 07/16/23 when R61 went without his pain medication for two days. UM1 confirmed she did not contact the Medical Director for his assistance at that time. UM1 stated the pharmacy and trying to obtain prescriptions were the problems with R61's medications. UM1 confirmed she had not involved the Medical Director in trying to ensure R61 had his pain medications. During an interview on 07/26/23 at 3:19 PM, the Pharmacy Consultant confirmed narcotic refills should be called or faxed in at least three days before the supply ran out. The Pharmacy Consultant stated if a prescription was needed, the pharmacy would contact the physician. Review of the facility's policy titled, Controlled Substances Policy, revised 08/2022, revealed no documentation related to the reordering of narcotic medications. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to ensure the appropriate nursing/physician response/follow-up to pharmacist recommendations were completed for one (Resident (R)46) of five residents reviewed for unnecessary medication in a total sample of 35 residents. Findings include: R46's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and history of stroke. R46's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/23, indicated a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating R46 was cognitively intact. R46's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, revealed orders for Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML (milliliter). Inject 5000 unit subcutaneously (into the resident's fatty tissue) every 12 hours for Anticoagulant. The order indicated an initial order date of 06/07/23. R46's Anticoagulant Therapy Care Plan, dated 06/12/23 and found in the EMR under the Care Plan tab, indicated, [R46] will be free from adverse reactions related to anticoagulant use through the review date. Interventions included, Monitor/document/report to MD [Medical Doctor] PRN [as needed] s/sx [signs/symptoms] of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB [shortness of breath], Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]; and Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review of R46's Pharmacy Consult Therapeutic Suggestions Report, dated 06/09/23 and provided directly to the survey team, indicated a recommendation to include a time duration for the administration of the resident's heparin. Documentation of follow-up by the facility/resident's physician related to the pharmacist's recommendation or any attempt to add a time duration for the administration of R46's Heparin could not be found in the resident's record. During an interview with the Interim Director of Nursing (iDON), the incoming Director of Nursing (DON), and Regional Clinical Director (RCD) on 07/25/23 at 3:57 PM, they confirmed the pharmacist was in the facility monthly to review every resident's medication regimen. The DON indicated she received the recommendations monthly via email and was then responsible for distributing the recommendations to the appropriate unit for follow-up. The iDON indicated she was then responsible for following up to ensure a response was received for each recommendation. The DON indicated it was her expectation that a response was received and initiated within 10 days of the pharmacist's recommendation. The DON and iDON indicated they had nothing to show a response to R46's pharmacy recommendation dated 06/09/23 after the initial recommendation was made and the DON indicated her expectation was follow-up should have occurred to ensure the resident was not receiving heparin unnecessarily for too long. During an interview with the Pharmacy Consultant on 07/26/23 at 9:57 AM, she indicated she was in the facility monthly to review resident medications and stated she had been having some trouble with getting a facility response to her recommendations. She stated she sent her report out every month on the following business day after her visit to the facility for facility/physician follow-up. She stated, The concern is not receiving timely response [to her recommendations] from both the physician and nursing [staff]. The third floor [the floor on which R46 resided] doesn't have a unit manager and so that floor is more of a challenge. The Pharmacy Consultant stated, I usually want them [residents] to switch to oral [anticoagulants] if [they are] on Heparin if I see they have been on it a while [longer than a month]. The facility's Pharmacy Consultant Services Policy dated 09/2022 read, in pertinent part, It is the policy of this facility to use outside resources to furnish pharmacy services for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (Resident (R)46) of five residents reviewed for unnecessary medication out of a total sample of 35 residents did not receive Heparin (an injectable anticoagulant) for longer than generally recommended after a surgical procedure. Findings include: R46's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and history of stroke. The resident was readmitted to the facility on [DATE] after a hospitalization for surgery on his digestive system. R46's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/23, indicated a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating R46 was cognitively intact. R46's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, revealed orders for Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML (milliliter). Inject 5000 unit subcutaneously (into the resident's fatty tissue) every 12 hours for Anticoagulant. The order indicated an initial order date of 06/07/23. R46's Anticoagulant Therapy Care Plan, dated 06/12/23 and found in the EMR under the Care Plan tab, indicated, (R46) will be free adverse reactions related to anticoagulant use through the review date. Interventions included, Monitor/document/report to MD (Medical Doctor) PRN (as needed) s/sx (signs/symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs); and Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. R46's Pharmacy Consult Therapeutic Suggestions Report, dated 06/09/23 and provided directly to the survey team, indicated a recommendation to include a time duration for the administration of the resident's heparin. Documentation of follow-up by the facility/resident's physician related to the pharmacist's recommendation or any attempt to add a time duration for the administration of R46's Heparin could not be found in the resident's record. During an interview with the Interim Director of Nursing (iDON), the incoming Director of Nursing (DON), and Regional Clinical Director (RCD) on 07/25/23 at 3:57 PM, the DON stated the administration of injectable Heparin was based on the resident's condition and the doctor's recommendation. She stated it was important for the doctor to receive and review pharmacy recommendations to ensure medications like Heparin were not administered for too long of a duration (usually no longer than 30 days). During an interview with the Pharmacy Consultant on 07/26/23 at 9:57 AM, she indicated she stated, I usually want them [residents] to switch to oral [anticoagulants] if [they are] on Heparin and I see they have been on it a while [longer than a month]. During an interview with R46's Physician/Medical Doctor (MD 1) on 07/25/23 at 1:53 PM, he indicated he was very familiar with the resident and stated, regarding the administration of the resident's Heparin, I can't remember heparin orders off hand. He is a terrible risk for DVT [blood clot]. He is on mini dose (of Heparin) .You're right. I should have changed it [to an oral anticoagulant]. I do have to concede to the heparin [discontinuing it]. I will change it [the resident's anticoagulant order]. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the timely availability of personal resident funds for one (Resident (R )21) of three residents reviewed for access to personal funds out of a total sample of 35 residents. The facility's banking hours were limited to Monday through Friday and residents did not have access to their money on weekends or on the same day if requested outside of the posted banking hours. Findings include: The facility's banking hours, posted in the hallway across from the nurse's station on each unit, indicated the facility's banking hours were Monday through Friday from 9:00 AM to 4:00 PM. R21's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile tab, revealed R21 was admitted to the facility on [DATE] with diagnoses including emphysema and chronic respiratory failure. R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R21 was cognitively intact. During an interview with R21 on 07/24/23 at 9:54 AM, she stated, If you need money you can go downstairs [to the Administrator to request it] and then it takes a while [to receive the money]. Last time I requested money I had to wait a week. We can only get money Monday through Friday. If you want money to spend on a weekend you have to [request it] on Friday. During an interview with the Regional Business Office Manager (BOM) on 07/26/23 at 11:51 AM, she indicated there was not a BOM working in the facility but that the BOM position was a regional position, and she was responsible for managing several facilities. She indicated she was the BOM who was in charge of the facility, but day to day money management was handled by the facility's Administrator. She stated the residents' personal funds cash was kept in the Administrator's office but that when funds were requested by a resident the money was expected to be available the same day, including on weekends. During an interview with the Administrator on 07/26/23 at 12:08 PM, he confirmed the cash used for resident fund requests was kept in his office and stated, This is the advice we give. If they [residents] want money on the weekend, they need to let us know on Friday. If they [residents] have to have it [money] on the weekend they have to let me know on Friday. NJAC 8:39-4.1(a)10

Based on observation and interview, the facility failed to ensure a clean and sanitary environment for five of 35 sampled residents (Resident (R) 43, R83, R95, R20, and R61) and one (Cherry Blossom) of two treatment carts located on the second floor. Findings include: 1. During an observation on 07/23/23 at 11:11 AM, R43's room was observed. The bed frame and overbed table frame were noted to have a buildup of dirt and debris. The wall behind the head of the bed was noted to have gouges. The floor was noted to be sticky. 2. During an observation on 07/23/23 at 1:56 PM, R83's room was observed. The overbed table frame and the bed frame were noted to have a buildup of dirt and debris. The floor around the perimeter of the bed was noted to be sticky. 3. During an observation on 07/23/23 at 2:43 PM, R95's room was observed. The overbed table frame, bed frame, and the front of the bedside table were noted to have a buildup of dirt and debris. The paint was chipping from the frame of the overbed table. The front of the television was noted to have splatters of an unknown substance. 4. During an observation on 07/23/23 at 6:05 PM, R20's room was observed. The overbed table frame and bed frame were noted to have a buildup of dirt and debris. The three-drawer bedside table had missing handles on the first and third drawers. Numerous splatters were observed on the wall behind the head of the bed, and the floor was sticky. 5. During an observation on 07/23/23 at 6:47 PM, R61's room was observed. The bed frame and overbed table were noted to have a heavy buildup of dirt and debris. There was a large buildup of dirt and debris under the bed. The oxygen concentrator was observed to have splatters, stains, and a buildup of debris on the front of the machine. The floor was sticky, and there was a hole in the wall behind the door where the doorknob came in contact with the wall. During an interview on 07/23/23 at 12:01 PM Housekeeper (HSK) 1 stated she cleaned the rooms five days per week. HSK1 stated each day she swept, mopped, cleaned the overbed table, dusted, and cleaned the sink and toilet. HSK1 stated she cleaned the bed frames and overbed table frames daily. 6. During an observation and interview on 07/26/23 at 10:11 AM, the treatment cart for Cherry Blossom was noted to have dried spills down both sides of the cart. The top had numerous dried splatters of some substance, and the platform was observed to have a heavy buildup of dust and debris. Licensed Practical Nurse (LPN) 2 stated the treatment carts were cleaned every two weeks by the housekeeping department. 7. During an observation and interview on 07/26/23 at 10:30 AM through 10:50 AM, the Administrator, Housekeeping Director (HSKD), and Regional Director of EVS (RDEVS) toured Hibiscus Highway on the second Floor and the following were noted: At 10:33 AM, the HSKD stated R61's room was scheduled for a complete clean. The HSKD stated the debris and stains on the oxygen concentration should have been cleaned during the daily cleaning. The HSKD, Administrator and RDEVS stated the hole in the wall was not the responsibility of the housekeeping department but should have been reported and fixed. At 10:36 AM, the HSKD stated R83's room needed some work and needed to be cleaned. At 10:38 AM, the HSKD stated he did not know why the paint was chipping on R95's overbed table frame. He stated it might be the chemicals that were used to clean it. The RDEVS confirmed there were splatters on the front of the television, and it needed to be cleaned. The RDEVS stated the floor was sticky, but that could be due to the chemicals that were used to clean with. The HSKD confirmed the room and equipment needed to be cleaned thoroughly. At 10:40 AM, R43's room was toured. The HSKD confirmed the bed and overbed table needed to be cleaned. At 10:42 AM, R20's room was toured. The HSKD confirmed the bed frame and overbed table frame needed to be cleaned, the splatters on the wall should be cleaned if possible, and the drawer handles on the bedside table repaired. At 10:44 AM, the HSKD confirmed the treatment cart for Cherry Blossom was dirty and needed to be cleaned. The HSKD stated it was the responsibility of the housekeeping department to clean bed frames, overbed tables, the outside of the treatment carts, the general environment, and the oxygen concentrators. The HSKD, Administrator, and Regional Director of EVS confirmed the housekeeping concerns. During an observation, interview, and record review on 07/26/23 at 10:45 AM, the RDEVS stated there was a list of rooms located at the nurses' station that were designated for high priority room cleaning, indicating they were to be cleaned first with special attention. Taped to the wall at the nurses' station was a form titled, Hi Priority Room Cleaning, dated 07/2023. R83 and R20's room were listed on the form as high priority for cleaning. NJAC 8:39-4.1(a)11 NJAC 8:39-31.8(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to provide three residents (Resident (R)28, R88, and R36) who were unable to carry out activities of daily living (ADLs) the necessary services to maintain grooming, and personal hygiene out of a total sample of 35. Findings include: 1. Review of an undated Face Sheet, found in the Profile tab of the electronic medical record (EMR), revealed R28 was admitted to the facility on [DATE] with diagnoses including schizophrenia, unspecified dementia, and Parkinson's disease. R28's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/23 assessed R28 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of eight of a possible 15 points. R28 was ambulatory via wheelchair and required extensive one person/staff assist with toileting, bathing, and hygiene. On 07/23/23 at 10:30 AM, R28 was observed in her room, on her bed, and calling out for assistance in Spanish. Her privacy curtain was partially opened and when approached she pointed angrily at her brief which was soaked with urine and stool seeped out of the leg openings of the brief. Her bedside table was cluttered including a breakfast tray not yet picked up. R28's call light was not accessible as she yelled out to be changed in Spanish. The call light was found on the floor behind the bed. The Unit Manager/Licensed Practical Nurse (UM1) was working the other end of the hall but stopped to locate a Certified Nurse Aid (CNA) to assist R28, and stated, there is only one CNA on this floor today with more than 50 people to get up. A follow-up visit an hour later confirmed R28 had been changed and her demeanor was much improved. 2. Review of an undated Face Sheet, found in the Profile tab of the EMR, revealed R88 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, abnormal/ unsteady gait, history of falls, and unspecified dementia. R88's quarterly MDS assessment with an ARD of 05/16/23 assessed R88 with moderate cognitive impairment with a BIMS score of 11 of a possible 15 points. R88 was independently ambulatory in her room and used a wheelchair for distance. R88 required extensive one person/staff assist with toileting, bathing, and hygiene. Observation on 07/25/23 at 9:30 AM revealed R88 was dressed and (R28's roommate) lying on her bed with a strong urine odor present. When asked, R88 nodded to indicate she was wet/soiled and pulled her shirt up to reveal a urine-soaked brief. The call light was initiated by R88 on request. After 10 minutes this writer looked to see if staff were in the hallway to respond to the call light. The LPN3 assigned to care for the residents on R28's and R88's hallway was located in Dayroom [ROOM NUMBER] on her cell phone. LPN3 was advised that R88 required assistance with her hygiene. LPN3 entered R88's room four minutes later. When LPN3 entered the room, R88 was exiting the bathroom with no brief on and pulling up her soaked pants. LPN3 instructed R88 to go back in the bathroom to put on a dry brief but did not offer assistance or provide dry clothing. CNA3 was passing in the hallway and stopped to assist R88 with her hygiene and clean clothes. CNA 3 was assigned to the other end of the hall, and not specifically to R28 and R88. CNA3 stated she was nearby and came to help R88. CNA3 stated everybody had to pitch in when we are short staffed and she worked both halls and was familiar with R28 and R88. Observation on 07/26/23 at 9:45 AM revealed R88 and R28 were in their room. R88 was lying on top of her bed and was asked if she was going to a 10 o'clock activity in the dayroom. She said no and pointed to her groin area to reveal she was in a soaked brief and pants, so she didn't want to leave her room. On 07/26/23 at 11:30 AM the Interim Director of Nursing (iDON) was interviewed regarding the ADL concerns for R28 and R88. She stated, R88 couldn't be wet because she [iDON] was just in there . When advised that one of the two women in that room had been found (by this writer) with soiled briefs each day of the survey, the iDON stated, .well, she's a heavy wetter . When pushed further for an interview the iDON stated .I am only interim while the new DON get her licensure issues worked out . when asked about staffing she stated, yes, she was a nurse but, no, she had not worked the floor to assist with the staffing shortages. 3. R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 14 out of 15,indicating R36 was cognitively intact. The MDS assessment indicated R36 required assistance from one staff member to bathe/shower. Review of R36's Activities of Daily Living Care Plan, dated 03/30/23 and found in the EMR under the Care Plan tab, indicated the resident was at risk for self-care deficit related to bathing. Interventions included maintain consistent schedule with daily routine and provide assistance with ADLs as needed. R36's undated Daily Rhythm of Life Document, found in the ADL book at the nurses station, indicated the resident's preference was to bathe on the day shift (7 AM to 3 PM) on Mondays and Fridays. R36's Stop and Watch Forms (staff documentation of resident bathing), dated 07/01/23 through 07/26/23 and found in the ADL book at the nurses station, indicated R36 received baths/showers on 07/09/23, 07/10/23, 07/11/23, 07/20/23, 07/21/23 and 07/24/23. There was no documentation in the resident's record to indicate R36 refused to shower/bathe during the referenced time frame. During an interview with R36 on 07/23/23 at 2:03 PM, she stated she had not received a shower in who knows how long. She further stated, There is no staff, and if no staff .no shower. That's the way it is.R36 was observed to be unkempt during the interview and her hair appeared oily. During an interview with the Interim Director of Nursing (iDON) on 07/25/23 at 3:48 PM, she indicated her expectation was residents receive baths/showers at least twice weekly/per their preference and that all shower/bath documentation was kept at the nurses' stations in ADL books. She indicated refusals to bathe/shower were expected to be documented in each resident's progress notes in the EMR. The iDON indicated residents were scheduled for bathing by room number and the schedule was also kept in the ADL books at the nurses' stations. A review of an undated facility policy titled ADL Care revealed Policy: It is the policy of this facility to provide ADL care to residents requiring such assistance to ensure all ADL needs are met on a daily basis .each residents physical functioning will be assessed .the level of ADL assistance required will be included on the residents care plan .a variety of approaches will be utilized in assisting residents with dementia . NJAC 8:39-27.2(g)(h)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of an undated Face Sheet, found in the Profile tab of the EMR, revealed R88 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, abnormal/ unsteady gait, history of falls, and unspecified dementia. R88's quarterly MDS assessment with an ARD of 05/16/23 assessed R88 with moderate cognitive impairment with a BIMS score of 11 of a possible 15 points. R88 was independently ambulatory in her room and used a wheelchair for distance. She required supervision and cueing for some of her Activities of Daily Living (ADLs), and extensive one person/staff assist with toileting, bathing, and hygiene. Observations of R88 on 07/23/23 at 2:30 PM revealed she was in her room sitting on the bed. She did not have anything to occupy or entertain her. R88 stated, .nothing to do .sit here all day and do it again tomorrow . R88 was ambulatory and could participate in many activities with some encouragement and cueing to keep her on task. She enjoys trying to help others. 4. Review of an undated Face Sheet, found in the Profile tab of the EMR, revealed R97 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, mood/adjustment disorder, and sepsis with metabolic encephalopathy. R97's MDS assessment with an ARD of 07/01/23 assessed R97 as cognitively intact with a BIMS score of 15 of a possible 15 points. R97 was ambulatory via wheelchair and required supervision by one person/staff assist with toileting, bathing, and hygiene. R97 was able to self-direct his activities but the thing he planned his day around was smoking. He stated that . other than smoking and tv there is absolutely nothing to do and they won't even let me go outside to feed the birds . A group meeting was conducted with six cognitively intact residents on 07/24/23 at 11:00 AM. The group agreed that staffing is their primary issue, and it interferes with their ability to enjoy activities, or go outside on nice days, or just get the care they need, especially on night shift. The activity calendar was reviewed, and the group stated they rarely followed the calendar and there was little to do to occupy their interests. The residents from the third floor stated there are activities scheduled every day at 10:00 AM, and activity staff don't even arrive until 11:00 AM. The group identified activities as a concern in the group meeting in May and were told there would be more outdoor activities, and new board games and puzzles were to be provided for resident use. They were told that the group could choose a special meal at least monthly, but they haven't received any follow up about any of those things NJAC 8:39-7.3(a) 2. Review of R43's admission Record, located under the Profile tab of the EMR, revealed R43 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, hypertension, and unstable angina. Review of R43's annual MDS with an ARD of 09/15/22 and located under the MDS tab of the EMR, revealed R43 scored a nine out of 15 on the BIMS which indicated R43 was moderately cognitively impaired. It was recorded it was very important to R43 to listen to music she liked, be around animals such as pets, do things with groups of people, do favorite activities, and go outside to get fresh air when the weather is good. It was also recorded R43 required extensive assistance with bed mobility and transfers. Review of R43's Care Plan, revised 03/23/23 and located under the Care Plan tab of the EMR, revealed, . attends all activities and is assisted as necessary . Review of the facility's Activity Calendar, dated 07/23/23 and provided by the Activities Director, revealed the following activities were scheduled for R43's floor: 10:00 AM - Rise and Shine Café 10:30 AM - Anagrams 2:15 PM - Karaoke During an observation and interview on 07/23/23 at 11:11 AM, Certified Nurse Aide (CNA) was observed providing personal care for R43. CNA1 confirmed R43 had not been out of bed to attend the activities at 10:00 AM and 10:30 AM. During a continuous observation on 07/23/23 from 1:39 PM through 2:30 PM, R43 was observed in her bed. R43's television was not on, and there was no music playing. Staff did not enter her room during that time, and R43 did not attend the Karaoke activity. Review of R43's Record of Record of One-to-One Activities and Resident Participation Record, dated 07/23/23 and provided by the Activities Director (AD), documented R43 had independent activity pursuits and watched television on 07/23/23. Review of the facility's Activity Calendar, dated 07/24/23 and provided by the Activities Director, revealed the following activities were scheduled for R43's floor: 10:15 AM - Move to the Groove 10:30 AM - Guess Who? 2:15 PM - Balloon Volleyball During observations on 07/24/23 at 10:15 AM, 10:30 AM, and 2:15 PM, R43 was observed in her bed. R43 did not attend the scheduled activities for the day, and there was no television or music playing in her room. Review of R43's Record of Record of One-to-One Activities and Resident Participation Record, dated 07/24/23 and provided by the Activities Director (AD), documented R43 had independent activity pursuits and watched television on 07/24/23. During an interview on 07/25/23 at 10:08 AM, CNA1 confirmed R43 liked to attend most activities but she had been the only aide on R43's floor on 07/23/23 and she did not have time to get R43 up to attend the activities. During an interview on 07/25/23 at 5:11 PM, Unit Manager (UM) 1 was asked why R43 was not taken to activities on 07/23/23 and 07/24/23. UM1 confirmed there was not enough staff to get R43 up to get her to activities. Based on record review, interviews, and facility policy review, the facility failed to provide a consistent program of preferred and planned activities for four (Residents (R)21, R43, R88, and R97) of seven residents reviewed for activities out of a total sample of 42 residents. Activities were not provided routinely for residents per their assessed preferences due to a lack of both nurse and activities staffing. In addition, activities posted on the activities schedule on the facility's third floor were not provided per the posted schedule. Findings include: The facility's Third Floor Activity Calendar, posted in the hallway across from the nurses' station, indicated the following scheduled activities during the survey period: Sunday 07/23/23 10:30 AM Anagrams and 2:15 PM Would You Rather, Monday 07/24/23 10:15 AM Move to the Groove, 10:30 AM Karaoke Fun, 2:15 PM BINGO, and 2:15 PM Balloon Volleyball, and Tuesday 07/25/23 10:15 AM Tone Up Tuesday, 10:30 AM Balloon Volleyball, 2:15 PM Afternoon Movie, and 4:00 PM Room Visits/Sensory Stimulation. 1. R21's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile Tab, revealed R21 was admitted to the facility on [DATE] with diagnoses including emphysema and chronic respiratory failure. R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R21 was cognitively intact. This MDS assessment indicated R21 required extensive assistance from staff to transfer in and out of bed and her wheelchair. R21's Activities Care Plan, dated 06/04/23 and found in the EMR under the Care Plan tab, indicated the resident engaged in group activities when not pursuing self-directed leisure. The resident's preferred activities were listed as reading, socializing, Resident Council, menu planning, video chatting, going outside when the weather was nice, crossword puzzles, parties, socials, and bingo. Interventions included: Provide with activity calendar monthly and Staff provide independent leisure materials of choice. R21's Life Enrichment Evaluation, dated 03/07/22 and found in the EMR under the Evaluations tab, indicated it was Very Important for the resident to: do things with groups of people, listen to music she liked, do her favorite activities, and go outside to get fresh air when the weather is good and Somewhat Important for the resident to: have books, newspapers, and magazines to read, be around animals such as pets, and keep up with the news. Preferred activity pursuits on the assessment included games, crafts, sports, talking/conversing, walking/wheeling outdoors, music, reading/audio books, writing, baking/cooking, trips/shopping, TV viewing, watching movies, groups/club organizations, and parties/social events. The resident's indicated preferred activity setting was Day/Activity Room. R21's Activity Participation Logs were not able to be located anywhere in the resident's record or in the Activity Logbook kept by the facility's Interim Activities Director. R21 was observed lying in her bed or in her wheelchair on 07/23/23 at 10:59 AM, on 07/24/23 at 9:51 AM, 12:01 PM, and 3:49 PM, and on 07/24/23 at 9:33 AM, 10:25 AM, 10:46 AM, and 12:03 PM. R21 was not engaged in any scheduled activities during the observations. The resident's television set was on during all the observations. None of the scheduled activities listed on the published and posted third floor Activity Calendar, with the exception of the 10/25/23 10:30 AM Balloon Volleyball Activity, were observed to be offered on the facility's third floor. Observation of the 10/25/23 Balloon Volleyball activity revealed three residents invited and participating in the activity, which was conducted at 11:15 AM rather than 10:30 AM since the Activities Assistant assigned to the third floor on that date had working hours of 11:00 AM until 7:00 PM. One of the residents observed attending the activity slept through the entire activity and no attempt was made by the activity assistant to awake and involve the resident in the activity. During an interview with R21 on 07/23/23 at 10:59 AM, she stated she was not able to get out of bed on that day to attend any activities because there was not enough (nursing) staff. She stated, Only one aide and two nurses (are working today) so they told her can't get me up. I have to stay in bed today. This happens frequently. During an interview with R21 on 07/24/23 at 9:51 AM, she stated, They [the facility] don't have anything [activities] on the weekends. Every weekend is like that. They [activities staff] will put something on the calendar but none of it happens. They don't have enough people. A lot of people stay in bed [instead of attending activities]. During an interview with R21 on 07/24/23 at 12:01 PM, she indicated none of the scheduled activities (per the posted activity calendar) had happened that morning. She stated she had been up out of bed and would have attended activities if they had been offered that morning. During an interview with R21 on 07/24/23 at 3:49 PM, she stated BINGO had been on the activity calendar for that afternoon at 2:30 PM, but the activity had not happened. She stated, They did not do [the scheduled] balloon volleyball at 2:15 [PM], either. No one has been here to invite me to anything. During an interview with R21 on 07/25/23 at 10:31 AM, the resident indicated she would have liked to attend the morning's scheduled activities (Tone-Up and Balloon Volleyball), however she was still in bed since nursing staff had not been in to get her up into her wheelchair yet that morning and so was unable to attend. She stated she had not been asked if she would like to participate in activities yet that morning, and stated she did not want to stay in bed but would rather get up and attend activities. During an interview with the Interim Activities Director (iAD) on 07/25/23 at 1:44 PM, she indicated she had been the interim director of activities since 04/02/23 and stated activities were scheduled to begin every morning at 10:30 AM. She stated different activities were scheduled each day. She stated morning activities were scheduled between 10:30 AM and 11:00 AM and then afternoon activities were scheduled between 2:15 PM and 3:00 PM. The last activity in the morning is 10:30 to 11:00 and then afternoon 2:15 until 3:00. The iAD stated her expectation was activities were to be offered based on the calendar for each unit on the weekend as well as during the week. She stated activity participation logs were kept for each resident to document attendance at activities. During a follow-up interview with the iAD on 07/25/23 at 2:41 PM, she stated she had not been able to find activity participation logs for any of the residents residing on the facility's third or fourth floor, including R21, from 04/02/23 through 07/25/23. She indicated her expectation was the Activity Aides would invite residents to activities, conduct the activities, and then document resident attendance at the activities. The iAD stated each floor had a different activities calendar each month, but some activities were provided jointly for the third and fourth floors. She stated if a joint activity was to occur, it was conducted in the Lounge on the third floor. The iAD confirmed BINGO had not been offered at all per the schedule on 07/24/23 and stated it was supposed to have been offered on the third floor on that day. During an interview with the iAD and Activity Assistant (AA) AA1 on 07/25/23 at 2:58 PM, AA 1 indicated he frequently worked on the third floor, was familiar with residents on the unit, and stated R21 enjoyed activities like reading, word searches, and BINGO. He stated his work hours were 11:00 AM to 7:00 PM and indicated morning activities were not offered on the floor he was working on each shift until after his arrival at 11:00 AM. The iAD confirmed morning activities were not being provided on the floor AA 1 was working on each shift since he did not arrive at work until after the scheduled morning activities were to be offered. During an interview with the Regional Activities Director (RAD) on 07/25/23 at 3:19 PM, she stated it was her expectation the activities calendar be followed for each floor. She stated, If it is on the calendar, it should be happening. Unless there is an emergency. She further stated resident attendance at all activities was expected to be recorded in the Activity Attendance Log. She stated activities staff was expected to be in the building and on the unit inviting residents to activities 15 to 30 minutes prior to the beginning of each activity to encourage residents to attend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R95's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R95 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, major depressive disorder, and seizures. Review of R95's Physician's Orders, dated 10/27/21 and located under the Orders tab of the EMR, revealed an order for bilateral half bed rails as an enabler for positioning. Review of R95's quarterly MDS with an ARD of 05/21/23 and located under the MDS tab of the EMR, revealed a BIMS was not attempted due to R95 rarely/never understood and that R95 had long and short-term memory problems. It was recorded R95 required extensive assistance with bed mobility, transfers, and walking; was dependent on staff for eating, personal hygiene, and bathing; and did not walk. Review of R95's Care Plan, dated 06/21/23 and located under the MDS tab of the EMR, revealed a focus related to R95 being found lying between her mattress and side rail. The goal was R95 would remain safe. Interventions included to reinforce the use of padded side rails at all times. Further review of R95's care plan revealed no focus, goals, or interventions related to R95's use of side rails. Review of R95's Side Rail Assessment, dated 05/08/23 and located under the Evaluations tab of the EMR, revealed R95 was non-ambulatory, was not comatose, had a history of falls, demonstrated poor bed mobility or difficulty moving to sitting position on the side of the bed, had poor balance or poor trunk control, took medications which required safety precautions, was not using the side rail for positioning or support, and previous interventions included lowering the bed to the floor, providing frequent staff monitoring at night, and periodic assistance to toileting for R95 at night. It was recorded that the recommendation for R95 was to use half side rails on each side of the bed. Review of R95's Health Status Note, dated 06/21/23 at 9:28 PM and located under the Progress Notes tab of the EMR, revealed, . Around 5:30 pm resident was observed lying between her bed mattress and the siderail, resident unable to give description, resident was assessed head to toe, no apparent injury noted, v/s [vital signs] stable, resident remains alert, with no sign of pain, no seizure activity noted . resident was properly repositioned in bed and made comfortable, safety/seizure precaution maintained, staff continue to monitor . During an observation on 07/23/23 at 11:06 AM, R95 was observed lying in bed. There were half side rails in the up position on each side of the bed. R95 was moving about bed without intention. During an observation on 07/23/23 at 2:43 PM, R95's bed was observed. The left side rail was noted to be padded and loose. When the left side rail was pushed away from the mattress, a gap measuring six inches was created between the mattress and the side rail. During an interview on 07/23/23 at 2:50 PM, Certified Nurse Aide (CNA) 1 confirmed R95 did not use her side rails to reposition in the bed. During an interview on 07/25/23 at 9:12 AM, Unit Manager (UM) 1 stated the facility utilized an assessment on admission and conversations with the resident and the resident's family in order to determine if siderails would be used for a resident. UM1 stated R95 had been admitted to the facility prior to her employment but she knew R95 had a history of seizures, and the side rails had most likely been implemented due to the seizures. UM1 stated on 06/21/23, R95 had turned herself sideways in the bed and was found by staff with her head resting on the padded left side rail. UM1 stated that was one reason she reinforced the use of the padding on the side rails. UM1 stated she would not confirm the side rail was an accident hazard for R95 because whether R95 was in her bed or in her geriatric chair, R95 would turn herself around. UM1 stated staff had to constantly reposition R95. UM1 stated she ensured the side rails were not a risk for R95 by padding them and making frequent rounds. Continuing with the interview on 07/25/23 at 9:12 AM, UM1 stated the facility's policy related to the use of side rails was to determine medical necessity before side rails were used. UM1 stated R95 was no longer able to transfer herself or assist with positioning while in the bed. UMCC stated she and the MDS Coordinator were responsible for ongoing assessments and evaluations to determine if side rails were appropriate for any resident. UM1 confirmed the medical record contained no documentation to show what the medical necessity was for the use of side rails for R95. UM1 was asked to provide the informed consent for the use of side rails with R95. UMCC stated she believed the informed consent was completed on admission and she was unsure if the document was still in R95's clinical record. During an observation and interview on 07/25/23 at 9:42 AM, UM1 and the surveyor observed R95's side rails. UM1 was shown the gap between R95's mattress and left side rail. UM1 stated, It's an accident hazard. UM1 confirmed the left side rail was loose and needed to be tightened. UM1 stated it was her expectation that staff notify her and maintenance when a side rail was noted to be loose. During an observation and interview on 07/25/23 at 12:38 PM, the Maintenance Director (MD) and Regional Director of Plant Operations (RDPO) observed R95's side rail. The MD confirmed the left side rail was loose, needed to be tightened, and had a gap greater than four inches. The MD stated there should be no gap or a bolster should be placed in the gap area. The MD stated staff was expected to call, page, or text with any concerns such as loose side rails or gaps between mattresses and side rails. On 07/26/23 at 10:06 AM, UM1 stated it was her responsibility to develop a comprehensive care plan related to the use of side rails. UM1 confirmed that R95's care plan did not address the use of side rails. On 07/26/23 at 12:21 PM, the Interim Director of Nursing (DON) confirmed the facility could not find any informed consents for the use of side rails for R95. 4. Review of R20's admission Record, located under the Profile tab of the EMR, revealed R20 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, vascular dementia, and repeated falls. Review of R20's Physician Order, dated 09/2021 and located under the Orders tab of the EMR, revealed . Half Side Rails up x [times] 2 . Review of R20's Care Plan, revised 01/26/22 and located under the Care Plan tab of the EMR, revealed a focus related to the use of bilateral half side rails as a positioning enabler. It was documented R20 had been educated on the risks and benefits of bilateral half side rails and provided consent for the use of the rails. Review of R20's annual MDS, with an ARD of 05/24/23, revealed R20 had a BIMS score of 13 out of 15, which indicated R20 was cognitively intact. It was recorded R20 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. It was recorded R20 had no functional limitations in range of motion and bed rails were not in use. Review of R20's Side Rail Assessment, dated 07/11/23 and located under the Evaluations tab of the EMR, revealed R20 was non-ambulatory, was not comatose, had demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed, had poor balance or poor trunk control, had postural hypotension, was on medications which would require safety precautions, currently used the side rail for positioning or support, had not expressed a desire to have the side rails raised while in bed for their own safety or comfort, and had not expressed a desire to have side rails not be released while sleeping. There was no recommendation marked related to if side rails were recommended and if so, what type. Review of R20's EMR and hard chart revealed no documentation related to the medical necessity for the use of bilateral side rails or an informed consent related to the use of the side rails. During an observation and interview on 07/23/23 at 11:34 AM, R20 was observed in her bed. The bed had padded half side rails in the up position on each side. CNA1 was assisting R20 with personal care. CNA1 stated R20 was unable to transfer to the side of the bed independently, roll independently, and did not use the side rails as a positioning enabler. R20 was unable to answer any questions related to orientation. During an observation on 07/23/23 at 11:49 AM, the left side rail on R20's bed was observed to be loose and unsecure. The side rail would move greater than one inch in all directions when in the up and locked position. During an observation and interview on 07/25/23 at 9:12 AM, UM1 stated R20 had been using bilateral side rails since admission. UM1 stated when R20 was sleeping, she could not control her movements. UM1 stated the side rails were used for safety and to help prevent falls. UM1 confirmed R20 could not intentionally roll in bed or transfer herself. UM1 was asked what the facility's policy was related to the use of side rails. UM1 stated it depended on the resident or the family or if the rails were medically necessary. UM1 stated she could not recall any interventions that had been attempted before using side rails on R20's bed. UM1 stated she did not know if there was an informed consent for the use of side rails with R20. UM1 and the surveyor observed R20's side rails. UM1 confirmed R20's left side rail was loose and moved more than one inch in all directions when in the up and locked position. 4. Review of R43's admission Record, located under the Profile tab of the EMR, revealed R43 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, hypertension, and unstable angina. Review of R43's Physician's Order, dated 01/23/20 and located under the Orders tab of the EMR, revealed, . Bilateral side rail x 2 . Review of R43's Side Rail Assessment, dated 04/06/21 and located under the Evaluations tab of the EMR, revealed R43 was non-ambulatory, was not comatose, had a history of falls, demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with poor balance or poor trunk control, took medications which would require safety precautions, and expressed a desire to have side rails raised while in bed for her own safety and/or comfort. Interventions included lowering R43's bed to the floor and periodic assistance with toileting at night. Recommendations were listed as bilateral half rails. Review of R43's EMR and hard chart revealed no documentation of a more recent side rail assessment. Review of R43's Care Plan, revised 12/23/21 and located under the Care Plan tab of the EMR, revealed a focus related to the use of bilateral half side rails. It was recorded R43 knew the risks and benefits of having bilateral side rails and that they were used for safety to promote R43's independence. It was documented R43 provided consent for the use of the side rails. Review of R43's quarterly MDS, with an ARD of 06/16/23 and located under the MDS tab of the EMR, revealed R43's BIMS score was four out of 15, which indicated R43 was severely cognitively impaired. It was recorded R43 required extensive assistance with bed mobility, transfers, dressing, and toileting. During an observation on 07/23/23 at 11:11 AM, R43 was observed lying in bed. Bilateral half side rails in the up position were noted on the bed. The side rails were noted to be loose and would move greater than one inch in all directions when pushed. The bed was not in the lowest position. During an interview on 07/25/23 at 9:15 AM, UM1 confirmed R43 could not transfer herself to the side of the bed and required extensive assistance with bed mobility. UM1 stated R43 did not use the bed rails on her bed. UM1 confirmed there was no medical reason listed in the clinical record for the use of side rails, that the latest side rail assessment was 04/06/21, and there was no signed informed consent contained in the medical record. UM1 confirmed side rail assessments were to be completed quarterly and stated she did not know why there was not one since 04/06/21. UM1 stated informed consents for the use of side rails were obtained on admission to the facility. During an observation and interview on 07/25/23 at 9:42 AM, UMI confirmed R43's bilateral side rails were loose, unsecure, and moved more than one inch in all directions when in the up and locked position. During an interview on 07/25/23 at 3:36 PM, the Interim Director of Nursing (DON) and Regional Nurse confirmed side rail assessments should be completed upon admission and quarterly thereafter. The Regional Nurse stated the side rails should be reassessed if there were any incidents and informed consents for the use of side rails should be obtained yearly. The Regional Nurse confirmed a comprehensive care plan should be developed for the use of side rails. The facility's Proper Use of Side Rails Policy; most recently revised in 09/2022, read, in pertinent part, It is the policy of the facility to utilize a person-centered approach when determining the use of side rails; and 3. If after an attempted alternative to side/bed rails has been made, and the alternatives do not meet the resident's needs, the facility shall: a. Evaluate the alternatives and document how these alternatives failed to meet the resident's assessed needs. If there is no appropriate alternative, document reason. b. Assess the resident for risks of entrapment, and other risks associated with the use of side/bed rails. c. Obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use. d .and f. Obtain physician's orders for the use of side rails; and 5. The use of side rails will be specified in the residents plan of care. NJAC 8:39-27.1(a) Based on record review, interviews, and policy review, the facility failed to ensure the use of side rails was assessed, physician's orders obtained, care plans developed, and/or informed consent obtained for the use of side rails for five (Residents (R )5, R36, R95, R20, and R43) of eleven residents who were reviewed for accidents out of a total sample of 42 residents. Findings include: 1. R5's admission Record, dated 07/26/23 and found in the Electronic Medical Record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and polyneuropathy. R5's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD)of 07/06/23 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating R5 was cognitively intact. The assessment indicated R5 required limited assistance from staff to complete all of his Activities of Daily Living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for the resident. Review of R5's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, revealed orders for the resident to have bilateral half rails applied to his bed as an enabler for positioning. Review of R5's comprehensive care plan, dated 07/06/23 and found in the EMR under the Care Plan tab, indicated no care plan to address the resident's use of side rails. R5's most recent Side Rail Assessment, dated 06/29/23 and found in the EMR under the Evaluation tab, indicated the resident was to have bilateral side rails placed on his bed to be used for an enabler for positioning in bed. Comprehensive review of R5's record revealed nothing to show informed consent had been obtained for the resident's use of side rails. R5 was observed in his room lying in bed or seated in his wheelchair on 07/23/23 at 1:53 PM, and on 07/25/23 at 9:36 AM, 10:44 AM, and 11:30 AM. The resident's bed was observed to have bilateral half side rails installed at the head of the bed. The resident stated he used his side rails for positioning in bed as well as to transfer in and out of bed to wheelchair. 2. R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 14 out of 15 indicating R36 was cognitively intact. The assessment indicated the resident required extensive assistance from staff to complete all her Activities of Daily Living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for the resident. Review of R36's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, revealed orders for the resident to have bilateral half rails applied to her bed as an enabler for positioning. Review of R36's comprehensive care plan, dated 03/30/23 and found in the EMR under the Care Plan tab, indicated no care plan to address the resident's use of side rails. R36's most recent Side Rail Assessment, dated 02/21/23 and found in the EMR under the Evaluation tab, indicated the resident was to have bilateral side rails placed on her bed to be used for and enabler for positioning in bed. Comprehensive review of R36's record revealed nothing to show informed consent had been obtained for the resident's use of side rails. R36 was observed in her room seated in bed or on the side of her bed on 07/23/23 at 2:06 PM, on 07/24/23 at 10:17 AM, and on 07/25/23 at 9:33 AM. The resident's bed had bilateral quarter rails installed at the head of the bed. The resident stated she used her side rails for positioning in her bed as well as to transfer in and out of her bed to her wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure sufficient staffing to meet the needs of the 141 residents in the facility. Five residents (Resident (R) 21, R36, R97, R17, R83, and R5) and staff members Certified Nursing Assistant (CNA 1), the facility's Medical Director, Licensed Practical Nurse (LPN anonymous), and Unit Manager (UM) 1 voiced concerns regarding sufficient staffing, and the facility exhibited multiple failures related to a lack of sufficient staffing throughout the survey. Findings include: 1. Review of the facility's 07/24/23 Resident Census and Conditions of Resident, provided on paper by the Interim Director of Nursing, revealed the facility had a current census of 141 residents. Of those residents, 45 were dependent with bathing, 31 were dependent with dressing, 39 were dependent with transferring, 39 were dependent for toilet use, and 20 were dependent for eating. Additionally, 94 residents required assistance of one to two staff with bathing, 100 required assistance with dressing, 75 required assistance with transferring, 72 required assistance with toilet use, and 56 required assistance with eating. There were 83 residents who were occasionally or frequently incontinent of bladder, 64 residents with dementia, and 41 residents received antipsychotic medications. Upon entry to the facility on [DATE] at 9:30 AM, there were two nurses and one aide observed on the 2nd floor to care for 49 residents. There were two nurses and one aide on the 3rd floor to care for 60 residents. 2. During Initial Pool interviews and observations, five residents voiced concerns related to a lack of sufficient staffing: a. R21's admission Record, dated 07/26/23 and found in the electronic medical record (EMR) under the Profile Tab, revealed R21 was admitted to the facility on [DATE] with diagnoses including emphysema and chronic respiratory failure. R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R21 was cognitively intact. During an interview with R21 on 07/23/23 at 10:59 AM, she stated she was not able to get out of bed on that day to attend any activities because there was not enough (nursing) staff. She stated, Only one aide and two nurses [are working today] so they told me they can't get me up. I have to stay in bed today. This happens frequently [on the weekends]. During an interview with R21 on 07/24/23 at 9:51 AM, she stated, They [the facility] don't have anything [activities] on the weekends. Every weekend is like that. They [activities staff] will put something on the calendar but none of it happens. They don't have enough people. A lot of people stay in bed [instead of attending activities due to lack of nursing staff on the weekends]. b. R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS Tab, revealed a BIMS assessment score of 14 out of 15 indicating R36 was cognitively intact. On 07/23/23 at 11:26 AM, R36 stated there was not enough staff to care for the residents. R36 stated there was only one aide to care for the residents on the 3rd floor. During an interview with R36 on 07/23/23 at 2:03 PM, she stated she had not received a shower in who knows how long. She further stated, There is no staff, and if no staff .no shower. That's the way it is. The resident was observed to be unkempt during the interview and he hair appeared oily. c. On 07/23/23 at 12:40 PM, R97 stated there was only one aide and two nurses on the 3rd floor. R97 stated the residents who smoked could not go smoke because there were not enough staff for supervision. d. R17s admission Record, dated 07/26/23 and found in the EMR under the Profile Tab, revealed she was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis. R17's admission MDS assessment, with an ARD of 06/08/23 and found in the EMR under the MDS Tab, revealed a BIMS assessment score of 14 out of 15 R17 was cognitively intact. During an interview conducted with R17 on 07/23/23 at 1:01 PM, she stated there were not enough nursing staff on most days. She indicated she was not able to get out of bed as frequently as she wanted to because of frequent lack of nursing staff and stated, We [residents] need help. It [the lack of nursing staff] isn't fair for the staff or for us [residents]. It [staffing shortage] used to be just on weekends but now it's most days. I'm supposed to be in my [wheelchair] twice a week at least. I only get in my chair once a month when my brother visits [because of lack of staffing]. They [nursing staff] have to have two staff and a lift to get me up, so I don't get up. They'll probably say I don't want to get up [out of bed] but that's not true. e. On 07/23/23 at 1:42 PM, R83 and her family member stated there was not enough staff to meet the residents' needs. The family member stated they had made many complaints about the staffing but nothing was done. R83 stated she did not feel like the aides gave her a thorough bath because they did not have time to do so. f. R5's admission Record, dated 07/26/23 and found in the EMR under the Profile Tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and polyneuropathy. R5's admission MDS assessment, with an ARD of 07/06/23 and found in the EMR under the MDS Tab, revealed a BIMS assessment score of 15 out of 15 indicating R5 was cognitively intact. During an interview with R5 on 07/23/23 at 10:48 AM, he stated, There are two nurses and one CNA for this entire floor today. R5 indicated staffing had been very short on the weekends since his admission on [DATE]. 3. Additional concerns related to short staffing were voiced by the staff during the survey: During an interview with Licensed Practical Nurse (LPN) LPN 5 on 07/23/23 at 11:56 AM, she indicated there were almost 60 residents on the third floor and there were only two nurses and one CNA working the day shift to take care of everyone on the floor and stated, Staffing is like this [the observed one CNA and two nurses on the third floor] frequently on the weekend. Then us [sic] nurses can't do our job because we have to act as an aide. It is hard. Like today there aren't enough people to get everyone up, so residents will have to stay in bed. During an interview on 07/25/23 at 10:08 AM, Certified Nurse Aide (CNA) 1 stated the facility might put two aides on the schedule for the 2nd and 3rd floors, but only one would show up. CNA1 stated she was unable to provide the care the residents needed by herself. CNA1 stated it was all she could to do just keep the residents clean, and sometimes she could not do that. During an interview on 07/25/23 at 10:27 AM, the facility's Medical Director confirmed, The facility is chronically understaffed. During an interview on 07/25/23 at 10:44 AM with a Licensed Practical Nurse (LPN), who wished to remain anonymous, stated the facility had been hiring staff but they did not stay. The LPN stated one aide could not care for all the residents on the 2nd or 3rd floor. The LPN stated, It's impossible. During an interview on 07/25/23 at 3:10 PM, Unit Manager (UM)1 reported the family member of R20 had showed up with an ambulance and transferred R20 to a different facility because of the staffing concerns. During an interview with LPN 4 and Unit Clerk (UC) UC 1 on 07/25/23 at 10:55 AM, both stated, Weekends are bad for staffing. LPN 4 stated she worked every other weekend in the facility and though there were supposed to be at least five CNAs scheduled on the third floor, there were typically only one or two CNAs actually working on Saturdays and Sundays on the third floor. LPN 4 stated the staffing observations made by the survey team on Sunday 07/23/23 were typical for the facility. LPN 4 stated, We need hands to be able to take everyone out [get everyone up from their beds] and so it happens where we cannot get everyone out of bed [on the weekends] and we get as much done as we can with ADLs/baths with the people [residents] we have but can't always get it [ADL care/bathing] done. During an interview with CNA 3 on 07/25/23 at 11:04 AM, she indicated she worked full time on the third floor and was scheduled to work every other weekend. She stated nursing staffing was low on the weekends. She stated, It happens that we have one or two aides on the weekends. I have had that happen more than two times recently. They offer a bonus if we come in. They ask people to come in but because of the shortage sometimes people don't want to come in. CNA 3 indicated showers could be done for residents who were ambulatory when staffing was short, but residents who were dependent upon staff to get out of bed were given bed baths on weekends when there was not enough staff. During an interview with an anonymous frequent visitor to the facility/family member on 07/25/23 at 12:28 PM, she indicated she visited the facility most days and stated, The weekends are terrible here for staff. I come here every weekend. I was [the resident's] care giver at home. I can't take care of him at home anymore, but he is my father! I found him in urine last weekend. He was soaked. During the week they have staff. It's the weekends that are the problem. 4. During the survey from 07/23/23 through 07/26/23, the following deficient practices related to insufficient staffing were identified: The facility failed to maintain residents' privacy during care in their rooms. Cross-reference F583: Personal Privacy/Confidentiality of Records. The facility failed to provide adequate and timely incontinence care. Cross-reference F677: Activities of Daily Living Care Provided for Dependent Residents. The facility failed to provide an individualized program of activities for dependent residents. Cross-reference F679: Activities Meet the Interests/Needs of Each Resident. The facility failed to have a qualified activities director. Cross-reference F680: Qualifications of Activity Professional. The facility failed to obtain informed consents, failed to conduct side rail evaluations, and failed to develop care plans related to the use of side rails. Cross-reference F700: Side Rails. The facility failed to have a full-time Registered Nurse (RN) Director of Nursing (DON) from 06/01/23 through 07/11/23. Cross-reference F727: RN 8 Hours/7 days/Week, Full Time DON. The facility failed to have sufficient/competent staff to meet the behavior health needs of residents. Cross-reference F741: Sufficient/Competent Staff for Behavioral Health Needs. During an interview on 07/25/23 at 4:44 PM, the Administrator stated the facility had a mock survey on 07/20/23 where it had been identified the facility had a staffing shortage. The Administrator stated, We've known about it for a while but identified it again on Thursday. The Administrator verbalized the facility was attempting to look at long-term staffing needs. The Administrator was asked why the unit managers, the Director of Nursing, and himself were not present at the facility on 07/23/23 when the survey began if they were aware of the staffing shortage. The Administrator did not comment. The Administrator was asked why the corporate nurses were not assisting in caring for the residents if it was known there was a staffing shortage. The Administrator did not comment. During an interview on 07/25/23 at 7:09 PM, the Interim DON reported the facility did not have a policy on sufficient staffing. The Interim DON stated the facility staffed related to the state requirements to the best of their ability. NJAC 8:39-25.2(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident council interview, staff interview, and record review, the facility failed to follow the menu and provide menus for meal selection for four (Resident (R)5, R21, R36, and R46) of 35 sampled residents. This deficient practice had the potential to affect 137 out of 141 (four residents received tube feedings) residents not affording them the opportunity to choose foods from the menu but instead receive whatever was being served. Findings include: On 07/23/23 at 10:32 AM during a tour of the kitchen, review of the menu for lunch revealed, BBQ Pork Lion, Country vegetable blend, baked beans, cornbread, margarine, and strawberry shortcake. The alternative was hamburger steak with grilled onions, brown gravy, seasoned spinach, and mashed potatoes. Observations of lunch on 07/23/23 at 12:30 PM revealed resident received BBQ Pork Lion, or hamburger steak, (no onions or gravy), country vegetable blend and mashed potatoes with ice cream. Residents were upset that strawberry shortcake was not provided as indicated. Observations of dinner on 07/24/23 at 4:30 PM revealed baked chicken, beef patty, sauteed green beans, mashed potatoes, and ice cream. The menu was country fried steak with mushroom gravy, sauteed green beans, mashed potatoes, dinner roll/bread, margarine, and vanilla ice cream. The alternative included garlic baked pork chop, buttered whole kernel corn (veg), and parsley noodles. During an interview on 07/24/23 at 4:33 PM with the Registered Dietician (RD) revealed whenever there is a menu substitution, we have a substitution for that must be competed and I am required to sign off on the substitution. Staff can reach me or the other dietician to discuss menu substitutions. Review of the menu substitution log revealed the last substitution was noted on 06/22/23 although observations on 07/23/23 revealed menu substitutions. During an interview on 07/25/23 at 10:56 AM with the Director of Dining (DM), Assistant Director of Dining (ADM), and the Ambassador of Dietary Services (ADS), revealed when substitutions must be made to the menu, they are written on the substitution log. When asked how residents know about the substitution, the ADM indicated when they [residents] get their trays. 1. R5's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and polyneuropathy. R5's admission MDS assessment, with an ARD of 07/06/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15 indicating R5 was cognitively intact. Review of R5's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, indicated orders for a Controlled Carbohydrate Diet and a 2-gram sodium restriction. Review of R5's Food Preferences Assessment, dated 07/26/23 and provided directly to the survey team, indicated No food refusals, or specific likes or dislikes. R5 was observed eating his lunch in his room on 07/23/23 at 1:41 PM. The resident was served two hot dogs with beans. The resident's menu indicated he was to be served strawberry shortcake and cornbread with his meal, but neither were observed on the resident's meal tray. R5 stated, The menu had strawberry shortcake and corn bread and I did not get either of them today. We haven't been getting cookies or cakes for weeks now. The food is horrible. If we don't want what is on the menu, they give us whatever they choose. They ran out of coffee this morning. They keep telling us the ice machine is broken. We don't get ice a lot. During an interview with R5 on 07/25/23 at 9:15 AM, he stated, Dinner last night was pork chops, and they were like rocks. The lunch peas yesterday were cold/almost frozen. This morning they ran out of sugar packets. They only have aspartame. They won't get it [regular sugar] until tomorrow, so I had no sugar with my oatmeal this morning. R5 was observed eating his lunch in his room on 07/25/23 at 12:23 PM. The resident was served a double portion of peas, chicken, potatoes, and gravy. The resident's menu indicated he was to be served a chocolate chip cookie, but no cookie was observed to be served with the resident's meal. The resident instead received two small cups of diced peaches. R5 stated, Them potatoes look like a rock in the garden. I don't know what those are. I was given pink sugar [Aspartame packets] instead of regular sugar and I don't like that pink stuff. I get regular sugar. They say they are out of it [sugar]. Those potatoes? Oh No I won't touch that. 2. R21's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed R21 was admitted to the facility on [DATE] with diagnoses including emphysema and chronic respiratory failure. R21's quarterly (MDS with an ARD of 06/04/23, indicated a BIMS score of 14 out of 15 indicating R21 was cognitively intact. Review of R21's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, indicated orders for a regular diet with no salt packet served on tray. Review of R21's Food Preferences Assessment, dated 07/26/23 and provided directly to the survey team, indicated the resident's regular diet and indicated no specific food likes, but indicated the resident disliked eggplant parmesan. The assessment indicated the resident wanted to be served a baked cheese omelet every morning for breakfast. During an interview with R21 on 07/24/23 at 9:59 AM, she stated, Yesterday I didn't get the strawberry shortcake I was supposed to have with my lunch. I get an omelet with cheese on it [every day for breakfast]. I always get that. They [staff] know. Saturday morning, they sent scrambled eggs and no cheese, and it was cold. The [dietary staff working that day] didn't tell them [the cooks] .They [staff] don't bring ice because the machine is broke [sic]. I like ice. R21 was observed eating her lunch in her room on 07/25/23 at 12:09 PM. The resident was served her lunch tray with chicken, potatoes, peas, and iced tea with a pink (Aspartame) sugar packet. The chocolate chip cookie the resident's menu indicated she was to receive with the meal was not served. R21 was served pudding instead. R21 stated, I was supposed to have a chocolate chip cookie and they gave me a pink sugar packet instead of real sugar. I would rather have real sugar. 3. R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 14 out of 15 indicating R36 was cognitively intact. Review of R36's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, indicated orders for a regular renal (kidney) diet with controlled carbohydrates. Review of R36's Food Preferences Assessment, dated 07/26/23 and provided directly to the survey team, indicated the resident's regular controlled carbohydrate renal diet and indicated no specific food likes, but indicated the resident disliked a variety of different kinds of prepared shrimp. R36 was observed eating her lunch in her room on 07/23/23 at 1:41 PM. The resident was served a peanut butter and jelly sandwich. The resident's menu indicated she was to be served strawberry shortcake with her meal, but it was not observed on the resident's meal tray. R36 stated, I did not get my strawberry shortcake. The resident further stated desserts had not recently been served per the menu. She stated, We haven't been getting dessert like strawberry shortcake and cookies for weeks. R36 stated the facility kept running out of ice because the ice machine was broken. R36 was observed eating her lunch in her room on 07/25/23 at 12:19 PM. The resident was served peas, chicken, potatoes, and gravy. R36 stated, I'm not eating those potatoes. I don't like potatoes anyway and those are burnt. R36 stated she was supposed to have been served a sugar cookie per her menu, but the cookie was not served with her meal. The resident was instead served a container of ice cream and a small bowl of canned peaches. 4. R46's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and history of stroke. R46's significant change MDS with an ARD of 06/12/23, indicated a BIMS of 15 out of 15 indicating R46 was cognitively intact. R46's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, revealed orders for the resident to receive a regular mechanical soft diet. Review of R46's Food Preferences Assessment, dated 07/26/23 and provided directly to the survey team, indicated the resident's regular mechanical soft diet and indicated the resident liked cranberry juice and disliked/was unable to have a large variety of foods including potatoes. During an interview with R46 on 07/24/23 at 10:56 AM, the resident indicated he could not eat potatoes, but potatoes were frequently served with his meals. R46 was observed eating his lunch in his room on 07/25/23 at 12:46 PM. The resident was served mashed potatoes, chicken and gravy (chopped), and peas. The resident again indicated he did not eat potatoes and was not supposed to be getting them. In addition, the resident was not served a sugar cookie per his menu. R46 was served pudding instead. R46 stated he wanted the cookie that was indicated on his diet card. NJAC 8:39-17.2(b) NJAC 8:39-17.4(e) NJAC 8:39-18.4(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interview, the facility failed to provide meals that were palatable and attractive to two residents (Resident (R)5 and R36) out of a sample of 35 residents. Specifically, the potatoes that were served to residents were burnt. Findings include: Observation of the serving line for lunch 07/25/23 revealed lunch being served was baked chicken, peas, roasted potatoes, the alternative was meatballs, mashed potatoes, and peas. Dessert was mixed fruit. In the preparation of the plates, it was asked if the potatoes were burnt, the cook replied, only on the top and they continued to fix plates to go out residents. During an interview on 07/25/23 at 11:50 PM with the Assistant Director of Dietary (ADM) revealed some problems with the oven not cooking evenly, and that was why they had not been able to bake cookies in the oven. Observations of lunch trays being served to the second floor; the burnt potatoes were on the resident's plates. 1. R5's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and polyneuropathy. R5's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/06/23 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating R5 was cognitively intact. R5 was observed eating his lunch in his room on 07/25/23 at 12:23 PM. The resident was served a double portion of peas, chicken, potatoes, and gravy. R5 stated, Them [sic] potatoes look like a rock in the garden. I don't know what those are. Those potatoes? Oh No I won't touch that. 2. R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 14 out of 15 indicating R36 was cognitively intact. R36 was observed eating her lunch in her room on 07/25/23 at 12:19 PM. The resident was served peas, chicken, potatoes, and gravy. R36 stated, I'm not eating those potatoes. I don't like potatoes anyway and those are burnt. During an interview on 07/25/23 at 3:06 PM with the Director of Dining (DM), Assistant Director of Dining (ADM), and the Ambassador of Dietary Services (ADS), in talking about the potatoes being burnt during lunch, no one commented. The DM that was assisting on the serving line revealed some of the potatoes were over cooked. NJAC 8:39-17.4(a)2 NJAC 8:39-17.4(e)

Based on observation, interview, record review, and policy review, the facility failed to ensure the ice machine was functioning properly to ensure residents received ice. Three of 35 sampled residents (Resident (R)5, R36, and R21) and five residents in a group meeting (R6, R13, R97, R114 and R130) expressed frustration that the facility ice machine was down, and the facility had not supplied sufficient ice despite voiced concerns by residents. Findings include: 1. During the initial observation of the kitchen on 07/23/23 at 10:32 AM, the ice machine had very little ice. The freezer contained three five-pound bags of ice. The Dietary Aide (DA) indicated the ice machine was down and had been down for about a week or so and we are having to bring ice into the facility. At one point it was over filling, now it is not making ice. 2. R5 was observed eating his lunch in his room on 07/23/23 at 1:41 PM. R5 stated, . They keep telling us the ice machine is broken. We don't get ice a lot . R5's admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/06/23 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status assessment score of 15 out of 15 (cognitively intact). 3. R36 was observed eating her lunch in her room on 07/23/23 at 1:41 PM. R36 stated the facility kept running out of ice because the ice machine was broken. R36's quarterly MDS assessment with an ARD of 06/21/23 and found in the EMR under the MDS Tab, revealed a BIMS assessment score of 14 out of 15 (cognitively intact). 4. During an interview with R21 on 07/24/23 at 9:59 AM, she stated, They [staff] don't bring ice because the machine is broke. I like ice. R21's quarterly MDS with an ARD of 06/04/23 and found in the EMR under the MDS Tab,, indicated a BIMS score of 14 out of 15 (cognitively intact). 5. A group meeting was held on 07/24/23 at 11:00 AM with five alert and oriented residents present (R6, R13, R97, R114 and R130). There was at least one resident from each hall/unit in attendance to represent the other residents. The residents stated the ice machine had been down for nearly a month and they cannot even get a cold drink. They have complained about not having any ice in the middle of summer but nothing ever happens. 6. During an interview on 07/24/23 at 4:14 PM, the Registered Dietitian (RD) stated without ice in cups, residents are not likely to drink their drinks, because they are not cold, which could cause some hydration problems. During an interview on 07/25/23 at 10:56 AM, the Ambassador of Dietary Services (ADS) revealed the ice machine has been broken for about a week or so. Our corporate maintenance people have been working on it and finally decided they will need to order a part. At this point we are having a company drop off bags of ice and keeping it in the cooler and on the units for residents. Review of Proposal No: 6432 from Automatic Ice Maker Co, dated 07/24/23 revealed a controller board has been ordered for and the date of acceptance was 07/24/23. During an interview on 07/25/23 at 11:49 AM, the ADS indicated, corporate has been coming back and forth to fix the ice machine and yesterday got the quote for the controller board. They have been working on the ice machine for a couple of weeks now. The ADS was asked to provide documentation of the work being done on the ice machine. This information was not provided. During an interview on 07/26/23 at 12:43 PM, the Maintenance Director (MD) revealed a technician that worked with the corporate company has been coming in to work on the ice machine. The MD stated the technician was in the building on Monday (07/24/23) working on the ice machine, and a part had been ordered. The ice machine was taking double the time to fill. The MD indicated he had been on the job for almost two weeks and the machine has been broken since he started, since Monday (07/24/23) we have been getting bags of ice for the residents. Review of the policy titled Safe Operation of Equipment revised 01/02/18 under Maintenance Service revealed, Maintenance service shall be provided to all areas of the building, grounds and equipment. The maintenance department is responsible for maintaining the building's grounds and equipment in a safe and operable manner at all times. Providing routinely scheduled maintenance service to all areas, including but not limited to: . Dietary equipment . NJAC 8:39-31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 07/23/23 at 2:43 PM, R95's bed was observed. The left side rail was noted to be padded and loose. When the left side rail was pushed away from the mattress, a gap measuring six inches was created between the mattress and the side rail. During an observation and interview on 07/25/23 at 9:42 AM, Unit Manager (UM1) and the surveyor observed R95's side rails. UM1 was shown the gap between R95's mattress and left side rail. UM1 stated, It's an accident hazard. UM1 confirmed the left side rail was loose, unsecure, and needed to be tightened. UM1 stated it was her expectation that staff notify her and maintenance when a side rail was noted to be loose. UM1 stated she would have the side rail tightened immediately. 4. During an observation on 07/23/23 at 11:49 AM, the left side rail on R20's bed was observed to be loose and unsecure. The side rail would move greater than one inch in all directions when in the up and locked position. During an observation and interview on 07/25/23 at 9:12 AM, UMI confirmed R20's left side rail was loose and moved more than one inch in all directions when in the up and locked position. 5. During an observation and interview on 07/25/23 at 9:42 AM, UMI confirmed R43's bilateral side rails were loose, unsecure, and moved more than one inch in all directions when in the up and locked position During an observation and interview on 07/25/23 at 12:38 PM, the Maintenance Director (MD) and Regional Director of Plant Operations (RDOP) observed R95, R20, and R43's side rails. The MD confirmed the side rails were loose and needed to be tightened. The MD and RDOP confirmed that bed and side rail inspections should occur annually and that the inspections consisted of observing for damaged mattresses, loose railings, remotes that were not working, and the general function of the beds. The MD and RDOP stated the facility did conduct the inspections yearly. They were asked to provide the bed and side rail inspection reports for the past year. During an interview on 07/25/23 at 2:15 PM and 4:45 PM, the surveyors again requested the inspection reports from the Administrator. Review of the facility's Maintenance Records indicated nothing to indicate routine physical inspections were being conducted for any of the beds in the facility with side rails applied to them. During an interview with the interim Director of Nursing (iDON), the incoming Director of Nursing (DON), and the Regional Clinical Director (RCD) on 07/25/23 at 3:35 PM, they confirmed their expectation was routine physical inspections of any resident bed with side rails was to be done to ensure resident safety. During an interview with the Administrator on 07/25/23 at 5:20 PM, he confirmed the facility was unable to locate any documentation to show routine physical inspections of resident beds with rails applied to them. He stated, I feel safe to say they [the inspections] have not been done. The facility's Proper Use of Side Rails Policy; most recently revised in 09/2022, read, in pertinent part, It is the policy of the facility to utilize a person-centered approach when determining the use of side rails; and 6. d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and rails. NJAC 8:39-31.2(e) NJAC 8:39-31.4(a)(c) Based on record review, interviews, and facility policy review, the facility failed to ensure physical bed inspections were routinely conducted related to the use of side rails for five (Residents (R) R5, R36, R95, R20, and R43) of eleven residents who were reviewed for accidents out of a total sample of 35 residents. Findings include: 1.R5's admission Record, dated 07/26/23 and found in the Electronic Medical Record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and polyneuropathy. R5's admission Minimum Data Set assessment, with an Assessment Reference Date (ARD) of 07/06/23 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating R5 was cognitively intact. The assessment indicated the resident required limited assistance from staff to complete all of his Activities of Daily Living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for the resident. R5's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders tab, indicated orders for the resident to have bilateral half rails applied to his bed as an enabler for positioning. R5 was observed in his room lying in bed or seated in his wheelchair on 07/23/23 at 1:53 PM, and on 07/25/23 at 9:36 AM, 10:44 AM, and 11:30 AM. The resident's bed was observed to have bilateral half side rails installed at the head of the bed. The resident stated he used his side rails for positioning in bed as well as to transfer in and out of bed to wheelchair. Comprehensive review of R5's record indicated nothing to show the resident's bed had been physically inspected for safety since his admission to the facility on [DATE]. 2.R36's admission Record, dated 07/26/23 and found in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and acute kidney failure. R36's quarterly MDS assessment, with an ARD of 06/21/23 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 14 out of 15 indicating R36 was cognitively intact. The assessment indicated the resident required extensive assistance from staff to complete all her Activities of Daily Living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for the resident. R36's Order Summary Report, dated 07/26/23 and found in the EMR under the Orders Tab, indicated orders for the resident to have bilateral half rails applied to her bed as an enabler for positioning. Comprehensive review of R5's record indicated nothing to show the resident's bed had been physically inspected for safety since his admission to the facility on [DATE]. R36 was observed in her room seated in bed or on the side of her bed on 07/23/23 at 2:06 PM, on 07/24/23 at 10:17 AM, and on 07/25/23 at 9:33 AM. The resident's bed had bilateral quarter rails installed at the head of the bed. The resident stated she used her side rails for positioning in her bed as well as to transfer in and out of her bed to her wheelchair.

Based on interviews and job description review, the facility failed to have a qualified Activities Director to oversee the activities department for all 141 current residents in the facility. This failure resulted in all residents not being provided with resident specific activities. Findings include: During an interview on 07/26/23 at 7:27 PM, the Administrator revealed that the previous activity director quit without notice in May 2023 and the facility started looking for a new candidate to fill that position. He confirmed that the current Activity Director (AD) was not qualified but stated they were looking to fill the role with the right person, felt the current AD was the best fit and was in school and would be completing the program in August 2023. The Administrator stated that finding staff currently is very difficult, when faced with something like this, you just do your best. During an interview on 03/01/23 at 9:44 AM, the Activity Director (AD) stated she had been the AD, since the previous Activities Director left in May. She verified that she had not completed her schooling or certification as an Activities Director. AD stated she was currently enrolled and attending courses for Recreational Therapy and would be completed in August 2023. Review of the undated job description titled, Director of Recreation reflects in part, Accepts professional obligations and commitments to professional development, by actively supporting local , state, and national organizations for the Recreational/Activity Coordinator, participating in basic and continuing education through professional organizations and educational institutions, keeping abreast of Federal, State and local requirements regarding activity programming, as well as current developments in long term health care, and by identifying and correcting deficiencies inn knowledge and skills. NJAC 8:39-7.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and job description review, the facility failed to have a licensed Director of Nursing to oversee the care of all 141 current residents in the facility. This failure increased the risk that all residents would not be provided with appropriate and accurate care and assessments. Findings include: During an interview on [DATE] at 9:44 AM, the Director of Nursing (DON) stated that she was not currently working as the DON due to her Registered Nurse (RN) license being expired and waiting on it to be reinstated. Her RN license expired on [DATE]. During an interview on [DATE] at 7:27 PM, the Administrator confirmed that he was notified on [DATE] by an email from corporate that the DON's RN license was expired and would need to be reinstated. The Administrator stated that the Interim Director of Nursing (iDON) was contacted about taking over as the Director of Nursing until the current DON's license was reinstated. He notified corporate to change the DON to the iDON on [DATE] stating that it took some time to get it worked out with the iDON. Review of the undated job description titled, Director of Nursing Services reflects in part, Must possess a valid Registered Nurse (RN) license, in good standing in accordance with laws of this stated, from an approved NJ Nursing School of Nursing. A minimum of five (5) years full time or equivalent clinical experience is required and a minimum of two years of clinical experience in long term care nursing with one year in a management/administrative or supervisory capacity is preferred. NJAC 8:39-25.1(a)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to have a system in place to ensure that facility garbage receptacles were covered, and all garbage was contained and removed timely to prevent a buildup of refuse, and that the receptacles including a trash compactor and the surrounding areas were maintained in a clean manner to prevent the accumulation of debris, pests and foul odors. The deficient practice was evidenced as follows: On 9/14/23 at 9:20 AM, two surveyors arrived at the facility's back parking lot and observed mounds of uncontained garbage bags approximately three to six feet high and approximately 50 feet long alongside the right side of the fence leading to a dumpster and trash compactor towards the back fence. The surveyors observed garbage bags piled at least six feet high behind and between two fences at the juncture of the right and back fence of the back parking lot. The rust-colored metal mesh dumpster was uncovered and overflowing with cardboard, with additional cardboard piled along the left side of the dumpster approximately five feet high. The door of the trash compactor could barely be accessed due to piled bags of clear and black bags of garbage. Multiple bags were ripped open exposing food debris and soiled briefs. There were an enormous amount of flies and yellow jacket bees at the dumpster's. There were additional black bags of garbage piled approximately six feet high behind the dumpster up to the back fence. There was a strong foul smell that permeated the parking lot. At 9:25 AM, the survey team entered the facility, and the receptionist informed the surveyors that the Licensed Nursing Home Administrator (LNHA) had not yet arrived at the facility. Shortly after, the LNHA arrived and stated that the garbage was supposed to be picked up today and the facility was having trouble with the refuse company. He further stated that he was going to call the refuse company again today and that the garbage should be picked up today. He stated, corporate had a contract with the refuse removal company. The LNHA further stated that he could not speak to how long it has been since the garbage was picked up. At approximately 9:35 AM, the surveyor took pictures and a video of the outdoor refuse area and the extensive buildup of debris. At 9:40 AM, a family member approached the survey team and stated that the outside garbage area is like that all the time. At 10:17 AM, the surveyor interviewed the Food Service Director (FSD) about the garbage disposal process and the buildup of refuse at the dumpster area in the presence of a second surveyor. He stated, I don't know what to tell you about it. They were supposed to pick it up. I think they come once a week on Friday. He acknowledged that there was a buildup of uncontained garbage. The FSD stated that clear garbage bags were used by housekeeping and that the black garbage bags were for kitchen refuse. He further stated that maybe once or twice before there were extra garbage bags outside the dumpster. He stated that he has no direct oversight for garbage pickup and did not have the contact information for the refuse removal company. In addition, the FSD stated that if he noticed a pile up of garbage that he emailed the LNHA and the Regional FSD. At 10:30 AM, the FSD provided the surveyor a copy of an email titled GARBAGE, dated 9/7/23. The email was sent to the LNHA, the Regional FSD and three others. Review of the email indicated the following content: GOOD AFTERNOON, TOMORROW IS FRIDAY AND THE GARBAGE IS OUT OF CONTROL. CAN WE GET AN ETA ON PICKUP? THANK YOU . At 11:00 AM, the surveyor interviewed the Director of Maintenance in the presence of a second surveyor. He stated that he started five days ago. He stated that when he started there was an overflow of garbage and further stated, I have no idea why the contractor had not picked up the garbage. In addition, he stated that he was told that part of his job was to keep that area clean and that because he was new, he cannot speak to much yet. At 11:40 AM, the surveyor interviewed the Director of Environmental Services (DES) in the presence of a second surveyor and the Regional of Environmental Services (RES). The DES stated, It is my role to make sure trash goes into the compactor and to police the area around the compactor and the parking lot area to make sure there's no debris. He stated that the compactor was emptied today, and the RES stated that occurred at 9:10 AM. The DES further stated, I think they come for the compactor biweekly. The RES stated that approximately 30 days ago corporate started negotiations with another waste management company and we think that is why the current company are not picking up that frequently. The DES stated that the last time the garbage was picked up was three to four weeks ago. At 11:53 AM, the surveyor interviewed the LNHA in the presence of a second surveyor. He stated that corporate handles the contractor. He stated that we are having constant problems with the company and were notified that corporate is negotiating with a new company and as of 10/1/23, we will be using the new company. The LNHA stated that the refuse company came today at 6 AM to get the old compactor and drop off an empty one. He stated, I have been calling corporate and the contractor for the last 2 weeks - It's not the correct thing to do to have the garbage build up. The LNHA further stated, I asked them to bring two other open containers for the extra garbage on the ground, but what I ask and what they do are two different things. He stated that this was the second time that he had trouble with this company, which was a month ago. The LNHA stated that it was his responsibility to call the contractor when the garbage needed to be picked up and that he did not think there were set days for pickup indicated in the contract. He stated that the DES or the FSD notified him when the compactor was almost full and then he called for service. He acknowledged that the directors were not usually the staff to dispose of garbage and that the directors relied on their staff to communicate when the compactor or dumpster were full. The LNHA could not speak to if this was part of the staff's job descriptions. In addition, he stated that he felt because corporate was changing waste management companies that retaliation was the reason the contractor had not picked up the garbage. At 12:45 PM, three surveyors and the LNHA toured the outside of the facility. The LNHA acknowledged that the buildup of garbage was unacceptable and acknowledged the foul odor including the odor of soiled briefs. He acknowledged that there was an extraordinary amount of uncontained and ripped open garbage bags and pests. He also acknowledged that it was difficult to access the door of the compactor due to having to step on and over open bags of garbage and swarms of pests. The LNHA also acknowledged that the cardboard dumpster was uncovered and that the cardboard debris was overflowing. He stated that the cardboard refuse was not picked up today and could not speak to the last time it was picked up. He could not speak to how frequently it gets picked up and stated that he calls when it is full. In addition, he stated, I didn't see it was that full till today and that the cardboard on the left side of the dumpster was probably from one day. The LNHA stated that he called the Procurement Officer multiple times for invoices of service and for a copy of the contract for refuse disposal with the waste management company. At 1:40 PM, the LNHA provided the surveyor copies of email exchanges between himself and corporate starting from 9/4/23. Review of the emails indicated the following: On 9/4/23 at 10:35 AM, the LNHA emailed the Procurement Officer an email titled Trash Compactor. The content indicated . I called, [name redacted] on Friday regarding emptying the compactor. The trash is now being dumped on the ground with the result that the whole area smells and maggots are all over. I am sure that sooner than later, the neighbors, residents and visitors alike will start calling both local and state dept's. Please help . On 9/4/23 at 11:38 AM, the Procurement Officer responded and included seven other email addresses. The email was titled Trash compactor. The content indicated, Team please see below so we can assist canterbury Thanks. On 9/5/23 at 7:24 PM, an email was sent to the LNHA from someone who he stated was my direct boss. She included seven others on the email titled Trash compactor. The content indicated, This is very concerning do we have a response here? On 9/12/23 at 1:12 PM, the LNHA sent an email to the Procurement Officer, his direct boss and included six others on an email titled Trash compactor. The content indicated Good afternoon all, Any updates on trash pickup? The trash on the grounds at this point will fill up two containers and require two staff x 8 hours to throw into the containers. Can we rent open containers while waiting to resolve issue with waste management? Thanks . On 9/12/23 at 4:25 PM, the LNHA sent an additional email to the same recipients noted above. The email was titled Trash compactor and indicated the following content [name redacted] from Cedar Grove Health Dept. just called and spoke with the maintenance director stating that they have multiple calls from neighbors complaining about trash on our parking lot. At 1:45 PM, in the presence of the survey team, the LNHA stated there was no facility policy related to garbage disposal or the maintenance of the dumpster area. At 1:54 PM, the LNHA provided two unsigned invoices from the waste management company dated 7/25/23 and 8/15/23, which he received from the Procurement Officer. He stated that he requested a copy of the waste management contract multiple times today from corporate but was unable to provide it. At 2:25 PM, in the presence of the survey team, the Chief Clinical Officer and the LNHA stated that they do not have a policy for garbage disposal or maintenance of the dumpster area. Review of the two unsigned invoices provided to the surveyor from waste management company #1 indicated that the facility was billed for services invoice number 00886246 dated 7/25/23 for 7/19/23 30 cubic yard trash compactor 14.49 tons and 7/25/23 30 cubic yard trash compactor 3.14 tons, and invoice number 00886265 dated 8/15/23 for 7/20/23 30 yard open top container 5.93 tons - Emergency/Expedited Service. Review of the job descriptions the facility provided to the surveyor, did not include evidence that there was any specific delineation of responsibility to notify the LNHA for the need to notify the waste management company for refuse pickup. The job descriptions provided and reviewed were as follows: Assistant Manager & Executive Chef of Dining Services (undated), Food Service Aide (undated), Environmental Services Director (undated), six additional housekeeper positions (undated) and the Maintenance Director (undated). NJAC 8:39-31.4(b); 31.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that a current copy of the advanced directive for a Do Not Resuscitate (DNR) was in the Resident's medical record. This deficient practice was identified for 1 of 28 residents (Resident #42) reviewed for advanced directives and was evidenced by the following: On 6/2/21 at 11:00 AM, Resident #42 was observed in the room with eyes closed. The surveyor reviewed Resident # 42's medical record. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to Hypertension, Peripheral Vascular Disease, Cerebrovascular Accident with left side residual weakness. The surveyor reviewed the Resident's chart (paper medical records) that had a sticker placed on the inside opening of the binding cover of the chart. The sticker reflected that the Resident was a Full Code. A Full Code indicates that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive including chest compressions. A review of a form titled New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) located in the chart under the Advanced Directive tab, indicated wishes that included Do Not Resuscitate (DNR) and as well as allowing natural death. The POLST was signed by the Resident's representative and the Physician on 3/26/21. On 6/8/21 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) taking care of Resident #42 who stated that the Advanced directive order can be found in the electronic Medical Record (eMAR). The LPN stated that in the case that the eMAR was offline, the nurses will then refer to the paper chart to check the code status of the Resident. The LPN acknowledged that the sticker affixed to the paper chart of Resident #42 should have been removed and replaced with DNR. On 6/8/21 at 1:30 PM, the surveyor spoke to the Administrator and the Director of Nursing (DON) regarding the above concern. The Administrator as well as the DON agreed that this was an oversight. They agreed that all information regarding a residents wishes for life sustaining treatment should be updated and correct. No further information was provided regarding this discrepancy was provided. NJAC 8:39-4.1 (31) (iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to follow acceptable standards of practice for the care and treatment of a Gastrostomy Tube (G-tube), a tube inserted through the stomach that allows nutrition to be directly administered into the stomach, for 1 of 1 residents (Resident #17) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/3/21 at 12:22 PM, the surveyor observed Resident #17 in bed with their eyes open. The resident did not acknowledge or respond to the surveyor. The surveyor observed a Feeding Pump at Resident #17's bedside that was not in use at the time. On 6/8/21 at 9:05 AM, the surveyor observed Resident #17 in bed positioned on their back with the head of the bed elevated. The feeding pump was alarming. There was a bottle of Jevity 1.5 ( a calorically dense therapeutic liquid food) hanging on the pump but not infusing. On that same day at 9:10 AM, the Licensed Practical Nurse (LPN) entered Resident #17's room and stated that the resident had reached the total volume of Jevity to be administered for that day, so she was going to flush the feeding tube. The LPN disconnected the Jevity feeding. The LPN filled a 60 milliliter piston syringe with water, inserted the tip of the Piston Syringe into the resident's G-tube. The LPN proceeded to use the plunger of the syringe to push the water through the G-tube. It was then that the surveyor asked the LPN to stop what she was doing and to step out of the room. The surveyor asked the LPN if it was her routine practice to use the plunger to flush G-tubes. The LPN replied that she usually allowed it to flow in by gravity but sometimes it was too thick and needed a little pressure. The surveyor asked the LPN what the facility's policy was regarding Gastrostomy Tube flushes. The LPN replied, to flush by gravity. The surveyor reviewed the June 2021 Order Summary Report which reflected a Physician's Orders for Enteral Feeding (tube feeding) in the afternoon administer Jevity 1.5 @ 55 ml/hour for Total Volume of 800 ml and flush G-tube with 300 ml of water every shift. There was an additional order to flush with 30 ml of water prior to and immediately following medication administration. The surveyor reviewed the admission Record which reflected that Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, traumatic brain injury, quadriplegia, gastrostomy status and persistent vegetative state. The surveyor reviewed the Annual Minimum Data Sheet (MDS), an assessment tool, which reflected that Resident #17 was in a Persistent vegetative state with no discernible consciousness. The surveyor reviewed the Facility's Care and Treatment of Feeding Tubes policy and procedure dated 11/2017. The policy's statement reflected, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. On 6/10/21 at 1:07 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and Regional Nurse. The DON and Regional Nurse both acknowledged that all medications, feedings, fluids, and Flushes should be administered using a feeding pump or by gravity and never pushed in by pressure with a syringe plunger. No further information was provided. NJAC 8:39-27.1 (a)

Complaint # NJ141308 Based on observation, interview, and record review it was determined that the facility failed to maintain a medication error rate below 5%. The surveyor observed 3 nurses administer 31 doses of medication to 5 residents and there were 3 errors which resulted in a medication error rate of 9.68 %. The deficient practice was evidenced by the following: Error 1: On 6/4/21 starting at 8:45 AM, the surveyor observed the 2nd floor Licensed Practical Nurse (LPN2) prepare medication for Resident #72. LPN2 placed medications, Seroquel 25 mg and Seroquel 75 mg (an antipsychotic medication) in a medication cup to equal Seroquel 75 mg that was documented on the screen of the Electronic Medication Administration Record (eMAR). LPN2 then administered the medication and signed for the administration of Seroquel 75 mg tablet. The surveyor discussed the documentation of the correct medication with LPN2, who agreed that she should have documented administering Seroquel 25 mg and Seroquel 50 mg separately on the eMAR. Error 2 and Error 3: On 6/4/21 at 9:26 AM, the surveyor observed the 3rd floor Licensed Practical Nurse (LPN3) administer medication to Resident #38. LPN3 administered Briviact Solution 50 mg / 5 ml (an anticonvulsant medication) and was planning to administer Prevacid 40 mg Packet (used to relieve heartburn), which was unavailable for administration. A review of the documented administration time for these medications on the eMAR, revealed that the administration time was 8:00 AM. A review of the manufacturers recommendation for Prevacid 40 mg, stated that it should be administered before eating, preferably before breakfast. Breakfast is generally delivered at 8:00 - 8:10 AM to the 3rd floor. The surveyor discussed the delay of the medication with LPN3, who stated that she was aware that the medication had to be administered at 8:00 AM. She also informed the surveyor that she had a window of an hour before 8:00 AM or an hour after to administer the medication. LPN3 agreed that 9:26 AM was beyond the window of administration. LPN3 revealed that she was not aware that Prevacid 40 mg needed to be administered before eating. On 6/8/21 at 2:17 PM, the surveyor discussed the medpass issues with the Director of Nursing and the Administrator. No further information was supplied. NJAC 8:39-29.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 6/1/21 at 10:30 AM, during a tour of the kitchen, the surveyor, along with the Dining Services Director (DSD), Ambassador of Dietary Service (ADS) and the facility Dietician, the surveyor observed the following: 1. In the rack where the dry pots and pans were placed, there were 7 food pans/trays that were observed to be wet nesting and stacked together. Wet-nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. FDA guidelines mandate that all wares should be air dried. Using towels to dry dishes is never permitted. 2. The drying rack was placed right next to the dishwasher machine exposing the dry pots and pans of water splash from the dish machine. The DSD acknowledged that the containers of food must be stored or protected from the contamination including protection from water splash. 3. The high temperature dishwasher was observed with a temperature of 140 degrees Fahrenheit (F) during the wash cycle. The ADS instructed the dishwasher to run the dishwasher four times with the temperature that remained at 140 degrees F. The DSD stated that the temperature should have reached to 150 degrees F as recommended by the Food and Drug Administration food code. A review of an updated facility policy titled, Pots and Ware Washing reflected under Storing Clean Dishes, Service ware and Utensils, to store clean dishes, service ware, utensils, and equipment out of the way of kitchen traffic. They should be covered or otherwise protected from dirt and condensation. On 6/2/21 at 2:00 PM, the surveyor discussed the above concern to the Administrator and the Director of Nursing. No further information was presented. NJAC 8:39-17.1(a);17.2(g)

Based on observation and interview, it was determined that the facility failed to properly dispose and maintain waste in the garbage compactor area as evidenced by the following: On 6/1/21 at 11:00 AM, in the presence of the Dining Services Director (DSD), Dietician and Ambassador of Dietary Service (ADS) the surveyor observed the garbage compactor area to be littered with soiled plastic gloves on the ground by the opening of the dumpster, old empty water bottles and dirty wood pellets. The dumpster was also observed to have a strong foul odor, white colored residue stains on the ground with flies hovering around the area. The DSD stated to the surveyor that the area was supposed to be cleaned with a power washer when needed, at least twice weekly. There was no documented cleaning schedule available for review. The ADS and the DSD both stated that the dumpster area needed to be cleaned. On 6/1/21 at 1:30 PM, the surveyor informed the Administrator, and the Director of Nursing regarding the above concern. No other information was presented. NJAC 8:39-31.5(a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices for 1 of 3 floors (4th floor), and 1 of 1 Residents reviewed for Respiratory therapy; Resident #89. This deficient practice was evidenced by the following: On 6/2/21 at 11:32 AM, the surveyor observed Resident #89 in bed calling out for assistance. The surveyor observed an Oxygen Concentrator at Resident #89's bedside, turned on, with the flow meter set at 2 Liters/minute. The surveyor observed that one end of the oxygen supply tubing was connected to the concentrator but the supply tubing which consisted of 2 soft prongs attached to the tubing (nasal cannula) used to deliver oxygen therapy into the resident's nasopharynx, was on the floor. At that time, the Licensed Practical Nurse (LPN) entered Resident #89's room and stated she was currently on orientation, working at the facility only a short time. The LPN picked up the nasal cannula from the floor, wiped it with a dry paper towel , placed it back into the resident's nostrils and quickly left the room. The surveyor identified the above observation and concern to the attention of the LPN in the presence of the Registered Nurse (RN), who stated that she was responsible for training and orienting the LPN. The RN stated that the LPN should have thrown out the contaminated cannula found on the floor and replaced it with a new one. The LPN replied, I wiped it with a paper towel. The RN told the LPN, you should have thrown it out. After speaking to the RN, the LPN acknowledged that she should have thrown the contaminated cannula that was found on the floor, in the trash. The surveyor reviewed the June Physician Order Summary (POS), which reflected a Physicians' order (PO) to administer Oxygen at 2 L/minute via a Nasal Cannula (NC) for Shortness of Breath (SOB) or to maintain SPO2( peripheral capillary oxygen saturation which measures the amount of oxygen in the blood) above 92% and a PO to change oxygen tubing every Wednesday at 6:00 AM and to replace the tubing if it touches a contaminated surface. The surveyor reviewed the admission Record which reflected Resident #89 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to dementia, diabetes mellitus and pleural effusion. The surveyor reviewed the admission Minimum Data Set (MDS), an assessment tool, dated 5/13/21, which reflected the Resident's cognition was severely impaired. The surveyor reviewed the facility's Oxygen Safety policy and procedure dated 1/1/12 and updated 11/2017. The policy's statement reflected, It is the policy of this facility to provide a safe environment for residents, staff and the public. This policy addresses the use and storage of oxygen and oxygen equipment. The policy did not address proper use/ storage or disposal of oxygen supply tubing. On 6/2/21 at 1:56 PM, the survey team discussed the above observations with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON stated that the LPN should have disposed of the tubing and further stated she would be doing immediate Infection Control Education with the LPN. On 6/4/21 at 9:50 AM, the surveyor observed the 4th floor Licensed Practical Nurse (LPN4) taking Resident #20's vitals (blood pressure, Heart Rate and Oxygen level) in the resident's room. The surveyor noted that there was a Personal Protective Equipment (PPE) bin outside of Resident #20's room. LPN4 was observed in Resident #20's room not wearing proper PPE, no gown, gloves or face shield, only wearing an N-95 mask. On 6/4/21 at 9:57 AM, LPN4 exited Resident #20's room and was observed using hand sanitizer to clean her hands. The surveyor discussed the presence of the PPE bin in front of Resident #20's room with LPN4, who responded, that Resident #20 is off of the 14 day quarantine and no PPE needed to be worn. The surveyor then pointed out that the signage posted on Resident #20's door stated, STOP DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room and wear a surgical mask. The surveyor also pointed out a second sign posted on the door reading, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Put on gloves before entry. Discard gloves before room exit. Put on gown before entry. Discard gown before room exit. LPN4 stated that the PPE bin along with the signage should have been removed from the entrance to Resident #20's room. On 6/4/21 at 10:00 AM, the surveyor and LPN4 reviewed Physician orders (PO) for resident #20. There were no orders removing Resident #20 off of 14 day quarantine. The surveyor along with LPN4 noted a PO dated 5/24/21 that read, Observe DROPLET and CONTACT PRECAUTIONS Perform Hand Hygiene before entering and leaving room. Maintain N-95 mask or face mask (if N-95 unavailable) and eye protection at all times when in resident room. Use gloves and gowns during high contact care activities (ex toileting, dressing, device care). Every shift for COVID-19 Precautions for 14 days. On 6/4/21 at 10:08 AM, another Licensed Practical Nurse informed LPN4 that Resident #20 would complete the 14 day quarantine on 6/8/21. The Licensed Practical Nurse informed LPN4 that when she entered Resident #20's room she would have to wear an N95, surgical mask on top of the N95, gloves, gown and remove all but the N95 prior to leaving the room. On 6/4/21 at 10:10 AM, the surveyor interviewed Resident #20 who stated that they were not vaccinated and was admitted to the facility on [DATE]. Resident #20 explained that they had COVID previously and the resident's physician did not feel that the vaccine was safe for the resident at this time. A review of the Face Sheet ( a document that gives a patient's information at a quick glance), revealed that Resident #20 was admitted to the facility on [DATE] from the hospital with diagnosis that included but were not limited to Chronic Obstructive Pulmonary Disease, Paraplegia and Lupus Erythmatosus. On 6/4/21 at 11:20 AM, the surveyor interviewed the Staff Educator Registered Nurse (SERN) who stated that Resident #20 was on a 14 day quarantine due to the resident's recent admission into the facility on 5/24/21 from the hospital. Resident #20 was also on droplet precaution due to a Multi-Drug Resistant Organism (MDRO) infection. The SERN stated that LPN4 should have worn her N95, a surgical mask (protecting the N95), a gown, gloves and eye protection (shield or goggles) when entering the Resident's room. The SERN also stated that LPN4 should have removed all the PPE but left on the N-95 mask prior to leaving the room and washed her hands before continuing any other activity in the facility. On 6/4/21 at 10:56 AM, the surveyor informed the Administrator of the incident that occurred with LPN4. The Administrator stated that Resident #20 was still on a 14 day quarantine. The Administrator added, Any resident that comes from the hospital is put on a 14 day quarantine. The Administrator included that all PPE should worn when caring for any resident that is on quarantine in the facility. On 6/4/21 at 12:00 PM, the surveyor interviewed the Infection Control Preventionist Nurse Practitioner (NP) who stated that LPN4 should have worn her N95, a surgical mask (protecting the N95), a gown, gloves and eye protection (shield or goggles) when entering the Resident's room. The NP added that LPN4 should have removed all the PPE, including the surgical mask prior to leaving the room and washed her hands before continuing any other activity in the facility. The NP also explained that Resident #20 is still on 14 day quarantine. The surveyor reviewed the facility policy, Considerations for Cohorting COVID-19 Residents. Review of section (b) Yellow Zone documented, This cohort serves as an observation area where persons are observed and monitored for symptoms that may be compatible with COVID-19. This cohort consists of :a. All unvaccinated persons from the community or other healthcare facilities who are newly or readmitted . These persons remain in the YELLOW ZONE for 14 days to monitor for symptoms that may be compatible. On 6/4/21 at 2:50 PM, the surveyor team discussed this and other findings with the DON and LNHA, no further information was supplied or presented. NJAC 8-39-19.4 (a)

On 6/3/21 at 12:29 PM, Surveyor #3 pulled a tray from the food truck (Cart 1) on the second floor. The surveyor along with the ADS, observed that the CNA immediately began distribution of meal trays to residents when the food truck reached the floor. The ADS was at the second-floor nursing station along with the surveyor with a calibrated thermometer awaiting the distribution of the final tray. On 6/3/21 at 12:35 PM, the last tray was delivered to a resident on the second floor. Surveyor #3 in the presence of the ADS, who had a calibrated thermometer to measure the temperature of the food, began taking the temperatures of the following items (regular consistency): Coffee 104.0 Degrees F Mashed Potato 129.6 Degrees F Meatballs 131.0 Degrees F Beets 120.0 Degrees F Fresh Milk 49.0 Degrees F Orange Juice 48.9 Degrees F On 6/3/21 at 12:31 PM, Surveyor #3 pulled a tray from the food truck (Cart 2) on the second floor. The surveyor observed the CNAs delivering meal trays to residents. On 6/3/21 at 12:45 PM, the last meal tray was delivered to a resident receiving meal trays from Cart 2, the ADS began taking temperatures of the following items (regular consistency) in the presence of surveyor #1: Coffee 126.3 Degrees F Mashed Potato 123.2 Degrees F Meatballs 121.6 Degrees F Beets 107.0 Degrees F Pudding 49.4 Degrees F Juice 49.2 Degrees F On 6/3/21 at 12:34 PM, Surveyor #3 pulled a tray from the food truck (Cart 3) on the second floor. The surveyor observed the CNAs beginning the delivery of meal trays to residents at this time. On 6/3/21 at 12:49 PM, the last meal tray was delivered to a resident receiving meal trays from Cart 3, the ADS began taking temperatures of the following items (regular consistency) in the presence of Surveyor #3: Coffee 132.3 Degrees F Mashed Potato 124.3 Degrees F Meatballs 121.6 Degrees F Beets 120.0 Degrees F Juice 58.6 Degrees F On 6/3/21 at 12:50 PM, the Surveyor #3 interviewed the ADS who agreed that the temperatures of the food were not maintained at an appetizing temperatures to the residents. On 6/3/21 at 2:30 PM, the surveyors met with the facility Administrator and Director of Nursing to discuss the food temperature discrepancy. The Administrator agreed that the hot food should be hotter and the cold food colder. No further information was supplied. A review of Food and Drug Administration guidelines for maintaining foods at safe temperatures document, at or below 41 degrees F (for cold foods) or at or above 135 degrees F (for hot foods). NJAC 8:39-17.4(e) Complaint # NJ141308 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of cold food and drink served to the residents. This deficient practice was identified for 7 of 7 residents confirmed during the lunchtime meal service on 6/3/21 for 3 of 3 nursing units (2nd Floor, 3rd Floor & 4th Floor) tested for food temperatures: On 6/3/21 at 11:38 AM, Surveyor #1 observed food truck arrive on the fourth floor. Surveyor #1 pulled a tray from the 2nd food truck. Surveyor #1 along with the Ambassador of Dietary Services (ADS), observed the Registered Nurse and Certified Nursing Assistant (CNA) deliver meal trays to residents. After the last meal tray was delivered to a resident at 11:58 AM, the ADS stated that the thermometer was calibrated that morning and took the temperatures of the following items (regular consistency): (3) Meatballs with Low Sodium (LS) gravy 120.2 Degrees F ½ cup Mashed Potatoes 122.9 Degrees F 3/8 cup Roasted beets 99.0 Degrees F Butterscotch pie 63.8 Degrees F 6 oz cup coffee 135.1 Degrees F Surveyor #1 discussed the food temperatures with the ADS. The ADS informed Surveyor #1 that the temperatures should be above 140 Degrees F for hot foods and below 41 Degrees F for cold foods. The ADS further stated that he was, very concerned and will be doing a full in service. On 6/3/21 at 12:01 PM, Surveyor #2 observed food truck arrive on the third floor. Surveyor #2 pulled a tray from the 3rd floor food truck. Surveyor #2 along with the ADS, observed the CNA deliver meal trays to residents. After the last meal tray was delivered to a resident at 12:09 PM, the ADS stated that the thermometer was calibrated that morning and took the temperatures of the following items (regular consistency): (3) Meatballs with LS gravy 121.9 Degrees F ½ cup Mashed Potatoes 122.5 Degrees F 3/8 cup Roasted beets 105.5 Degrees F 6 oz cup coffee 115.7 Degrees F Apple Juice 50.2 Degrees F On 6/3/21 at 12:03 PM, Surveyor #2 observed 2nd third floor food truck arrive on the third floor. Surveyor #2 pulled a tray from the 2nd food truck. Surveyor #2 along with the ADS, observed the CNA deliver meal trays to residents. After the last meal tray was delivered to a resident at 12:18 PM, the ADS took the temperatures of the following items (regular consistency): (3) Meatballs with LS gravy 119.4 Degrees F ½ cup Mashed Potatoes 124.5 Degrees F 3/8 cup Roasted beets 111.0 Degrees F 6 oz cup coffee 134.0 Degrees F Apple Juice 32.6 Degrees F Margarine 73.3 Degrees F Surveyor #2 discussed the food temperatures with the ADS. The ADS informed Surveyor #2 that the temperatures should be above 135 Degrees F for hot foods and below 41 Degrees F for cold foods. The Ambassador further stated that he was, very concerned and would be doing a full inservice.