Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to a.) treat each resident with respect and dignity in a manner that promotes their quality of life during breakfast and b.) provide privacy during med administration for 1 of 6 residents, (Resident #39), observed during medication pass administration. This deficient practice was evidenced by the following: On 2/10/25 at 8:44 AM, during the medication administration pass observation, the surveyor observed the Licensed Practical Nurse (LPN), prepared medications (meds) for Resident #39, and brought them inside the dining area in the 2 East unit. The surveyor observed that there was a total of five residents inside the dining area eating their breakfast including Resident #39. The LPN also checked Resident #39's blood pressure inside the dining room. After the LPN administered the meds, the surveyor interviewed the LPN outside the dining room. The surveyor asked the LPN if it was appropriate to administer and check the blood pressure of the resident inside the dining room where other residents were inside, and the resident was still eating. The LPN responded that it was the resident's preference. The surveyor asked the LPN if the resident's preference was in the resident's care plan (CP), and she responded that the surveyor had to ask the Unit Manager about the CP. On 2/10/25 at 8:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding the concern with the LPN who administered meds and checked Resident #39's blood pressure inside the dining area with other residents, and the RN/UM responded that the resident had a behavior of swaying hands and at times some resident when they were in the dining room did not want to go back to the room to get their meds. The surveyor asked the RN/UM if the behavior of swaying hands and preference to have meds taken in the dining room were in the resident's CP, and the RN/UM responded no. The RN/UM further stated that she should have documented it in the CP of the resident about the behavior and resident's preferences. At that time, the surveyor asked the RN/UM to print the resident's CP and eMAR (electronic Medication Administration Record). A review of the provided CP by the RN/UM revealed that the resident's CP did not identify resident with behavior of swaying hands and preference of taking meds inside the dining room. There was no documented evidence in the CP that the resident had a behavior of declining to take meds in their room or preferred to take meds inside the dining room. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (elevated blood pressure), type 2 diabetes mellitus without complications, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/1/25, under Section C Cognitive Patterns, a brief interview for mental status (BIMS) score of 13 out of 15, which reflected that the resident's cognitive status was intact. Section D for Mood and Section E for Behavior was coded 00, which reflected that the resident had no documented behavior. A review of the Progress Notes and assessment tab in the electronic medical records revealed that there was no documented evidence that the resident had an unusual behavior of swaying hands or preferences to take meds in the dining room. On 2/13/25 at 2:14 PM, the survey team met with the Licensed Nursing Home Administration (LNHA) and the Director of Nursing (DON), and the surveyor notified the above findings and concerns with Resident #39. On 2/14/25 at 1:07 PM, the survey team met with the LNHA and DON. The DON stated that the nurse (who did not identify) interviewed the resident and Resident #39 did not mind checking their blood pressure and taking meds inside the dining room. The DON confirmed that the interview of the nurse of Resident #39 was done after the surveyor's inquiry. A review of the facility's Resident Rights Policy, with a reviewed/revised date of 3/5/24, that was provided by the Regional Nurse revealed: Resident Rights: The resident has the right to a dignified existence, self-determination . 4. Respect and dignity . Policy Explanation and Compliance Guidelines: 11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents . On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, Regional Director of Clinical Services, Regional Nurse, and Licensed Practical Nurse/Unit Manager for an exit conference, and the LNHA did not provide additional information. NJAC 8:39-4.1(a)3,12; 27.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ183033 Based on interviews, medical record reviews, and review of other pertinent facility documents, it was determined that the facility failed to ensure that the physician was consulted and notified immediately of resident's change in condition and follow the facility's policy and protocol with regard to notification of changes. This deficient practice was identified for 1 of 3 residents, (Resident #443), reviewed. This deficient practice was evidence by the following: A review of the admission Record (an admission summary) revealed that Resident #443 was admitted to facility with diagnoses which included but were not limited to; Parkinson's Disease without dyskinesia, without mention of fluctuations, other Alzheimer's Disease, multiple myeloma (a cancer of plasma cells, a type of white blood cell that normally produces antibodies) not having achieved remission, type 2 diabetes mellitus without complications, nonrheumatic aortic (valve) insufficiency, aneurism of the ascending aorta, without rupture, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review Resident #443's progress notes (PN) revealed that on [DATE] at approximately 3:10 PM, Resident #443's responsible party (RP) informed Licensed Practical Nurse #1 (LPN#1) that the resident looked dehydrated. The PN revealed that the resident was observed, and vital signs were obtained. The PN further revealed, MD called at around 4:24 PM no answer and unable to leave voice message. The PN revealed that the resident was encouraged to drink fluids and eat but consumed less than 25 percent. Further review of the above PN revealed no further attempts by LPN #1 to contact Resident #443's physician until 10:59 PM when the physician was notified that Resident #443 expired at 10:57 PM. A telephone interview was conducted with LPN #1 on [DATE] at 11:38 AM. LPN #1 stated that she was caring for Resident #443 on evening shift on [DATE], LPN #1 stated she was notified by Resident #443's RP that the resident appeared dehydrated. LPN #1 stated that she assessed the resident, and their vital signs were okay, but the resident's skin turgor was poor. LPN #1 further stated that she called the resident's physician to discuss the resident's appetite and skin turgor, and to propose intravenous (IV) fluids for the resident and LPN #1 did not receive a call back after she called the physician and left a voice message. LPN #1 did not recall the name of the physician she attempted to contact but stated that her practice was to call the physician listed on the resident's profile. LPN #1 further stated that it was her practice to notify the Nursing Supervisor (NS) if she was unable to reach a resident's physician regarding a concern. An interview was conducted with LPN #2 on [DATE] at 12:11 PM. LPN #2 stated that she was working as the NS on [DATE] when Resident #443 expired. LPN #2 stated that it was the expectation that nurses reported anything that was outside of a resident's baseline to the NS, the physician should have been called, and then any new orders followed. LPN #2 further stated that if staff was unable to reach a resident's physician, the Medical Director should have been called. On that same date and time, LPN #2 stated that if a resident was dehydrated, the first steps would be to call the physician if the resident was not in acute distress. LPN #2 stated that on [DATE], the nurse assigned to Resident #443 attempted to contact the resident's physician but got no answer and left a voice message. LPN #2 stated that LPN #2 made her aware of Resident #443's condition because she was the NS. LPN #2 stated that she instructed LPN #1 to send a text message to the physician instead of calling but was unsure if LPN #1 was able to reach the resident's physician by text. LPN #2 stated that it was important that nurses reported concerns because it could lead to a resident declining if they did not get what they needed. LPN #2 further stated that was important to have clear lines of communication so that facility staff could do everything that needed to be done for residents. An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 1:03 PM. The ADON stated that staff, including agency staff, were instructed to go to Unit Managers if they had concerns about residents, and on the weekend they should call the NS. The ADON stated that if a nurse was unable to reach a physician, they should notify the NS who would then call the Medical Director. The ADON reviewed the PN regarding Resident 443's RP's concern about dehydration. The ADON stated, It does not appear that (LPN #1) followed our process for physician notification when there were concerns for dehydration. A review of the facility's Notification of Changes Policy, reviewed/revised [DATE], revealed under Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician [ .] when there is a change requiring notification. Under Definitions: the policy revealed that the need to alter treatment significantly means a need to stop a form of treatment, or commence a new form of treatment to deal with a problem. Further review of the policy revealed under Compliance Guidelines, Circumstances requiring notification include: [ .] 3. Circumstance that require a need to alter treatment. This may include: a. New treatment. NJAC 8:39-13.1 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a licensed staff credentials were verified upon hire. This deficient practice was identified for 1 of 9 newly hired licensed staff reviewed. This deficient practice was evidenced by the following: On [DATE] at 1:30 PM, the surveyor reviewed ten randomly selected new employee files. The review for license verification/renewal for one of the new licensed employees, Social Worker (SW), revealed no license in her employee file. On [DATE] at 12:19 PM, the surveyor requested from the Regional Nurse, the SW's license. The Regional Nurse stated, She works full time as a SW. I think something with pending status on her license, the License Nursing Home Administrator (LNHA) will come in and give more information. On [DATE] at 12:56 PM, the LNHA provided the surveyor a New Jersey Division Consumer Affairs license verification printout dated [DATE] at 9:14 AM, which revealed license expiration date [DATE] and license status was inactive. The LNHA provided a second printout dated [DATE] at 9:16 AM, which revealed license status Reinstatement Pending. The verification was completed after surveyor inquiry. There was no documented evidence that the SW's license was verified prior to the date of hire of [DATE]. At that time, the LNHA stated to the surveyor, Her license erroneously expired, and her reinstatement was pending. The LNHA read an email from the Regional Human Resources (HR) Case Management dated [DATE] regarding user error when SW tried to renew her license who may have selected inactivate versus renew. The LNHA further stated that the HR should have gone online verified it and printed it upon hire. The LNHA also stated that We have HR and regional person responsible for employee file. Furthermore, the LNHA stated that the expectation was every employee should have license verified, and printed or in file upon hire. He further stated that it was important because employees need to have the correct licensing board and nothing against their license. He added that, Maybe the previous HR did not print it, should have been followed up upon hire, the expectation was to have the license in the employee file, and it should have been checked by the HR. The LNHA confirmed that the SW was hired on [DATE] with no license verification in the employee file. On [DATE] at 2:45 PM, the surveyor notified the LNHA and the Director of Nursing, and the Regional Director of Clinical Services, the concern regarding SW's license missing in the employee file. A review of the facility's Hiring Policy, dated 12/2024, revealed, The Human Resources Director, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. NJAC 8:39-39.2, 40.1

Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold notices for 1 of 1 resident, (Resident #175), reviewed for hospitalizations. This deficient practice was evidenced by the following: On 2/7/25 at 11:33 AM, the surveyor observed Resident #175's outside door with a posted sign for Enhanced Barrier Precautions (EBP are measures implemented in healthcare settings to prevent the transmission of infections, particularly in situations where standard precautions alone may not be sufficient) and the resident was not inside the room. On that same date and time, the Certified Nursing Aide (CNA) informed the surveyor that the resident was in therapy. The surveyor reviewed the medical records of Resident #175 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site not specified, ESBL (Extended-spectrum beta-lactamases are a type of enzyme or chemical produced by some bacteria. ESBL enzymes make some antibiotics ineffective in treating bacterial infections) resistance, other retention of urine, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified anxiety disorders, unspecified protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD, is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). A review of the Minimum Data Set (MDS), an assessment tool, revealed the following assessment reference dates (ARD) and Section A Identification Information: -ARD 11/20/24, had an unplanned discharge (d/c) to the hospital, and a return was anticipated. -ARD 12/5/24, had an unplanned d/c to the hospital, and a return was anticipated. -ARD 2/1/25, had an unplanned d/c to the hospital, and a return was anticipated. A review of the Progress Notes (PN) revealed the following Nurses Notes: -On 11/20/24 at 10:00 PM, Licensed Practical Nurse #1 (LPN#1) called the hospital at 9:58 PM and was notified that the resident would be admitted for diagnosis of suprapubic catheter malfunction. -On 12/5/24 at 2:02 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) spoke with the emergency room and was notified that the resident was admitted for UTI and suprapubic malfunction. -On 2/1/25 at 7:11 PM, LPN#2 documented that the resident was admitted to the hospital with a diagnosis of ESBL of the urine. Further review of the medical records revealed that there was no documented evidence that the written notifications for bed hold notices were provided to the resident or resident representative on 11/20/24, 12/5/24, and 2/1/25. On 2/14/25 at 1:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified of the concern regarding Resident #175's bed hold notices. On 2/18/25 at 10:40 AM, the LPN/UM, in the presence of the Regional Director of Clinical Services (RDCS), Regional Nurse, and LNHA provided the two binders for Bed Hold Notifications, the binders were for 2024 and 2025. A review of the provided binders revealed that there were no bed hold notices for dates 11/20/24, 12/5/24, and 2/1/25. On 2/18/25 at 11:20 AM, the DON flipped over the pages in the 2025 bed hold notices binder and the DON confirmed that there were no notices for Resident #175 for January and February 2025. The LNHA confirmed also that there were no other bed hold notices in the 2024 binder for the resident except for 11/24/24. Both the LNHA and DON also confirmed that there were no other binders for bed hold notices except for the 2024 and 2025 binders that were reviewed in the presence of the survey team. A review of the facility's Transfer or Discharge, Facility-Initiated Policy, with a revision date of October 2022, that was provided by the LNHA revealed: Notice of Transfer or Discharge (Emergent or Therapeutic Leave): 5. Notice of Facility Bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. 6. Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, RDCS, Regional Nurse, and LPN/UM for an exit conference, the LNHA did not provide additional information. NJAC 8:39-4.1(a)31,32; 5.1; 5.2(a); 5.3

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 1 of 38 residents, (Resident #18), reviewed for Minimum Data Set (MDS). This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2024 showed: An SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. Documentation of criteria met is essential in the resident's medical record. Required for various scenarios like hospice enrollment, a consistent pattern of changes, etc. On 2/7/25 at 11:49 AM, the surveyor observed Resident # 18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical records of Resident #18 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A review of the comprehensive MDS with an assessment reference date (ARD) of 7/11/24, revealed in Section C Cognitive Patterns a brief interview for mental status (BIMS) score of 13 of 15, which reflected an intact cognition. Section K: Nutrition reflected that the resident's weight was 157 pounds (lbs). A review of the quarterly MDS (qMDS) with an ARD of 10/4/24, revealed a BIMS score of 6 of 15, which reflected that the resident's cognitive status was severely impaired. Section K reflected that the resident's weight was 163 lbs. A review of the qMDS with an ARD of 12/27/24, revealed a BIMS score of 5 of 15, which reflected that the resident's cognitive status was severely impaired. Section K reflected that the resident's weight was 181 lbs. A review of the Dietary Assessment and Documentation (admission assessment) that was electronically signed by Dietician #1 (D#1) on 7/5/24, reflected that the resident's weight was taken on 7/4/24, and it was 157.1 lbs. A review of the Dietary Assessment and Documentation (quarterly) that was electronically signed by D#2 on 10/4/24, reflected that the resident's weight was taken on 10/3/24, and it was 180 lbs. A review of the Nutrition Notes that was electronically signed by D#3 on 12/22/24, reflected that the resident's weight was 181.2 lbs, noted weights on November was 179.8 lbs, September was 163.2 lbs indicative of a significant 11%/18 lbs gain for three months. A review of the personalized Care Plan (CP) revealed that the resident had a history of planned significant weight gain that was identified on 1/20/25, revised focus CP that was revised by D#3. Further review of the personalized CP revealed that Resident #18 had a focus CP for dependent on staff for activities, cognitive stimulation, and social interaction related to Cognitive deficits that were revised on 7/23/202, by Activity Director. Further review of the medical records revealed that there was no documented evidence that the Interdisciplinary Team (IDT) met and decided that the SCSA would not be necessary to be done due to the above two changes in the resident's status, specifically for change in cognitive status from cognitively intact to severely impaired cognition for two qMDS, 10/4/24, and 12/27/24, and weight gain of more than 11% for three months. On 2/12/25 at 1:08 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who informed the surveyor that the facility followed the RAI manual for MDS and that there was no separate policy for MDS. The surveyor notified the MDSC/RN of the above findings and concerns. The surveyor asked the MDSC/RN if she should have done a SCSA due to the above findings, and she responded Yes. The MDSC/RN further stated that she would review Resident #18's records and would get back to the surveyor as to why the SCSA was not done. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns. On 2/14/25 at 11:25 AM, the MDSC/RN informed the surveyor that the resident's cognition fluctuated, and the team did not feel that it was necessary to make significant changes for the two quarters after the comprehensive MDS when the BIMS score declined from cognitively intact to severely impaired cognition. The surveyor asked the MDSC/RN if there was documentation that the team met and decided that the resident's BIMS fluctuated and not to proceed with significant change. The MDSC/RN was unable to provide a document that the team met and decided not to proceed with significant change. At that same time, the MDSC/RN further stated that it looks like the two quarters' BIMS scores were probably not accurate. The surveyor asked the MDSC/RN, if the team believed it was wrong, the assessment for cognitive status, and what the facility did to correct it, and the MDSC/RN did not respond. On 2/14/25 at 12:56 PM, the MDSC/RN informed the surveyor that the team did not feel that significant change was necessary because of the fluctuating cognitive status of the resident. The MDS Coordinator was unable to provide documentation that the facility met and decided not to proceed with significant change for Resident#18. A review of facility provided CP by Regional Nurse revealed that the CP for lymphedema was initiated on 2/14/25, after the surveyor's inquiry. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, Regional Director for Clinical Services, Regional Nurse, and Licensed Practical Nurse/Unit Manager at an exit conference, the LNHA did not provide additional information. NJAC 8:39-11.2(i)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents, (Residents #18 and #190), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, the surveyor observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical records of Resident #18 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A review of the quarterly MDS (qMDS) with an assessment reference date (ARD) of 10/4/24, revealed a brief interview for mental status (BIMS) score of 6 of 15, which reflected that the resident's cognitive status was severely impaired. Section K: Nutrition reflected that the resident's weight was 163 lbs. A review of the qMDS with an ARD of 12/27/24, revealed a BIMS score of 5 of 15, which reflected that the resident's cognitive status was severely impaired. Section K reflected that the resident's weight was 181 lbs. A review of the Dietary Assessment and Documentation (quarterly) that was electronically signed by Dietician #1 (D#1) on 10/4/24, reflected that the resident's weight was taken on 10/3/24, and it was 180 pounds (lbs). A review of the Nutrition Notes (NN) that was electronically by D#2 signed on 12/22/24, reflected that the resident's weight was 181.2 lbs, November weight of 179.8 lbs and September 163.2 lbs, indicative of a significant 11%/18 lbs gain for three months. A review of NN that was electronically signed by D#3 on 1/26/25, reflected that on 1/23/25, the weight was 179.9 lbs, on 12/3/24, the weight was 181.2 lbs, on 10/10/24, the weight was 183.5 lbs, and on 7/25/24, the weight was 158.9 lbs, and was noted with weight gain of 21 lbs or 13% for 182 days. The NN also included that the weight gain was unplanned and considered significant for Resident #18. On 2/12/25 at 1:08 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who informed the surveyor that the facility followed the RAI manual for MDS and that there was no separate policy for MDS. The surveyor notified the MDSC/RN of the above findings and concerns. The MDSC/RN stated that she would review Resident #18's records and would get back to the surveyor. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns that the qMDS ARD 10/4/24 Section K weight of 163 lbs did not match on what the Dietary Assessment and Documentation documented on 10/4/24 by D#1 that the weight obtained on 10/3/24 was 180 lbs. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, Regional Director for Clinical Services (RDCS), Regional Nurse, and Licensed Practical Nurse/Unit Manager at an exit conference, the LNHA did not provide additional information. 2. On 2/14/25 at 9:11 AM, the surveyor reviewed the closed medical records for Resident #190. A review of Resident #190's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia, hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy). A review of Resident #190's most recent Progress Note indicated that the resident was discharged (d/c) home with family. A review of Resident #190's most recent discharge return not anticipated (drna) MDS, reflected that the resident was d/c to a short term general hospital. The MDS was coded incorrectly. On 2/14/25 at 9:20 AM, the surveyor interviewed the first floor Unit Manager (UM) regarding Resident #190. The first floor UM stated that Resident #190 was d/c home. On 2/14/25 at 10:04 AM, the surveyor interviewed the MDSC/RN regarding Resident #190. The MDSC/RN stated that she was not the person that coded Resident #190's drna MDS. She reviewed the resident's medical record and confirmed that the MDS was coded incorrectly. On 2/14/25 at 1:54 PM, the surveyor notified the LNHA and the DON of the concern that Resident #190's drna MDS was coded incorrectly. On 2/18/25 at 11:50 AM, in the presence of the LNHA and RDCS, the DON stated that the MDS was coded in error and that it was corrected after surveyor inquiry. The LNHA did not provide any additional information. The facility did not have a policy regarding MDS. N.J.A.C. 8:39-11.2, 33.2 (d)

3. On 2/7/25 at 11:35 AM, the surveyor observed Resident #180 lying on the bed, awake, and stated that they were at the facility for rehabilitation and had to go back to the doctor to remove the metal in their left arm. The surveyor observed the resident with a splint in use on their left arm. A review of Resident #180's medical records revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified intracranial injury with loss of consciousness status unknown, subsequent encounter, undifferentiated schizophrenia (is a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), unspecified protein-calorie malnutrition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and bipolar disorder (is a mental health condition characterized by significant mood swings) unspecified. A review of the personalized CP revealed that there was no documented evidence that the left arm splint was identified and there were no interventions for care of the splint. On 2/10/25 at 8:28 AM, the surveyor observed the resident in the presence of LPN#2 during medication pass administration with a left arm splint. LPN#2 informed the surveyor that the resident would be going to the surgeon on Wednesday to remove the metal in the resident's left arm. LPN#2 stated that the resident should be always using the splint. She further stated that the resident sustained a fall incident at home which was why the splint was in use. On 2/12/25 at 1:29 PM, the survey team met with the LNHA and the DON, and the surveyor notified them of the above findings and concerns regarding the splint. On 2/14/25 at 1:07 PM, the survey team met with the LNHA and DON. The DON stated that the order and CP for the splint of Resident #180 were entered into the medical record after the surveyor's inquiry. 4. According to the AR of Resident #442, the resident was admitted to the facility with diagnoses which included but not limited to bipolar disorder, unspecified; altered mental status, unspecified; type 2 diabetes mellitus (DM) without complications; chronic obstructive pulmonary disease, unspecified; end stage renal disease; and dependence on hemodialysis. A review of the most recent MDS, with a brief interview for mental status (BIMS) of 6 of 15, which indicated that the resident was severely cognitively impaired. Further review of the resident's MDS revealed that Resident #442 had frequent urinary incontinence and frequent bowel incontinence. A review of Resident #442's CP initiated on 4/8/2024, and revised on 7/8/2024, revealed a focus, which indicated that Resident #442 was at risk for skin breakdown related to incontinence and dementia. The resident's CP revealed no Interventions/Tasks r/t the resident's risk for skin breakdown. Further review of Resident #442's CP initiated on 4/8/2024, and revised on 7/8/2024, revealed a Focus, which indicated that Resident #442 had DM. The resident's CP revealed no Interventions/Tasks related to the resident's diagnosis of DM. During an interview on 2/14/2025 at 1:35 PM, the DON confirmed the absence of interventions on Resident #442's CP. The DON stated that the CPs purpose was to inform staff of how to care for the resident. The DON stated that when CPs were not complete staff would need to rely on their basic nursing knowledge to care for a resident. A review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised March 2022, revealed under Policy Interpretation and Implementation, that the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This policy section further revealed that the CP should indicate which professional services were responsible for each element of care. Further review of this section of the facility policy revealed that CP interventions should be chosen after data gathering, sequencing of events, consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 7. The comprehensive, person-centered CP: a. includes measurable objectives and timeframes . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 9. CP interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . 12. The interdisciplinary team reviews and updates the CP .at least quarterly The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desire outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, RDCS, Regional Nurse, and Licensed Practical Nurse/Unit Manager at an exit conference, the LNHA did not provide additional information NJAC 8:39-11.2 (d)(e), 27.1 (a) Complaint#: NJ175914 Based on observations, interviews, review of medical records, and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 4 of 38 residents (Residents #111, #172, #180, and #442), reviewed for a care plan. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair, and stated that they had just returned from a physical therapy (PT)session. Resident #111 further stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. The surveyor observed a Fall Risk wrist band on Resident #111's wrist and that the resident's bed was low to the ground. On 2/11/25 at 10:37 AM, the surveyor interviewed Resident #111's Licensed Practical Nurse #1 (LPN#1) regarding the process for fall risk assessment and falls. LPN#1 stated that a fall risk assessment was done on admission and that it may be done by the Unit Manager quarterly but was not sure. She added that PT saw the resident within 24 hours to determine if the resident was a fall risk. LPN#1 stated that most residents had a care plan (CP) that included risk for fall with interventions that included frequent checks and floor mats. LPN#1 further stated that if a resident had a fall then a risk management/incident report was done which included statements from staff. She added that an investigation for the cause was done and that the Unit Manager would update the CP with a new intervention. A review of Resident #111's admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), type 2 diabetes mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy) and hypertension (high blood pressure). A review of Resident #111's most recent discharge return anticipated Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident's cognitive skills for decision making were moderately impaired. A review of Resident #111's Progress Notes (PN) indicated that that in November 2024, the resident was transferred to the hospital for abnormal vital signs and elevated blood sugar. A review of Resident #111's current active CP, with an initiated date of 11/19/24, included the following focus areas that were not individualized to the resident and complete: I am at risk of skin breakdown r/t (related to) I have hypertension r/t I am at risk for pain Further review of the electronic medical record indicated that Resident #111 had a previous CP that was individualized and comprehensive but that it had been completed (not active or current) on 11/4/24. Resident #111's active current CP did not include all of the previous focus areas or interventions that were implemented. On 2/11/25 at 12:46 PM, the surveyor interviewed the first floor Unit Manager (UM) regarding CP. The first floor UM stated that upon admission a baseline CP was done and that the CP was later updated by the supervisor, UM, Assistant Director of Nursing (ADON) or Director of Nursing (DON). The first floor UM stated that the CP did not have to be closed (completed) if went to hospital and came back a couple days later but that he would have to ask MDS. On 2/11/25 at 1:10 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) regarding CP. The MDSC/RN stated that she may open the CP but that usually other departments completed them and reviewed them. The MDSC/RN further stated that the CP was closed (completed) when the resident was discharged home or to the hospital and that when they returned a new CP was opened. The surveyor asked that if the information in the completed CP should be continued in the new CP if still relevant. The MDSC stated most probably The MDSC/RN added that the interventions should be in place but that she was not sure if the CP had to be closed out. On 2/12/25 at 1:43 PM, the surveyor notified the LNHA and DON the concern that Resident #111 did not have an individualized complete active CP that included all relevant focus areas that were individualized and were implemented prior to the resident's hospitalization. On 2/13/25 at 2:14 PM, in the presence of the LNHA and DON, the Regional Director of Clinical Services (RDCS) stated when Resident #111 went to the hospital the MDSC/RN had canceled the CP instead of resolving it and that a new CP had to be initiated. On 2/14/25 at 9:59 AM, the MDSC/RN stated that apparently the CP was not supposed to have been canceled (completed) when the resident went to the hospital unless they are there for 30 days. She added that if there was a bedhold then it does not get canceled (completed). The MDSC/RN stated that for Resident #111, someone canceled the CP by accident and that now it was updated. The LNHA did not provide any additional information. 2. On 2/7/25 at 11:00 AM, the surveyor observed Resident #172 resting in their bed with their eyes closed. The resident did not respond to the surveyor's greeting. On 2/11/25 at 9:05 AM, the surveyor reviewed the medical records of Resident #172. The AR revealed that Resident #172 had diagnoses that included, but were not limited to, cerebral infarction (stroke), dementia, dysphagia (difficulty swallowing foods or liquids), and type 2 diabetes mellitus. chronic kidney disease, muscle weakness, bipolar disorder and depression. A review of the comprehensive MDS with an assessment reference date (ARD) of 1/2/25, indicated the facility assessed the resident's cognition and Resident #172 was coded as being rarely/never understood. The resident was coded for impairments to both sides of their upper and lower extremities. Additionally, the resident was dependent on staff assistance with all activities of daily living (ADLs). A review of the resident's CP for ADLs revealed it was not complete and individualized for Resident #172. The CP had an initiation date of 1/15/25 and a last revised date of 2/9/25. The focus and interventions of the CP included areas that had been left documented Specify and not individualized for the resident. On 2/14/25 at 1:07 PM, the surveyor notified the LNHA, and the DON of the above concern for Resident #172's ADL CP. On 2/18/25 at 11:32 AM, the LNHA, the DON, and the RDCS met with the survey team. The DON stated Resident #172's CP was incomplete and was updated by the staff. The DON also stated that re-education would be provided to their staff to ensure CPs were completed.

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure that a.) the monthly Psychoactive Review (behavior monitoring) was done routinely and accurately and b.) identified behaviors were discussed with the interdisciplinary team for 1 of 5 residents, (Resident #175), reviewed for unnecessary medications, according to the standard of clinical practice and facility policy. This deficient practice was evidenced by the following: 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 case-finding, 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 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 2/7/25 at 11:33 AM, the surveyor did not observe Resident #175 inside their room. On that same date and time, the Certified Nursing Aide (CNA) informed the surveyor that the resident was in therapy. The CNA further stated that Resident #175 was cognitively impaired and no unusual behavior. The surveyor reviewed the medical records of Resident #175 and revealed: A review of the admission Record (or face sheet, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site not specified, ESBL (Extended-spectrum beta-lactamases are a type of enzyme or chemical produced by some bacteria. ESBL enzymes make some antibiotics ineffective in treating bacterial infections) resistance, other retention of urine, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified anxiety disorders, unspecified protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD, is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 11/20/24, revealed in Section C Cognitive Patterns, a brief interview for mental status (BIMS) score of 3 of 15, which reflected that the resident's cognitive status was severely impaired. A review of the December 2024, January 2025, and February 2025 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) with physician orders (PO) revealed: -A PO with a start date of 12/12/24 and discontinued (d/c) on 1/13/25 for Quetiapine fumarate tablet (tab) 25 mg (milligram), give one tab by mouth at bedtime (HS) for psychosis. -A PO with a start date of 1/14/25 and d/c on 2/1/25 for Trazodone HCL (hydrochloride) tab 50 mg, give 1/2 tab (25 mg) by mouth at HS for depression. -A PO with a start date of 2/5/25 for Trazodone 50 mg, give ½ (25 mg) tab by mouth at HS for depression. -A PO with a start date of 2/6/25 for Quetiapine fumarate tab 25 mg, give ½ tab by mouth two times a day for psychosis. -A review of the December 2024 behavior monitoring for psychotropics revealed that 1 of 60 shifts was documented for the behavior of impulsiveness, 3 of 60 shifts were blanks, and 56 of 60 were documented no behaviors. For dates 12/12/24 to 12/17/24 were documented in the eMAR and for dates 12/18/24 to 12/31/24 were documented in the eTAR. -A review of January 2025 eTAR behavior monitoring for psychotropics revealed that 1 of 93 shifts was blank, 2 of 93 shifts behaviors were documented (1/17/25 restlessness and 1/18/25 poor sleep, anxiety, and restlessness), and 90 of 93 shifts no behaviors were documented. A review of the Psychoactive Review (PR) dated 2/1/25, which was electronically signed by the Licensed Practical Nurse/Unit Manager (LPN/UM) for the reason of evaluation was a monthly review for a target behavior of depression, anxiety, and sleep for medication (med) trazodone 25 mg. The PR reflected that no behavior or mood was identified for the period of review. Further review of the above PR dated 2/1/25 revealed that there were no other medications (meds) listed that were reviewed except for trazodone. The PR did not reflect the documented behaviors in December 2024 and January 2025 to reflect what behaviors were monitored in the eMAR and eTAR. Further review of the medical records revealed that there was no evidence that PR was done routinely and there was no other PR documented except 2/1/25. A review of the Psychiatric Consult follow-up dated 1/28/25, revealed that the Nurse Practitioner (NP) documented that there were no recent behaviors had been reported by the nursing. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Services (RDCS), and Director of Nursing (DON). The surveyor notified the above concerns with Resident#175's behavior monitoring, PR (monthly) not done routinely with incomplete information, and the NP psychiatric follow-up consult note did not reflect what were documented in the January 2025 PR identified behaviors. On 2/13/25 at 2:14 PM, the survey team met with the LNHA, RDCS, and DON. The RDCS acknowledged that there was only one PR summary that was done, which was the 2/1/25. The RDCS stated that the reason why there was only one PR done for the resident was because the psychoactive med was started on 12/12/24, which was midway the month of December 2024, and the med was d/c. She further stated that it was not normal practice, and the best practice was that PR should be done monthly, for example, the PR for 2/1/25 was for the January 2025 psychoactive meds review, and if January 2025 PR was done, it should be for December 2024 psychoactive med. A review of the facility's Psychotropic Med Use Policy, with a revision date of July 2022, was provided by LPN/UM revealed: Policy Interpretation and Implementation: 2. Drugs in the following categories are considered psychotropic meds and are subject to prescribing, monitoring, and review requirements specific to psychotropic meds: a. Anti-psychotics; b. Anti-depressants . 8. Consideration of the use of any psychotropic med is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, RDCS, Regional Nurse (Registered Nurse), and LPN/UM for an exit conference, the LNHA did not provide additional information. NJAC 8:39-11.2(b)

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a) the resident's current active care plan (CP) contained the interventions that were implemented after each resident's fall, in order to prevent any additional falls; and b) ensure a fall risk assessment was done quarterly in accordance with their facility policy for 1 of 2 residents reviewed for accidents/falls (Resident #111). The deficient practice was evidenced by the following: On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair. Resident #111 stated that they had just returned from a physical therapy session. Resident #111 stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. The surveyor observed a Fall Risk wrist band on Resident #111's wrist and that the resident's bed was low to the ground. On 2/11/25 at 9:58 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) to provide any incidents or investigations for the last six months for Resident #111. On 2/11/25 at 10:37 AM, the surveyor interviewed Resident #111's Licensed Practical Nurse (LPN) regarding the process for fall risk assessment and falls. The LPN stated that a fall risk assessment was done on admission and that it may be done by the unit manager quarterly but was not sure. She added that physical therapy saw the resident within 24 hours to determine if the resident was a fall risk. The LPN stated that most residents had a CP that included risk for fall with interventions that included frequent checks and floor mats. The LPN stated that if a resident had a fall then a risk management/incident report was done which included statements from staff. She added that an investigation for the cause was done and that the unit manager would update the CP with a new intervention. A review of Resident #111's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), type 2 diabetes mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy) and hypertension (high blood pressure). A review of Resident #111's most recent discharge return anticipated Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident's cognitive skills for decision making were moderately impaired. Further review of the MDS indicated the resident had one fall with no injury since admission or prior assessment. A review of Resident #111's Progress Notes (PN) indicated that in October 2024, the resident was found sitting on the floor and had an unwitnessed fall. Further review of the PN indicated that in November 2024 the resident was transferred to the hospital for abnormal vital signs and elevated blood sugar. A review of Resident #111's current active CP, with an initiated date of 11/19/24, indicated a focus area of at risk for falls r/t (related to); a goal of my risk for falling will be reduced with my current interventions; and one intervention of maintain clutter-free environment. A review of the facility provided incident report of Resident #111's October 2024 fall included a printout of a CP with the focus area of at risk for falls and related injuries secondary to history of multiple fall from the community, impaired mobility requiring ADL (activities of daily living) assistance, episodes of being impulsive and diagnosis of hypotension anemia, DM (diabetes mellitus), syncope, CKD (chronic kidney disease), and HTN (hypertension) which was initiated 5/24/2022, and revised on 10/18/20224. Further review of the printout indicated that the resident had a fall in June 2024 and October 2024. The following interventions were added after the resident's falls: resident educated on safety, calling for staff assistance as well as wheelchair safety.; clothes hamper relocated to resident room to free up space in bathroom.; Smaller trash bin placed in bathroom to ensure clear path for resident when transferring self. These interventions were not included in Resident #111's current active CP. Further review of the electronic medical record indicated that Resident #111 had a previous CP that included the falls and interventions but that it had been completed (not active or current) on 11/4/24. Resident #111's active current CP did not have any of the previous implemented interventions listed to attempt to prevent any further falls. A review of Resident #111's fall risk assessments included the following: January 2024 which was included in the NSG (nursing): Quarterly/Annual/SignificantChange Evaluation which reflected the evaluation was in progress, not completed. June 2024 was listed as other not quarterly and was dated the same day as the resident's fall. October 2024 was listed as other not quarterly and was dated the same day as the resident's fall. November 2024 which was included in the NSG: Admission/readmission Evaluation and listed as a readmission There were no quarterly fall risk assessments for April 2024, July 2024 and January 2025. On 2/11/25 at 12:46 PM, the surveyor interviewed the first floor Unit Manager (UM) regarding the process for fall risk assessment and CP related to fall and fall risk. The first floor UM stated that upon admission a fall risk assessment and a baseline CP was done and that the CP was later updated by the supervisor, UM, Assistant Director of Nursing (ADON) or Director of Nursing (DON). The first floor UM stated that the fall risk assessment was done on admission then repeated quarterly and if something happened. The first floor UM stated that when a fall occurred an incident report risk management was done and that the CP would be updated with a new intervention to prevent a future fall. The surveyor asked if a CP was completed when a resident went to the hospital. The first floor UM stated that the CP did not have to be closed (completed) if went to hospital and came back a couple days later but that he would have to ask MDS. The surveyor then asked the first floor UM to view Resident #111's active CP for fall risk. The first floor UM confirmed that Resident #111's current active CP had only one intervention for a fall risk and did not mention the falls at the facility. The first floor UM then confirmed that Resident #111 had a completed CP that had the falls and multiple interventions to prevent a fall. The surveyor asked if Resident #111's active current CP should have the completed CP for falls with interventions and he stated it should be in the current CP. On 2/11/25 at 01:10 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) regarding CP and fall risk assessment. The MDSC/RN stated that she may open the CP but that usually other departments completed them and reviewed them. The MDSC/RN stated that the CP was closed (completed) when the resident was discharged home or to the hospital and that when they returned a new CP was opened. The surveyor asked that if the information in the completed CP should be continued in the new CP if still relevant. The MDSC/RN stated most probably. She added that the interventions should be in place but that she was not sure if the CP had to be closed out. The MDSC/RN stated that she did not do anything with the fall risk assessment. On 2/12/25 at 11:42 AM, the first floor UM stated that the quarterly nursing assessment usually contained the fall risk. On 2/12/25 at 1:43 PM, the surveyor notified the LNHA and DON the concern that Resident #111 did not have a current active CP that included the interventions implemented prior to the resident's hospitalization and that the resident did not have quarterly fall risk assessments done. On 2/13/25 at 2:14 PM, in the presence of the LNHA and DON, the Regional Director of Clinical Services (RDCS) stated that in regards to the quarterly risk assessment that because of the different changes of positions that it was unclear with MDS and nursing who was initiating the quarterly assessment (fall, pain, braden, elopement, siderail) and that now the MDSC/RN would be providing assessment dates and nursing would follow the risk assessment based on the dates provided. The RDCS stated that when Resident #111 went to the hospital the MDSC/RN had canceled the CP instead of resolving it and that a new CP had to be initiated. On 2/14/25 at 9:59 AM, the MDSC/RN stated that apparently the CP was not supposed to have been canceled (completed) when the resident went to the hospital unless they are there for 30 days. She added that if there was a bedhold then it does not get canceled (completed). The MDSC stated that for Resident #111, someone canceled the CP by accident and that now it was updated. The MDSC stated that nursing was supposed to do the quarterly nursing assessment. The LNHA did not provide any additional information. A review of the facility provided policy titled, Fall Prevention Program with a reviewed/revised date of 10/16/24, included the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk 5. Low/Moderate Risk Possible Protocols: . g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes . 9. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated . A review of the facility provide policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022, included the following: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desire outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to monitor enteral tube feeding administration to assure the total volume (TV) administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 resident, (Residents #172), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: On 2/7/25 at 10:45 AM, the surveyor observed Resident #172 lying in bed with the head of the bed elevated and their eyes were closed. The resident had enteral feeding equipment and supplies at the bedside. On 2/11/25 at 9:05 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #172. A review of the admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, cerebral infarction (stroke), dementia, type 2 diabetes mellitus, and gastrostomy (tube that is inserted through the abdominal wall into the stomach to provide nutrition, fluids, and medication). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/2/25, indicated that resident's cognitive status was severely impaired. In Section K (Swallowing/Nutritional Status), Resident #172 was coded as receiving nutrition through a feeding tube while a resident. A review of the physician's order (PO) dated 10/2/24, indicated the resident was NPO [nothing by mouth]. A review of the PO dated 1/3/24, indicated every day (7AM to 3PM) shift to document the TV infused once the enteral feeding was completed. A review of the PO dated 1/28/25, indicated to provide Diabetisource 1.2 via feeding tube at 55 milliliter/hour (ml/hr) to be started at 4 PM and turned off once a TV of 1100 ml was infused. A review of the resident's care plan (CP) included a CP with a focus on enteral feeding. An intervention of the CP indicated the resident needed to be provided enteral feedings and to view the PO. A review of the February 2025 Medication Administration Record (MAR) revealed for 6 of 11 days the documented TV infused was less than order TV of 1100 ml to be administered. The entries revealed the following: On 2/1/25, the nurse documented the TV infused as 500 ml. On 2/2/25, the nurse documented the TV infused as 450 ml. On 2/3/25, the nurse documented the TV infused as 500 ml. On 2/4/25, the nurse documented the TV infused as 500 ml. On 2/5/25, the nurse documented the TV infused as 500 ml. On 2/6/25, the nurse documented the TV infused as 500 ml. A review of the progress notes revealed there was no documentation that indicated why the TV documented was less than 1100 ml, which was the ordered TV to be infused to the resident. On 2/13/25 at 11:57 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) about enteral feeding and nursing documentation. The LPN stated an enteral feeding for a resident was administered according to the PO and the total volume infused depended on the PO. The LPN further explained the administration and TV infused was documented in the MAR. On 2/13/25 at 1:24 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about tube feeding administration and TV documentation. The RN/UM stated PO were entered in the EMR and there was a set of orders for enteral feeding. The RN/UM further explained a resident's enteral feeding was administered per PO and the nurses documented the TV of the enteral feeding to be infused in the MAR. The surveyor reviewed with the RN/UM the documented TV infused in the February 2025 MAR. The RN/UM could not speak to why the nurses documented 500 or 450 for the TV infused and would follow up with the nurses to provide additional information. On 2/13/25 at 2:18 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Director of Clinical Services of the above concern for the documented TV infused which differed from the prescribed total volume to be administered to the resident. On 2/14/25 at 1:07 PM, the LNHA and the DON met with the survey team. The DON stated some of the nurses were confused about the volume to document and were documenting the total infused on their shift. The DON added that in-service education was initiated. There was no additional information provided by the facility. A review of the facility's Enteral Tube Feeding via Continuous Pump Policy, with a last revised date of November 2018. Under Preparation it specified, 1. Verify that there is a PO for this procedure . Under Documentation indicated the person performing the procedure should record information in the resident's medical record which included, 3. Amount and type of enteral feeding .5. All assessment data obtained during the procedure . NJAC 8:39-25.2(c)2; 27.1 (a)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents and b.) develop an individualized care plan in accordance with professional standards of practice for one 1 of 4 residents, (Resident #187), reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/7/25 at 11:00 AM, the surveyor observed the Resident #187 sitting on the bed, nebulizer (neb) machine on top of the bedside table, mask in the drawer and not in the bag. The resident stated they placed the neb in the drawer and did not put it back in the plastic bag. The plastic bag was dated 2/1/25. The resident stated, I had an infection before, not now. I use that for breathing. A review of the admission Record (an admission summary) revealed diagnoses which included but not limited to; encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft, and pneumonia unspecified organism. A review of the Order Summary Report (OSR) revealed: Ciprofloxacin HCl (hydrochoride) Oral Tablet (tab) 750 mg (milligram), give one tab by mouth every 12 hours for pneumonia. Do not crush, ordered on 1/8/25, completed on 1/13/25; Budesonide Suspension 0.5 mg/2 ml (milliliters) one vial inhale orally via neb two times a day for shortness of breath. Further review of the OSR revealed that there was no order for neb change of mask or tubing. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/14/25, revealed Brief Interview of Mental Status (BIMS) score of 12 out of 15 indicating intact cognition. A review of the Care Plans (CP) reflected that the resident was on antibiotics for pneumonia and with altered respiratory status/difficulty breathing, date initiated 1/8/25. Further review of the CP revealed that there were no goals or interventions for respiratory care and no individual CP for neb. On 2/14/25 at 10:00 AM, the surveyor interviewed the 3rd Floor Unit Manager (UM), License Practical Nurse (LPN), and the UM stated, Everyone's tubing and neb mask, the nurses change every week on Wednesday night and dated. Everyone has their own individual bag, and is dated, and changed every week. The UM confirmed that the Resident #187 should have an order to change neb weekly and a CP in place. On 2/14/25 at 10:15 AM, the UM confirmed with the surveyor by looking in the Electronic Health Record, I don't see the order for neb to be changed weekly, there should be an order to change them every week. The UM further stated that there was no CP, it was started but it did not have goals, interventions or anything about the neb. The UM also stated that the CP was initiated by the admitting nurse and I'm supposed to go back and ensure everything was in place. The UM further stated I don't have an explanation for this one. On 2/14/25 at 1:39 PM, the surveyor notified the Director of Nursing (DON) and the License Nursing Home Administrator (LNHA) regarding concerns with the care of the neb mask/tubing and CP. A review of the facility's Nebulizer Therapy Policy, dated 4/16/24, revealed, Care of the equipment change neb tubing as ordered and a policy on CP, Comprehensive Person-Centered revealed, .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being NJAC 8:39-25.2(c)3

Based on observation, interview, and record review, it was determined that the facility failed to, a.) ensure a resident's medication, blood sugar check, and times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 2 of 3 residents (Residents #77 and #121) and b.) clarify duplicate orders for 1 of 3 residents, (Resident #77), reviewed for dialysis, according to facility's policy and standard of clinical practice. The deficient practice was evidenced by the following: 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 case finding, 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 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. 1. On 2/7/25 at 10:29 AM, Surveyor #1 (S#1) observed Resident#77 seated in a wheelchair in the day room in a group activity. Surveyor #2 (S#2) reviewed the medical records of Resident #77. A review of the admission Record (AR, admission summary) reflected that Resident #77 was admitted to the facility with a diagnosis that included but was not limited to diabetes mellitus, end-stage renal disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids), and dependence on renal dialysis. A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 10/31/24 revealed in Section C Cognitive Status with a BIMS (Brief Interview for Mental Status) score of 10 of 15, which reflected that the resident's cognition was moderately impaired. The cMDS revealed that the resident was on dialysis. A review of the February 2025 electronic Medication Administration Record (eMAR) revealed: Start date of 1/29/25 for Blood sugar (BS) without overage before meals and at HS (bedtime) for monitoring. Start date 1/31/25 Finger stick one time a day for monitoring (plotted at 5:30 AM). Further review of the above February 2025 eMAR revealed that on 2/1/25 at 11:30 AM was coded X, on 2/4/25 at 11:30 AM was coded NA, on 2/6/25 at 11:30 AM was coded X, and 2/8/25 at 11:30 AM was coded X. On 2/11/25 at 11:56 AM, S#2 interviewed the Registered Nurse (RN), who informed the surveyor that she was the nurse of Resident # 77 who was currently not at the facility and was at the dialysis center. The RN stated that the resident was picked up today at around 10:00 AM, usually, picked up at around 9-9:30 AM and comes back around 3-3:30 PM. The RN also stated that the resident was cognitively impaired, and required minimal to maximal assistance depending on days when the resident had dialysis required more help. At that same time, S#2 asked the RN regarding the resident's February 2025 eMAR. S#2 asked the RN why there were duplicate orders for BS, one early morning and the other one before meals and at HS without coverage for both. S#2 also asked what was the code X on 2/1/25 and 2/6/25 at 11:30 AM for BS, and the RN had no response. The RN confirmed that the NA was not applicable. On 2/11/25 at 12:02 PM, the Registered Nurse/Unit Manager (RN/UM) informed S#2 that she was aware of the concerns of the surveyor about duplicate orders and the Accu check (BS) coding that was not according to the resident's dialysis timing and that she corrected it after the surveyor's inquiry. She further stated that the nurse should have picked it up when the resident came back from hospitalization and followed the correct order and plotting of orders according to dialysis time and days. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). S#2 notified the above concerns with Resident#77's orders not according to dialysis days and times and duplicate orders for Accu-Chek. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, Regional Director of Clinical Services (RDCS), Regional Nurse, and Licensed Practical Nurse/Unit Manager for an exit conference, the LNHA did not provide additional information. 2. On 2/7/25 at 10:21 AM, S#1 observed Resident #121 resting in bed with their bed. The resident did not respond to the surveyor's greeting. On 2/13/25 at 9:04 AM, S#1 reviewed the medical records of Resident #121. A review of the AR documented the resident had diagnoses that included but were not limited to, ESRD and dependence on renal [kidney] dialysis. A review of the quarterly MDS, with an ARD of 12/24/24, indicated a BIMS score of 10 out of 15, which indicated the resident had moderate cognitive impairment. A review of the physician's order (PO) dated 9/24/24, indicated change medications and treatment timing from facility's medication (med) and treatment administration time to accommodate hemodialysis treatment. A review of PO dated 11/18/24, indicated the resident had dialysis every Monday, Wednesday, and Friday at a dialysis center with a pickup time of 3:00 PM. A review of progress notes revealed the nurses documented that the resident returned to the facility from dialysis at 7:45 PM on 1/13/25, 7:35 PM on 1/15/25, 8:25 PM on 1/22/25, 8:00 PM on 1/29/25, 8:30 PM on 2/5/25, and 8:10 PM on 2/12/25. A med administration note dated 2/4/25 at 5:57 PM, indicated that the Brimonidine Tartrate eye drops were not given as Pt[Patient] at dialysis appointment. A review of January 2025 and February 2025 eMAR revealed the following: An entry with a start date of 10/24/24 for Brimonidine Tartrate 0.2% eye drops, instill one drop to both eyes two times a day which was scheduled to be administered to the resident at 9:05 AM and 6:05 PM. The Brimonidine Tartrate eye drops were signed as administered at 6:05 PM by the nurses on 1/13/25, 1/15/25, 1/22/25, 1/29/25, 2/5/25, and 2/12/25. On 2/4/25, was signed 9 which indicated Other/See Nurses Note. On 2/13/25 at 11:42 AM, S#1 asked the Licensed Practical Nurse (LPN) about care for dialysis residents. The LPN stated that a resident's med should be scheduled around their dialysis sessions. The LPN further explained that if there was a med scheduled for when the resident was not in the facility, the nurse should call the physician to clarify the order. On 2/13/25 at 2:18 PM, S#1 notified the LNHA, the DON, and the RDCS about the concern of Resident #121's Brimonidine Tartrate 0.2% eye drops med scheduled time not being adjusted to accommodate when the resident was out of the facility to dialysis. On 2/14/25 at 1:07 PM, the LNHA and the DON met with S#1. The DON acknowledged the eye drop med should have been clarified by the nurses. The DON stated the eye drop order was clarified and education would be provided to the nursing staff. A review of the facility's Hemodialysis Policy that was provided by the LNHA on 2/7/25 at 2:49 PM, revealed that the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. NJAC 8:39-11.2(b), 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/10/25 at 6:30 AM, Surveyor #2 (S#2) entered the facility and met with the Certified Nursing Aide (CNA), who informed the surveyor that she was from 7:00 AM-3:00 PM shift CNA and assigned to check the staffing for nursing. The surveyor observed the posted sign for NHRCSR dated 2/9/25, Evening Shift 3:00 PM-11:00 PM with the census of 205. On 2/10/25 at 8:02 AM, the SC provided the Nursing Daily Staffing Sheet for the date 2/9/25, with handwritten information on the side of the paper of the following: Friday 202 3 bed Saturday 203 2 bed [NAME] 203 3 bed At that same time, the surveyor asked the SC what those handwritten notes in blue ink pen were that the SC provided. The SC stated that on Friday, 2/7/25, the census was 202, with a 3-bed hold, on Saturday, 2/8/25, the census was 203, with a 2-bed hold, and on Sunday, 2/9/25, the census was 203, with a 3-bed hold. The SC stated that the posted staffing that the surveyor observed today for 2/9/25, was for Sunday, and the census was wrong. A review of the facility Policy and Procedure titled Nurse Staffing Posting Information dated 2/5/2025 revealed, The facility will post the Nurse Staffing Sheet at the beginning of each shift. N.J.A.C. 8:39-41.2 (a)(b)(c)(d) Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 7 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: 1. On 2/7/25 at 8:47 AM, upon entry to the facility, Surveyor #1 (S#1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main lobby. The NHRCSR posted was dated 2/6/25 for the [7:00 AM to 3:00 PM] day shift. There was no NHRCSR for 2/7/25 posted. On 2/7/25 at 9:20 AM, S#1 interviewed the receptionist by the main lobby, who stated, I am responsible for posting the staffing. I know it's the wrong date, I was waiting on the Staffing Coordinator (SC) to come in, she's running late. She will usually give me the numbers and I will correct it on the paper. I am the one printing out the staffing. On 2/11/25 at 1:15 PM, S#1 interviewed the SC in the presence of the Regional Director of Recruitment and Labor Management. The SC stated, [Name Redacted] or whoever is on the front desk is responsible for posting the staffing. I am the one who gives the numbers, the number of nurses, Certified Nursing Assistants (CNAs), and the census. I will email or text the census, for it to be corrected on the form. The person on the front desk prints the NHRCSR. The corrected one was printed out after you guys arrived. The SC confirmed that [Name Redacted] did not print out the NHRCSR correctly for 2/7//25. The Regional Director of Recruitment confirmed, Usually it gets posted at the beginning of the shift, 7AM, 3PM, and 11PM. On 2/11/25 at 1:46 PM, the Unit Manager (UM) for the 4th floor provided the facility Policy and Procedure titled, Nurse Staffing Posting Information dated 2/5/25, which revealed, The facility will post the Nurse Staffing Sheet at the beginning of each shift. On 2/13/25 at 2:17 PM, S#1 notified the License Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) regarding incorrect posting of the NHRCSR. The LNHA stated, The expectation is, it's due on the receptionist desk when he comes in the beginning of the shift.

Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 1 resident, (Resident #48), reviewed for food concerns. This deficient practice was evidenced by the following: On 2/7/25 at 10:41 AM, the surveyor observed Resident #48 lying in their bed with the head of the bed elevated. The resident was alert, and verbally responsive. Resident #48 expressed concerns with their meals. The resident stated that they selected from a menu the food items they wanted and did not get what was requested most of the time. The resident further explained that if they received a food item they did not request, the staff would call the kitchen, and the resident would just get what's available .whatever they have left at the time. Resident #48 stated they did discuss with kitchen and registered dietician (RD) about not getting food items requested and the issue still occurs. On 2/11/25 at 9:35 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #48. A review of the admission Record (admission summary) documented the resident had diagnoses that included but were not limited to hypertension and type 2 diabetes mellitus. A review of the comprehensive Minimum Data Set (MDS), an assessment a tool, with an assessment reference (ARD) of 12/18/24, indicated a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the physician's order dated 1/29/25, revealed the resident had a no concentrated sweets, regular texture, and regular (thin) liquid diet. A review of the resident's care plan (CP) included a CP for nutrition with an initiation dated of 12/12/24, and a revision dated of 1/29/25. An intervention of the CP indicated Honor food/beverages preferences as available and offer alternatives with an initiation date of 12/12/24. On 2/11/25 at 1:10 PM, the surveyor observed Resident #48 sitting at a table in the dining area of their unit. The resident had a bowl of soup only and there was no meal ticket for the resident on the table. The surveyor asked Resident #48 about their meal. The resident replied that they had received turkey meatloaf instead of the roasted chicken that they had requested. The resident stated that they told staff in dining area who called the kitchen. Resident #48 further explained that the staff informed them that there was no more chicken left and Resident #48 asked for a salad which she was waiting to receive. The surveyor interviewed the Medical Record Staff (MRS) who had followed up with the kitchen for Resident #48. The MRS stated that Resident #48 wanted chicken instead of the turkey meatloaf, the kitchen was called, they did not have any more roast chicken, and the resident selected a salad. On 2/11/25 at 1:22 PM, the surveyor interviewed the Food Service Director (FSD). The FSD stated the menu schedule was available on the units for all the residents to review and for staff to inform residents of available options. The FSD further explained three-week cycle selective menus were provided to some of the residents so that they could choose their preference for each meal. The FSD acknowledged food preferences of residents should be honored. The FSD confirmed that Resident #48 was provided a menu to select their food items for each meal. The surveyor informed the FSD of the concern that the resident ordered a roast chicken for lunch and did not receive it on their lunch tray. The FSD stated that sometimes residents changed their mind and would want the alternative option that was being served to other residents. The surveyor requested the meal ticket for the resident's lunch today and the resident's selective menu. The FSD provided the selective menu and the meal ticket. The FSD reviewed with the surveyor the selective menu for Resident #48. For today's lunch meal the resident crossed out turkey meatloaf and the Chicken, Roast option remained. The FSD confirmed that the resident selected the roasted chicken option, and the crossed-out item indicated the resident did not want that food item. The surveyor reviewed with the FSD the resident's lunch meal ticket, which revealed listed food items of fruit cocktail, vegetable barley soup, turkey meatloaf/gravy, mashed potatoes with gravy, peas and carrots. The FSD could not speak to why the resident received turkey meatloaf when the resident had ordered the roast chicken on the selective menu. The FSD stated she would follow up to determine what happened. On 2/13/25 at 2:18 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) of the above concern for Resident #48's food preferences not being honored. On 2/14/25 at 1:07 PM, the LNHA and the DON met with the survey team. The LNHA stated the facility investigated and that it was the unclear writing of white that confused the dietary staff. The surveyor showed the selective menu of Resident #48 where turkey meatloaf was crossed out in ink and chicken, roast in typed format remained. The LNHA and the DON stated they would in-service staff that moving forward staff were to clarify anything that was unclear. The surveyor reviewed the facility provided policy titled, Nutritional Management with a last review date of 4/9/24. Under CP Implementation indicated: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Under Monitoring/revision of the policy indicated: .Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met . NJAC 8:39-17.4 (e); 27.1 (a)

COMPLAINT #: NJ173918 Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 4 of the 38 residents reviewed, (Residents #131, #162, #175, and #493). This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:47 AM, the surveyor observed Resident #162 seated in a wheelchair outside their room with a right leg prosthesis in use. The surveyor reviewed the medical records of Resident #162, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dehiscence of amputation stump (a rare medical condition where the surgical incision site from a previous amputation reopens or separates, exposing the underlying tissues and bones), acquired absence of right leg below the knee, encounter for orthopedic aftercare following surgical amputation, and type 2 diabetes mellitus without complications. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 12/21/24, under Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 9 of 15, which reflected that the resident had moderately impaired cognition. A review of the Progress Notes (PN) revealed that the physician's visit notes were all late entries, created on 2/11/25, for an effective date from 9/20/24 through 1/14/25. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Services (RDCS), and the Director of Nursing (DON), and the surveyor notified them of the concerns above regarding late entries of the physician. On 2/18/25 at 11:25 AM, the survey team met with the RDCS, DON, and the LNHA. The RDCS stated that the monthly physician visit notes should be done within the 1st 90 days and then every 60 days thereafter. 2. On 2/7/25 at 11:33 AM, the surveyor observed Resident #175's outside door with a posted sign for Enhanced Barrier Precautions (EBP were measures implemented in healthcare settings to prevent the transmission of infections, particularly in situations where standard precautions alone may not be sufficient) and the resident was not inside the room. On that same date and time, the Certified Nursing Aide (CNA) informed the surveyor that the resident was in therapy. The CNA further stated that Resident #175 was cognitively impaired, and no unusual behavior. The surveyor reviewed the medical records of Resident #175 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site not specified, ESBL (Extended-spectrum beta-lactamases are a type of enzyme or chemical produced by some bacteria. ESBL enzymes make some antibiotics ineffective in treating bacterial infections) resistance, other retention of urine, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified anxiety disorders, unspecified protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD, is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). A review of the most recent comprehensive MDS (cMDS), with an ARD of 11/20/24, revealed a BIMS score of 3 of 15, which reflected that the resident's cognitive status was severely impaired. The cMDS also reflected that Resident #175 did not receive influenza vaccination in the facility, the pneumococcal vaccination was not up to date, and the pneumococcal vaccination was not offered. A review of the December 2024, January 2025, and February 2025 electronic Medication Administration Record (eMAR) with physician orders (PO) revealed: -A PO with a start date of 12/12/24 and discontinued (d/c) on 1/13/25 for Quetiapine fumarate tablet (tab) 25 mg (milligram), give one tab by mouth at bedtime (HS) for psychosis. -A PO with a start date of 1/14/25 and d/c on 2/1/25 for Trazodone HCL (hydrochloride) tab 50 mg, give 1/2 tab (25 mg) by mouth at HS for depression. -A PO with a start date of 2/5/25 for Trazodone 50 mg, give ½ (25 mg) tab by mouth at HS for depression. -A PO with a start date of 2/6/25 for Quetiapine fumarate tab 25 mg, give ½ tab by mouth two times a day for psychosis. Further review of the medical records revealed that there was no documented evidence that influenza and pneumococcal vaccinations were offered and declined by the resident or by the Resident Representative (RR) or education was provided. There was no evidence that the consent was offered and signed by the resident or the RR to start on psychoactive medications. On 2/10/25 at 9:22 AM, the surveyor discussed with the LNHA, DON, and Assistant DON (ADON) regarding the expectation that the survey team must have access to residents' medical records as part of the survey process and the facility to provide asked documents timely, and the LNHA acknowledged. On 2/10/25 at 11:18 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager #1 (LPN/UM#1) in the 1 East nursing station about Resident #175's vaccination status and consent forms. LPN/UM#1 showed the packet that was being given to the resident and/or RR for consent as part of the admission packet. At that same time, LPN/UM#1 was unable to locate the resident's vaccination consent forms and psychoactive signed consent. LPN/UM#1 had checked the resident's paper chart and electronic medical records and stated that he did not find evidence that the consent for vaccinations and psychotropic were done. LPN/UM#1 had no response when asked why the resident did not have consent for psychotropic use and vaccinations. A review of the electronic medical records revealed that the COVID-19 vaccine, Prevnar-20 (pneumococcal vaccine), and influenza consents status were pending. Later, LPN/UM#1 stated that the Infection Preventionist Nurse (IPN) would probably have the vaccination consent forms. Both the surveyor and LPN/UM#1 went to the IPN's office. In the IPN's office, the IPN stated that she only had a few in her binder of vaccination consent forms that were signed because some of them were on the residents' charts. The IPN further stated that it was the responsibility of the admission nurse to get consent as part of their admission packet. The IPN showed the binder and confirmed that there was no consent for Resident #175. The IPN further stated that the vaccines should be offered to all residents. On 2/10/25 at 1:05 PM, LPN/UM#1 informed the surveyor that he found the vaccines and psychotropic consents of Resident #175 in the copying machine because the admission person scanned it during admission and probably forgot it in the copying machine when they were scanning it. On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, RDCS, Regional Nurse, and LPN/UM#1 for an exit conference, the LNHA did not provide additional information. 2. On 2/10/25 at 1:07 PM, the surveyor observed Resident #131 lying in their bed using a tablet. The resident was alert, oriented and verbally responsive. The resident stated that they used to smoke, and that the facility was now a smoke free facility. Resident #131 stated that they didn't need to smoke, they were ok with not smoking and had no concerns with the facility. On 2/10/25 at 1:15 PM, the surveyor interviewed LPN#2, who was assigned to care for Resident #131. LPN#2 stated Resident #131 use to smoke prior to update of smoke free facility policy and that the resident did not smoke anymore. LPN#2 verbalized no concern for the resident. On 2/10/25 at 1:26 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that Resident #131 did not smoke anymore after the implementation of the smoke free policy. The RN/UM stated the interdisciplinary team (IDT) met with the resident to inform and educate the resident of the update policy, and the resident was agreeable. On 2/13/25 at 9:49 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #131. A review of the AR documented that the resident had diagnoses that included but were not limited to, anemia and thrombocytopenia (blood has lower than normal number of platelets. A review of the qMDS with an ARD of 1/29/25, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. On 2/13/25 at 11:31 AM, the surveyor interviewed the RN/UM about documentation about the IDT meeting with the resident about the facility's updated smoking policy and the resident agreeable. The RN/UM stated that the documentation should be found in the resident's medical records. The surveyor notified the RN/UM that documentation and agreement was not found in Resident #131's medical records. The RN/UM stated she would ask the Social Worker (SW) if they had a copy. On 2/13/25 at 11:51 AM, the RN/UM stated that the LNHA had the agreement and would provide to the surveyor. On 2/13/25 at 12:46 PM, the surveyor interviewed the LNHA who stated that the IDT had a meeting with Resident #131 about the facility's updated policy in October 2024. The LNHA provided copy of a progress note for the IDT meeting. A team care plan meeting note dated 10/9/24, indicated the IDT meeting with Resident #131 which documented that the resident was educated on the updated facility policy of being smoke free and verbalized understanding. Resident #131 was agreeable, would discontinue smoking, denies need for counseling, and expressed interest in alternate assistance with smoking cessation. The note documented that nursing/IDT would follow up. The surveyor asked the LNHA about follow up on the alternate assistance with smoking cessation. The LNHA stated nicotine patch, and psychology was offered to the resident. The LNHA was to provide additional information regarding the follow up for the alternate assistance with smoking cessation. On 2/13/25 at 2:18 PM, the surveyor notified the LNHA, the DON, and the RDCS of the concern of the care planning of smoking and there being no documentation of cessation interventions in chart. On 2/14/25 at 1:07 PM, the surveyors met with the DON and the LNHA. The LNHA provided an untitled document letter dated 10/15/24 which indicated the resident had refused cessation interventions. The surveyor asked the LNHA where the document was located and if it was in the resident's medical record. The LNHA replied the document was not in the medical record and stated it was filed in his office. There was no additional documentation provided by the facility. 3. A review of the facility AR revealed that Resident #493 was admitted with diagnoses which included but were not limited to; cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, benign prostatic hyperplasia (prostate enlargement), and urinary incontinence. A review of the MDS, revealed Resident #493 had a BIMS score of 12 of 15, which indicated moderate cognition impairment and Resident #493 was dependent for toileting hygiene. A review of Care Plan (CP), initiated 4/8/2024, included at risk of skin breakdown related to (r/t) incontinence bowel and bladder (B&B). Interventions included but were not limited to keep skin clean and dry, provide protective/preventive skin care, toilet with appropriate staff assistance as needed (prn), and provide incontinence care prn. A review of CP initiated on 4/13/24 included at risk for constipation r/t constipation, decreased mobility. Interventions included but were not limited to record bowel movement patterns each day and describe amount, color, and consistency. A review of Resident #493's 5/2024 Certified Nurse Aide (CNA) Intervention/Task Report sheet for Bladder incontinence revealed that Resident #493's assigned CNA(s) did not document, on each shift, whether Resident #493 had urinary incontinence = 0-Continent, 1-Incontinent, 2-Did not void, 3-Continence not rated due to Indwelling Catheter, 4- Continence not rated due to Condom Catheter, 5 - Continence not rated due to Urinary Ostomy. The Bladder Continence intervention had missing signatures for 5/1/24, 5/2/24, 5/3/24, 5/7/24, 5/8/24, 5/9/24, 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/15/24, 5/16/24, 5/18/24, 5/21 - 5/31/24 for 7am-3pm shift. Bladder Continence signatures were missing for 5/1/24, 5/4/24, 5/5/24, 5/9/24, 5/10/24, 5/13/245/18/24, 5/23/24, 5/27/24 for 3pm-11pm shift. The Bladder Continence intervention/task had missing signatures for 5/2/24 and 5/3/24 for 11pm-7am shift Further review of the above revealed a total of 35 missed opportunities out of 93. A review of Resident #493's 5/2024 Certified Nurse Aide (CNA) Intervention/Task Report sheet for Bowel Management revealed that Resident #493's assigned CNA(s) did not document, on each shift, whether Resident #493 had bowel continence = 0-Continent, 2- No bowel movement, 3- Continence not rated due to Ostomy; Size of Bowel Movement (BM) = 1-None, 2 - Small, 3 - Medium, 4 - Large; Consistency of BM = 1 - Formed/Normal, 2 - Loose/Diarrhea, 3 - Constipated/hard, 4 - Putty like. Bowel Management intervention/task had missing signatures for 5/1/24, 5/2/24, 5/3/24, 5/7/24, 5/8/24, 5/9/24, 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/15/24, 5/16/24, 5/18/24, 5/21-5/31/24 for 7am-3pm. Bowel Management intervention/task had missing signatures for 5/1/24, 5/4/24, 5/5/24, 59-5/10/24, 5/13/24, 5/18/24, 5/23/24, 5/27/24 for 3pm-11pm shift. Bowel Management intervention/task had missing signatures for 5/2/24 and 5/3/2. for 11pm-7am shift. A review of the above revealed a total of 35 missed opportunities out of 93. During interview with the surveyor on 2/13/2024 at 12:29 PM, with current LPN/UM#1 on 1-East, confirmed that there were missing signatures for the dates mentioned and stated that it was important that there were no blanks because resident's bowel and bladder regimen should be monitored to prevent any further change in health for example constipation for the bowel and to ensure resident was voiding with no issue. LPN/UM#1 further stated that it was also important to sign and check for resident's skin integrity. He also stated that he did not know what the Xs meant. During an interview with the surveyor on 2/13/204 at 1:30 PM, with assigned Licensed Practical Nurse/Unit Manager #2 (LPN/UM#2) during the mentioned time on 1-East, confirmed that there were blanks and that it was important that there were no blanks to ensure the tasks were completed. LPN/UM#2 further stated that if the resident is not checked then skin can start to excoriate, and resident can attempt to get up which could lead to a fall. LPN/UM#2 stated that she does not know what the X meant. During an interview with the surveyor on 2/14/204 at 1:29 PM, with the DON, she confirmed that there were blanks and stated that there should not be any blanks. She further stated that it was important to sign to show that the care was provided and that it was very concerning. The DON stated that she did not know what the X meant. During an interview with the surveyor on 2/18/204 at 11:53 AM, with the RDCS, the RDCS confirmed that there were blanks, she stated that there should be no blanks on the ADL sheets. She further stated that it was important to document so we know the type of care that was provided. A review of a facility's Incontinence Policy, reviewed/revised 12/3/24, revealed: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Resident that are incontinent of bladder or bowel will receive appropriate treatment . NJAC 8:39-23.2 (a)(b); 27.1, 35.2 (a)(c)(d) 4,5,6,13

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene, use of personal protective equipment (PPE) practices, and use of disinfecting wipes for 3 of 6 staff (1 Certified Nursing Aide and 2 Nurses) and b.) ensure that the COVID-19 infection precaution was posted and ensure the physician order for transmission based precautions (TBP) was followed for 1 of 1 resident, (Resident #292), and follow appropriate infection control practices, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 2/10/25 at 6:54 AM, during the incontinence tour, the surveyor observed the Certified Nursing Aide (CNA) come out of the elevator with a surgical mask not covering the nose and mouth. The CNA informed the surveyor that she was one of the CNAs in the unit and confirmed that almost all residents in her assignments were incontinent of both bladder and bowel elimination. On that same date at 6:57 AM, both the surveyor and CNA went inside room [ROOM NUMBER]. The CNA stated that the resident in the room by the door, Resident # 93 was her resident and the resident was incontinent. Inside the resident's room, the CNA did not perform hand hygiene before and after touching her surgical mask. The surveyor observed the CNA adjusted her mask to cover her nose with the same surgical mask, took a pair of gloves inside her pocket sweater, and donned (put on) gloves. The CNA did not perform hand hygiene before donning gloves. After the CNA checked the resident's incontinence pad, the CNA immediately doffed (removed) off the used gloves and disposed of to the garbage receptacle inside the resident's room. The CNA did not perform hand hygiene after the removal of gloves and before exiting the resident's room. Outside the resident's room, the CNA pulled down her surgical mask below her nose and did not perform hand hygiene after touching her mask. The surveyor asked the CNA about her surgical mask not covering her nose and the doffing off gloves without performing hand hygiene. The CNA stated that at times the mask fell off because she could not breathe. After the surveyor notified the CNA of the concerns with hand hygiene and the use of gloves, the CNA went to wash her hands in another room. The surveyor observed the CNA open the faucet and take soap from the dispenser without wetting her hands first. The CNA performed handwashing (scrubbing) under the stream of water for 22 seconds. At that same time, the CNA acknowledged that she scrubbed her hands under the stream of water and stated that it was the appropriate way of washing hands. On 2/10/25 at 7:00 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) went to room [ROOM NUMBER]. The surveyor observed the RN/UM donned gloves without performing hand hygiene and checked Resident #97's incontinence pad. The RN/UM did not perform hand hygiene after doffing gloves and before exiting the resident's room. Outside the room, the surveyor notified the RN/UM of the concern regarding the CNA's hand hygiene and use of gloves. The RN/UM stated that the CNA should have washed hands before and after the use of gloves and not stored gloves in the pocket. She further stated that the CNA should wear the mask properly which was to cover both mouth and nose. Afterward, the surveyor notified the RN/UM of the concerns that she did not perform hand hygiene before and after the use of gloves as well. 2. On 2/10/25 at 8:16 AM, during medication (med) administration pass, the surveyor observed the Licensed Practical Nurse (LPN) used the disinfecting wipes for cleaning the blood pressure (bp) apparatus (app) before and after use. The surveyor observed the LPN after the use of disinfecting wipes left the cover lid open and went to other resident without covering the disinfecting wipes container. On 2/10/25 at 8:40 AM, the surveyor interviewed the LPN after med administration pass observation of two residents and discussed the concern that from 8:16 AM to 8:40 AM, the disinfecting wipes container was left open. The LPN responded that because she was not finished with the med administration pass to all residents in her assignment that was why she did not close the cover of the disinfecting wipes. The LPN acknowledged that it was depicting the purpose of the disinfectant wipes if the container lid was left open for some time. On 2/10/25 at 11:37 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN) and notified of the concerns with the CNA, RN/UM, and the LPN. The IPN stated that CNA and RN/UM should have done hand hygiene before and after gloves use, and surgical masks should be worn properly to cover the mouth and nose. The IPN also stated that hand hygiene should not be under a stream of running water. She further stated that the LPN should have closed the container of disinfecting wipes to keep them wet. On 2/14/25 at 1:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns. The DON stated that the CNA should follow the facility's policy and protocol about the storage of PPE, proper use of masks, and hand hygiene, as well as the RN/UM. She further stated that the facility was taking seriously the concerns of the surveyor with regard to infection control and in-service ongoing. A review of the facility's Safety Data Sheet of [disinfecting wipes] revealed under Section 7. Handling and Storage: storage conditions: Keep the container closed when not in use . On 2/18/25 at 1:47 PM, the survey team met with the LNHA, DON, Regional Director of Clinical Services, Regional Nurse, and Licensed Practical Nurse/Unit Manager for an exit conference, the LNHA did not provide additional information. 3. On 2/7/25 at 10:24 AM, the surveyor interviewed the first floor Unit Manager (UM) regarding if the unit had any residents that were on transmission based precautions (TBP). The first floor UM stated that Resident #292 was on TBP for COVID-19 (a highly contagious respiratory disease caused by the coronavirus SARS-CoV-2). On 2/7/25 at 10:54 AM, the surveyor observed Resident #292's room door closed. The surveyor observed that there was no signage outside the room to indicate the resident was on TBP and that in order to enter the room PPE including a N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) was required to be donned. The surveyor observed a large cart near the resident's room that contained PPE which also included N95 masks and had instructions for donning and doffing PPE. The surveyor asked the first floor UM to observe Resident #292's room. The first floor UM confirmed that there was no signage outside the room to indicate that the resident was on TBP and what was required to don prior to entrance into the room. The first floor UM stated that he thought that the sign was on the inside of the door. The first floor UM confirmed that Resident #292 was transferred to the facility from the hospital and was COVID-19 positive and was on TBP. A review of Resident #292's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to COVID-19 and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). A review of Resident #292's care plan, included the following with an initiated date of 2/6/25: I am COVID-19+ /has had COVID-19 exposure and/or is exhibiting symptoms consistent with COVID-19 until 2/7/25 midnight. On 2/12/25 at 1:03 PM, the surveyor interviewed the IPN regarding TBP and Resident #292. The IPN stated that there should be signage on the door to indicate TBP. She added that if the resident was on a unit that was not the designated COVID-19 unit that the resident's door should remain closed. The surveyor notified the IPN of the observation of Resident #292's room. The IPN confirmed that the resident was not on the facility's designated COVID-19 unit and that there should have been signage on the outside of the door. She added that a staff probably put the sign on the inside of the door (when it was in the open position) before the resident came to the facility. The IPN stated that the sign should not be on the inside of the door and that for COVID-19, the door should be closed. On 2/12/25 at 1:40 PM, the surveyor notified the LNHA, DON, and RDCS of the concern that Resident #292 did not have TBP signage posted outside the room and that the UM stated that it was probably inside the door. The DON stated that she had placed the TBP sign herself. The surveyor asked the DON if a resident had COVID-19 should the TBP signage be on the inside of the door when the door should be closed. The DON stated that the TBP signage should not be on the inside of the door. A review of the Resident #292's February 2025 Medication Administration Record (MAR) included the following order: Strict Isolation Contact/Droplet precautions: All activities and services performed in room. every shift for COVID-19 until 2/7/2025 23:59. Further review indicated that the evening and night shift on 2/5/25 was not signed as administered (done). A review of Resident #292's Progress Notes (PN) for 2/5/25 did not indicate the resident was on TBP. On 2/13/25 at 2:14 PM, in the presence of the LNHA and DON, the RDCS stated that the TBP sign was posted on the inside of the door. On 2/14/25 at 1:22 PM, in the presence of the LNHA, the DON stated that she investigated the TBP sign for Resident #292 and that the door was opened when the TBP signage was posted and that she inserviced the staff. On 2/14/25 at 1:54 PM, the surveyor notified the LNHA and DON the concern that Resident #292's MAR was not signed for TBP for two shifts and that the PN did not indicate that the resident was on TBP for 2/5/25. On 2/18/25 at 11:42 AM, in the presence of the LNHA and RDCS, the DON stated that she reached out to the staff members and they stated that it was an omission but that they knew the resident was on TBP. The LNHA did not provide any additional information. A review of the facility provided policy titled Transmission-Based (Isolation) Precautions with a reviewed/revised date of 2/5/25 included the following: 1. Facility staff will apply TBP, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission . 9. e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room .Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage . N.J.A.C. 8:39-19.4(a)(1,2),(l),(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Surveyor#2 (S#2) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #13's quarterly MDS (qMDS) with an ARD of 12/14/24, was completed late on 12/30/24. A review of Resident #60's cMDS with an ARD of 12/21/24, was completed late on 12/26/24, and the care plan decisions were completed late on 12/31/24. A review of Resident #68's qMDS with an ARD of 9/11/24, was completed late on 9/26/24. A review of Resident #102's qMDS with an ARD of 12/30/24, was completed late on 1/17/25. A review of Resident #103's cMDS with an ARD of 11/6/24, was completed late on 11/14/24. A review of Resident #187's cMDS with an ARD of 1/14/25, was completed late on 1/30/25. On 2/14/25 at 9:43 AM, S#2 interviewed MDSC/RN, who stated, We go by the RAI manual, we complete them by 14 days from admission and the others 14 days from the ARD. She further stated that the MDSs were late because it was a big building and I am the only one doing the subacute. Sometimes they are late, I will make sure these are a priority going forward. On 2/14/25 at 1:39 PM, S#2 notified the DON and the LNHA regarding concerns with late MDSs completion. On 2/14/25 at 11:25 AM, the MDSC/RN provided the Final Validation Reports (CMS Submission Report) for the late MDSs which confirmed assessments were completed late. 3. A review of Resident #48's cMDS with an ARD of 12/18/24, was completed late on 1/3/25. A review of Resident #121's cMDS with an ARD of 10/1/24, was completed late on 10/11/24. A review of Resident #121's qMDS, with an ARD 12/24/24, was completed late on 1/16/25. A review of Resident #172's cMDS with an ARD of 10/9/24, was completed late on 10/16/24. On 2/14/25 at 1:07 PM, Surveyor #3 (S#3) notified the LNHA and the DON of the identified late completion of the MDS assessments. A review of the facility's MDS Completion and Submission Timeframes Policy, revealed, Timeframes for completion .is based on the current requirements published in the Resident Assessment Instrument Manual. On 2/18/25 at 1:26 PM, the survey team met with the LNHA, DON, and Regional Director of Clinical Services. The LNHA did not provide additional information. NJAC 8:39 - 11.1 REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 14 of 38 residents, (Residents #13, #18, #48, #60, #68, #77, #102, #103, #121, #162, #172, #175, #180, and #187), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following: 1. Surveyor#1 (S#1) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #18's comprehensive MDS (cMDS) with an assessment reference date (ARD) of 7/11/24, was completed on 7/18/24. A review of Resident #77's cMDS with an ARD of 10/31/24, was completed on 11/12/24. A review of Resident #162's cMDS with an ARD of 9/27/24, was completed on 10/9/24. A review of Resident #175's cMDS with an ARD of 11/20/24, was completed on 12/3/24. A review of Resident #180's cMDS with an ARD of 12/9/24, was completed on 12/23/24. The above MDS of Residents #18, #77, #162, #175, and #180 completion dates were presented in the electronic medical records (EMR) in red. On 2/12/25 at 1:08 PM, S#1 interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) regarding the MDS of the above residents on which completion dates were presented in red. S#1 asked the MDSC/RN what the facility's protocol was for completing MDS and how many days the MDS should be completed, and the MDSC/RN responded that she had to get back to the surveyor. At that same time, the MDSC/RN informed the surveyor that the facility utilized the Resident Assessment Instrument (RAI) manual as the facility's guidelines for MDS and that the facility had no separate policy for MDS. On that same date and time, S#1 asked the MDSC/RN to review the above Residents # 18, #77, #162, #175, and #180's cMDS, determine if the facility completed the assessments according to the RAI manual, and provide the transmittal reports. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S#1 notified them of the above findings and concerns regarding MDS of Residents #18, #77, #162, #175, and #180. On 2/13/25 at 1:51 PM, the MDSC/RN met with S#1 and provided a CMS's RAI 3.0 Manual (October 2024 version) that included the required assessment summary and specified days when to complete and submit the MDS. The MDSC/RN confirmed that the above MDS for Residents #18, #77, #162, #175, and #180 were completed beyond the required 14 days. A review of the provided documents by the MDSC/RN revealed: The 7/11/24 cMDS of Resident #18 was completed on 7/18/24. The Resident was admitted on [DATE], MDS should have been completed by 7/17/24. The 10/31/24 cMDS of Resident #77 was completed on 11/12/24. The resident was admitted on [DATE], MDS should have been completed by 11/9/24. The 9/27/24 cMDS of Resident #162 was completed on 10/9/24. The Resident was admitted [DATE], MDS should have been completed by 10/3/24. The 11/20/24 cMDS of Resident #175 was completed on 12/3/24. The Resident was admitted on [DATE], MDS should have been completed by 11/26/24. The 12/9/24 cMDS of Resident #180 was completed on 12/23/24. The Resident was admitted on [DATE], MDS should have been completed by 12/15/24. A review of the provided RAI Manual with an October 2024 version, that was provided by the MDSC/RN revealed that the admission (comprehensive) assessment completion date will be no later than the 14th calendar day of the resident's admission (admission date +13 calendar days).

Based on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments, and write, sign, and date progress notes at each visit. This deficient practice was identified for 14 of 35 residents, (Residents#10, #13, #16, #18, #50, #60, #68, #102, #103, #121, #131, #149, #175, and #180), reviewed for physician services. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, Surveyor #1 (S#1) observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical record of Resident #18 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A review of the Progress Notes (PN) and Assessment tabs in the electronic medical records (EMR) revealed that there was no evidence that Physician #1 (P#1) wrote, signed, and dated PN and documented in the assessment tab from July 2024 through February 11, 2025 his visit notes. Further review of the EMR revealed that Nurse Practitioner #1 (NP#1) documented on 1/23/25, that the reason for a visit was due to an acute cough and that the SNF (Skilled Nursing Facility) H & P (history and physical) not yet on file. A review of the monthly physician orders (MPO) revealed that on 7/9/2024, the orders were 225 days overdue for P#1 to sign. 2. On 2/7/25 at 11:28 AM, S#1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident # 175 was on contact precaution for ESBL (Extended-spectrum beta-lactamases are a type of enzyme or chemical produced by some bacteria. ESBL enzymes make some antibiotics ineffective in treating bacterial infections) in urine with a foley catheter and required to use PPE (personal protective equipment) gown, gloves when providing direct care. S#1 reviewed the medical records of Resident #175 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site not specified, ESBL resistance, other retention of urine, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified anxiety disorders, unspecified protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD, is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). A review of the PN and Assessment tabs in the EMR revealed that there was no evidence that Physician #2 (P#2) wrote, signed, and dated PN and documented it in the assessment tab from November 2024 through February 11, 2025 his visit notes. Further review of the EMR revealed that Nurse Practitioner #2 (NP#2) documented on 2/10/25, that the reason for a visit was due to a UTI (urinary tract infection)/ESBL. A review of the MPO revealed that on 12/14/2024, the orders were 60 days overdue for P#2 to sign. 3. On 2/7/25 at 11:35 AM, S#1 observed Resident #180 lying on the bed, awake, and stated that they were at the facility for rehabilitation and had to go back to the doctor to remove the metal in their left arm. The surveyor observed the resident with a splint in use on their left arm. S#1 reviewed the medical records of Resident #180 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified intracranial injury with loss of consciousness status unknown, subsequent encounter, undifferentiated schizophrenia (is a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), unspecified protein-calorie malnutrition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and bipolar disorder (is a mental health condition characterized by significant mood swings) unspecified. A review of the PN and Assessment tabs in the EMR revealed that there was no evidence that P#2 wrote, signed, and dated PN in a timely manner from December 2024 through January 11, 2025. The PN dated 12/6, 12/9, 12/12, 12/15, 12/18, 12/21, 12/24, 12/27, 12/30, and 1/11/25 were all created on 1/13/25. There was no documented evidence that P#2 wrote his visit notes in the assessment tab of EMR December 2024 through from February 11, 2025. Further review of the EMR revealed that there was NP wrote and signed the PN and the Assessment tab. A review of the MPO revealed that on 12/5/2024, the orders were 69 days overdue for P#2 to sign. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S#1 notified them of the above findings and concerns regarding physician services for Residents #18, #175, and #180. On 2/13/25 at 2:14 PM, the survey team met with the LNHA, Regional Director for Clinical Services (RDCS), and DON. The RDCS stated that as far as physician services with no physician notes, we did reach out to the physicians and had been periodically reaching out. The RDCS acknowledged it was an ongoing problem with regard to physician services signing orders and writing their visit notes. On 2/18/25 at 11:25 AM, the survey team met with the RDCS, DON, and LNHA. The surveyor asked what the facility's standard of practice was for signing orders and visits, and the RDCS stated that the physician's visits would be done monthly for the 1st 90 days and then convert to every 60 days thereafter. She further stated that the signing of orders should be signed off monthly by the physician in the EMR and the physician had 10 days from the due date. 11. On 2/13/25 at 9:04 AM, Surveyor #3 (S#3) reviewed Resident #121's medical records. The AR documented that Resident #121 had diagnoses that included but were not limited, type 2 diabetes mellitus, end stage renal disease, kidney transplant, dependence on renal [kidney] dialysis, and anemia. A review of the PN revealed a PN written by P#2, the resident's primary physician, with effective dates of 10/18/24, 11/13/24, 12/17/24, and 1/15/25, were written on 2/12/25, after the surveyor's inquiry. A review of the order review history revealed P#2 last signed orders for the resident on 11/2/24. 12. On 2/13/25 at 9:28 AM, S#3 reviewed Resident #16's medical records. The AR documented that Resident #16 had diagnoses that included but were not limited, left bundle branch block (condition where electrical impulse that causes your heart to beat is disrupted or blocked), heart disease, osteoarthritis, major depressive disorder, and hypertension (high blood pressure). A review of the PN revealed the following: NP #2 wrote a PN on 9/18/24. NP #1 wrote PN on 11/5/24, 11/7/24, 11/14/24, and 2/6/25. There were no PN written by P#3, the resident's primary physician, from June 2024 to February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. 13. On 2/13/25 at 9:36 AM, S#3 reviewed Resident #149's medical records. The AR documented that Resident #149 had diagnoses that included but were not limited, Alzheimer's disease, type 2 diabetes mellitus, anxiety disorder, and anemia. A review of the PN revealed P#3, the resident's primary physician, wrote PN with effective dates of 6/27/24, 7/29/24, and 11/17/24. There were no PN written by P#3 in August 2024, September 2024, October 2024, December 2024, January 2025, and February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. 14. On 2/13/25 at 9:36 AM, S#3 reviewed Resident #131's medical records. The AR documented that Resident #131 had diagnoses that included but were not limited, anemia and thrombocytopenia (blood has lower than normal number of platelets. A review of the PN revealed there were no PN written by P#3, the resident's primary physician, from June 2024 to February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. On 2/13/25 at 2:18 PM, S#3 notified the LNHA, the DON, and the RDCS of the concerns with PPN, review, and signing of orders for residents. A review of the facility's Physician Visits Policy, with a revision date of April 2013, that was provided by the Regional Nurse revealed that the attending physician must make visits in accordance with applicable state and federal regulations. Policy Interpretation and Implementation: 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every 30 days for the 1st 90 days following the resident's admission, and then at least every 60 days thereafter. 3. Non-physician practitioners (physician assistant, NP) may perform required visits (initial and follow-up), sign orders, and sign certifications/re-certifications as permitted by state and federal regulations . NJAC 8:39-11.2(1); 23.2(b)(d) 4. A review of the medical record for Resident #10, revealed the resident's physician had not hand signed or electronically signed the MPO for October 2024, November 2024, and January 2025. 5. A review of the medical record for Resident #13, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025. A review of the Physician PN (PPN) for Resident #13, revealed that the physician did not conduct face to face visits and did not write PN for the month of July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025. 6. A review of the medical record for Resident #50, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, August 2024, September 2024, October 2024, November 2024, December 2024 and January 2025. A review of the PPN for Resident #50, revealed that the physician did not conduct face to face visits and did not write PN for the month of June 2024, July 2024, August 2024, October 2024, and January 2025. 7. A review of the medical record for Resident #60, revealed the resident's physician had not hand signed or electronically signed the MPO for January 2025. 8. A review of the medical record for Resident #68, revealed the resident's physician had not hand signed or electronically signed the MPO for January 2025. A review of the PPN for Resident #68, revealed that the physician did not conduct face to face visits and did not write PN for the month of January 2025, a late entry was created on 2/12/25, and back dated for January 15, 2025. 9. A review of the medical record for Resident #102, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, September 2024, November 2024, and January 2025. A review of the PPN for Resident #102, revealed that the physician did not conduct face to face visits and did not write PN for the month of July 2024, August 2024, September 2024, January 2025, a late entry was created on 2/13/25, and back dated for December 28, 2024. 10. A review of the medical record for Resident #103, revealed the resident's physician had not hand signed or electronically signed the MPO for December 2024 and January 2025. A review of the PPN for Resident #103, revealed that the physician did not conduct face to face visits and did not write PN for the month of November 2024, December 2024, and January 2025, a late entry was created on 2/12/25, and back dated for November 2024, December 2024 and January 2025. On 2/14/25 at 10:00 AM, Surveyor #2 (S#2) interviewed the 3rd Floor LPN/UM who stated, I know they're supposed to come in once a month, I have to review the policy. After they see the patient, they usually write a PN in Electronic Health Record (EHR). I'm not sure about signing orders, I have to review it, but I believe it's once a month. They document under the PPN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # 165432 Based on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin to the state survey agency for one (Resident (R) 9) of 12 sampled residents reviewed for abuse. Findings Include: Review of R9's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R9 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance and mood disturbance, repeated falls, muscle weakness, and age-related osteoporosis. Review of R9's Care Plan, located under the Care Plan tab of the EMR and dated 10/02/22, revealed, R9 is using a psychotropic medication Seroquel to manage target symptoms of fighting and being combative during care. It was recorded R9 had behavioral issues of hitting and pushing on tables. Review of R9's quarterly Minimum Data Sheet (MDS), with an assessment reference date (ARD) of 06/21/23 and located under the MDS tab of the EMR, revealed R9 had long and short-term memory problems and was severely impaired in cognitive skills for daily decision making. Review of R9's Progress Notes, dated 06/24/23 at 11:30 as a late entry by Licensed Practical Nurse (LPN) 1 and located under the Progress Notes tab of the EMR, revealed, . Responded to the call of CNA [Certified Nurse Aide] for [R9], in the common bathroom referring to two purplish skin discoloration on her right side under breast which measures 4x5cm. [centimeters] and 4.5x6cm. I did the assessment and reveals [sic] . Mobility on standing/sitting no abnormalities noted, Range of motion, both extremities with equal strength. Residents [sic] denies pain during the assessment during touch and motion, no restlessness. Resident stays in the dining room most of the time during the shift, calm. ALL concern [sic] are aware, The supervisor, Manager, [family member] and primary doctor . Review of R9's Progress Notes, dated 06/25/23 at 12:36 and located under the Progress Notes tab of the EMR, revealed R9 had a chest x-ray to determine any injuries. Review of R9's Radiology Results Report, dated 06/25/23, revealed, . Right Ribs, View of the right ribs show no fracture . No pneumothorax or hydrothorax is seen . Review of the facility investigation titled, #4290 DMC- Skin date: 06/24/23 11:30, revealed, 0n 624123 [R9] was noted to have bruising to the rib in 2 areas. investigation started right away. Assessment was done on the entire body and no other swelling or bruising present. MD and family aware. Medical Data: [R9] is an 8l-year-old female admitted to the facility on [DATE] with diagnosis that include osteoporosis, seizure disorder, dementia with behavioral disturbance, repeated falls, diabetes, cognitive impairment. She requires extensive assistance for ADLs and is ambulatory with assistance which her friend often does. [R9] is incontinent of bowel and bladder and is provided incontinent care as needed. Staff anticipate her needs and monitor frequently for safety. [R9] is care planned as behavioral issues as evidenced by physical behaviors including hitting, pushing tables, habitually leaning over and on tables and sleeping and combative towards staff. She is at high risk for falls, bruising and injury related to cognitive impairment with behaviors. [R9] was observed bumping against the table when she was seen attempting to stand independently, in the dining room the day before from staff. She is known for unsteadiness and bumps into things. Conclusion and Interventions: After a complete investigation, review of the medical chart, statements, skin assessment, and pattern of patient behaviors, it is concluded that the resident was seen attempting to stand on her own and bumped into the table. The IDCT [Interdisciplinary Care Team] agrees that there was no evidence of abuse or neglect. The team reviewed the care plan, and it was determined that she will continue to be monitored. During an interview on 10/20/23 at 1:46 PM, the Director of Nursing (DON), Assistant Administrator, and Regional Clinical Support stated R9 was combative, fought with the staff, had padded side rail, and liked to lean over the bedside table, and because she likes to slam her head against the table, a pillow is kept on the table to prevent injury. The Regional Clinical Support stated the facility's investigation concluded the bruising noted on 06/24/23 was not abuse and neglect. The Regional Clinical Support confirmed that although the facility did do an investigation of the injury of unknown origin, they did not report it as required to the state survey agency. Review of the facility's policy titled, Abuse Neglect and Exploitation, revised February 2023, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will have written procedures that include Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-9.4 (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 164077 Based on resident and staff interview and medical record review, the facility staff failed to administer physician ordered medications as scheduled for one (Resident (R) 6) of 12 sampled residents. Findings included: Review of R6's Face Sheet, located in the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia of the left side, diabetes mellitus, and depression. Review of R6's annual Minimum Data Set (MDS), located in EMR, revealed R6 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R6's Physician's Orders and Medication Administration Records (MARS), located in the EMR, revealed R6 was to receive the following medications: Prandin, an antidiabetic medication - one milligram (mg) orally twice daily; Baclofen, a muscle relaxant - 10 mg orally twice daily; Carbamazepine, an anticonvulsant - 200 mg orally twice daily; Gabapentin, used to treat nerve pain - 300 mg orally three times daily; and Lisinopril, used to treat high blood pressure - 20 mg orally twice daily. Review of R6's Medication Administration Record (MAR), located in the EMR, revealed the following: Prandin was scheduled to be given at 7:30 AM; Baclofen was scheduled to be given at 9:00 AM; Caramazepine was scheduled to be given at 9:00 AM; Gabapentin was scheduled to be given at 2:00 PM; and Lisinopril was scheduled to be given at 9:00 AM. Review of R6's Time Stamp Report for the month of April 2023, revealed the following: 04/01/23 - Prandin was administered at 10:59 AM; 04/01/23 - Baclofen was administered at 11:02 AM; 04/01/23 - Caramazepine was administered at 10:59 AM; and 04/01/23 - Gabapentin was administered at 3:15 PM. Review of R6's Time Stamp Report for the month of May 2023 revealed the following: 05/10/23 - Lisinopril was administered at 12:47 PM; 05/14/23 - Prandin was administered at 9:28 AM; and 05/21/23 - Prandin was administered at 9:55 AM. During an interview on 10/19/23 at 1:30 PM, R6 stated, I will get my medications up to two hours late. It doesn't happen all the time, but it does happen. During an interview on 10/20/23 at 2:30 PM, the Director of Nursing (DON) confirmed R6's medications had been administered late on 04/01/23, 05/10/23, 05/14/23, and 05/23/23. The DON stated, Medications are to be administrated an hour before or an hour after the time the medication is scheduled. Any medication given outside of those parameters are considered late. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policy, the facility failed to provide timely Minimum Data Set (MDS) data submission in one (Resident (R) 343) of six residents reviewed for MDS transmission out of a total sample of 43 residents. Findings include: Review of R343's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R343 was admitted to the facility on [DATE]. R343's admitting diagnoses included Huntington's disease (a progressive neurodegenerative disease), malignant neoplasm (cancer) of brain, dementia with agitation, anxiety disorder, a cardiac pacemaker, malnutrition, and repeated falls. Review on 05/02/23 of R343's MDS with an Assessment Reference Date (ARD) of 04/23/23, located under the MDS tab, indicated this MDS was not complete due to the majority of the MDS sections being colored red (in process) instead of green (completed). Review on 05/03/23, of R343's MDS indicated the majority of the MDS sections were colored yellow (in progress). Review on 05/04/23, of R343's MDS indicated the majority of the MDS sections were colored green (completed). Review on 05/04/23 of R343's MDS under the tracking/discharge heading indicated: Next full: ARD: 05/02/23 2 days overdue; Next ARD: 04/26/23 8 days overdue. During an interview on 05/04/2023 at 2:35 PM with the MDS Coordinator (MDSC) 2, the MDSC2 stated since 2020 she has been the only MDS Coordinator for the majority of that time. MDSC2 said the MDS department should be staffed with two full time coordinators and one per diem staff member. MDSC2 said she currently has per-diem staff to assist, but only for 16-20 hours a week. MDSC2 confirmed R343's MDS data submission was late. During an interview on 05/04/23 at 5:40 PM with the Administrator, the Administrator said timely submission of MDS information had been an ongoing issue. The Administrator agreed it was impossible for one MDS Coordinator to fulfill the MDS requirements for a facility of this size. The Administrator stated the corporate office has approved to continue to supply the MDS department with per diem staff and remote staff assistance. A review of the facility's policy titled, Resident Assessments revised 03/2022 indicated, Policy Statement A comprehensive assessment of every resident's needs is made at intervals designated by OBRA (Omnibus Budget Reconciliation Act of 1987) and PPS (Prospective Payment System) requirements. Policy Interpretation and Implementation .1. The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: (1) admission Assessment (Comprehensive) .b. PPS required assessment .(1) 5-day Assessment .2. The RAI (Resident Assessment Instrument) User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. 3. A comprehensive assessment includes: a. completion of the Minimum Data Set (MDS) . A review of Centers for Medicare and Medicaid Services (CMS) Manual, RAI Version 3.0 Manual Chapter 2 page 2-19 stated, .Assessment Management Requirements and Tips for Comprehensive Assessments: The ARD (item A2300) is the last day of the observation/look back period .For example, if the ARD is set for day 14 of a resident's admission .while the beginning of the observation period for MDS items requiring a 14-day observation period would be day 1 of admission (ARD + 13 previous calendar days) .RAI OBRA-required Assessment Summary .MDS Completion Date .No Later Than 14th calendar day of the resident's admission (admission date + 13 calendar days) .01. admission Assessment .The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home . NJAC 8:39-11.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure a hearing aid was in place in one of 43 sampled residents (Resident (R) 2) in order to maintain her hearing abilities. This deficient practice created a potential for a lack of communication to occur. Findings include: Review of R2's undated electronic medical record (EMR) Face Sheet, under the Profile tab, revealed R2 was admitted to the facility on [DATE]. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicative of intact cognition. On the same annual MDS, R2 was able to hear with minimal difficulty if hearing aid used. Review of R2's EMR Orders tab for current physician's orders included an order, dated 12/03/2020, for right hearing aid accountability every shift. Review of R2's EMR Care Plan tab revealed a Care Plan, dated 03/16/23. The Care Plan stated R2 has a communication problem r/t [related to] a Hearing deficit in right ear. She wears hearing aid to right ear, which has been effective. R2 is at risk for the development of a Communication deficit and for not having her needs well-known r/t her hearing deficit. Additionally, the Care Plan noted Ensure hearing aid (right) is in place. Insert hearing aid to right ear in A.M; Remove at H.S. (hour of sleep). During an observation, on 05/01/23 at 1:35 PM, R2 was in bed. R2 pointed at her right ear when attempts were made to converse with her. Certified Nursing Assistant (CNA2) said R2 has a hearing aid, the nurse keeps it. R2 was observed, on 05/01/23 at 3:45 PM, lying in bed with the television on and without her hearing aid in her right ear. During an observation on 05/02/23 at 11:52 AM, R2 was observed seated in her wheelchair in the dining room. There was no hearing aid observed in her right ear. R2 was observed to point at staff and a different table than where she was seated. The Nursing Supervisor (NS) said R2 wanted to sit at her usual table. R2 remained in the dining room, on 05/02/23 at 12:00 PM, eating her lunch. No hearing aid was observed in her right ear. During an observation, on 05/02/23 at 1:00 PM, R2 remained seated at a dining room table. R2 was not observed to converse with anyone in the dining room. She was not observed to have a hearing aid in her right ear. During an observation on 05/03/23 at 9:11 AM, R2 was noted to be in bed eating her breakfast. In an attempt to talk with R2, she pointed to her right ear and said, I can't hear. An interview, on 05/03/23 at 9:19 AM, was completed by writing questions to R2 which solicited a verbal response from her. R2 said the nurse had her hearing aid and that she wanted to wear it. During an interview with the Registered Nurse (RN) 2 on 05/03/23 at 11:05 AM, RN2 said R2's hearing aid was kept in the medication cart. RN2 said she typically put it in R2's ear after she was up. When told R2 was not observed to have her hearing aid in on 05/01/23, 05/02/23, or 05/03/23, RN2 said she would put it in for R2. R2 was able to have a conversation on 05/04/23 at 8:15 AM, while in her room eating breakfast. R2 pointed to her right ear indicating the hearing aid was in her ear. R2 said she wants to have the hearing aid every day. The facility's policy and procedure titled Hearing Impaired Resident, Care of was dated 02/2018. The policy stated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. NJAC 8:39-27.5(a)

Based on observation, interview, record review, and review of policy, the facility failed to consistently provide daily range of motion (ROM) services for one (Resident (R) 126) of two residents sampled for limited ROM out of a total sample of 43 residents. This failure had the potential for the resident to lose mobility and independence. Findings include: Review of the admission Record, located in the Profile tab of R126's electronic medical record (EMR), documented an admission date of 05/04/21. R126's diagnoses included hemiplegia and hemiparesis (paralysis and weakness) following a cerebral infarction (stroke) affecting his right side. Review of R126's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R126 was cognitively intact. Review of R126's Care Plan, last updated on 03/20/23, revealed that R126 was to have restorative nursing active ROM to both upper (arms) and lower extremities (legs) of two sets with ten repetitions. Review of R126's May 2023 Physician's Orders revealed an order, dated 04/11/23, for nursing restorative active range of motion to both upper and lower extremities two sets with ten repetitions, as tolerated, two times per day. During interview and observation of R126 on 05/01/23 at 1:10 PM, R126 said he was not receiving any therapy services since his discharge from physical therapy in April 2023. During observation and interview of R126 on 05/03/23 at 9:38 AM, R126 stated he was not sure what restorative therapy was or who was supposed to be doing it with him. During an interview on 05/03/23 at 10:18 AM, Certified Nursing Assistant (CNA) 51, stated restorative therapy is on the CNA assignment sheets and in the computer under tasks, but CNAs usually do not have time to complete this task. CNA51 was unsure if R126 should be receiving restorative therapy. During an interview on 05/03/23 at 10:21 AM, CNA55 stated she was aware CNAs do the restorative therapy but did not know if R126 had restorative therapy ordered. During an interview on 05/03/23 at 10:36 AM, Registered Nurse (RN) 15 stated there was a restorative notebook in the nurses' station which explains the restorative nursing plan for the resident, including what and how often it should be done. RN15 was unable to locate the notebook. During an interview on 05/03/23 at 10:41 AM, CNA85 stated he had never heard of a restorative nursing plan for R126. CNA85 acknowledged that he was assigned to take care of R126 yesterday and today. CNA85 stated the restorative nursing plan was neither listed on his assignment sheet nor did the nurse explain that R126 was to receive restorative ROM. During an interview and observation on 05/03/23 at 11:51 AM, RN15 found the restorative nursing notebook. Review of this notebook showed there was no current restorative plan for R126, and other residents included in the notebook were discharged from the facility, and one resident record was dated the year 2015. During an interview on 05/04/23 at 9:33 AM, the Director of Therapy said that R126 still had an order for restorative therapy in place. She could not find the written copy of R126's plan in the restorative notebook. She was unsure how restorative orders are communicated to nursing, but that each nurses' station should have a restorative notebook. During observation and interview on 05/04/23 at 9:47AM, RN35 showed a printed copy of the restorative checklist for CNAs for R126. The boxes for the AM and PM shifts were checked. She stated she initialed the daytime checks for the CNAs, and the evening nurse checks the PM boxes. RN35 stated she was unaware if the CNAs actually completed the therapy. Review of the facility policy dated 6/23/22 included the following: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Definition: the Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently as possible. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Policy Explanation and Compliance Guidelines: Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision-making regarding services to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability. The Restorative Nurse and restorative aides receive additional training on restorative nursing program and activities upon hire and as needed. NJAC 8:39-27.1(a) NJAC 8:39-27.2(m)

Based on observation, interview, record review, and review of facility policy, the facility failed to obtain physician orders and develop a care plan with interventions for one of two residents (Resident (R) 292) reviewed for oxygen therapy from a total sample of 43 residents. Findings include: Observation on 05/02/23 at 9:57 AM revealed R292 in bed receiving morning care. R292 was wearing a nasal cannula with an oxygen concentrator at bedside. There was a portable tank of oxygen observed on the back of R292's wheelchair. Observation 05/03/23 at 3:07 PM revealed R292 sitting up in her wheelchair with nasal oxygen in place. The oxygen concentrator for set two liters per minute. The humidifier jar had a date of 05/03/23. Review of R292's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/23, located in the electronic medical records (EMR) MDS tab, assessed R292 had Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition Further review of this MDS for special treatments and procedures documented that R292 was receiving oxygen therapy. Review of the resident physician's active orders summary, dated 05/03/23 and located in the EMR Orders tab, revealed no orders for R292 to receive oxygen therapy. Review of R292's undated care plan, located in the EMR tab Care Plans, revealed there was no care plan with interventions developed for the resident's use of oxygen therapy. During an interview on 05/03/23 at 3:07 PM, R292 stated that she was utilizing oxygen before admission to the facility due to a diagnosis of chronic obstructive pulmonary and difficulty catching her breath. R292 stated she wears the oxygen cannula continuously. Interview with the Unit Manager (UM) 4 on 05/03/23 at 4:02 PM revealed that she was not aware that R292 was on oxygen therapy. She stated there should be an order for the oxygen indicating the flow rate and how often the resident oxygen level should be monitored to ensure the resident is maintaining an adequate oxygenation level. UM 4 further stated a care plan with interventions should have been developed. UM4 stated that the floor nurses and unit manager are responsible for developing and revising the care plans. Review of facility policy titled Oxygen Administration, with a revision date of October 2021, revealed the following . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs for the resident. NJAC 8:39-11.1 NJAC 8:39-11.2 NJAC 8:39-25.2(c)4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure a medication regimen review was completed by a pharmacist at least once a month in one resident (Resident (R) 150) out of five residents reviewed for unnecessary medications out of a total sample of 43 residents. Findings include: Review of R150's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R150 was admitted to the facility on [DATE]. R150's admitting diagnoses included heart disease, left above the knee amputation, aortocoronary bypass graft, long term use of insulin, anxiety disorder, and major depressive disorder. Review of R150's EMR under the Orders tab indicated R150's ordered medications included: metformin hcl (hydrochloric acid) oral tablet 500 milligrams (mg) one tablet two times day; Percocet oral tablet, one tablet every six hours for phantom pain; alprazolam tablet 0.5 give one tablet by mouth every eight hours as needed for anxiety for 14 days; abilify oral tablet two mg one at bedtime for MDD (major depressive disorder); trazodone hcl tablet 300 mg - give one tab during night shift for depression (2 AM); venlafaxine hcl ER (extended release) tablet 150 mg give one tablet in evening for depression; sertraline hcl tablet 100 mg give two tabs one time day; insulin glargine solution 100 unit/milliliters (ml) inject 14 units at bedtime. Review of R150's EMR did not reveal a Medication Regimen Review(MMR) completed by a pharmacist for R150. During an interview on 05/04/23 at 6:50 PM with the Director of Nursing (DON), the DON said she was able to locate a MRR for January and April of 2023, but could not locate reviews for the months of February and March of 2023 for R150. The DON stated the facility's Pharmacist should complete monthly MRRs for all of the facility's residents. Review of the facility's policy titled, Medication Regimen Review dated 06/23/22, indicated, Policy: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Policy Explanation and Compliance Guidelines: 1. Medication Regimen Review (MRR) .is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .4. The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed. a. The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities .6. Written communications from the pharmacist shall become part of the resident's medical record . NJAC 8:39-29.3(a)

Based on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored for one of five residents (Resident (R) 15) reviewed for unnecessary medications. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication. Findings include: Review of R157's printed admission Record, from the electronic medical record (EMR) Profile tab, showed an admission date of 08/03/22 with medical diagnoses that included major depressive disorder, unspecified psychosis (out of touch with reality) not due to a substance or known physiological condition, and Alzheimer's dementia. Review of R157's printed Order Summary, from the EMR Orders tab, showed the following orders: atypical antipsychotic quetiapine 12.5 milligrams (mg) daily at bedtime for psychosis, with an order to monitor behavior for efficacy; an antidepressant medication Remeron 15mg at bedtime for depression, with an order to monitor behavior for efficacy; and a mood stabilizing medication valproic acid 125mg every 12 hours for a mood disorder, but no order for efficacy monitoring was found. During an interview on 05/04/23 at 2:49 PM regarding psychotropic efficacy monitoring for R157, the Director of Nursing (DON) stated, There is one [behavior monitoring] for the Remeron and quetiapine, but I do not see one for the valproic acid. In an interview on 05/04/23 at 2:59 PM regarding the efficacy monitoring for the mood stabilizer medication, Unit Manager (UM) 3 reviewed R157's medication and treatment administration record, and stated, I did it for the Remeron and Seroquel [brand name for quetiapine], I don't know how I missed it unless I thought it was for seizure. I need to update it; I'll go update it now. UM3 confirmed valproic acid when used as a mood stabilizer should be monitored for efficacy like the other psychoactive meds. Review of the facility policy titled Psychotherapeutic Drug Management, revised August 2022, revealed: . XIII. Nursing Responsibility A. Consider other factors that may be causing expressions or indications of distress before initiating a psychotropic medication, such as an underlying medical condition (e.g., urinary tract infection, dehydration, delirium), environmental (lighting, noise) or psychosocial stressors. i. Monitoring should also include evaluation of the effectiveness of non? pharmacological approaches prior to administering PRN medications. C. Will monitor the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present) . NJAC 8:39-29.3(a) NJAC 8:39-33.2(c)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the admission Record, located in the profile tab of R33's EMR, documented an admission date of 04/03/14. R33's diagnoses included muscular dystrophy, multiple sclerosis, and paraplegia. Review of R33's quarterly MDS with an ARD of 02/10/23, showed her mental status could not be assessed and R33 required assistance with all activities of daily living (ADLs), including grooming and eating. During an observation and interview on 05/01/23 at 11:30 AM, the R33 had long uncombed, frizzy grey hair. Family member (F)1 stated that her hair was usually combed and colored and R33 to be clean and comfortable. F1 has asked facility staff to cut her hair. During an observation on 05/02/23 at 9:49 AM, R33 was on her back, asleep, her hair was uncombed, frizzy, and appeared tangled. During an interview on 05/02/23, at 10:02 AM, CNA 51 said when a resident is up they should have their hair combed. CNA 51 stated R33 can be resistive, but usually can be reapproached later for care. During an interview on 05/02/23, at 10:05 AM, CNA 55 stated residents should be cleaned up in the morning before breakfast with hair combed, teeth brushed and check for incontinence and dressed if the resident wants. During an observation on 05/03/23 at 9:34 AM, R33 was in bed asleep. Her hair was frizzy and splayed across her pillow. During an interview on 05/04/23 at 9:47 AM, RN35 said she was surprised R33's hair was not combed and knew her F1 wanted the resident to have a haircut. 8. Review of the admission Record, located in the Profile tab of R72's EMR revealed an admission date of 07/21/15. R72's diagnoses included hemiplegia and hemiparesis (paralysis and weakness) following an unspecified cerebrovascular disease (stroke) affecting the left side Review of R72's quarterly MDS with an ARD of 04/12/23, revealed BIMS score of 15 out of 15 indicating that the resident was cognitively intact and required assistance with Activities of Daily Living (ADLs), including bathing, dressing and grooming. During observation and interview on 05/01/23, at 1:38 PM, R72 had long grey and brown facial hair on her chin and cheeks. R72 stated she did not like facial hair. Her family recently visited and she had facial hair then. During observation and interview on 05/02/23, at 10:00 AM, R72 still had the facial hair on her chin and cheeks. R72 stated she thinks the staff will shave it off when she gets her weekly bath on Sunday. During an interview on 05/2/23, at 10:11 AM, CNA55 said residents should be groomed when they get up for the day. CNA55 stated she did not know R72 had facial hair, which should have been removed Sunday when she had her bath. During an interview on 05/2/23 at 10:12 AM, CNA51 said residents should be cleaned up when they get up in the morning. CNA51 stated she was unaware that R72 had facial hair. During an interview on 05/2/23 at 10:15 AM, RN15 said that all residents should be properly groomed and R72's facial hair removal should be part of the assigned CNA's duties. During an interview on 05/04/23 at 4:14 PM, the DON said she expects residents to be well groomed and presentable. Females should have facial hair removed if they wish, and hair should be combed. CNA's should be well instructed regarding transfers and safety issues for resident's if they do not know what to do they should ask questions. During an interview on 05/04/23 04:18 PM the Administrator said resident's should be dressed and groomed when they are up for the day. CNA's should receive instructions from the nurses. Review of facility policy titled, Activities of Daily Living (ADLs), dated 10/2022, revealed Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. NJAC 8:39-4.1(a)22 NJAC 8:39-27.2(g) Based on observations, interviews, record review, and review of facility policy, the facility failed provide assistance with grooming and personal hygiene in eight residents (R)292, R2, R17, R20, R136, R162, R33, and R72) from a total sample of 43 residents. This had the potential to affect the residents' physical and mental well-being. Findings include: 1. Observation on 05/03/23 at 3:07 PM revealed R292 dressed, sitting in her wheelchair with her hair uncombed. During an interview with R292 on 05/03/23 at 3:07 PM, the resident stated she had not received a shower or bath since being admitted to the facility on [DATE]. R292 stated that maybe the staff would not give her shower due to the wound on her back, but she would not mind taking whirlpool bath. R292 stated none of the staff had offered to help her take a shower. Review of the resident's admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/12/23, located the EMR tab for MDS, revealed R292 was cognitively intact with Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS revealed that R292 required physical help with bathing activity. Review of the physicians' orders for April 2023, located in the EMR tab for Orders, revealed that R292 was to receive bath/shower/nail care twice a week. Document any refusals. On Mondays and Fridays. Review of the resident's undated care plan located in the EMR tab for Care Plans identified thatR292 had a self-care deficit due to limited mobility and required one staff member to assist with bathing. The care plan also documented the resident was to have shower/bath specify day and shift. Review of the unit's shower schedule, located in the unit's shower book at the nurses' station, revealed R292 was not on the list for showers. Review of the resident's April 2023 activities of daily living (ADLs) sheet, located in the EMR tab Tasks, completed by the Certified Nursing Assistants (CNAs), revealed there was no documentation that R292 had received a shower or bath for the entire month. Continued review revealed no documentation of the resident refusing to shower or bathe. Interview with Unit Manager (UM) 4 on 05/03/23 at 4:02 PM revealed there was no problem with the R292 taking a shower or bath according to the resident's wishes. The UM was unaware the resident had not received a shower or bath since admission to the facility on [DATE]. Interview with CNA 49 on 05/04/23 at 10:45 AM revealed she gives R292 a complete bed bath every day. She was hesitant to put the resident in the shower due to the wound on her back. CNA49 stated that she had not offered the resident to sit in whirlpool bath. She also stated that it was up to the nurses to decide whether the resident received a shower or bath. CNA49 stated that she had not asked the nurses about giving the resident a shower or bath. Interview with the Licensed Practical Nurse (LPN) 48 on 05/04/23 at 10:50 AM revealed R292 could shower and she was not aware the resident had not received any showers or baths. 2. During an observation on 05/01/23 at 1:35 PM, R2 was lying in bed and R2 had facial hair on her upper lip. R2 said she could not talk as she couldn't hear. During an observation on 05/01/23 at 3:45 PM, R2 was observed in bed with facial hair on her upper lip. On 05/02/23 at 11:52 AM, R2 was observed seated in the dining room. R2 was observed to have facial hair on her upper lip. During an observation on 05/02/23 at 1:00 PM, R2 was observed in the dining room with facial hair on her upper lip. 05/03/23 at 9:19 AM, R2 was observed with facial hair on her upper lip. Review of R2's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 05/24/18 with medical diagnoses that included spondylosis (degenerative changes in spine). Review of R2's annual MDS, located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 02/15/23 revealed R2 required extensive physical assistance of one person for her personal hygiene needs. Review of R2's Care Plan, located in the EMR under the RAI tab and last updated 02/23, revealed R2 has an ADL self-care performance deficit r/t chronic cervical [neck] spondylosis .requires extensive assistance by one staff with her weekly shower. In an interview with CNA1 on 05/03/23 at 10:20 AM, CNA1 said the residents receive a shower once a week. CNA1 said they take care of chin hairs and clean and trim nails. When asked about R2, CNA1 said sometimes R2 refuses. When asked where CNA1 would document refusals, CNA1 said she would tell the nurse. Review of R2's Nurses Progress Notes revealed no refusal of ADL care in the past 30 days. During an interview on 05/03/23 at 11:05 AM, the Registered Nurse (RN) 2 said showers were given one time a week and that the women were supposed to be shaved in the shower. 3. During an observation on 05/01/23 at 12:55 PM, R17 was observed to have facial hair on her chin. When asked if R17 received assistance with her ADL care needs, R17 said I don't know,. During an observation on 05/01/23 at 3:42 PM, R17 was observed in bed asleep. The facial hair on her chin remained. During an observation on 05/02/23 at 12:45 PM, R17 was observed in bed. The facial hair remained on R17's chin. On 05/03/23 at 9:07 AM, R17 was observed, in bed, eating breakfast. The facial hair remained on R17's chin. Review of R17's Face Sheet located in the EMR under the Resident tab, revealed an admission date of 05/17/22 with medical diagnoses that included myocardial infarction (heart attack). Review of R17's quarterly MDS, located in the EMR under the RAI tab with an ARD of 02/04/23, revealed a BIMS score of 14 out of 15, indicating R17 was cognitively intact. The MDS revealed R17 required extensive assistance for her personal hygiene needs. Review of R17's Care Plan, located in the EMR under the RAI tab and last updated 05/27/22, read, impaired functional ADL performance .needs extensive assist with ADL's .personal hygiene. Review of R17's EMR, Nurse's Progress Notes, revealed no refusal of ADL care in the past 30 days. 4.During an observation on 05/01/23 at 1:25 PM, R20 was observed in her wheelchair in the dining room. R20 was observed with facial hair on her upper lip. During an observation on 05/02/23 at 12:22 PM, R20 was observed laying in bed. R20 was observed with facial hair on her upper lip. During an observation on 05/03/23 at 9:14 AM, R20 was observed in her wheelchair in the dining room. R20 was observed with facial hair on her upper lip. Review of R20's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 09/09/19 with medical diagnoses including dementia. Review of R20's quarterly MDS, located in the EMR under the RAI tab with an ARD of 03/15/23, revealed a BIMS score of five out of 15, indicating R20 was severely impaired cognitively. The MDS revealed R20 required extensive assistance of one person for her ADL needs. Review of R20's Care Plan, located in the EMR under the RAI tab last updated 12/19/19 read, ADL self-care performance deficit r/t dementia .requires extensive assist by one staff. Review of R20's EMR revealed only one refusal of personal hygiene care on 04/25/23, over the past 30 days. Review of R20's EMR Nurses Progress Notes revealed R20 never rejected care over the past 30 days. In an interview with CNA3 on 05/03/23 at 11:07 AM, CNA3 said she liked shaving the female residents but sometimes they refuse. 5. During an observation on 05/01/23 at 1:48 PM, R136 was observed walking in the hall with two therapists. R136 was observed to have facial hair on her chin. During an observation on 05/01/23 at 3:46 PM, R136 was observed asleep in her wheelchair in the dining room. R136 was observed to have facial hair on her chin. During an observation on 05/02/23 at 11:56 AM, R136 was observed seated in her wheelchair at the dining table. R136 was observed to have facial hair on her chin. During an observation on 05/03/23 at 9:15 AM, R136 was observed in the dining room seated in her wheelchair. R136 was observed to have facial hair on her chin. Review of R136's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 05/25/21 with medical diagnoses that included Alzheimer's Disease. Review of R136's quarterly MDS, located in the EMR under the RAI tab with an ARD of 02/18/23, revealed a BIMS score of eight out of 15 indicating R136 had moderately impaired cognition. The MDS revealed R136 required extensive assistance for her personal hygiene care. Review of R136's Care Plan, located in the EMR under the RAI tab and last updated 06/07/21, read, .dependent on staff with all her ADL's, required extensive to total assist of 1-2 persons. Review of R136's EMR revealed R136 never refused personal hygiene care for the past 30 days. Review of R136's EMR, Nurses Progress Notes, revealed R136 never rejected care over the past 30 days. 6. During an observation on 05/01/23 at 3:48 PM, R162 was observed in bed in her room. R162 was observed to have facial hair on her chin. During an observation on 05/02/23 at 1:45 PM, R162 was observed to have facial hair on her chin. R162 was observed on 05/02/23 at 9:29 AM, while seated in her wheelchair in the dining room. R162 was observed to have facial hair on her chin. During an observation on 05/03/23 at 9:27 AM, R162 was observed lying in bed. R162 was observed to have facial hair on her chin. Review of R162's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 09/23/22 with medical diagnoses including dementia. Review of R162's quarterly MDS, located in the EMR under the RAI tab with and ARD of 03/18/23, revealed R162 required extensive physical assistance of one person for her personal hygiene needs. Review of R162's Care Plan, located in the EMR under the RAI tab and initiated 09/23/22, read, R162 .has an ADL self-care performance deficit r/t (related to) dementia .shower every Thursday. In an interview with CNA2 on 05/03/23 at 10:38 AM, CNA2 said R162 can be very combative with ADL care. Review of R162's EMR revealed three refusals of personal hygiene care on 04/26/23, 04/27/23, and 04/30/23 in the past 30 days. Review of R162's EMR, Nurses Progress Notes, revealed R162 never rejected care in the past 30 days. During an interview with the Director of Nurses (DON) on 05/03/2 at 11:14 AM, the DON said the residents should have their chin hairs shaved as needed, not with just showers. The DON said, I expect them to go back again if they cannot do it during the shower. The DON said the CNA's document refusals in their notes and can go to the nurse to write a note in the record. The DON said everyone has access to document.

Complaint #NJ159325 Based on observation, interview, document review, facility policy review, and employee handbook review, the facility Administrator failed to ensure staff COVID-19 testing was completed twice weekly as required and were not falsified and failed to ensure facility infection control practices were implemented regarding the use of N95 masks. Findings included: Review of the Employee Handbook, not dated, specified, in part, on pages 40 and 41, Code of Conduct. The Company endeavors to maintain a positive work environment. Each employee plays a role in fostering this environment. Accordingly, we all must abide by certain rules of conduct, based on honesty, common sense, and fair play. The following list enumerates the types of conduct that is not acceptable of Company employees: Falsifying timesheets, application forms, or other Company records. Failing to meet the Company's expected level of performance and quality requirements. The observance of these rules will help to ensure that our workplace remains a safe and desirable place to work. 1. On 01/18/2023 at 5:45 PM, the Infection Preventionist (IP) Nurse was interviewed. The IP Nurse stated the facility was supposed to be testing all employees two times per week, on Mondays and Thursdays. The IP Nurse explained that staff who did not work on Mondays or Thursdays knew they were supposed to test themselves at the facility prior to starting their shift. A telephone interview with a state Epidemiologist (EPI) on 01/18/2023 at 12:56 PM, revealed since the facility had been in COVID-19 outbreak status since July 2022, the state EPI and the local health department (LHD) had been asked to consult with the facility to offer support, guidance, and education to assist them in getting beyond the outbreak. The EPI stated they asked the facility to be on weekly phone/Zoom calls dating back to November 2022. The EPI stated phone/Zoom calls were conducted weekly with much resistance from the facility staff. The EPI stated during the calls, the EPI and the LHD staff would educate the facility on fit testing for N95 masks, basic infection control practices, and COVID-19 testing of employees. The EPI stated during the call on 11/03/2022, the LHD and the EPI requested the facility send staff COVID-19 testing logs for review. At the end of the call, when the facility administrator (NHA) thought she had hung up from the call, the EPI and LHD overheard the NHA instruct Unit Clerk (UC) #12 to make up the logs and go upstairs and have employees sign that they were being tested for the last two weeks. The EPI stated they wanted the facility to take ownership of what they could control. On 01/20/2023 at 11:20 AM, UC #12 was interviewed. UC #12 confirmed she was on the Thursday calls with the EPI and the LHD. She revealed they discussed new resident and staff COVID-19 cases. She stated they also asked if the facility was completing COVID-19 testing the way they recommended. UC #12 stated it was her responsibility for tracking both resident and employees testing, especially on Mondays and Thursdays. During the interview, UC #12 stated she recalled in November 2022, the LHD and EPI requested the facility's staff COVID-19 testing logs for November 2022. UC #12 revealed that at the end of the call, the NHA told her to create logs that did not exist and have staff sign them. UC #12 stated the NHA realized she had not hung up from the call and stated, I hope they didn't hear me. UC #12 indicated some staff had tested but the facility was not testing the way the LHD and EPI had recommended. According to UC #12, the EPI and the LHD expected every single person to be tested; however, not every single person was being tested. The UC stated the LHD wanted testing logs, so the facility made them up. UC #12 stated the honest answer to the health department would have been to tell them they did not test all the staff. On 01/20/2023 at 2:06 PM, a follow-up interview with UC #12 regarding the COVID-19 testing logs sent to the LHD revealed UC #12 added the names of staff who were scheduled to work on testing days to a log. UC #12 stated she also talked to staff and if they stated they had worked on a testing day, she asked them to sign the log that they had self-tested. UC #12 stated the NHA, and UC #12 wanted to give the health department the information for which they asked. According to UC #12, each employee self-tested for COVID-19 and she could not ensure that each employee was tested as required. On 01/20/2023 at 11:33 AM, the Regional Director of Operations (RDO) was interviewed. The RDO stated he was in disbelief. He stated he did not understand the logic behind making up documents and lying. The RDO stated that type of practice was not doing anyone any good. The Administrator was unavailable for interview. 2. A review of the undated OSHA standards regarding personal protective equipment, titled, Respiratory protection, revealed, In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite specific procedures. The standard further indicated the respiratory protection program shall include fit testing procedures for tight-fitting respirators. The section for fit testing, indicated, before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. The fit testing section also included, The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. 2.a. Observation and interviews on 01/18/2023 at 11:22 AM, with Licensed Practical Nurse (LPN) #3; at 11:53 AM with LPN #4; at 11:57 AM with Unit Manager (UM) #1; at 12:07 PM with Registered Dietician (RD) #5; at 1:48 PM with the Activities Director (AD); at 2:57 PM with Dietary Aide (DA) #8; and on 01/19/2023 at 11:03 AM with Registered Nurse (RN) #19 revealed the staff were not wearing the N95 mask the facility required and for which they had been fit tested. On 01/18/2023 at 5:45 PM, the Infection Preventionist (IP) Nurse was interviewed. The IP Nurse stated all employees were fit tested with the Medline REF: NON24506A N95 Respirator mask. The IP Nurse stated every employee should be wearing a Medline N95 mask in their size. On 01/19/2023 at 10:30 AM, the RDO was interviewed. The RDO stated his expectation was that all staff should be wearing an N95 mask that they were fit tested to wear. 2.b. On 01/19/2023 at 10:56 AM, Certified Nurse Aide (CNA) #10 was interviewed. CNA #10 stated it was her second day working at the facility as an agency contracted employee and was assigned to the COVID-19 unit. CNA #10 stated she had not had a fit test for the facility required N95 mask she was wearing. A review of CNA #10's employee file revealed a Respirator Fit Test Sheet, dated 01/18/2023, that indicated the facility had fit tested the CNA with a Medline N95 respirator and passed the fit test. On 01/19/2023 at 2:23 PM, a follow-up interview with CNA #10 revealed two facility employees approached her between 11:00 AM and 12:00 PM and stated the Director of Nursing (DON) needed her to sign an N95 fit test form. CNA #10 stated she signed the form, but the facility had not fit tested her for the N95 mask she was required to wear. On 01/19/2023 at 3:40 PM, Staffing Coordinator (SC) #11 was interviewed with the RDO present. SC #11 stated the DON told the IP Nurse and SC #11 to make sure all staff had on the proper PPE. The IP Nurse asked SC #11 to have CNA #10 sign a form indicating the CNA had been fit tested. SC #11 stated she asked CNA #10 to sign a fit testing blank form that only had the CNA's name and title. 2.c. A review of a facility provided list of employees revealed there were 197 individuals employed at the facility. A review of employees' Respirator Fit Test Sheet revealed 144 employees had been fit tested for an N95 respirator mask. Further review of the fit test sheets revealed 80 of the 140 employees had not been fit tested within the last year. On 01/18/2023 at 5:45 PM, the IP Nurse was interviewed. Upon review of the Respirator Fit Test Sheet for employees, the IP Nurse confirmed there were 80 employees that were overdue for the annual fit testing requirement, and she could not ensure that all employees had been fit tested. On 01/19/2023 at 3:03 PM, the DON was interviewed with the RDO present. The DON stated that until she went through the fit testing records, she was not aware that so many of the fit tests were over a year old and overdue. The Administrator was unavailable for interview. New Jersey Administrative Code § 8:39-5.1(a)

Complaint #NJ159325 Based on observations, interviews, record reviews, document review, facility policy reviews, and review of the Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) guidelines, it was determined the facility failed to: 1. Ensure eight employees on 3 of 5 floors of the facility were wearing an N95 respirator (a mask that forms a seal against the user's face to filter airborne particles) for which they had been fit tested. 2. Ensure 80 of 140 employees were fit tested for an N95 mask annually. 3. Ensure 47 of 47 staff from a contracted nursing agency, who had worked at the facility since October 2022, were fit tested for an N95 mask. 4. Ensure 1 of 2 employees observed removed disposable personal protective equipment (PPE) when exiting the room of residents who had COVID-19. 5. Ensure that a vitals machine (machine on wheels that measures blood pressure, temperature, and oxygen saturation) was cleaned between resident use. Findings included: 1. A review of the undated policy titled, N95 Respiratory Program, indicated, The purpose of this program is to ensure that all employees required to wear respiratory protection as a condition of their employment are protected from respiratory hazards through the proper use of respirators. All respirator use will occur within the context of a comprehensive program as per the standards set forth by OSHA or (for public employers in NYS) the Department of Labor, Public Safety and Health Program (PESH). This requires a written program, medical evaluation, training, and fit testing. Further review revealed, Fit testing is conducted to determine how well the seal of a respirator 'fits' on an individual's face and that a good seal can be obtained. Respirators that do not seal do not offer adequate protection. Employees shall be fit tested with a respirator of the same make, model, style and size as that of the respirator that will be used by the employee. Further review of the policy revealed the Infection Preventionist will be responsible for the administration of the respiratory protection program and thus is called the Respiratory Protection Program Administrator. The policy revealed duties of the Respiratory Administration Administrator included Select respiratory protection products. Involve users in selection whenever possible. Monitor respirator use to ensure that respirators are used in accordance with this program, training received, and manufacturer's instructions. Arrange for and/or conduct training and fit testing. Further review of the policy revealed, Department heads are responsible for ensuring that the respiratory protection program is implemented in their particular units. In addition to being knowledgeable about the program requirements for their own protection, department heads must also ensure that the program is understood and followed by the employees under their charge. Duties of the Department Head include: Knowing the hazards in the area in which they work. Knowing types of respirators that need to be used. Ensuring the respirator program and worksite procedures are followed. Ensuring staff use respirators, as required. Notifying Respiratory Protection Program Administrator of any problems with respirator use or changes in work processes that would impact the program. According to the policy, the duties of the employee included Wear respirator when indicated. A review of the Centers for Disease Control and Prevention (CDC) guidelines, titled, Types of Masks and Respirators, updated 09/08/2022, revealed, Employers who want to distribute N95 respirators to employees shall follow an Occupational Safety and Health (OSHA) respiratory protection program. A review of the undated OSHA standards regarding personal protective equipment, titled, Respiratory protection, revealed, In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite specific procedures. The standard further indicated the respiratory protection program shall include fit testing procedures for tight-fitting respirators. The section for fit testing, indicated, before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. The fit testing section also included, The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. On 01/18/2023 at 10:00 AM, during an entrance conference, the Regional Director of Operations (RDO) stated there were seven residents who were positive for COVID-19 at the facility. Four of the residents were new admissions to the facility, two were readmissions, and one resident transferred from another floor to the COVID-19 positive unit. 1.a. On 01/18/2023 at 11:22 AM, Licensed Practical Nurse (LPN) #3 was interviewed. LPN #3 stated she was fit tested for an N95 mask by her contract agency. However, the facility required she wear an N95 mask that the facility provided, even though she had not been fit tested for the N95 mask provided by the facility. On 01/18/2023 at 11:53 AM, LPN #4 was interviewed on the 1 East Unit. LPN #4 was observed wearing an N95 duck billed mask. LPN #3 stated the type of mask he was wearing was much more comfortable than the one he was fit tested for by the facility. On 01/18/2023 at 11:57 AM, Unit Manager (UM) #1 was interviewed. UM #1 was observed wearing a black KN95 mask. When interviewed, UM #1 stated she was fit tested at the facility for a Medline N95 mask but it was uncomfortable to wear during an eight-hour shift, and decided she was not going to wear it. UM #1 stated she was never instructed that she could only wear the type of N95 mask she was fit tested for. On 01/18/2023 at 12:05 PM, Certified Nursing Assistant (CNA) #13 was observed assisting a resident with dining, while wearing a KN95 mask (does not form a tight seal and some are not approved by OSHA or the National Institute for Occupational Safety and Health [NIOSH]). On 01/18/2023 at 12:07 PM, Registered Dietician (RD) #5 was interviewed on the 1 East Unit. RD #5 was observed wearing a 3M Aura 1870 (brand name) N95 mask. RD #5 stated the mask she was wearing was more comfortable than the facility issued masks. She stated she had not been fit tested for the type of mask she was wearing and was aware she was required to wear a mask she was fit tested to wear. On 01/18/2023 at 1:48 PM, the Activities Director (AD) was interviewed. The AD was observed to be wearing a KN95 mask. When interviewed, the AD stated the facility assigned N95 mask was in her car, then stated it was in her office. The AD confirmed she was not wearing the facility assigned mask she was instructed to wear during a COVID-19 outbreak. On 01/18/2023 at 2:57 PM, Dietary Aide (DA) #8 was observed wearing a 3M (brand name) N95 mask with only one strap holding the mask around his head, and the chin strap was hanging down. He stated he was fit tested for the Medline N95 mask, but he can't breathe in that one, so he chose to wear the 3M N95 mask that he had not been fit tested to wear. On 01/19/2023 at 11:03 AM, Registered Nurse (RN) #19 was interviewed on the 1 East Unit. RN #19 was assigned to the COVID-19 positive unit. She was wearing a Dasheng OT3TW (brand name) N95 mask. RN #19 stated the mask she was wearing was much more comfortable than the mask the facility provided. She revealed she was fit tested with a Medline brand mask but did think it mattered. On 01/18/2023 at 5:45 PM, the Infection Preventionist (IP Nurse) was interviewed. The IP Nurse stated all employees were fit tested with the Medline REF: NON24506A N95 Respirator mask. The IP Nurse stated every employee should be wearing a Medline N95 mask in their size. On 01/19/2023 at 10:30 AM, the RDO was interviewed. The RDO stated his expectation was that all staff should be wearing an N95 mask that they were fit tested to wear. 1.b. On 01/19/2023 at 10:56 AM, CNA #10 was interviewed. CNA #10 stated it was her second day working at the facility as an agency contracted employee and was assigned to the COVID-19 unit. CNA #10 stated she had not had a fit test for the facility required N95 mask she was wearing. A review of CNA #10's employee file revealed a Respirator Fit Test Sheet, dated 01/18/2023, which indicated the facility had fit tested the CNA with a Medline N95 respirator and passed the fit test. On 01/19/2023 at 2:23 PM, a follow-up interview with CNA #10 revealed two facility employees approached her between 11:00 AM and 12:00 PM and stated the Director of Nursing (DON) needed her to sign an N95 fit test form. CNA #10 stated she signed the form, but the facility had not fit tested her for the N95 mask she was required to wear. On 01/19/2023 at 2:30 PM, an interview with the RDO and CNA #10 revealed the CNA relayed the fit testing information to the RDO. At 2:35 PM on 01/19/2023, the RDO stated he had nothing, and it was not a behavior that he supported. On 01/19/2023 at 3:03 PM, the DON was interviewed with the RDO present. The DON stated her expectation was agency staff should also be fit tested for the facility's designated N95 mask. The DON indicated she was not trained to do the fit testing, but the IP Nurse and the Assistant Director of Nursing (ADON) completed the fit testing. The DON stated she instructed the IP Nurse and the facility scheduler to make sure everyone in the facility was wearing the correct personal protective equipment (PPE). The DON stated, I don't know what to say but thought the facility could make some changes to make sure it did not happen again. On 01/19/2023 at 3:40 PM, Staffing Coordinator (SC) #11 was interviewed with the RDO present. SC #11 stated the DON told the IP Nurse and SC #11 to make sure all staff had on the proper PPE. The IP Nurse asked SC #11 to have CNA #10 sign a form indicating the CNA had been fit tested. SC #11 stated she asked CNA #10 to sign a fit testing blank form that only had the CNA's name and title. On 01/19/2023 at 4:05 PM, the IP Nurse was interviewed with the RDO present. The RDO asked the IP Nurse to be truthful with the surveyor about the fit testing for CNA #10. The IP Nurse stated the facility's file for CNA #10 was not complete. On 01/19/2023 at 4:20 PM, an interview was conducted with the DON, IP Nurse, SC #11, and the RDO. The IP Nurse stated the surveyor asked for the agency staff orientation, fit testing, and vaccination records. Staff wanted the files to be perfect, but they were not. According to the IP Nurse, they all put forms in a binder; however, they did not have all the required forms. The IP Nurse stated she was not honest, and she had to own it. The DON stated she also helped put the files together and confirmed all the agency files were incomplete. The IP Nurse further stated the facility had not fit tested any of the agency staff since she started in October 2022. Since October 2022, there had been 47 different agency staff that had worked at the facility without a respirator fit test. 1.c. Further review of the undated policy titled, N95 Respiratory Program, revealed Fit testing will be conducted at least annually AND: Prior to being allowed to wear any respirator or if the model of respirator available for use changes or if the employee changes weight by 10% or more or if the employee has any changes in facial structure or scarring. Records of fit testing shall be maintained by the Respiratory Protection Administrator for at least 3 years. A review of a facility provided list of employees revealed there were 197 individuals employed at the facility. A review of employees' Respirator Fit Test Sheet revealed 144 employees had been fit tested for an N95 respirator mask. Further review of the fit test sheets revealed 80 of the 140 employees had not been fit tested within the last year. On 01/18/2023 at 5:45 PM, the IP Nurse was interviewed. Upon review of the Respirator Fit Test Sheet for employees, the IP Nurse confirmed there were 80 employees that were overdue for the annual fit testing requirement, and she could not ensure that all employees had been fit tested. On 01/19/2023 at 3:03 PM, the DON was interviewed with the RDO present. The DON stated that until she went through the fit testing records, she was not aware that so many of the fit tests were over a year old and overdue. 2. A review of the facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures, revised/reviewed 03/23/2022, revealed, the facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. According to the policy, 12. If there are COVID-19 cases in the facility: a) Staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based availability). A review of the facility policy titled, Donning and Doffing PPE (Personal Protective Equipment), revised March 2022, revealed after exiting a resident room when wearing PPE, staff should 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse. On 01/19/2023 at 11:10 AM, Unit Manager (UM) #1 was observed entering the COVID-19 unit. UM #1 was wearing a facility designated N95 mask covered with a surgical mask with a built-in face shield. UM #1 was observed donning a disposable isolation gown and gloves. She gathered the items needed for resident care and entered the room of a resident who had COVID-19. Upon exiting the resident's room, UM #1 removed her isolation gown and gloves but kept on the N95 mask and the surgical mask with the built-in face shield she was wearing when she entered the room of the resident who had COVID-19. Further observation revealed UM #1 performed hand hygiene and left the COVID-19 positive unit. On 01/19/2023 at 11:30 AM, UM #1 was interviewed. UM #1 stated she left on the same mask all day even if she was on and off the COVID-19 unit and in and out of resident rooms. On 01/19/2023 at 11:44 AM, the Infection Preventionist (IP) nurse was interviewed. The IP Nurse stated it was her expectation if an employee was going in and out of residents' room who were COVID-19 positive, they should change their outer mask. According to the IP, the employee should get a new, clean outer mask when they leave the room. 3. The facility policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised 03/23/2022, revealed, Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitoring equipment) are used, or if not available, then equipment is cleaned and disinfected according to manufacturers' instructions using EPA-registered disinfectant for healthcare setting prior to use on another resident. On 01/19/2023 at 10:44 AM, on the 1 East Unit, Licensed Practical Nurse (LPN) #4 was observed wheeling a vitals machine into a resident's room who was not positive for COVID-19. There was no observation that the vitals machine was cleaned prior to entering the room. LPN #4 obtained the resident's blood pressure (BP) and exited the room. The LPN documented the resident's BP and started into another resident's room with the vitals machine. The surveyor interviewed LPN #4 to see if there was any special procedure he completed prior to taking the vitals machine into the next resident's room. He initially stated no, and there were no disinfecting wipes observed on the vitals machine cart. LPN #4 then took a new package of disinfecting wipes from inside the medication cart, donned a pair of gloves, and wiped the screen and desk part of the machine, and the BP cuff. LPN #4 doffed the gloves and stated he was going to go wash his hands. When asked if he had completed the procedure, LPN #4 donned another pair of gloves and proceeded to wipe down the thermometer and the pole and wheeled legs of the machine. LPN #4 once again doffed his gloves and went to wash his hands. There was no observation of LPN #4 cleaning the pulse oximeter or any of the wires attached to the machine. An interview with LPN #4 at 10:55 AM on 01/19/2023 revealed once he entered a resident's room with the machine, it was considered to be contaminated. He stated he knew he was required to wipe it down between residents but stated, To be honest he only sometimes cleaned the machine. On 01/19/2023 at 11:03 AM, RN #19 was interviewed. RN #19 was observed by her medication cart with her assigned vitals machine. RN #19 stated she was working in the COVID-19 positive unit. She stated she took care of residents who did not have COVID-19 prior to entering the COVID-19 unit. RN #19 stated she was being honest by stating she only cleaned the machine prior to entering and when leaving the COVID-19 unit. RN #19 stated she knew she should but did not clean the vitals machine between each resident use. On 01/19/2023 at 11:44 AM, the Infection Preventionist (IP) nurse was interviewed. The IP Nurse stated the expectation was for the vitals machine to be sanitized between each resident use. New Jersey Administrative Code § 8:39-19.4(a)1-6

Complaint #NJ159325 Based on interviews, document review, facility policy review, and a review of the Centers for Disease Control and Prevention (CDC) community transmission levels, it was determined the facility failed to ensure all staff were tested twice per week based on the community transmission levels. Findings included: The facility policy titled, Atlas Healthcare Policy for Emergent Infectious Diseases (including COVID-19)/Outbreak Response, revised December 2022, revealed Once notified by the public health authorities at either the federal, state and/or local level that the EID [Emergent Infectious Disease] is likely to or already has spread to the care center's community, the care center will activate specific surveillance and screening as instructed by Centers for Disease Control and Prevention (CDC), state agency and/or the local public health authorities. The policy revealed Any employee who test positive for COVID-19, refuse to participate in COVID-19 testing, or refuse to authorize release of their testing results to the LTC will be excluded from work until such time as such staff undergoes testing and the results of such testing are disclosed to the LTC. A review of the state's COVID-19 Weekly Activity Report revealed the CDC Community Transmission levels used for healthcare settings are High in all counties as of November 3, 2022. A review of the 11/10/2022, 11/17/2022, and 11/24/2022 weekly activity reports revealed the community transmission level continued to be High for the county where the facility was located. A telephone interview with a state Epidemiologist (EPI) on 01/18/2023 at 12:56 PM, revealed since the facility had been in COVID-19 outbreak status since July 2022, the state EPI and the local health department (LHD) had been asked to consult with the facility to offer support, guidance, and education to assist them in getting beyond the outbreak. The EPI stated they asked the facility to be on weekly phone/Zoom calls dating back to November 2022. The EPI stated phone/Zoom calls were conducted weekly with much resistance from the facility staff. The EPI stated during the calls, the EPI and the LHD staff would educate the facility on fit testing for N95 masks, basic infection control practices, and COVID-19 testing of employees. The EPI stated during the call on 11/03/2022, the LHD and the EPI requested the facility send staff COVID-19 testing logs for review. At the end of the call, when the facility administrator (NHA) thought she had hung up from the call, the EPI and LHD overheard the NHA instruct Unit Clerk (UC) #12 to make up the logs and go upstairs and have employees sign that they were being tested for the last two weeks. The EPI stated they wanted the facility to take ownership of what they could control. On 01/20/2023 at 11:20 AM, UC #12 was interviewed. UC #12 confirmed she was on the Thursday calls with the EPI and the LHD. She revealed they discussed new resident and staff COVID-19 cases. She stated they also asked if the facility was completing COVID-19 testing per their recommendations. UC #12 stated she recalled in November 2022, the LHD and EPI requested the facility's staff COVID-19 testing logs for November 2022. UC #12 revealed that at the end of the call, the NHA told her to create logs that did not exist and have staff sign them. UC #12 stated the NHA realized she had not hung up from the call and stated, I hope they didn't hear me. UC #12 indicated some staff had tested but the facility was not testing the way the LHD and EPI had recommended. According to UC #12, the EPI and the LHD expected every single person to be tested; however, not every single person was being tested. The UC stated the LHD wanted testing logs, so the facility made them up. UC #12 stated the honest answer to the health department would have been to tell them they did not test all the staff. Continued interview with UC #12 in the presence of the Regional Director of Operations (RDO) revealed it was UC #12's responsibility to track employee COVID-19 tests. UC #12 stated the facility was currently conducting staff and resident COVID-19 tests on Mondays and Thursdays and she kept a log. She stated employees also received a reminder on Monday and Thursdays that they needed to test. She stated when staff arrived at work, they signed in, and tested. The UC stated if she was not working on testing days, staff needed to self-test before beginning their shift. UC #12 stated supervisors had a copy of staff schedules and if an employee self-tested the supervisor was supposed to wait with the test for 15 minutes to obtain the results. UC #12 stated she (UC #12), a supervisor, or the Infection Preventionist (IP) Nurse was with staff during testing. She stated they reviewed the sign in sheets and put the information on a log, then compared the log to the staffing schedule. UC #12 stated they try to look at everyone's schedule. A review of a Rapid Testing Log for 11/14/2022 revealed the log was attached to an email the facility sent to the LHD on 11/18/2022. The log contained five pages worth of testing results. On 01/20/2023 at 2:06 PM, a follow-up interview with UC #12 regarding the COVID-19 testing logs sent to the LHD revealed UC #12 added the names of staff who were scheduled to work on testing days to a log. UC #12 stated she also talked to staff and if they stated they had worked on a testing day, she asked them to sign the log that they had self-tested. UC #12 stated the NHA and UC #12 wanted to give the health department the information for which they asked. According to UC #12, each employee self-tested for COVID-19 and she could not ensure that each employee was tested as required. On 01/18/2023 at 11:22 AM, Licensed Practical Nurse (LPN) #3, who worked as a contract agency nurse, was interviewed. LPN #3 stated she had worked four shifts at the facility. She stated the last time she tested for COVID-19 was on Sunday, 01/15/2023. LPN #3 stated she forgot to test when she came in for her shift that morning. On 01/18/2023 at 1:48 PM the Activities Director (AD) was interviewed. The AD stated she completed a COVID-19 test on Monday (01/16/2023) and was tested two times per week. The AD stated staff tested themselves when they came to work and sometimes they were tested on the unit. She stated if there was an outbreak or if they had a new case of COVID-19, the facility would test staff when they tested residents. On 01/18/2023 at 11:35 AM, Unit Manager (UM) #2 was interviewed. UM #2 stated staff tested on Mondays and Thursdays. UM #2 stated staff self-tested with a rapid test when they came into work. On 01/18/2023 at 5:45 PM, the Infection Preventionist (IP) Nurse was interviewed. The IP Nurse stated the facility was supposed to be testing all employees two times per week, on Mondays and Thursdays. The IP Nurse explained that staff who did not work on Monday or Thursday were supposed to test themselves at the facility prior to starting their shift. However, the IP Nurse was unable to explain how the facility monitored to ensure all staff were tested for COVID-19 twice per week. On 01/20/2023 at 11:33 AM, the Regional Director of Operations (RDO) was interviewed. The RDO stated he was in disbelief. He stated he did not understand the logic behind making up documents and lying. The RDO stated that type of practice was not doing anyone any good. The Administrator was unavailable for interview. New Jersey Department of Health (NJDOH) Executive Directive (ED) No. 21-012 (Revised), dated 12/22/2022, indicated, b. Facilities must test residents and staff as follows: Routine testing - Test all covered workers, in accordance with E.O. [Executive Order] 252, E.O. 283, E.O. 290, and NJDOH E.D. 21-011, if the covered workers (a) have not yet submitted proof of full primary series vaccination, (b) have not yet submitted proof of being up to date on COVID-19 vaccination, and/or (c) have requested and received an authorized medical or religious exemption to COVID-19 vaccination. c. Long-Term Care Facilities shall follow CDC [Centers for Disease Control and Prevention] guidance, as modified and updated by the CDC, for testing, except where applicable New Jersey Executive Orders and Executive Directives are more restrictive than CDC guidance. NJDOH ED No. 21-011 (2nd Revised), dated 09/02/2022, indicated, Section 2: Vaccination and Testing Documentation for Heath Care and High-Risk Congregate Settings, 6. Each covered worker who is not yet up to date with their COVID-19 vaccinations (including but not limited to those who have a documented COVID-19 vaccination exemption), and who are not tested through their covered setting, shall provide proof of testing, including results, to their covered setting. This shall occur once or twice weekly until the covered worker is up to date with their COVID-19 vaccinations. f. Up to date with COVID-19 vaccinations means that covered workers in health care and high-risk congregate settings received a primary series (either a 2-dose primary series of a COVID-19 vaccine or a single-dose primary series COVID-19 vaccine) and the first booster dose for which they are eligible as recommended by the CDC [Centers for Disease Control and Prevention]. Further, Section 4: Testing Frequency for Health Care and High-Risk Congregate Settings, 20. Covered settings should base their testing frequency on the extent of the virus in the community, and should, therefore, use the CDC Community Transmission Levels reported on the CDC COVID-19 Data Tracker and included in the DOH's [Department of Health's] weekly COVID-19 Surveillance Report, https://www.nj.gov/health/cd/statistics/covid/ in the prior week as follows: CDC Community Transmission Level / Minimum Testing Frequency Low (blue) / Once a week Moderate (yellow) / Once a week Substantial (orange) / Twice a week High (red) / Twice a week 21. Covered settings should monitor the Community Transmission Level every week and adjust the frequency of covered worker testing according to the table above. a. If the Community Transmission Level increases to a higher level of acuity, the covered setting should begin requiring covered workers who are not up to date with their COVID-19 vaccinations, as applicable, to be tested at the frequency shown in the table above as soon as the criteria for the higher activity are met. b. If the Community Transmission Level decreased to a lower level of acuity, the covered setting should continue requiring covered workers who are not up to date with their COVID-19 vaccinations, as applicable, to be tested at the higher frequency level until the relevant activity level has remained at the lower activity level for at least two weeks before reducing testing frequency. New Jersey Administrative Code § 8:39-19.4(a)1-6

Complaint #NJ159325 Based on interviews, facility policy review, facility document review, and the facility employee handbook review, the facility failed to ensure the facility's compliance and ethics program was being implemented for two identified concerns related to the facility's infection control program. Specifically, the facility failed to have a process for ensuring the integrity of reported COVID-19 testing data and failed to ensure respirator fit testing documentation was not falsified for 1 of 197 employees. Findings included: Review of the Employee Handbook, not dated, revealed, Our Corporate Compliance Program is designed to prevent fraudulent activities and to assure that our Company operates in compliance with the requirements of all health care programs with which we work. The policy further indicated, Each employee has an individual responsibility to report any activity by any employee, physician, subcontractor, resident, visitor, volunteer or vendor that appears to violate applicable laws, regulations or the Company's Code of Conduct. Reports should be made immediately and failure to report known or possible inappropriate activity is grounds for disciplinary action up to and including suspension or termination of employment. In addition, Anyone who engages or attempts to engage in any form of retaliation against an employee for good faith participation in the Company's Corporate Compliance Program will be disciplined, up to and including dismissal. Further review under the handbook's Code of Conduct section revealed, Each employee plays a role in fostering this environment. Accordingly, we all must abide by certain rules of conduct, based on honesty, common sense, and fair play. The following list enumerates the types of conduct that is not acceptable of Company employees: Falsifying timesheets, application forms, or other Company records. Failing to meet the Company's expected level of performance and quality requirements. The employee handbook further revealed, The observance of these rules will help to ensure that our workplace remains a safe and desirable place to work. A telephone interview with a state Epidemiologist (EPI) on 01/18/2023 at 12:56 PM, revealed since the facility had been in COVID-19 outbreak status since July 2022, the state EPI and the local health department (LHD) had been asked to consult with the facility to offer support, guidance, and education to assist them in getting beyond the outbreak. The EPI stated they asked the facility to be on weekly phone/Zoom calls dating back to November 2022. The EPI stated phone/Zoom calls were conducted weekly with much resistance from the facility staff. The EPI stated during the calls, the EPI and the LHD staff would educate the facility on fit testing for N95 masks, basic infection control practices, and COVID-19 testing of employees. The EPI stated during the call on 11/03/2022, the LHD and the EPI requested the facility send staff COVID-19 testing logs for review. At the end of the call, when the facility administrator (NHA) thought she had hung up from the call, the EPI and LHD overheard the NHA instruct Unit Clerk (UC) #12 to make up the logs and go upstairs and have employees sign that they were being tested for the last two weeks. The EPI stated they wanted the facility to take ownership of what they could control. On 01/20/2023 at 11:20 AM, UC #12 was interviewed. UC #12 confirmed she was on the Thursday calls with the EPI and the LHD. She revealed they discussed new resident and staff COVID-19 cases. She stated they also asked if the facility was completing COVID-19 testing the way they recommended. UC #12 stated it was her responsibility for tracking both resident and employees testing, especially on Mondays and Thursdays. During the interview, UC #12 stated she recalled in November 2022, the LHD and EPI requested the facility's staff COVID-19 testing logs for November 2022. UC #12 revealed that at the end of the call, the NHA told her to create logs that did not exist and have staff sign them. UC #12 stated the NHA realized she had not hung up from the call and stated, I hope they didn't hear me. UC #12 indicated some staff had tested but the facility was not testing the way the LHD and EPI had recommended. According to UC #12, the EPI and the LHD expected every single person to be tested; however, not every single person was being tested. The UC stated the LHD wanted testing logs, so the facility made them up. UC #12 stated the honest answer to the health department would have been to tell them they did not test all the staff. On 01/20/2023 at 2:06 PM, a follow-up interview with UC #12 regarding the COVID-19 testing logs sent to the LHD revealed UC #12 added the names of staff who were scheduled to work on testing days to a log. UC #12 stated she also talked to staff and if they stated they had worked on a testing day, she asked them to sign the log that they had self-tested. UC #12 stated the NHA and UC #12 wanted to give the health department the information for which they asked. According to UC #12, each employee self-tested for COVID-19 and she could not ensure that each employee was tested as required. On 01/20/2023 at 11:33 AM, the Regional Director of Operations (RDO) was interviewed. The RDO stated he was in disbelief with what he was hearing. He stated he did not understand the logic behind making up documents and the lying. The RDO stated that practice was not doing anyone any good. The NHA was not available for interview. 2. On 01/19/2023 at 10:56 AM, CNA #10 was interviewed. CNA #10 stated it was her second day working at the facility as an agency contracted employee and was assigned to the COVID-19 unit. CNA #10 stated she had not had been fit tested for the facility required N95 mask she was wearing. A review of CNA #10's employee file revealed a Respirator Fit Test Sheet, dated 01/18/2023, which indicated the facility had fit tested the CNA with a Medline N95 respirator and passed the fit test. On 01/19/2023 at 2:23 PM, a follow-up interview with CNA #10 revealed two facility employees approached her between 11:00 AM and 12:00 PM and stated the Director of Nursing (DON) needed her to sign an N95 fit test form. CNA #10 stated she signed the form, but the facility had not fit tested her for the N95 mask she was required to wear. On 01/19/2023 at 3:40 PM, Staffing Coordinator (SC) #11 was interviewed with the Regional Director of Operations (RDO) present. SC #11 stated the DON told the Infection Preventionist (IP) Nurse and SC #11 to make sure all staff had on the proper personal protective equipment (PPE). The IP Nurse asked SC #11 to have CNA #10 sign a form indicating the CNA had been fit tested. SC #11 stated she asked CNA #10 to sign a blank fit testing form that only had the CNA's name and title documented on the form. On 01/19/2023 at 4:05 PM, the IP Nurse was interviewed with the RDO present. The RDO asked the IP Nurse to be truthful with the surveyor about fit testing for CNA #10. The IP Nurse stated the facility's file for CNA #10 was not complete. On 01/19/2023 at 3:03 PM, the DON was interviewed with the RDO present. The DON stated her expectation was agency staff should also be fit tested for the facility's designated N95 mask. The DON indicated she was not trained to do the fit testing, but the IP Nurse and the Assistant Director of Nursing (ADON) completed the fit testing. The DON stated she instructed the IP Nurse and the facility scheduler to make sure everyone in the facility was wearing the correct PPE. The DON stated, I don't know what to say but thought the facility could make some changes to make sure it did not happen again. On 01/19/2023 at 4:20 PM, an interview was conducted with the DON, IP Nurse, SC #11, and the RDO. The IP Nurse stated the surveyor asked for the agency staff fit testing. Staff wanted the files to be perfect, but they were not. According to the IP Nurse, they (DON, SC #11, and IP Nurse) all put forms in a binder. The IP Nurse stated she was not honest, and she had to own it. The DON stated she also helped put the files together and confirmed all the agency files were incomplete. The IP Nurse further stated the facility had not fit tested any of the agency staff since she started in October 2022. Since October 2022, there had been 47 different agency staff that had worked at the facility without a respirator fit test. On 01/20/2023 at 11:33 AM, the Regional Director of Operations (RDO) was interviewed. The RDO stated he was in disbelief with what he was hearing. He stated he did not understand the logic behind making up documents and the lying. The RDO stated that practice was not doing anyone any good. New Jersey Administrative Code § 8:39-5.1(a)