**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure timely reporting of an injury of unknown origin for one out of five residents reviewed for abuse (Resident (R) 97). This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear. Findings include: Review of R97's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed with severely impaired cognition. The resident had short and long-term memory problems and exhibited physical behaviors toward others almost daily and other behavioral symptoms and rejection of care occasionally. Review of R97's Care Plan initiated on 03/23/24 updated 06/05/24 and located under the Care Plan tab of the EMR revealed, I am at risk for misappropriation, neglect, abuse and/or exploitation r/t [related to] Dementia. The goal was, I will not experience any form of abuse, neglect, misappropriation and/or exploitation through review date. The approaches included, Assess me for s/s [signs/symptoms] of abuse and/or neglect (ex. bruises, wt [weight] loss, behavior, psychosocial status) and report to appropriate resources . Investigate all allegations of abuse & [and] neglect promptly . [and] provide support and ensure I am free from abuse.Review of R97's Nurse's Note written on 06/02/24 at 11:36 AM and located under the Progress Notes tab of the EMR revealed, Nurse was notified by CNA [Certified Nurse Aide] that resident presented with new bruises all over bilateral lower extremities, chest, abdomen, hip into coccyx area. Resident also has swelling on abdominal area. Review of R97's Reportable Event Record/Report dated 06/03/25, in the investigation packet, revealed bruising was noted to R97's sternal area, along the lateral aspects following the seams of the bra line, right posterior hip, and coccyx. R97 was unable to explain the bruising and staff was unaware of the cause of the bruising. The report documented R97's injury of unknown origin was found on 06/02/24 at 11:36 AM, and the initial report was called in to the State Survey Agency (SSA) on 06/02/24 at 5:31 PM, almost six hours after the injury was discovered.During an interview on 07/24/25 at 6:11 PM, the Director of Nursing (DON) stated she was unsure when she was alerted to R97's unexplained injuries, but the injury was discovered on 06/02/24 at 11:36 AM and should have been reported to her immediately. She stated with an injury of unknown origin, there was a two-hour reporting window, and it should have been reported to the SSA within two hours of discovery.Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated September 2022 revealed, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: . The state licensing/certification agency responsible for surveying/licensing the facility . 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 102) reviewed for choices and food preferences were honored, Specifically, 27 out of 28 residents residing in the secure dementia unit were not offered choices of food, beverages, and condiments at meals. This failure could lead to dissatisfaction with meals, weight loss, or malnutrition.Findings include:Review of R102's admission Record located under the Profile tab in his electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, mood disorder, chronic kidney disease, and anemia.Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated R102 had severely impaired cognition. The resident did not exhibit any mood or behavioral problems. The resident received a mechanically altered, therapeutic diet.During an interview on 07/21/25 at 11:54 AM, R102's Family Member (F1) stated the residents on the secure dementia unit were not offered choices of food or beverages at meals. F1 stated she provided information on the resident likes and dislikes, but added, I know they give him/her things he/she doesn't like, like today's tuna casserole. He/she doesn't like fish. I told them that. Review of R102's Care Plan dated 02/11/25 and located under the Care Plan tab of the EMR revealed, [R102] is at risk for malnutrition r/t [related to] Hx [history of] significant weight change, inadequate caloric intake with need of supplementation, need of therapeutic/mechanically altered diet, [and] PMHx: [past medical history of] Afib [atrial fibrillation], CKD [chronic kidney disease], Anemia, Dementia, HTN [hypertension], [and] HLD [high cholesterol]. The approaches included, Encourage H2O [water] intake at and between meals for hydration . [and] Honor food and fluid preferences to optimize PO [oral] intake, update PRN [as needed]. -Dislikes: fish, mushrooms.Review of R102's Dietary Assessment and Documentation dated 11/03/24 and located under the Assessments tab of the EMR revealed, Food preferences were reviewed and updated with the kitchen. Dislikes fish, mushrooms. Review of R102's meal tray card provided on paper from the kitchen revealed the dislikes of fish and mushrooms were included on the card. During observation of lunch in the secure dementia unit on 07/21/25 beginning at 11:58 AM, all residents but one (who received a grilled cheese sandwich) were served tuna casserole, tater tots, and green beans. There were no condiments, such as salt, pepper, or ketchup, available or offered to the residents. All residents received a glass of lemonade; there were no other beverages available or offered, though one resident requested and received a cup of coffee. No water was served with the meal. R102 was served tuna casserole, tater tots, green beans, and a glass of lemonade. The resident did not receive water with their meal as directed on the Care Plan. The resident was observed to only eat bites of their meal while being assisted by F1.During observation of lunch in the secure dementia unit on 07/24/25 beginning at 11:50 AM, all residents but one (who received a veggie burger) were served pasta and sauce, meatballs, and spinach. All residents were served a glass of strawberry-kiwi juice, there were no other beverages available or offered. Additionally, no condiments were available or offered. During an interview on 07/24/25 at 11:57 AM, Certified Nure Aide (CNA) 2 stated the kitchen typically sent one type of juice with each meal. She stated the residents were only given the juice that was sent, they were not offered a choice of beverage. During an interview on 07/24/25 at 12:04 PM, CNA7 stated the kitchen typically sent the main meal for all residents; their orders were not taken, and they were not offered choices at meals.During an interview on 07/24/25 at 12:05 PM, CNA1 stated all residents were served the main meal; however, they could ask for something different and it would be requested from the kitchen.During an interview on 07/24/25 at 1:26 PM, the Dietary Manager (DM) stated that since the residents in the secure dementia unit were cognitively impaired, the weekly menus were left out at the front desk for the family members to fill out with resident preferences. She stated there was no system in place to offer residents a choice of meals unless the family members were in the facility to fill out the menus each week. The DM stated residents' likes and dislikes were assessed upon admission, and the kitchen should serve something different if a food is listed as a dislike. The DM stated R102 did not like fish, so he/she should have received a substitute for the tuna casserole. The DM explained that in the facility's main dining room, there was a menu provided, and servers assisted the residents to choose their preferences at the beginning of each meal. The DM stated the staff should be offering a choice of beverages. She stated in the main dining room, different types of juice, different types of soda, water, coffee, tea, hot chocolate, and milk were offered.Review of the facility's policy titled, Food and Nutrition Services, dated October 2017 revealed, The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits . Reasonable efforts will be made to accommodate resident choices and preferences. NJAC 8:39-4.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 01/30/24 at 11:56 AM, Resident #301 was observed in bed, restless and groaning. There was a private duty caregiver at the resident's bedside who stated that she was a live-in caregiver (LIC). The LIC stated that the resident fell at home and broke their leg and had gotten pain medication when needed. On 02/02/24 at 11:52 AM, Resident #301 was observed in a wheelchair accompanied by their son. The surveyor inquired with the son as to whether the resident was having pain and the son stated, not now and stated that he/she would have made it verbally known if they had pain. According to the admission Record, Resident #301 had diagnoses which included, but were not limited to, Alzheimer's disease, unspecified fracture of shaft of left femur, fracture of superior rim of left pubis, and osteoarthritis of knee. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/29/24, included the resident had a Brief Interview for Mental Status score of 99 which indicated that the resident was unable to complete the interview. Review of the Care Plan (CP), initiated 01/22/24, did not include a resident's Focus for Pain. Review of the Order Summary Report, dated Active orders as of 02/06/24, revealed and order for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for mild pain. Review of the Medication Administration Record, dated 01/01/2024-01/31/2024, revealed Resident #301 received pain medication on 01/23/24 at 0712 and again on 01/24/24 at 0713. During an interview with the surveyor on 02/02/24 at 12:05 PM, the Certified Nursing Assistant (CNA) who was caring for Resident #301, stated that she would ask the resident if he/she had pain and they would respond by stating, ouch. The CNA stated that if the resident had pain that she would tell the nurse and she would also make sure the resident did not seem to be in distress. During an interview with the surveyor on 02/05/24 at 11:03 AM, LPN #2 stated that a CP included interventions used for the residents as a part of their care. LPN #2 further stated that if a resident had pain that she would have expected to see pain management interventions on the CP. During an interview with the surveyor on 02/05/24 at 11:25 AM, the Licensed Practical Nurse Unit Manager (LPN/UM #2) stated that she would have expected to see a Focus of pain on a CP for a resident that had fractures with the interventions to choose from. She stated that there was a pain template that could have been modified for a resident. During an interview with the surveyor on 02/06/24 at 10:49 AM, the Director of Rehabilitation (DOR) stated that a CP was a snapshot of a resident and their needs and that every discipline was able to add to the CP their perspective from their discipline. The DOR stated that unless a resident complained of pain that she would not have expected to see a Focus of pain on the CP. The surveyor and the DOR reviewed Resident #301's CP together in the EMR and the DOR acknowledged that she did not see a focus of pain on the CP. During an interview with the surveyor on 02/06/24 at 11:47 AM, the surveyor and LPN #2 reviewed Resident #301's CP together in the EMR and LPN #2 acknowledged that she did not see a Focus of pain on the CP and that she would have expected to have seen it. LPN #2 stated that it was important to include pain on the CP because the interventions and goals were specific for each resident. During an interview with the surveyor on 02/06/24 at 11:56 AM, the surveyor and LPN/UM #2 reviewed Resident #301's CP together in the EMR and LPN/UM #2 acknowledged that she did not see a Focus of pain on the CP. She stated that if a resident was in pain, that pain should have been on the CP and that it was important that the pain was addressed. LPN/UM #2 then stated, I will put it in now. During an interview with the surveyor on 02/06/24 at 12:11 PM, the Assistant Director of Nursing (ADON) stated that if a resident had a femur and pelvic fractures that she would have expected to see pain on the CP. The surveyor and the ADON reviewed Resident #301's CP together in the EMR and the ADON was made aware that the Focus Pain was added by LPN/UM #2 after surveyor inquiry. During an interview with the surveyor on 02/06/24 at 12:19 PM, the DON stated that if a resident had a femur and pelvic fractures that she would have expected to see pain on the CP. The surveyor and the DON reviewed Resident #301's CP together in the EMR and the DON was made aware that the Focus Pain was added by LPN/UM #2 after surveyor inquiry. During an interview with the surveyor on 02/06/24 at 12:27 PM, the MDSC acknowledged that if a resident had a diagnosis of femur and pelvic fractures that she would have expected to see pain on the CP. On 02/06/24 at 03:39 PM, the surveyors met with the administration team and the surveyor discussed concerns about Resident #301's pain not being addressed on a CP and that it was added after surveyor inquiry. On 02/07/24 at 11:19 AM, the surveyors met with the administration team and the Regional Nurse (RN) stated that a full house pain CP audit was completed and that every resident that had a pain assessment with a pain CP, and in-services were completed. Review of the facility's Comprehensive Care Plans policy, undated, included, 1. The care planning process will include an assessment of the resident's strengths and needs .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with resident's preferences, will also be addressed in the plan of care, and, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs . Review of the facility's Pain Assessment and Management policy, revised October 2022, included, Defining Goals and Appropriate Interventions. 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. NJAC8:39-11.2 (e)(f) Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include residents' a.) preference for activities and b.) risk for pain. This deficient practice was identified for 1 of 1 resident (Resident #253) reviewed for activities and for 2 of 2 residents (Resident #145 and #301) reviewed for pain management and was evidenced by the following: 1. On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. According to the admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/10/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident's cognition was moderately impaired. Further review of the MDS included it was very important to the resident to do things with groups of people, and, participate in religious services or practices. Review of the Recreation Assessment, dated 01/11/24, included, religion is important to [Resident #253] and [he/she] expressed interest in receiving Communion and religious visits. Review of the care plan, initiated 01/04/24, did not include the resident's preferences for activities or interventions to ensure the resident's activity preferences were met. During an interview with the surveyor on 02/01/24 at 11:52 AM, the Activities Director (AD) stated that the activities staff complete an initial assessment when residents are admitted to determine their activity preferences. During an interview with the surveyor on 02/01/24 at 12:10 PM, the Assistant Activities Director (AAD) stated that every resident was assessed for activity preferences upon admission to the facility. The AAD further stated she completed the Resident #253's Recreation Assessment, and that the resident was religious and Communion was available for the resident to attend. During a follow-up interview with the surveyor on 02/06/24 at 9:32 AM, the AD stated that the assigned activities staff member will document a resident's Recreation Assessment in the Electronic Medical Record (EMR) and then initiate a care plan related to the resident's preferences. The AD further stated that the activities staff who completed Resident #253's Recreation Assessment should have included the resident's activity preferences in the resident's care plan. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated that resident care plans are initiated upon admission and should include resident preferences. The DON further explained that care plans include the resident's needs in order to develop a plan of care with appropriate interventions. When asked about Resident #253, the DON stated the care plan should have included the resident's activity preferences. 2. On 01/30/24 at 10:26 AM, the surveyor observed Resident #145 lying in bed. The resident complained of abdominal pain and stated he/she reported it to the facility staff. On 02/02/24 at 10:53 AM, the surveyor observed Resident #145 sitting in a wheelchair in his/her room. The resident stated that he/she had been receiving medication from the nurse that had helped with the abdominal pain. The resident also stated that he/she had an ultrasound of the abdomen and was waiting for the results. According to the admission Record, Resident #145 was admitted with diagnoses which included, but were not limited to, calculus of kidney (kidney stone), unspecified abdominal pain, hydronephrosis (kidney swelling), and cirrhosis of liver (liver damage). Review of the admission MDS, dated [DATE], included the resident had a BIMS score of 13, which indicated the resident's cognition was intact. Review of the Order Summary Report, as of 02/05/24, included an order for an ultrasound of the abdomen, dated 01/30/24. Further review of the Order Summary Report included an order for Mylanta Maximum Strength Oral Suspension give 30 milliliters by mouth every 6 hours as needed for stomach upset and heartburn, ordered 01/29/24, and Carafate 1 gram give one tablet by mouth four times a day for stomach pain, ordered 01/30/24. Review of the Physician Note, dated 11/26/23, included, under assessment/plan, belly pain. Review of the Physicians Progress Note, dated 01/31/24, included Resident #145 complains of belly pain. Review of the Physicians Progress Note, dated 02/03/24, included Resident #145 complains of belly pain, and, Ascites [fluid collecting in the abdomen] with renal cyst on US [ultrasound], will add Aldactone [a diuretic] 25 mg [milligram] daily. Review of the care plan, initiated 12/19/23, did not include the resident's risk for pain or pain management interventions. During an interview with the surveyor on 02/05/24 at 11:00 AM, the Licensed Practical Nurse (LPN) stated that care plans are initiated upon admission and includes resident treatments. The LPN further stated that care plans inform the staff about the care required for the resident. When asked about Resident #145, the LPN stated the resident complained of abdominal pain, and the physician ordered Carafate and an abdominal ultrasound. The LPN then stated that since the resident was admitted with a diagnosis of abdominal pain and received treatment for the pain, the resident's pain management should have been included on the care plan. During an interview with the surveyor on 02/05/24 at 11:50 AM, the LPN/Unit Manager (LPN/UM) stated each department is responsible for updating the resident care plans and that care plans should include anything the resident requires interventions for. The LPN/UM further stated that care plans benefit the resident because staff can refer to them for the appropriate interventions. When asked about Resident #145, the LPN/UM stated the resident complained of abdominal pain and the physician ordered an abdominal ultrasound and medication to help with the pain. At that time, the LPN/UM checked the resident's care plan and acknowledged that it did not include the resident's abdominal pain. The LPN/UM further stated she was unsure if the abdominal pain should be included on the care plan, but that it can be added on and probably will be. During an interview with the surveyor on 02/05/24 at 9:10 AM, the MDS Coordinator (MDSC) stated UMs are responsible for initiating and updating the resident care plans which includes any ongoing problems or risks for problems the resident has. The MDSC explained that care plans should be initiated within 24-72 hours and be updated as soon as there are nay new changes to the resident's treatment. The MDSC further stated that the purpose of care plans were to be able to give proper care to the resident, prevent deterioration, and to refer to any special services. When asked about Resident #145, the MDSC stated the resident's diagnosis of abdominal pain and the facility's management of that pain should have been included on the care plan. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated that resident care plans are initiated upon admission and should include the resident's diagnoses. The DON further explained that care plans include the resident's needs in order to develop a plan of care with appropriate interventions. When asked about Resident #145, the DON stated the resident's pain management should have been included on the care plan.

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with meaningful activities that reflected the resident's preferences for 1 of 1 resident (Resident #253) reviewed for activities. This deficient practice was evidenced by the following: On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. On 02/01/24 at 9:45 AM, the surveyor sat in the lounge outside of Resident #253's room. There was an Activities Calendar on the table in the lounge that included a 10:00 AM sing-along activity. The calendar did not indicate where the activity was located. At 10:15 AM, the surveyor did not observe any sing-along activities on the unit, and staff did not enter the resident's room to offer to take her to an activity. Further review of the Activities Calendar included a 10:45 AM Communion activity. At 10:49 AM, the surveyor was still seated in the lounge and did not observe any Communion activity on the unit or staff offering to take the resident to the activity. At 10:51 AM, the surveyor observed a visitor enter the resident's room. When the surveyor entered the resident's room, the visitor identified him/herself as the resident's family member. When asked if the resident was offered to attend the sing-along or the Communion, the resident's family member asked the resident who stated, no. The resident's family member further stated that those would have been activities the resident would have attended. According to the admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/10/24, included the resident had a Brief Interview for Mental Status score of 10 which indicated the resident's cognition was moderately impaired. Further review of the MDS included it was very important to the resident to do things with groups of people, and, participate in religious services or practices. Review of the Recreation Assessment, dated 01/11/24, included, religion is important to [Resident #253] and [he/she] expressed interest in receiving Communion and religious visits. Review of the care plan, initiated 01/04/24, included the resident had a communication problem r/t [related to] hearing deficit, with an intervention that staff will anticipate and meet needs. The care plan did not include the resident's preferences for activities or interventions to ensure the resident's activity preferences are met. During an interview with the surveyor on 02/01/24 at 10:55 AM, the Certified Nursing Assistant (CNA) stated that there were no activities offered on the first floor subacute unit and that the calendar posted indicated the activities offered on the second floor units. The CNA further stated that if a resident needed assistance getting to and from an activity, the activities staff would assist the resident. The CNA added that it was important for residents to attend activities to prevent boredom and provide socialization. When asked about Resident #253, the CNA stated the resident does not attend activities. During an interview with the surveyor on 02/01/24 at 11:00 AM, the Licensed Practical Nurse (LPN) stated there were no specific activities on the subacute unit and if residents needed help going to and from an activity, the resident should have notified the staff. The LPN further stated that activities were important so that residents felt more at home. When asked about Resident #253, the LPN stated that he/she attends physical therapy, and the nursing staff place him/her in the lounge to watch television. During an interview with the surveyor on 02/01/24 at 11:08 AM, the LPN/Unit Manager (LPN/UM) stated that the activities calendar posted on the subacute unit informs the residents of activities available on the second floor and that if residents needed assistance getting to and from the activity, the nursing or activity staff would assist the resident. The LPN further stated that activities were important because they provided stimulation, distraction, and socialization. When asked about Resident #253, the LPN stated the resident required moderate assistance with activities of daily living and that staff could have assisted the resident with going to activities. During an interview with the surveyor on 02/01/24 at 11:52 AM, the Activities Director (AD) stated that the activities staff completed an initial assessment when residents were admitted to determine their activity preferences. During an interview with the surveyor on 02/01/24 at 12:10 PM, the Assistant Activities Director (AAD) stated that every resident was assessed for activity preferences upon admission to the facility. The AAD further stated she completed the resident's Recreation Assessment, and that Resident #253 was religious and Communion was available for the resident to attend. The AAD also stated she was unsure if staff assisted the resident with attending activities, but that staff should have offered to take the resident to activities as long as there were no schedule conflicts with physical therapy. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated upon admission, the activities staff assess the resident to determine what activities the resident enjoys. The DON further stated that residents on the subacute unit have to attend activities on separate units. The DON added that nursing or activities staff will assist residents to and from the activities if needed and that activities are important for the residents' psychosocial wellbeing. When informed about Resident #253 missing activities that he/she would have liked to participate in, the DON stated that the CNAs on the unit are familiar with the resident's routine and should have taken him/her to the activities. Review of the facility's undated Activities policy, included, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Further review of the policy included, All staff will assist residents to and from activities when necessary. NJAC 8:39-7.3(a)

b.) On 02/01/2024 at 10:01 AM, the surveyor observed Resident # 3 in his/her room. At that time, Resident # 3 did not have protective heel boots on. During this time, he/she said they do not get protective heel boots put on him/her. On 02/05/2024 at 10:48 AM, the surveyor observed Resident # 3 in his/her room. At that time, Resident # 3 did not have protective heel boots on. On 02/05/2024 at 11:16 AM during an interview with the surveyor, Licensed Practical Nurse #2 confirmed an order for protective heel boots appeared in the orders in the Electronic Medical Record (EMR). On the same date at 11:20 AM, during an interview with the surveyor, CNA # 3 assigned to Resident # 3 said that protective heel boots were not in Resident # 3's room. On the same date at 11:37 AM, during an interview with the surveyor while in Resident # 3's room, the Registered Nurse/Unit Manager (RN/UM # 1) observed that the resident did not have protective heel boots on. At that time, RN/UM # 1 stated that the order could have been transcribed improperly. She concluded by saying she will make sure it appeared on the nurse's end. On 02/06/2024 at 4:00 PM during an interview with the surveyor, the Director of Nursing (DON) replied, Yes when asked by the surveyor if a resident had an order for protective heel boots to be worn while in bed every shift, should they have been placed on the resident's heels while they were in bed. The DON concluded by replying, Effects the skin integrity when asked by the surveyor what potential results could have occurred if the protective heel boots were not worn according to the order. A review of the EMR for Resident # 3 revealed a physician's order for protective boots to heels for every shift that was revised on 11/11/2023 and discontinued on 02/05/2024 at 11:24 AM. A review of the paper-chart for Resident # 3 revealed a telephone order sheet dated 11/11/2023 that revealed, Protective boots to heels. An initial and hand-written statement revealed, Noted 11/11/23 adjacent to the order. A review of the facility's policy Pressure Injury Prevention and Management revised 7/25/22, included, 4. Interventions for Prevention and to promote healing c.i. Redistribute pressure (such as repositioning, protecting and or offloading heels, etc.), iii. Provide appropriate, pressure re-distributing, support surfaces, iv. Provide non-irritating surfaces. N.J.A.C. § 8:39-27.1 (a) Complaint #NJ168566 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure a pressure reducing device was used correctly and b.) failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development specifically by not providing protective boots to heels as ordered. This deficient practice was identified for two (2) of four (4) residents (Resident #3 and #104) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in their room. A staff member identified Resident #104 in the dayroom, sitting in a high back wheelchair, with a chair alarm on the back of the wheelchair. The surveyor reviewed the medical record for Resident #104. According to the admission Record (AR), Resident #104 had diagnoses which included: unspecified dementia with behavioral disturbance, hypertension (high blood pressure), and senile degeneration of brain (progressive decline in a person's ability to think and remember). A review the annual Minimum Data Set (MDS), an assessment tool, dated 11/25/23, reflected the Brief Interview for Mental Status (BIMS) score was left blank as it indicated in section C0100 it was not conducted due to the resident rarely/never understood. A review in Section H - Bladder and Bowel indicated the resident was frequently incontinent. A review in Section M - Skin condition revealed the resident was at risk for developing pressure ulcers/injuries. A further review indicated the resident did not have one or more unhealed pressure ulcers/injuries. A review of the individualized comprehensive care plan (ICCP) included a focus area, dated 9/11/23, for I am at risk for skin breakdown r/t [related to] dementia. Interventions included to assess for changes in skin condition each shift, change bedding as needed, complete skin risk assessment as per facility policy, keep skin clean and dry, low air loss mattress, monitor skin care daily, provide incontinence care prn [as needed], and provide protective/preventative skin care. A review of the skin assessments from 09/25/23 to 02/06/24, indicated that the resident's skin was intact. On 02/01/24 at 10:24 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a pressure reducing device, which was a black cushion covered with a white towel, that was directly underneath the resident. On 02/01/24 at 01:04 PM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident was still seated on top of the white towel covered black cushion that was directly underneath the resident. On 02/02/24 at 10:41 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a white towel covered black cushion that was directly underneath the resident. On 02/05/24 at 10:28 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a white blanket covered black cushion that was directly underneath the resident. On 02/05/24 at 10:29 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she rounded on her residents every 2 hours and more frequently if needed. CNA #1 stated that most of the residents sat in the dayroom/dining room so staff would monitor the residents on the comfort care (dementia) unit. When asked if she placed anything underneath the residents while they were sitting in the chairs? CNA #1 stated that she did not personally put anything underneath her residents unless the resident was in the bed then she would put a blue chuck (pad) underneath the resident. CNA #1 then stated that if you put something underneath the resident it could damage their skin. She further stated that she felt that some CNAs placed towels underneath residents because it was a way of being lazy, so they did not have to toilet the resident frequently. CNA #1 then stated that the towel could have been used to prevent the resident from sliding and slipping out of their chair. She concluded that instead of putting a towel or blanket underneath a resident they could have gotten another cushion to prevent residents from sliding. On 02/05/24 at 10:35 AM, the surveyor interviewed CNA #2 who stated that she was caring for Resident #104 today (2/5/24). CNA #2 stated that she rounded on her residents when she first came in, after breakfast and then frequently throughout the day. She stated that the staff was very helpful and assisted her if she needed anything, because she was from an agency. When asked if she would put anything underneath the resident for those that needed to be toileted more frequently, CNA #2 stated that sometimes she would put a bath blanket underneath the resident but not a towel because the bath blanket was softer. She further stated that some cushions were plastic and the bath blanket was a barrier for comfort. CNA #2 emphasized that it was not to absorb anything but more of a cushion and comfort for the resident. She explained that a towel should not be underneath the resident because if a resident was sitting on it for a long period of time it could cause skin irritation and the goal was to prevent skin breakdown. CNA #2 stated that most of the resident's skin were fragile, and that staff needed to be mindful and ensure the resident was comfortable. CNA #2 stated that Resident #104 was on hospice and that the hospice aide came and provide morning care, dressed the resident, assisted with breakfast, and placed the resident in the wheelchair this morning. On 02/05/24 at 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that staff rounded on the resident every hour. She further stated that if a resident needed to be toileted more frequently then they ensured that the resident was toileted more often. When asked if they would put anything underneath the resident, LPN #1 stated that they did not put anything underneath the resident because if they allowed urine to soak if could cause skin break down. She explained if the resident had a cushion seat, then they still should not place anything on top of the cushion directly underneath the resident because it could have caused skin breakdown. LPN #1 stated that Resident #104 was incontinent and currently did not have any wounds or skin breakdown. At that time, the surveyor and LPN #1 walked over to Resident #104 sitting in their high back wheelchair. LPN #1 confirmed Resident #104 was sitting directly on a white blanket that was placed on top of the black cushion. She acknowledged the resident should not have been sitting on the blanket. LPN #1 stated that the hospice aide got the resident up in the morning but that if someone had seen the blanket that they should have removed it. LPN #1 concluded they should remove the blanket to prevent skin breakdown. On 02/05/24 at 11:04 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the comfort care unit who stated that the residents in wheelchairs were provided seat cushions which helped prevent skin breakdown. The LPN/UM stated that the therapy department provided a blue gel pad that was placed underneath the seat cushion to prevent the resident from sliding. When asked if they placed anything on top of the cushion the LPN/UM stated that the resident should not have anything like a towel or blanket directly underneath them. She explained that the towels could have slid and it would not be conducive for the residents skin integrity. At that time, the surveyor and the LPN/UM walked over to Resident #104. The LPN/UM confirmed the resident was sitting directly on a white blanket that was placed on top of the black cushion. She then stated that the resident should not have had the blanket directly underneath them as it was not normal procedure. On 02/05/24 at 11:11 AM, the surveyor observed staff remove the blanket from underneath Resident #104. On 02/05/24 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The DON stated that the unit managers, the nurses, and the CNAs should round on their residents as soon as they started their shift. She further stated that the CNAs should have rounded on their residents at least every 2 hours and more often as needed. When asked if the staff needed to put anything underneath the resident that needed to be toileted frequently the DON stated it was very rare if you see the staff placing the chucks underneath the resident, which was used on the beds to prevent anything penetrating the sheets. The DON then stated that sometimes the staff used a towel or blanket to prevent residents from sliding. The DON then acknowledged they should not be placing a towel or blanket directly underneath the resident. At that time, the LNHA confirmed that staff should not have a towel of blanket on top of the cushion and should not be underneath as a barrier for residents that were incontinent. The LNHA then stated that a towel or blanket should only be placed underneath a resident if the resident or resident's representative requested it, and it was care planned for it. The LNHA acknowledged that the towel and blanket should not have been directly underneath the resident because it could have compromised the resident's skin integrity. On 02/05/24 at 12:05 PM, the LNHA stated in the presence of the survey team that she went to the comfort care unit and the LPN/UM informed her that it was the hospice aide that had placed the blanket underneath the resident because she thought to make the resident more comfortable. On 02/07/24 at 09:49 AM, the surveyor interviewed the Director of Rehab (DOR) who stated that every resident with a wheelchair had the blue gel pad placed directly underneath the cushion to prevent the resident from sliding out of the chair. The DOR stated that the purpose of the cushion was for additional support, to prevent any skin breakdown, wounds and for comfort. She stated that there should not have been a towel or blanket on top of the cushion because the resident could have slid, and it was not supportive. The DOR emphasized another layer should not have been between the resident and the cushion. She then stated that some residents do request it, but they should be care planned as a preference. On 02/07/24 at 11:27 AM, Regional Nurse #1 stated in the presence of the Licensed Nurse Home Administrator (LNHA), the Director of Nursing (DON), Regional Nurse #2, the Regional LNHA and the survey team that items such as a towel and blanket should not be placed directly underneath the resident because it increased the risk for falls and skin integrity issues. She further stated that you are not getting the benefit of the cushion if you are putting something on top of the cushion.

Complaint #NJ168222 and NJ168566 Based on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 1 of 7 residents (Resident # 97) investigated for Accidents. The deficient practice was evidenced by the following: On 01/30/2024 at 10:55 AM, during the initial tour of the facility, the surveyor observed Resident # 97 in their room in bed. The surveyor observed two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, They haven't used them. when the surveyor asked if the facility had used the floor mats while he/she was in bed. On 02/05/2024 at 09:46 AM, the surveyor observed Resident # 97 in their room in bed. The surveyor observed the two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, No when the surveyor asked if the facility had used the floor mats while he/she was in bed. A review of Resident # 97's Minimum Data Set (an assessment tool) dated 07/17/2023, revealed under section J that he/she had a fall in the last month prior to admission. A review of Resident # 97's Electronic Medical Record (EMR) revealed under Orders, a physician's order for bilateral floor mats beside bed while in bed every shift. The order was started on 08/30/2023. A review of Resident # 97's EMR revealed under Care Plan a focus for risk of falls related to impaired balance and mobility. The focus revealed an initiated date of 09/08/2023. The care plan revealed an intervention for bilateral floor mats at bedside. The intervention revealed an initiated date of 09/25/2023. On 02/05/2024 at 09:54 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM #1) replied, Yes. [He/She] should have them [floor mats] by the bed. At the time of the interview the surveyor showed RN/UM #1 the bilateral floor mats placed against the walls in Resident # 97's room. On 02/06/2024 at 4:00 PM, during an interview with the surveyor, the Director of Nursing said the bilateral floor mats should not have been folded against the wall. During the same interview, the Regional Nurse #1 replied, Injury could occur when the surveyor asked what potential results could have occurred if the floor mats were not placed according to the order. A review of the facility policy titled, Comprehensive Care Plans with a copyright date of 2023, revealed under subsection, Policy Explanation and Compliance Guidelines number 3. letter a. that, The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. § 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates are not 5 percent or greater. This deficient practice was identified for 2 of 5 residents (Resident #143 and Resident #147), and 1of 2 nurses on the second-floor nursing unit during the Medication Administration task. The deficient practice was evidenced by the following: On 02/01/2024 at 08:55 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN) prepare and administer medications to Resident #143 which included Metformin HCL (a medication used for managing high blood sugar levels) 500 milligrams (mg). That medication had a pharmacy label on the package which instructed to give with food. The surveyor observed Resident #143 in their room as the LPN administered the medication. At that time, the surveyor did not observe any food available in the vicinity of the resident. The LPN did not offer the resident any food with the medication. On 02/01/2024 at 09:00 AM, during the medication administration, the surveyor observed the LPN prepare and administer Avacopan (a medication used to treat a group of rare autoimmune conditions that causes an inflammation of blood vessels) 10 mg to Resident #147. That medication had a pharmacy label on the package which instructed to give with food. The surveyor observed Resident #147 in their room as the LPN administered the medication and the LPN did not offer the resident any food with the medication. The surveyor observed a covered meal tray next to the resident. The LPN did not ask the resident if he/she ate their breakfast. On 02/01/2024 at 09:06 AM, the surveyor interviewed the LPN once she returned to the medication cart. The surveyor inquired as to what the policy was about medications that say to take with food. The LPN responded, I try to give meds [medications] to them around breakfast time. The trays come up [to the floor] at 8:35am. I saw the aides delivered trays. There are also snacks in the bottom drawer cart that we can offer with meds. At that time, when the LPN opened the bottom drawer of the medication cart, the surveyor observed no snacks in the drawer. On 02/06/2024 at 04:04 PM, during an interview with the Director of Nursing (DON) and [NAME] Nurse #2, the surveyor inquired as to the expectation when medications were marked to take with food. The DON replied, It should be taken with food, no crackers or cookies, it should be a meal. When the surveyor inquired as to whether the nurses should have assumed that the residents ate breakfast because they saw the food trays had been delivered, the Regional Nurse #2 responded, They should ask the resident or look at the resident's tray, they should not assume. Review of Resident #143's admission Record reflected the resident was admitted to the facility with diagnosis which included but was not limited to type 2 diabetes mellitus without complications (disease affecting blood sugars) and antineutrophilic cytoplasmic antibody vasculitis (group of rare autoimmune conditions that causes an inflammation of blood vessels). Review of Resident #143's Physician Order Summary (POS) included an order for Metformin HCl 500 MG Tablet. Give 1 tablet by mouth two times a day for DM [diabetes mellitus] with a start date of 10/11/2023. The POS also included an order for Avacopan Oral Capsule 10 MG. The order specified to give 3 capsules by mouth two times a day for vasculitis to be administer with food. Medication should be swallowed whole. Do not crush, chew or open capsules. The order for the medication revealed a start date of 12/27/2023. Review of the facility's policy, Medication Administration, updated on 05/30/23, revealed under the subsection titled, Policy Explanation and Compliance Guidelines, #14 Administer medication as ordered in accordance with manufacturer, a. Provide appropriate amount food and fluid. N.J.A.C 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to maintain medications with appropriate dating of medications for 1 of 3 medication administration carts inspected and was evidenced by the following: On [DATE] at 10:43 AM, the surveyor inspected the medication storage cart labeled Cart A on the 2 (two) North Unit with the Licensed Practical Nurse (LPN). The surveyor identified that there was an undated opened foil package containing 17-unit dose vials of the medication Ipratropium Bromide/Albuterol (DuoNeb) used for nebulizer treatments. The surveyor interviewed the LPN at the time of the inspection who confirmed that the medication should have been dated when opened because the medication was only good for two weeks after the foil package was opened. On [DATE] at 10:53 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) for 2 North who stated that medications should have been dated when they were opened because some medications, once opened, expired quicker than other medications. The LPN/UM confirmed that all medications that were on the list of short expiration medications should have been dated when opened and that the nurse could have referred to this list if there were any questions regarding the expiration of medications. She added that the list of short expiration medications was in a book on the medication carts. The surveyor reviewed the list, located on the medication cart, titled, Pharma Accurate. The list contained the medication Ipratropium Bromide/Albuterol (DuoNeb) and indicated that the medication should have been discarded 7 to 14 days once removed from the foil package. On [DATE] at 01:05 PM, the surveyor interviewed the Pharmacy Consultant (PC) who stated that medications with short expiration dates must be dated when opened so that the nurses would have known when the medication would expire from that date. The PC confirmed that Ipratropium Bromide/Albuterol (DuoNeb) expired two weeks after the foil package was opened and that it should have been dated as soon as the nurse opened the foil package. The facility policy titled, Medication Storage indicated that it was the policy of the facility to ensure all medications houses on the premises will be stored in the pharmacy and/or storage rooms according to the manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. NJAC 8:39-29.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident's medical record contained an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, specifically by failing to include pertinent information in the electronic medical record. The deficient practice was discovered for 1 of 1 resident (Resident # 150) reviewed for Medical Records. The deficient practice was evidenced by the following: A review of Resident #150's Electronic Medical Record (EMR) under Progress Notes revealed that he/she was discovered by staff not breathing. The note revealed that the Nurse Supervisor was notified and Resident #150 was declared deceased . The note concluded by revealing that the physician, family, funeral home, and facility administration were notified. A review of Resident #150's physician's orders in the EMR revealed that Resident #150 was a Full Code, meaning life saving measures would have been implemented if the Resident's health declined. A review of the facility provided document titled, Timeline revealed a description of events by date and time leading up to Resident #150's death. The timeline revealed that on [DATE] at 05:40 AM, Cardiopulmonary Resuscitation (CPR) was initiated by the assigned nurse. The document concluded that CPR was discontinued at 05:50 AM. The document further revealed that Resident #150 was unresponsive, cold to touch, and displayed rigidity (inability to be moved out of shape). A review of the facility provided document titled, Witness Statement that was completed by the Registered Nurse present at the time of Resident #150's death confirmed that CPR was initiated around 05:45 AM on [DATE]. The document further revealed that once the physician was notified, CPR was discontinued around 5:50 AM. A review of the document titled, Abstract of Death Certificate Information revealed that Resident #150's immediate cause of death was a Cerebrovascular Accident (damage to the brain from interruption of its blood supply). The document further revealed that the manner of death was natural. On [DATE] at 04:02 PM, during an interview with the surveyor, the Director of Nursing (DON) confirmed CPR was initiated at the time Resident #150 was discovered not breathing. The DON further described that Resident #150 appeared to have been in rigor mortis (stiffening of the joints and muscles of a body after death). On [DATE] at 10:03 AM, during an interview with the surveyor, the Unit Manager/Registered Nurse replied, Of course when asked if CPR had to be documented in a resident's progress note. On [DATE] at 10:36 AM, during an interview with the surveyor, Regional Nurse #1 replied, Yes, absolutely when asked if CPR should have been included in the progress notes in the EMR. Regional Nurse #1 said at the time the nurse documenting could not access Resident #150's record due to Resident #150 being discharged from the EMR. A review of the facility provided policy titled, Documentation of Medical Record revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. N.J.A.C. § 8:39-35.2 (d) 6

Based on observation, interviews, record review and review of facility documentation, it was determined that the facility failed to properly execute its food and nutrition services by not following the established portion control procedure. This deficient practice was evidenced by the following: On 01/30/24 at 11:17 AM, the surveyor interviewed the Director of Dietary (DD) who stated that the facility utilized a four week cycle menu and that they were in week three. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. The cook was observed to use the food scoop and tongs to plate the food, rested her hands on the counter, used the scoop and tongs again, then used her gloved hand to remove whole green beans from the steam table and placed them on a plate, rested her hands on the counter, touched the front of her surgical mask, then used the scoop to plate food again. On 02/02/24 at 12:24 PM, the surveyor interviewed the cook who stated her role was to get the plate, place the food that was called out on to the plate, and then pass it to the dietary aide. The cook was made aware of the surveyor's observation when she used her hands to serve the green beans. The cook acknowledged that she should not have used her hands to serve the food and stated that she was in a hurry and trying to get the food out of the kitchen. The cook stated that it was important to use the utensils to serve the food to prevent cross contamination. The surveyor inquired as to the portion size that was served on each plate and the cook stated, the scoop is four ounces. On 02/05/24 at 12:28 PM, the surveyor interviewed the DD who acknowledged that the cook plated the green beans with her hands. The DD stated that the cook should not have used her hands and that she should have used the tongs to serve the vegetables. The DD stated that it was important to use the scoop because it was a four-ounce (oz) measure for portions and that the portion sizes were established guidelines. The surveyor inquired that if the cook used her hands to serve the food how would she have known the portion size. The DD stated the cook did not know the portion size with her hands and that the scoop was accurate. The DD acknowledged that the use of hands to serve the food did not ensure an accurate four oz portion and that the cook would not have known the portion size using the tongs either. The DD stated that the cook should have used the scoop or spoodle (perforated measured spoon) to serve the green beans. On 02/05/24 at 01:07 PM, the surveyor interviewed the cook and inquired as to whether she knew what portion size to serve on meal trays. The cook stated that everyone got the same portion or if she was told it was a double portion that they would get double the protein. The cook stated that she knew what a portion size was because she had been doing this a long time. When the surveyor inquired about the portion size using her hands, the cook stated that it was the same as the tongs, my finger is just as long as the tong. The cook further stated that it was important to make sure the portion size was correct because she wanted to give the residents enough food to eat and that she did not want them to go hungry. On 02/06/24 at 11:30 AM, the surveyor interviewed the Corporate Registered Dietician (CRD) who stated she was contracted and that today was her first day in the facility. The CRD stated that portion sizes were determined, and most facilities would use a scoop and that it would have depended on whatever the menu extension was. The CRD was unable to speak to where the portion size information came from and who made the menu. The CRD stated that the cook should have used whatever scoop was indicated for that item. She stated that whatever company the facility used that they would use the menu extensions and serving sizes from their menu. The CRD stated, Usually whatever company comes in will have a Registered Dietician from that company that develops the menu. On 02/06/24 at 04:09 PM, the administration team was made aware of the kitchen concerns. At that time, the surveyor interviewed the Regional Nurse (RN) about meal portion sizes. The surveyor inquired as to what the expectation was for kitchen staff to accurately portion the food. The RN stated the cook should not have used her hands but should have used the appropriate scoops, spoodle, ladle, or premeasured devices to ensure the proper nutritional caloric intake of each resident. During the interview with the RN, the Regional Licensed Nursing Home Administrator stated the importance of accurate food portioning was adequate nutrition and intake for the resident. A review of the facility documentation, Week 4 menu, dated 11/29/23, revealed the menu on 02/05/24 included Seasoned [NAME] Beans. A review of the facility documentation, Master Menu, September 2023, Week: 4, Day: MONDAY, revealed under MENU ITEM in the LUNCH column was [NAME] Beans, and the portion size listed under the REGULAR column was ½ cup. A review of the facility documentation, Operations Policy and Procedure Manual Job Descriptions: Cook, revised 2/25/2008, revealed Duties and Responsibilities: Dietary Service: 3. Serve food in accordance with established portion control procedures. A review of the facility policy, Maintaining a Sanitary Tray Line, revised 3/2023, revealed Compliance guidelines: 3. During tray assembly, staff shall: b. Use utensils such as tongs, serving spoons, etc. to handle food as much as possible. NJAC 8:39-17.2(a); 17.4(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/30/24 at 10:01 AM, the surveyor arrived in the kitchen and was informed by the [NAME] that the Director of Dietary (DD) was not on location. At 10:06 AM, in the presence of the Cook, the surveyor toured the kitchen and observed the following: 1. On a rolling metal rack in the dairy refrigerator, there were four trays containing oval tan patties, that the [NAME] identified as hash browns, that were uncovered with no label or dates. The [NAME] acknowledged the trays should have been covered, labeled and dated. There was one 3.5 pound (lb) opened package of [NAME] that was wrapped in clear plastic wrap with no open or use by date. The [NAME] stated that he did not know when it was opened and that it should have had a label marked when it was opened. The [NAME] stated it was important to make sure food was labeled and dated when it was opened so the staff knew when the food would have gone bad. The [NAME] stated they would be thrown away. There was one opened plastic bag marked grated parmesan cheese that was wrapped in clear plastic wrap with no open or use by dates. There was one opened plastic bag marked mozzarella cheese that was wrapped in clear plastic wrap with no open or use by dates. The [NAME] was unable to state when they could have been used by and stated he would discard them. At 10:16 AM, the Director of Dietary (DD) joined the tour, and the [NAME] left the area. 2. In the freezer, there was one box marked pancakes with the inner clear plastic bag open with the pancakes visible and open to air. The surveyor inquired as to whether the pancakes should be visible and open to air and the DD stated no, because something could have been wrong with them, and that she would throw them away. There was one tied clear plastic bag containing round tan dough with brown chips, with no label or dates. The DD stated the bag contained chocolate chip cookies and acknowledged that the bag had no label. The DD stated the bag should have had a label marked with the date that they were opened to make sure they were not old and out of date. There were two white undated cardboard packages marked cherry blintzes. The packages had tan stains and the edge of the packages were opened with the blintzes visible and open to air. The DD acknowledged the blintzes were not wrapped nor stored correctly and stated they should have been dated when they were taken out of the box. The DD removed them from the freezer. 3. In the can section in the dry storage room, there was one 6 lb dented can of crushed pineapple, one 106 ounce (oz) dented can of tropical fruit salad, and two 6 lb 10 oz dented cans of pumpkin. The DD removed the cans to the dented can section. 4. In the working supply overflow can section in the kitchen, there was one 6 lb 7 oz dented can of stewed tomatoes. The DD acknowledged the dented cans and removed them to the dented can section. The DD and stated it was important that the cans were not dented to prevent illness. 5. There was an uncovered mixer with the bowl visibly clean with white debris noted behind the bowl on the stand and brown debris on the handle. The DD acknowledged the debris, stated it should have been wiped and that it was important to keep the mixer clean to prevent cross contamination. 6. In the dairy prep area, there was one roll of clear plastic wrap that was uncovered and exposed and one roll of foil that was uncovered and exposed. The DD stated that the clear plastic wrap and the foil were used to cover pans and that they should not have been open and exposed because dust could have gotten on them. 7. In the spice area, there was one opened 16 oz jar of white pepper, one opened 18 oz jar of garlic powder, one opened 1 lb jar of celery seed, all with no open or use by dates and no expiration dates. The DD stated that the spices should have been dated when they were opened and threw the spices into the trash. 8. In the meat refrigerator, there was a large roasting pan partially covered with a sheet pan, with the meat visible and open to air and a label marked beef 1/30. The DD identified the meat as brisket and stated the meat should not have been visible. 9. In the freezer, there was a half pan covered with clear plastic wrap that was covered with ice with no labels or dates. The DD identified the contents as chicken backs bones and stated that it should have had a label with the date that the chicken was put in the freezer. The DD stated it was important that food was labeled and dated to ensure that it did not become potentially hazardous. The DD removed the pan from the freezer. Stuck to the underside of that half pan was a plastic bin that contained six packages of individually wrapped dark red meat, that the DD identified as beef [NAME], that had ice and frozen red liquid in the bags. There were no labels and no dates. Stuck to the underside of the plastic bin was a sheet pan that contained a tied bag of frozen tan meat with no label and no dates. The DD identified the meat as chicken legs. Resting under the sheet pan was a cardboard box labeled boneless shank meat, dated 2021. Inside the box was a knotted clear plastic bag that contained seven beef [NAME] with visible ice on the meat and in the bag, and a large piece of ice resting on the bag. The DD stated the meats were not stored correctly and that they should have been labeled with the received dates and dated when they were prepped and placed into the freezer. The DD further stated that it was important to store and label food correctly for safety, to decrease cross contamination and for the prevention of food borne illness. 10. In the dry storage area spice cabinet, there was one opened 8 oz jar of white pepper, one opened 12 oz jar of ground basil, one opened 1 lb jar of ground ginger and one opened 18 oz jar of garlic powder with no open or use by or expiration dates. The DD stated the spices should have been marked when they were opened and then disposed of them in the trash. 11. In the cook prep area, there was one roll of clear plastic wrap that was opened and uncovered. The DD stated the plastic wrap was used to cover food and that it should have been covered. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. The cook was observed to use the food scoop and tongs to plate the food, rested her hands on the counter, used the scoop and tongs again, then used her gloved hand to remove whole green beans from the steam table and placed them on a plate, rested her hands on the counter, touched the front of her surgical mask, then used the scoop to plate food again. On 02/02/24 at 12:24 PM, the surveyor interviewed the cook who stated her role was to get the plate, place the food that was called out on to the plate, and then pass it to the dietary aide. The cook was made aware of the surveyor's observation when she used her hands to serve the green beans. The cook acknowledged that she should not have used her hands to serve the food and stated that she was in a hurry and trying to get the food out of the kitchen. The cook stated that it was important to use the utensils to serve the food to prevent cross contamination. On 02/05/24 at 12:28 PM, the surveyor interviewed the DD who acknowledged that the cook plated the green beans with her hands. The DD stated that the cook should not have used her hands and that she should have used the tongs to serve the vegetables. The DD further stated that it was important to use the utensils to serve the food to prevent cross contamination. A review of the facility policy, Maintaining a Sanitary Tray Line, revised 3/2023, revealed Policy: This facility prioritizes tray assembly to ensure foods are handles safely and held at proper temperatures to prevent the spread of bacteria that may cause food borne illness. Compliance guidelines: 3. During tray assembly, staff shall: b. Use utensils such as tongs, serving spoons, etc. to handle food .g. Change gloves after sneezing, coughing or touching face, hands or hair with gloved hand. A review of the facility documentation, Operations Policy and Procedure Manual Job Descriptions: Cook, revised 2/25/2008, revealed Duties and Responsibilities: Safety and Sanitation: 2. Ensure that safety regulations and precautions are followed at all times by all personnel. 3. Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/01/2024 at 08:55 AM, during the Medication Administration task on 2 South unit, surveyor # 2 observed LPN # 2 administering medications to Resident # 19. Upon finishing the medication administration, surveyor # 2 observed LPN #2 exit the room and approach the medication cart. Surveyor # 2 then observed LPN #2 prepare medication for Resident #143. LPN #2 did not perform hand hygiene between finishing the medication administration with Resident # 19 and beginning the medication administration for Resident #143. During an interview with surveyor # 2 at that time, LPN #2 was asked when hand washing was to be performed and LPN #2 stated, between residents. When asked if she had washed her hands between Resident #19 and Resident # 143, LPN #2 responded, No, I forgot. On 02/01/24 at 11:37 AM, surveyor # 2 interviewed the Infection Preventionist (IP) who was asked when hand hygiene should have been done during medication administration. The IP stated, hand hygiene should be done prior to starting, and after giving medication. They should use hand sanitizer or washing hands with soap and water. It is recommended to wash with soap and water every three patients. 3. On 02/02/24 at 11:00 AM, on 2 South Unit, surveyor #3 observed LPN#3 perform a wound care treatment for Resident #65, assisted by CNA#2. LPN/UM#2 was also present for the observation. LPN/UM #2 stated she was there to observe the wound care task, to complete competencies for LPN#3, and as moral support. Surveyor #3 observed CNA #2 enter the resident's room and don gloves. She then assisted LPN #3 in repositioning Resident #65's incontinence diaper which was opened in the front, while the back of incontinence diaper was pulled down. CNA#2 then rolled the resident to their left side allowing LPN#3 to perform the wound care. At that time, CNA#2 held the resident in the side position by placing her gloved hands-on the resident's buttock area and lower back. LPN#3 then proceeded to complete the wound care on resident #65. With the same gloves, CNA#2 and LPN#3 redressed the resident, reapplied the incontinence diaper, and repositioned the resident. With the same gloves, CNA#2 then held the resident's hands, repositioned the resident's blankets, and adjusted the bed pillows. CNA#2 then removed her gloves and proceeded to the bathroom to wash her hands with soap and water for 40 seconds. On 02/02/24 at 11:25 AM, surveyor#3 interviewed CNA#2 and made her aware of the wound care observations. CNA #2 stated that she was not aware of any breach in the infection prevention protocol and was not aware she did not change her gloves. CNA#2 stated she should have changed her gloves and that improper hand hygiene could have spread infection. On 02/02/24 at 11:35 AM, surveyor#3 interviewed LPN/UM#2 and discussed the wound care observation. LPN/UM#2 stated that CNA#2 should have changed her gloves after she assisted with the dressing change, before she proceeded to reposition the resident, and when she touched the resident's hands. A review of the facility policy, Hand Hygiene, accessed June 2023, revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or use of an antiseptic hand rub .Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The handout Hand Hygiene Table revealed Condition: Between resident contacts, After handling contaminated objects, Before preparing or handling medications, Before and after handling clean or soiled dressings, linens etc., After handling items potentially contaminated with blood, body fluids, secretions, or excretions, When, during resident care, moving from a contaminated body site to a clean body site . A review of the undated facility policy, Nursing Pertinent Policies, revealed, Assisting the Resident with In-Room Meals, Preparation: 11. Employees must wash their hands before serving food to residents .if there is contact with soiled dishes, clothing or the resident's personal effects, employee must wash his/her hands before serving food to the next resident. NJAC 8:39-19.4 (m)(n) Complaint NJ # 165358 Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated: a) during a meal tray pass observation for 1 of 4 units, (2 North unit), b) during medication administration for 1 of 3 residents observed (Resident #143), and c) during wound care for 1 of 3 residents observed (Resident #65). The deficient practice was evidenced as follows: 1. On 01/30/24 at 12:34 PM, the covered food cart arrived on The [NAME] hallway on Unit 2 North. At 12:51 PM, surveyor #1 observed a Certified Nursing Aide (CNA #1) who approached the food cart, removed a tray from the cart, entered Resident # 302's room and placed it on their bed side table (BST). CNA #1 then removed the lid from the foam cup, removed the lid from the orange soda bottle that was previously resting on the Resident's BST, poured the soda into the foam cup and replaced the lids on the soda and the foam cup. CNA #1 then removed the wrapping from the straw and placed the straw into the foam cup lid, removed the plastic plate cover and exited the room. CNA #1 returned to the food cart and placed the plastic plate cover on top of the food cart, removed a meal tray from the cart and entered Resident #303's room and placed the meal tray on the BST. CNA #1 returned to the food cart, removed a tray, and placed it on top of the food cart. CNA#1 partially lifted the lid from the ice cream, removed the silverware from the plastic baggie with her hands and placed them on the tray, opened a can of cola and poured the contents into a foam cup, placed a lid on the cup, removed half the straw wrapper and placed the straw into the lid of the foam cup. CNA #1 then entered Resident #72's room and, while holding the meal tray in her left hand, used her right hand to remove trash from the BST and throw it into the trashcan. CNA #1 then placed the meal tray on the BST, moved the Resident's wheelchair closer to his/her bed, removed a blanket from the Resident, moved the Resident's legs over the side of the bed, assisted the Resident to sit up on the side of the bed, then provided hands on assistance to transfer the Resident to the wheelchair and repositioned the Resident once in the wheelchair. CNA #1 then moved the wheelchair closer to the bed, moved the BST in front of the Resident, removed the lid from the soup, removed the lid from the ice cream, moved the foam cup closer to the Resident, removed the plastic lid from the plate and exited the room. CNA #1 placed the plastic lid on top of the food cart then moved the beverage cart, that was next to the food cart, into the snack room, opened the refrigerator and placed the containers of juice into the refrigerator. No hand hygiene was observed during the observation. On 01/30/24 at 12:58 PM, surveyor #1 interviewed CNA #1 who stated that when the food carts arrived on the unit that it was the CNA and nurse's responsibility to check the trays for accuracy and to serve the trays to the residents. CNA #1 stated during meal tray pass that hand hygiene (HH), which she explained was washing with soap and water or using hand gel, should have been done before meal tray pass was started, when it was completed, and that sometimes she performed HH in between if she touched their stuff like silverware or cups and continued, I was rushed today because the trays were late. Surveyor #1 informed CNA #1 of the meal tray pass observation and that no HH was observed. CNA #1 acknowledged that she did not perform HH between passing each resident's tray and that she should have performed HH after delivering Resident #302's tray. CNA #1 stated that it was important to have performed HH correctly to prevent cross contamination and shared germs. On 01/30/24 at 01:15 PM, surveyor #1 interviewed the Licensed Practical Nurse (LPN #1) who stated that it was the CNA's responsibility to distribute meal trays on the unit and that HH should have been performed between each tray that was passed. Surveyor #1 informed LPN #1 of the CNA's meal tray pass observation. LPN #1 stated that CNA #1 did not perform HH correctly and that she should have cleaned her hands before and after touching each tray. LPN #1 further stated that it was important to perform HH correctly, so germs were not transferred from resident to resident. On 01/30/24 at 01:26 PM, surveyor #1 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that staff were responsible for the distribution of meal trays on the unit and that she expected staff to perform HH before and after obtaining a meal tray and serving the next resident. Surveyor #1 informed the LPN/UM #1 of the CNA's meal tray pass observation. LPN/UM #1 acknowledged that CNA #1 did not perform HH correctly between each resident and stated that HH was important so germs were eliminated, and contamination was avoided. On 02/01/24 at 10:42 AM, surveyor #1 interviewed the Assistant Director of Nursing (ADON) who stated that it was the CNA's responsibility to distribute meal trays on the unit and that HH should have been performed after the resident's trays were set down, if the CNA had to help the resident open food items, any contact with the resident, and when anything was touched. Surveyor #1 informed the ADON of the CNA's meal tray pass observation from 01/30/24. The ADON stated that CNA #1 did not perform HH correctly and that it was important for proper HH to prevent food borne disease and passing of germs. On 02/01/24 at 11:26 AM, surveyor #1 interviewed the Infection Control Nurse (ICN) who stated that during meal tray pass, she expected HH to be performed when the trays were touched or when food was opened for a resident. Surveyor #1 informed the ICN of the CNA's meal tray pass observation from 01/30/24. ICN stated that CNA #1 did not perform HH correctly and that it was important for proper HH to prevent the spread of germs or infection. On 02/01/24 at 11:41 AM, surveyor #1 interviewed the Director of Nursing (DON) who stated that the CNAs passed the meal trays to the residents, and she expected HH to have been performed every time they touched anything or they go to get another tray on the cart. Surveyor #1 informed the DON of the CNA's meal tray pass observation from 01/30/24. The DON acknowledged that CNA #1 did no HH and that she expected staff to perform HH between each resident. The DON stated that it was important to perform HH correctly to prevent the passing of germs. On 02/06/24 at 03:39 PM, the surveyors met with the administration team who were made aware of CNA #1's meal tray pass observation from 01/30/24. A review of facility documentation revealed Meeting Sign-In Sheets for topics which included: Hand Hygiene .signed by CNA #1 and dated 11/29/23, and 12/12/23. A review of facility documentation, dated 12/02/23 and 01/10/24, revealed a Hand washing observation performed by CNA #1, and rated A=Performs skill independently and completely. Both forms were signed by an Observer. A review of facility documentation revealed an Employee Education Packet, Hand Hygiene, dated 11/29/23, for CNA #1 with Competency Demonstrated box checked YES and Observer Initials marked.

Based on observation, interview, record review and review of other documentation, it was determined that the facility failed to ensure a right palm protector was applied and removed daily according to the physician's order, for 1 of 2 residents reviewed for limited range of motion, (Resident #53). This deficient practice was evidenced by the following: On 9/20/21 at 11:57 AM, the surveyor observed resident #53 in the residents' room, sitting in a wheelchair, neatly dressed and groomed. The residents' right arm was lying limp against his/her right side. Resident #53, using his/her left hand, positioned his/her right arm across his/her lap. The surveyor observed that the resident's right hand was tightly contracted; a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. There was no palm protector in place. The resident stated that he/she is mostly independent but needs assistance transferring and getting dressed. The resident added that he/she does not use a brace or palm protector for her arm and said, If I had one, I'd wear it! A review of the resident's medical records identified that the resident was admitted to the facility with diagnoses which included but not limited to; hemiplegia; paralysis of one side of the body, affecting the right dominant side. A review of Resident #53's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/18/2021, revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating that the resident is cognitively intact. Under section O, Special Treatments, Procedures, and Programs, restorative nursing programs included a splint or brace assistance. A review of the July, August and September 2021 Physician's Order Summary Report revealed a physician order with an original start date of 4/26/18, for a right palm protector; put on during AM (morning) care off at HS (hour of sleep). Resident may wear longer if desired. Day shifts and evening shift. A review of the Treatment Administration Record (TAR) dated July, August, and September of 2021, included documentation that the right palm protector had been applied and removed as ordered. During an interview with the surveyor on 9/21/21 at 09:05 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #2) was asked if the Resident #53 had a palm protector. At that time, the surveyor and LPN/UM #2 reviewed the TAR that indicated that the palm protector was in the treatment plan and documented as applied and removed. The UM stated that if the resident was not wearing the palm protector, it must be in in her room. The surveyor and LPN/UM #2 went to the resident's room and LPN/UM #2 was unable to locate the palm protector. LPN/UM #2 asked Resident #53 where the palm protector was and the resident replied, I don't have one. LPN/UM #2 stated that she would follow up with Occupational Therapy and said maybe it was discontinued, and we didn't take it off the TAR. During an interview with the surveyor on 9/22/21 at 10:13 AM, the Therapy Program Manager (TPM) stated that the process for notification of changes in services are documented in the therapy network computer system. The TPM said the therapist will notify the nurses of any changes such as resident refusal of treatment. She went on to say the therapist will complete a Nursing/Therapy Communication for Adaptive Equipment and Positioning form to give to nursing. The TPM also said that the therapist is responsible for documenting a formal order in the electronic record that is accessible to nursing and physicians. The TPM was unable to provide copies of the Nursing/Therapy Communication for Adaptive Equipment and Positioning form for Resident #53. During a follow up interview with the surveyor on 9/23/21 at 11:03 AM, the TPM stated that the therapist documented in therapy notes to discontinue the palm protector and to use a towel roll, but it was not appropriately communicated to nursing or the physician. The TPM acknowledged that there was no documentation in the EMR that the order was discontinued by therapy, nor was there a Nursing/Therapy Communication for Adaptive Equipment and Positioning form to alert nursing. During an interview with the surveyor on 9/28/21 at 10:37 AM, the Certified Nursing Assistant (CNA #2) caring for resident #53, stated that she has not seen the resident wearing a palm protector or appliance while under her care for the past week. During an interview with the surveyor on 9/28/21 at 10:40 AM, LPN #2, caring for Resident #53, stated that she has been the resident's primary day shift nurse for the past six months. LPN #2 added that she had never seen the resident wearing a palm protector or any other hand device including a rolled towel, during that six-month period. A review of an undated facility policy titled Coordination of Specialized Rehabilitative Services, revealed under the Policy Interpretation and Implementation section, number 3. Once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment and will give discharge recommendations to the nursing supervisor and/or designee who will implement to assure that the resident maintains his/her functional and physical status. NJAC 8:39-11.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial tour of the Seaside unit on 9/17/21 at 10:16 AM, the surveyor observed a Foley catheter drainage bag that was attached to Resident #35's bed frame. The drainage bag contained urine and was not covered to maintain privacy. During an interview with the surveyor on 9/21/21 at 9:33 AM, Resident #35 stated that he/she wears a leg bag (drainage bag secured to the leg) when he/she is in a wheelchair. At that time, the surveyor observed that the drainage bag attached to the bed was not covered to maintain privacy. A review of the MDS dated for 6/26/21, revealed Resident #35 had a BIMS score of 15/15 indicating the Resident is cognitively intact. The MDS also revealed that Resident #35 had an indwelling Foley catheter. A review of the Care Plan (plan that provides direction on an individual's care) revealed Resident #35 had an indwelling Foley catheter due to retention of urine. During an interview with the surveyor on 9/21/21 at 10:01 AM, Certified Nursing Assistant (CNA #2) said that Resident #35's catheter tube is disconnected from the drainage bag and replaced with a leg bag when he/she gets up. She also said Resident #35's leg bag is rinsed after use and stored in a plastic bag that's inside the bathroom. She said that Resident #35 gets a new leg bag weekly. CNA #2 further stated that Resident #35 does not need a privacy cover for the drainage bag because he/she uses a leg bag that is under his/her clothing. During an interview with the surveyor on 9/21/21 at 12:54 PM, Licensed Practical Nurse (LPN #1) said Resident #35 gets a new leg bag about every week. A review of the manufacture package instructions for the Covidien Dover Urine Leg Bag (the bag Resident #35 uses) indicated that the bag is single use. A review of a facility policy titled, Preventing Catheter Associated Urinary Tract Infections (CAUTI) with review dates of 1/2019 and 11/2020, under section 3.3 revealed, If there are breaks in aseptic technique, disconnection of tubing or leakage from the bag; the drainage system should be replaced. The catheter-tubing junction should be disinfected with 70% alcohol or CHG before connection to the new drainage system. If the catheter becomes contaminated, the catheter should also be replaced. Urinary drainage bags may be changed one time using aseptic technique. NJAC 8:39-19.4 (a) 8:39-27.1(a) Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a) maintain a Foley catheter bag in manner to promote dignity, b) failed to ensure the catheter or privacy bag did not come into contact of the floor, c) change a resident leg bag daily as per facility policy for 2 of 2 Residents reviewed for Urinary Catheter (Resident #33 and Resident # 35) . This deficient practice was evidenced by the following: 1. During the initial tour of the [NAME] unit on 9/17/21 at 11:41 AM, Resident #33 was observed lying in bed. The Foley was attached to the bed and visible from the hallway and not in a privacy bag. On 09/21/21 at 11:31 AM, Resident #33 was observed in his/her room sitting in a wheelchair. The Foley was in a blue privacy bag attached under the seat of the wheelchair in contact with the floor. On 9/22/21 at 11:58 AM, Resident #33 was observed in his/her room sitting in the wheelchair. The Foley was in a blue privacy bag attached under the seat of the wheelchair in contact with the floor. On 9/27/21 at 09:18 AM, Resident #33 was observed lying in bed watching TV. The Foley was attached to the bed, with the privacy bag above the Foley bag itself. The Foley bag was in contact with the floor and visible from the hallway. According to the Record of Admission, Resident #33 was admitted with diagnosis including but not limited to; Acute Kidney Injury. A review of the Minimum Data Set (MDS) an assessment tool, dated 7/2/21, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident is cognitively intact. The MDS further revealed the Resident has Urinary Retention and used an indwelling catheter. A review of Resident #33's care plan revealed under Problem/Strengths section with original date of 6/26/21 At risk for complications related to use of indwelling catheter. Under the Goal revealed will remain free of urinary tract infection. Under the interventions section indicated Keep Drainage Bag covered to promote dignity. During an interview with the surveyor on 9/22/21 at 11:51 AM, Certified Nursing Assistant (CNA# 1) said we put the Foley in a privacy bag when they come out and hang under the wheelchair. CNA #1 went on to say No, the Foley shouldn't be touching the floor even in a privacy bag. If a resident uses a leg bag I put it on during AM care. She also said when the leg bag is dirty I tell the nurse and get a new one. We don't change the leg bag every day. On 9/22/21 at 11:58 AM the surveyor accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM #1), went to Resident #33's room. The LPN/UM #1 confirmed the Foley in the privacy bag was in contact with the floor. The Unit Manager said No it (the Foley) is supposed to be off the floor. During an interview with the surveyor on 9/27/21 at 12:37 PM, the Director of Nursing said the expectation is the Foley should be covered in privacy bag when in the bed and wheelchair and not to be on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to A.) provide a duration of use for an order of Ativan gel (a psychotropic medication) as needed and B.) failed to follow the duration indicated on the controlled drug administration record by administering Ativan past the duration of the order for 2 of 5 residents reviewed for unnecessary medications, (Resident #19, Resident #16). The deficient practice was evidenced by the following: 1. According to a Minimum Data Set (an assessment tool), dated [DATE], Resident #19 had diagnoses including but not limited to; Non-Alzheimer's Dementia (cognitive impairment of the brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear), and Depression (condition associated with the lowering of a person's mood). A review of Resident #19's physician's orders revealed an order dated [DATE], for Ativan 0.5 milligram (mg) gel as needed every 4 hours. The directions for use indicated to apply 2 mg by topical route (directly on to the skin), every four hours as needed, if oral Ativan is not tolerated. A further review of the physician's orders revealed that the order for oral lorazepam 1 mg tablet was discontinued on [DATE]. A review of the Controlled Drug Administration Record (Count-down log of the receipt and administration of controlled drugs) with a received date of [DATE], labeled for lorazepam (generic name for Ativan) 1 mg/ml (milliliter) TDG. The label instructions for use indicated, Apply one syringe (1 mg) to skin every 4 hours as needed for 14 days (only if oral Ativan not tolerated). A review of the Controlled Drug Administration Record showed administration of the Ativan gel from March of 2021 through August of 2021. During an interview with the surveyor on [DATE] at 12:41 PM, Licensed Practical Nurse (LPN #2) said Resident #19 did not have an order for oral Ativan. During an interview with the surveyor on [DATE] at 8:38 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #2) confirmed an order for Ativan gel 0.5 mg that began in March, 2021. LPN/UM #2 said she was not sure how the order for Ativan did not come out of the system after 14 days. During an interview with the surveyor On [DATE] at 10:00 AM, when asked if a new order for Ativan was needed after 14 days, the Assistant Administrator said the physician should have written a new script. A review of the Consultant Pharmacy Evaluation form for Resident #19, did not include documentation regarding the as needed Ativan from March, 2021 through September, 2021. 2. According to Resident #16's medical record (MR), Resident #16 had the following diagnoses: major depressive disorder, anxiety disorder, restlessness and agitation, and Alzheimer's disease. A review of the physician's orders revealed Resident #16 had the following order, dated [DATE]: Lorazepam (a medication used to treat anxiety) 0.5 mg tablet 1 tablet (0.5 mg) by oral route every 4 hours for 30 days as needed for agitation. According to the MDS dated [DATE], Resident #16 had a Brief Interview for Status score of 4, indicating severe cognitive impairment. Section I of the MDS identified the following active psychiatric/mood disorders: anxiety disorder and depression. Section N of the MDS revealed that Resident #16 received daily antianxiety medication. A review of the monthly Consultant Pharmacist Evaluation (CP) form for Resident #16 revealed that on [DATE], the CP made the following comment: Lorazepam prn (as needed) - [DATE] - past stop (x 30 days) A review of the Medication Administration Record Form (MAR) for [DATE], [DATE], and [DATE], revealed that Resident #16 had an order for Lorazepam 0.5 mg tablet give 1 tablet (0.5 mg) by oral route every 4 hours for 30 days as needed for agitation, dated [DATE]. A review of the [DATE] MAR for Resident #16 revealed an order for Lorazepam 0.5 mg tablet give 1 tablet (0.5 mg) by oral route every 4 hours for 30 days as needed for agitation, start date [DATE] and a discontinuation date of [DATE]. During an interview with the surveyor on [DATE] at 10:22 AM, LPN/UM#3 stated, I believe the physician renewed the prescription. We get the monthly recommendations from pharmacy and we read what is on there and we will contact the physician to see if they agree or disagree with the recommendations. Psych (psychiatry) does a lot of our recommendations but since he/she is on hospice the physician and hospice collaborate for her care needs. A review of the Consultant Pharmacist's Monthly Report, the CP had the following suggestion dated [DATE] for Resident #16: The medication administration record should clearly indicate the last day for prn (as necessary) lorazepam therapy (was ordered for 30 days on [DATE]). Please discontinue prn lorazepam. A review of the Action Taken response area of the sheet revealed the following: Noted. Med continued per MD. During an interview with the surveyor on [DATE] at 10:03 AM, the Director of Nursing (DON) presented the surveyor with a physician progress note, dated [DATE] for the continued use of oral Ativan (lorazepam). The surveyor referenced that the original order for the oral Lorazepam was dated [DATE]. The DON responded, That would have expired after 30 days and we would have had to get a new order and the physician would have to document a rationale for continuation of the drug. The DON further stated, The [DATE] CP recommendation was addressed, I'm told. The surveyor asked the DON what the time frame would be for the facility to respond to the CP monthly recommendations, per facility policy. The DON responded, I'm not sure of the time frame we have to respond but I tell our nurses to try and get it done within a week, preferably sooner. The pharmacist emails them to us and then we distribute it to our nursing units. I'm not sure if we have a policy for that at this time. The surveyor then asked the DON how the 30-day Lorazepam order with a start date of [DATE] could continue for approximately 3 months without a documented physician rationale and a new prescription. The DON responded, In order for the order to continue we would need to have a new prescription every 30 days with a documented rationale by the physician. A review of the facility Integrated Progress Notes for Resident #16, with a date range of [DATE] up to and including [DATE] did not include documentation of a rationale for continued use of Lorazepam. A review of the facility policy title, Psychotropic Medication Policy and Procedure with a review date of 5/2021, under the section titled, Responsible Party - Actions Required: Primary Care Physician, PA or APN number 2. revealed, Document's rationale and diagnosis for use and identifies target symptoms. Number 8. under the same section revealed, Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. A review of the same policy under the section titled, Pharmacist and/or consulting pharmacist, number 7. revealed, Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. Number 9. under the same section revealed, Notifies the physician and the nursing unit if whenever a psychotropic medication is past due for review. The surveyor reviewed the facility policy titled Monthly Consultant Reports, reviewed date: 4/13. The following was revealed under the heading Policy Interpretation and Implementation: 2. It is the responsibility of the Director of Nursing Services to implement the consultant's recommendations. N.J.A.C. 8:39-29.3(a)(4)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/17/2021 from 9:58 to 10:55 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. The FSD was observed to perform testing of the wash water temperature and the sanitizer level of the three-compartment sink. Upon completion of the temperature and sanitizer level the surveyor requested to see a copy of the temperature and chemical sanitization logs for the three-compartment sink. The FSD stated, I don't have a temperature log or sanitizer level log for the three-compartment sink. I've never had a log for that in 18 years. The FSD further stated, You're right, I should have one for monitoring purposes. We test for sanitizer and the maintenance department tests the water temperatures. We will have to start a log. 2. During the observation of the high temperature dishmachine the surveyor observed the assigned Kitchen Utility (KU) staff member utilize a 1-Temp-Thermolabel (a test strip for verifying cage washer sanitation, for cart washers and washer disinfectors to assess for appropriate water temperatures). The FSD explained that the thermo label is then attached to the Dish Machine Temps log for monitoring. The log is completed three times a day for the breakfast, lunch, and dinner meals. On interview the KU stated to the surveyor, Before I start dishwashing, I ensure the machine is meeting minimum temperature requirements for the wash and rinse. If the machine is not meeting the minimum requirements, then I report it to the supervisor. The surveyor requested to see the Dish Machine Temps log. The Dish Machine Temps log was observed to be completed up to the 14th of September for all meals with attached 1-Temp-Thermolabels. No temperatures were recorded for 7:00 AM, 11:00 AM and 4:00 PM on the 15th of September. No temperatures were recorded on the 16th of September for 7:00 AM, 11:00 AM and 4:00 PM. No temperature was recorded on the 17th of September. On interview the FSD stated, I'm guessing they didn't do them on those days. It should be completed before each service and before initiating dish washing. 3. A Temperature log was attached to the front doors of refrigerator box #9. No internal temperatures of the refrigerator were recorded for the following dates: 9/10/2021 AM, 9/11/2021 AM and PM, 9/12/2021 AM and PM, 9/14/2021 PM, 9/15/2021 PM, 9/16/2021 PM and 9/17/2021 AM. The following was revealed according to the instructions on the log, This log will be maintained for each refrigerator and freezer (both walk-in and reach-in units) in the facility. A designated food service employee will record the time, air-temperature, and their initials. The food service supervisor will for each facility will verify that food service employees have taken the required temperatures by visually monitoring food service employees and reviewing, initialing, and dating a sample of logs each month. 4. On a middle shelf of refrigerator box 7, a Styrofoam plate with clear plastic covering contained sliced tomatoes and a bowl, with clear plastic covering, contained a garden type salad. No dates were observed on either food product. On interview the FSD stated, They were from last night, but they're not dated so I'm throwing them away. In addition, a lower shelf had 2 sheet pans that contained 7 smoked fish platters. 2 of 7 smoked fish platters had no dates. The FSD stated, They were from last night for Yom Kippur. They should have been dated. I'm trashing them. Review of the refrigerator box #7 Daily Freezer/Refrigerator Temperature Log revealed that no temperatures were recorded on 9/10/2021 AM, 9/11/2021 AM and PM, 9/12/2021 AM and PM, 9/16/2021 AM and PM and 9/17/2021 AM. 5. Review of the refrigerator Box #5 Daily Freezer/Refrigerator Temperature Log revealed that internal temperatures were not recorded for the following dates: 9/10/2021 AM, 9/11/2021 AM and PM, 9/12/2021 AM and PM, 9/15/2021 AM, 9/16/2021 AM and PM and 9/17/2021 AM. 6. The surveyor removed the can opener from its slot in the dairy prep area. The surveyor wiped their index finger on the upper can opener area next to the blade used to open cans. A black, greasy substance was observed on the surveyor's finger. On interview the FSD stated, a KU washes it once per week. The FSD removed the can opener and instructed a KU staff to clean it. 7. In Dairy Freezer #2 on an upper shelf, a blue plastic bag contained frozen cod. The bag was removed from its original container and was not labeled or dated. The FSD stated, It's not labeled or dated. I'm throwing it away. On the same shelf, a bag contained frozen cinnamon rolls. The bag was removed from its original container and had no dates. They are going in the trash too. We are usually not in this situation. 8. In the Dairy Dry Storage area, a can of shredded sauerkraut on an upper rack of a multi-tiered rack, had a significant dent in the side of the can. The FSD stated The KU must have missed that one. The FSD removed the can to the designated dented can area. 9. A cleaned and sanitized meat slicer in the meat kitchen was observed on top of a counter. The meat slicer was observed to have unidentified food debris below the blade surface. The FSD and surveyor went to the break room and interviewed the cooks. When questioned whether they had used the meat slicer on this date, all staff responded no. The FSD directed the cook to clean and sanitize the meat slicer. On 9/23/2021 from 10:07 to 10:22 AM the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM #3), observed the following on the Seaside/Comfort Care Unit Pantry: 1. On the door of the refrigerator an 8-ounce whole milk had a manufacturer's sell by date of SEP 21 On a lower shelf in the refrigerator, an Olive Garden Signature Italian Dressing bottle had a manufacturer's best by date of JUL/02/18'. On an upper shelf, an opened and exposed 8-ounce whole milk had a sell by date of SEP 18. On an upper shelf, a Styrofoam plate covered with clear plastic wrap contained an unidentified sandwich with sliced onions and a tomato slice also on the plate. The plate had no name or date. On the upper shelf a cardboard bowl with a white plastic lid that contained an unidentified food had no name or date. On the same shelf, a small, plastic, clear container with a red plastic lid contained an unidentified white liquid. The container had no name or date. 2. In an upper cabinet, an apple was observed on the upper shelf. The apple was mushy to the touch. When interviewed LPN/UM #3 stated, The foodservice department is responsible for maintaining the pantry and discards any foods that are expired or unlabeled. Maintenance does daily temperature checks. The LPN/UM threw all the foods away in the presence of the surveyor. On 9/27/2021 from 11:16 to 11:47 AM, the surveyors, accompanied by the FSD observed the following in the kitchen: 1. In refrigerator box 15 on a lower shelf, an aluminum pan contained sliced deli salami. The pan was dated 9/21. On interview the FSD stated, Sliced deli meats are good for three days. I'm throwing that in the trash. The surveyor reviewed the facility policy titled Food Storage, reviewed date: 4/13. The following was revealed under the heading Policy Interpretation and Implementation: 9. Dented cans are stored on the bottom shelf in labeled areas for such. 10. All prepared food products stored in the refrigerator must be covered, labeled, and dated with the date and time that the food was prepared. All refrigerated products must be stored at 41 F or lower. All prepared food shall be discarded after 72 hours from the date the food was prepared. 11. The food services manager, or his/her designee, will check refrigerators for proper temperatures. The food services manager will maintain records of such information. The surveyor reviewed the facility policy titled Sanitation, reviewed date: 4/13. The following was revealed under the heading Policy Interpretation and Implementation: 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. 9. The food services manager will be responsible for scheduling cleaning of kitchen. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. 10. The surveyor reviewed the facility policy titled Foods Brought by Family/Visitors, R:4/2018. The following was revealed under the heading Policy Interpretation and Implementation: 6. All unopened perishable food must be kept in nursing unit refrigerator labeled with resident's name and date received. All opened perishable food will be destroyed. 10. Disposal of outdated food and cleaning procedures for these areas will follow facility food safety and sanitation practices and the task shall be completed by the dietary department. N.J.A.C. 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide supervision and implement procedures to prevent a fall in 1 of 8 residents (Resident #114) that were reviewed for accidents. This deficient practice was evidenced by the following: The surveyor observed the Resident #114 seated in a recliner chair, without a table tray attached to it on the following dates and times: 10/27/19 at 11:16 AM, 10/29/19 at 11:15 AM, 11:25 AM, and 12:09 AM, 10/30/19 at 12:05 PM and 1:59 PM, 10/31/19 at 2:07 PM, and 11/1/19 at 12:11 PM. The surveyor observed the Resident #114 seated in a recliner chair, with a table tray attached to it on the following dates and times: 10/29/19 at 9:21 AM, 9:50 AM, and 11:10 AM, and 10/30/19 at 9:25 AM. According to the resident's face sheet, Resident #114 was admitted to the facility on [DATE] with diagnoses including, but not limited to syncope (a sudden, temporary loss of consciousness which may lead to fainting) and dizziness. According to Resident #114's 10/18/19 Minimum Data Set (MDS), the resident was not able to complete the Brief Interview for Mental Status (BIMS) as a result of memory problems. An MDS is a tool that assesses various conditions of a long-term care facility resident at various points in time. A BIMS score is used to assess the cognitive status of a resident at a given point in time. According to the Fall Risk Evaluation for Resident #114, the resident was determined to be at high risk for falls, where a total score of 10 or above indicated a high risk. The resident was considered to be a high risk on the following dates and with the following scores: 4/17/19, 6/15/19, 7/12/19, and 7/16/19, all with scores of 16 and 10/18/19 with a score of 17. According the physician's orders dated 7/18/19 Resident #114 had an order to be out of bed to the Geri chair with table top tray. The tray was to be removed at meals and activities. This was consistent with the plan of care related to falls for Resident #114. The surveyor obtained and reviewed two incident reports related to falls for Resident #114, dated 10/19/19 at 1:00 PM and 6:00 PM. According to the fall report dated 10/19/19 at 1:00 PM, Resident #114 slid out of the recliner chair. The table tray was not in use at the time of the incident. After being assessed and determined to have no injuries, the facility staff took action in an effort to avoid future occurrences. This involved keeping Resident #114 by the nursing station for close observation and monitoring when the table tray was off due to the need for the resident's legs to be elevated. On 11/1/19 at 9:08 AM, the survey team interviewed the Registered Nurse (RN# 1), who was the supervisor on the date of the referenced falls. When asked about the first fall on 10/19/19 at 1:00 PM, RN #1 stated that Resident #114 was in the living room and sitting in the recliner chair with no table tray in place due to the need to extend the chair back and elevate the resident's legs due to swelling to the feet . RN #1 acknowledged that the absence of the table tray on the recliner may have allowed Resident #114 to get up and confirmed that the resident was able to sit up from a seated position. He further stated that Resident #114 was seated in the recliner chair near the nursing station to allow for closer observation and to ensure continued use of the table tray. According to the fall report dated 10/19/19 at 6:00 PM, Resident #114 was found lying on the floor. After being assessed, Resident #114 was treated for an abrasion on the forehead and skin tears on the right elbow and left, lower knee. The actions taken to prevent future occurrences included placing the resident near the nursing station for close observation and keeping the resident in the Geri chair with the table tray for safety and its removal during meal times and activities. On 11/1/19 at approximately 9:15 AM, the surveyor interviewed RN #1 further. When asked about the second fall on 10/19/19 at 6:00 PM, RN #1 confirmed that the table tray was not in use at this time. He stated that the resident had just eaten dinner and staff likely did not have time to put it back on because the incident probably happened so fast. The survey team then asked the facility staff why Resident #114 was in the living room, since the resident was supposed to be near the nursing station for close observation, as determined to be necessary earlier in the day, in order to prevent subsequent falls. No members of the facility staff were able to answer this question. The surveyor obtained and reviewed the facility's fall policy titled, Falls Management dated 2/14. According to the policy, it was necessary for the care team to monitor for any indicators of increased falls, examine possible causative factors, and then implement a plan of care to eliminate these factors. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and other facility documentation, it was determined that the facility failed to perform an assessment to determine the risk for using bed rails and to obtain consent prior to the installation and use of bed rails. This deficient practice was identified for 1 of 8 residents (Resident #82) reviewed for accidents and was evidenced by the following: The surveyor observed the resident lying in bed, with full bed rails up on both sides of the bed on the following dates and times: 10/29/19 at 9:30 AM and 1:40 PM, 10/30/19 at 9:32 AM, and 10/31/19 at 10:06 AM. The surveyor obtained and reviewed a copy of the current physician's orders for Resident #82, dated 10/2/19. According to the physician's order, Resident #82 had an order for bed rail for positioning and for use as an enabler and referenced to use them every day. The surveyor obtained and reviewed a copy of the current Treatment Administration Record (TAR) for Resident #82 for October 2019. According to the TAR, Resident #82 used the bed rails every day and in accordance with the physician's order. On 10/31/19 at 10:55 AM, the surveyor interviewed LPN #1 regarding the use of bed rails. LPN #1 stated that there was an order for the use of bed rails, but there was no evaluation of the risk to the resident. At this time, LPN #1 stated that an assessment for bed rails is used for newer residents, which also required consent. She further stated that this policy regarding newly admitted residents was implemented in the past year. After looking further, LPN #1 confirmed that there was no assessment or consent for the use of bed rails at 11:12 AM. When asked, she stated this was probably due to the fact that assessments and evaluations were used only for newer residents and this did not take effect until November of 2018. On 10/31/19 at 1:10 PM, the surveyors interviewed the Director of Nursing (DON). The DON stated there was a new policy implemented in November of 2018, related to newly admitted residents. According to the DON, newly admitted residents were assessed for the need and use of bed rails. If newly admitted residents were determined to need bed rails, it was necessary to obtain a physician's order for them and consent from the resident or the resident's representative to use them. The DON then repeated that the consent was signed upon determining need and that the continued use was reviewed on a quarterly basis with staff and annually with the resident's family. The DON further stated that the referenced processes would be assessed using a Bed Rail Assessment form and that the form would only be used for new residents as a result of not knowing a new resident's risk for falls. He then stated he thought this bed rail assessment would eventually be used for all residents in the facility. On 11/1/19 9:35 AM, the surveyor interviewed LPN #1. In the presence of the survey team and facility staff, LPN #1 confirmed that the facility was not able to determine the exact date on which the bed rails were put into use. She also reconfirmed that there was no assessment or consent for the use of bed rails for Resident #82. The surveyor obtained and reviewed the facility policy regarding the use of bed rails. The policy was titled, Restraint Management; Bed Rails with a review date of 5/15. The policy indicated that an assessment was necessary to determine the resident's symptoms or reason for using bed rails. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNA) received 12 hours of mandatory education training, annually as required. This deficient practice was identified for 5 of 5 CNA files reviewed and was evidenced by the following: On 11/1/19 at 10:30 AM, the surveyor obtained and reviewed the performance evaluations and continuing education (CE) records of five randomly selected CNA staff members, from the Licensed Nursing Home Administrator (LNHA). Upon review of the records, the surveyor noted the following: CNA #1 had a date of hire of 9/6/2016. CNA #2 had a date of hire of 9/11/2015. CNA #3 had a date of hire of 7/31/2015. CNA #4 had a date of hire of 5/19/2000. CNA #5 had a date of hire of 3/11/2010. On 11/1/19 at 10:46 AM, the surveyor interviewed the LNHA regarding the continuing education credits for CNA staff. She confirmed that CE credits for CNA staff were counted in terms of a calendar year, from January 1 through December 31 of a given year. Further review revealed that the five files contained a Course status report with the courses enrolled. It also indicated the status and length of time devoted to course completion. The referenced information was not completed on all the forms and did not add up to 12 hours of CE credits, as indicated by the following: CNA #1 had 7 hours and 30 minutes of CE credits. CNA #2 had 7 hours and 30 minutes of CE credits. CNA #3 had 6 hours and 30 minutes of CE credits. CNA #4 had 5 hours and 30 minutes of CE credits. CNA #5 had 6 hours and 30 minutes of CE credits. At 12:39 PM, the surveyor interviewed the LNHA, in the presence of the survey team. The LNHA confirmed that the recorded CE credits were accurate for each of the five CNA staff members for 2018. The LNHA further acknowledged that there were less than 12 hours of CE credits, as required, for 5 of 5 CNA staff members reviewed for CE educational requirements. NJAC 839-43.17(b)