Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #104) was free from verbal abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #104) and was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident # 104 was admitted to the facility with the diagnoses which included but was not limited to Parkinson's disease, atrial fibrillation, depression and diabetes mellites (DM). The annual Minimum Data Set (MDS), an assessment tool used to facilitate a resident's care dated 5/29/25, indicated that Resident #104 scored a 11/15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had moderate cognitive impairment. The MDS also reflected that the resident did not exhibit any behaviors.A review of the form AAS-45 (Facility Reportable Event) dated 8/5/25, indicated that on 8/2/25 a housekeeper told Resident #104 to learn to use the toilet when the housekeeper had to clean up feces from the resident's toilet. A review of a Physical Therapist (PT) untimed statement dated 8/4/25, indicated that as the therapist was attempting to take Resident #104 for a PT session, the resident refused to go and was emotionally upset because the resident reported that a staff member humiliated them. The resident reported that a staff member had to clean the resident's toilet too often because the resident was going to the bathroom (defecating) often.A review of Resident #104's untimed statement taken 8/4/25, revealed that on 8/2/25 a housekeeper was cleaning, and the resident overheard the housekeeper saying that she had to Wipe shit off the floor and from around the toilet. I cleaned up shit this morning and now I have to do it again.A review of the emailed statement dated 8/8/25 at 12:35 PM, from the alleged perpetrator (housekeeper), reflected that the housekeeper admitted that an aide had told her that Resident #104 defecated all over the front of the toilet and it went down the front of the toilet and on the floor. The housekeeper stated, I said to [Resident #104] to come and see how you shit all over the toilet and this is so nasty, can't you shit in the toilet.The facility provided the surveyor with the full investigation and conclusion and summary related that the incident.A review of the Summary and Conclusion dated 8/6/25, indicated that the facility immediately provided the resident with 1:1 emotional support and the housekeeper was placed on administrative leave and was not permitted to return to work pending the outcome of an internal investigation.During the investigation the facility contacted the housekeeper, and the housekeeper admitted to making the comments aloud in the hall and then entered the resident's room and told the resident that he/she needed to learn how to use the toilet.As a result, the housekeeper was immediately terminated, and the facility proceeded to interview other residents in the area where Resident #104 resided. No other residents had complaints regarding any mistreatment from the housekeeper.On 9/03/2025 at 10:54 AM, the surveyor interviewed Resident #104 who stated that he/she felt that the facility did a good job and fired the housekeeper that embarrassed him/her. The resident stated that they had been doing ok and stated that they felt safe in the facility. During the interview the resident's psychologist entered the resident's room for a session with the resident.On 9/04/2025 at 11:02 AM the surveyor interviewed the Social Worker (SW) who stated that when Resident #104 reported that a housekeeper verbally abused him/her, the housekeeper was immediately terminated. The SW stated that the facility reported the incident to the Department of Health and investigated. He confirmed that the abuse was verified because the housekeeper admitted that she made derogatory comments to the resident about learning how to use the toilet by not getting feces on the toilet or on the floor. He stated that the facility provided the resident with 1:1 emotional support and the resident was being followed by a mental health specialist. The SW continued to explain that during the investigative process, the resident was interviewed, and statements were obtained from staff and other residents. He stated that he interviewed other residents that were alert and oriented and who were exposed to the housekeeper. He stated that was very important to interview other residents to ensure that it was not happening to them and to know as to what extent this was happening. The SW provide the surveyor with typed list of other residents interviewed in the immediate area of Resident #104 and according to the list, no other residents were affected.On 9/04/2025 at 11:18 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she had reported the event to the New Jersey Department of Health (NJDOH) the same day the resident reported the incident on 8/4/25. She stated that she remembered that the SW conducted interviews with other residents on the unit or exposed to the housekeeper. The ADON stated that interviews with other residents would be important to ensure that any abuse was not happening to others and if it was, as to what extent it was occurring and to provide support and help to others that may have been affected.On 9/04/2025 at 11:31 AM, the surveyor interviewed the PT who stated that he was not sure what date Resident #104 reported that a housekeeper was verbally abusive to him/her but that no other resident reported any occurrence of abuse to him that day. He stated that he immediately reported the residents' concerns to the administration. He stated that Resident #104 did not want to attend therapy because she felt humiliated by housekeeper who made her feel bad about getting stool on the toilet and on the floor. On 9/04/2025 at 11:42 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who was also the abuse officer for the facility who stated that the verbal abuse allegation was substantiated when the housekeeper admitted that she was verbally inappropriate with the resident. He stated that the facility takes all allegation of abuse seriously and the housekeeper was terminated immediately. The LNHA stated that the SW was responsible to interview other residents on the units that the housekeeper was working on to make sure other residents were not affected. He stated that resident interview revealed that no other residents were affected by the housekeeper. The LNHA provided the surveyor with education that was conducted for all other employees in the facility from 8/15/25 until 8/20/25 regarding identification of types of abuse and on how to report abuse which contained employee signatures. On 9/05/2025 at 10:23 AM, the facility provided the surveyor with additional information and documentation that 6 (six) alert and oriented residents were interviewed by the SW regarding any abuse with staff or housekeeper while residing at the facility and each resident denied any mistreatment. The surveyor interviewed the unsampled residents and all stated that they had not experienced any mistreatment by any staff member while in the facility. The surveyor also reviewed the housekeepers file which indicated that the facility conducted a background check prior to hire in 2016 and that the housekeeper had training on the facilities abuse policy and procedures while an employee.A review of the facility policy dated 10/24/22 and titled, Abuse Prohibition indicated that the center prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property and exploitation for all residents. The policy specified that verbal abuse is any use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. NJAC 8:39-4.1(a)(5)

Complaints: NJ00176578, NJ00181499, NJ00184013, NJ00184932 Based on interviews, record review, and review of other pertinent facility documents on 06/04/2025 and 06/06/2025, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that; a.) medications were administered according to Physician orders (POs), b.) bloodwork was obtained and faxed according to POs, and c.) Physicians were notified that medications were not administered or available. This deficient practice was identified for 1 out of 3 residents reviewed for quality of care (Resident #5). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Review of Resident #5's undated admission RECORD revealed that Resident #5 was admitted to the facility with diagnosis that included but were not limited to acute myeloblastic leukemia (AML) (an aggressive cancer of the blood and bone marrow), not having achieved remission; anemia, unspecified; post-traumatic stress disorder; muscle weakness (unspecified); chronic kidney disease; and difficulty walking, not elsewhere classified. Review of Resident #5's Minimum Data Set (MDS), an assessment tool dated 07/04/2024, was conducted. The MDS revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severely impaired cognition. Review of Resident#5's Medication Review Report (MRR), was conducted. The MRR revealed POs that included but were not limited to: Epoetin Alfa Injection Solution (a medication used to treat anemia by helping the body produce red blood cells) 1000 UNIT/ML (milliliter). Inject 2 ml subcutaneously one time a day every 7 days for anemia. HOLD RETACRIT (another name for epoetin alfa) IF HGB (hemoglobin) EXCEEDS 10. The order start date was 06/30/2024. Venclexta (a medication used in combination with other medications to treat AML) Oral Tablet 100 MG. Give 1 tablet by mouth once a day, 14 days on and 14 days off, for AML. The order start date was 07/16/2024 CBC (a blood test that measures the number and size of the different cells in the blood), and CMP (a blood test that aims to evaluate the function of essential organs in the body) every Monday and Thursday. The order start date was 07/10/2024. Fax lab results to Resident #5's Oncologist on evening shift every Monday and Thursday. The order start date was 07/11/2024. Resident #5's Medication Administration Records (MARs) for June, July, and August 2024 were reviewed. The MAR revealed no documentation for the 08/05/2024 dose of Epoetin Alfa Injection Solution. The MAR revealed that the code NN was entered for the following medication doses and orders: Epoetin Alfa Injection Solution on: 06/30/2024, 07/07/2024, and 07/14/2024. Venclexta Oral Tablet on: 07/16/2024, and 08/21/2024. Fax CBC and CMP results to Resident #5's Oncologist on: 08/19/2024. Review of the Chart Codes/ Follow Up Codes section of the MAR revealed that the code NN indicated No/See Nurse Notes. A review of Resident #5's progress notes (PNs) was conducted. An eMAR (electronic medication administration record) PN written by LPN #1, effective 06/30/2024 at 8:50 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/07/2024 at 8:13 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/14/2024 at 8:46 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/16/2024 at 8:30 A.M., revealed that Venclexta oral tablet was on order. An eMAR PN written by LPN #2 effective 08/21/2024 at 9:00 A.M., revealed, [family member] bringing in due to comes from oncology pharmacy and it is shipped to her home. when she arrives will administer. Review of Resident #5's PN revealed no documentation that the aforementioned medications were administered. Resident #5's PNs revealed no documentation that the resident's physician was notified that the medication doses were not available and not given. An eMAR PN written by LPN #3 effective 08/19/2024 at 10:49 P.M., revealed that lab results were not available. Review of Resident #5's PN revealed no documentation that the aforementioned lab test results were obtained or faxed. Resident #5's PNs revealed no documentation that the resident's physician was notified that the lab test results were not available or faxed to Resident #5's Oncologist. Further review of Resident #5's PNs revealed a Lab Result Note written by Nurse Practitioner (NP)#1, dated 07/12/2024 at 11:03 P.M. The note indicated that Resident #5's Oncologist was notified of an abnormal bloodwork result and transfusion was discussed. The note further revealed Pt [patient] also get Epo [Epoetin Alfa] in center. A follow-up note dated 08/08/2024 at 3:57 P.M., written by NP #1 was reviewed. The follow-up note revealed under the Assessment & Plan section, pt gets epo inj in center weekly. and under the Health Concerns section, Pt is on Epo weekly in center. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 06/06/2025 at 10:18 A.M. LPN #2 stated that the process if ordered medications were not available was to follow up with the pharmacy, notify the patient and their family, and notify the doctor. LPN #2 stated that if medications were not given the reason would be documented in the electronic medical record. LPN #2 stated that if medications were not given the doctor was notified and the notification was documented in the electronic medical record (EMR). During the same interview LPN #2 stated that when she documented on order in the PN it meant that the medication was not given. LPN #2 further stated that the pharmacy should have been called and physician notified in these instances. An interview was conducted with LPN #1 on 06/06/2025 at 11:19 A.M. LPN #1 stated that the process if ordered medications were not available was to notify the resident's doctor or use the facility's on-call service to notify a doctor. LPN #2 stated that if a medication was not available sometimes a doctor would decide to order a different medication. LPN #1 stated that if a medication was not given, she would document that in the EMR. LPN #1 stated that when she documented, on order, in the PN it meant that delivery by the pharmacy was scheduled. LPN #1 further stated that when the medication arrived and was given, the administration would have been documented in the EMR. LPN #1 stated that all documentation should have been completed by the end of the shift. An interview was conducted with Nurse Practitioner (NP) #1 on 06/06/2025 at 11:36 A.M. NP #1 stated that Epoetin Alfa was important for anemia treatment because it helped with hemoglobin levels and red blood cell production. NP#1 stated that what when she documented in center, it meant, at this facility. NP#1 further explained that if Epoetin Alfa were unavailable or not administered, she would have expected to be notified so that adjustments could have been made. An interview was conducted with the Director of Nursing on 06/06/2025 at 12:14 P.M. The DON stated that it was the expectation a resident's doctor was notified if an ordered medication was not available. The DON stated that the assigned nurse or Unit Manager were responsible for making the notification. The DON stated that the notification should have been documented in the MAR or PN. The DON stated that it was the assigned nurse's responsibility to ensure that labs were completed as ordered. The DON stated that if something was not documented in the medical record, it was not done. The DON further stated that the expectation was that all documentation was completed before the end of that shift. During a follow-up interview on 06/06/2025 at 1:19 P.M., the DON confirmed that no documentation of physician notification was available for the NN codes or blanks in the MAR on the aforementioned dates. The DON confirmed that there was no documentation that a physician was notified that Resident #5's labs were not drawn or that results were not available. The DON further stated that if lab results were not available, the expectation was that a doctor was notified, and labs were obtained as soon as possible. A follow-up telephone interview was conducted with Resident #5's physician, the facility's Medical Director (MD) on 06/10/2025 at 2:09 P.M. The MD stated that when medication were ordered it was his expectation that they were given. The MD stated that if ordered labs were not obtained he expected to have been notified. The MD stated, medications are ordered for a reason and we need to be informed if medications are not given because it can affect what we do next, it can guide our decisions. The MD further stated that Resident #5's Oncologist (ONC) should have been notified if Venclexta was not given. A telephone interview was conducted with Resident #5's ONC on 06/12/2025 at 1:50 P.M. The ONC stated that Resident #5 was treated for an aggressive form of AML. The ONC stated that Venclexta was part of the resident's chemotherapy regimen and timing of this medication was very important because it was part of a combination treatment. The ONC stated that he was not aware that Resident #5 had missed doses of Venclexta. The ONC further stated that it was his expectation that he would have been notified of missed doses of Venclexta. The facility Charge Nurse- LPN (job code NCL1) job description with a revision date of 6/16/17 was reviewed. On page 1 of 6 under POSITION SUMMARY, the job description revealed, [ .] The Charge Nurse- LPN ensures the delivery of efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. Page 2 of 6 of the job description document revealed under Clinical Leadership, 2.11 Ensures that Physician Orders are followed as prescribed; [ .] 2.13 Ensures that patient's attending physician and family or responsible party are promptly notified of any significant change in the patient's health condition; The facility policy NSG115 Physician/Advanced Practice Provider (APP) Notification, with a revision date of 12/16/2024 was reviewed. The policy revealed on page 1 of 2 under POLICY, Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostic, a licensed nurse will: [.] Collect pertinent patient information (e.g., age, diagnoses, .labs, recent changes in medications, [ . ] etc.), Report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. Page 1 of 2 of the policy revealed under PURPOSE, To support effective communication and notification of physicians/APPs. N.J.A.C. : 8:39-27.1 (a)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 1 of 3 residents (Resident #108) reviewed for hospitalization. This deficient practice was evidenced by the following: During the initial tour of the facility on 04/24/24 at 11:08 AM, the surveyor observed Resident #108 lying in bed awake. The resident was unable to be interviewed at that time due to a language barrier. Review of Resident #108's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: age-related debility, muscle wasting and atrophy (waste away, unspecified site), and obstructive and reflux uropathy (disorder of the urinary tract that occurs due to blocked urinary flow). Review of Resident #108's Progress Notes (PN) revealed a PN dated 03/26/24 at 01:05 AM, Follow-up care for abnormal labs. Vitals taken BP-(blood pressure) 132/58, P-103, RR (respirations, breathing) 17, T-(temperature) 97.1 (tympanic, temperature taken by inserting thermometer in the ear), SpO2-(pulse oximetry, probe placed on finger to obtain percentage of oxygen in the blood) 99% on room air. Skin flush. Slow to react to care. Send to .hospital at 12:52 am via stretcher x 2 assist. Call placed to Son .and left a message. There was no documented evidence that either the resident or responsible party were provided with written notification that the resident was transferred to the hospital in the resident's electronic health record (EHR). On 04/29/24 at 11:23 AM, the surveyor interviewed the Social Services Director (SSD) who stated that she had worked at the facility for 16 years. SSD stated she was responsible to notify the Ombudsman (an appointed official who investigates individual complaints) when a resident was hospitalized and nursing notified both the resident and their family with written notice on their way out of the facility. On 04/30/24 at 09:55 AM, the surveyor interviewed the Director of Nursing (DON)who stated that nursing was responsible to phone both the resident, family and physician and document the details of hospital transfer in the Progress Notes. DON stated that there was no written documentation provided to the resident or family upon hospital transfer from the facility. On 04/30/24 at 10:30 AM, The DON provided the surveyor with a policy related to Discharge and Transfer. She stated that the nurses had not been notifying the resident or representative in writing prior to discharge or of bed hold. DON stated the resident's were sick when they were leaving and the families sometimes got mad. Review of the facility policy, Discharge and Transfer (Revision Date 11/15/22) revealed the following: .A Center must immediately inform the patient/patient representative, consult with the patient's physician, and notify consistent with below when there is a decision to transfer or discharge the patient from the Center. The patient and patient representative must be notified in writing prior to the transfer or discharge and in a language and manner they understand . NJAC 8:39-4.1(a) 31

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a significant change assessment within 14 days after a resident elected hospice services using the Resident Assessment Instrument (RAI) process. This deficient practice was identified for 1 of 2 residents (Resident #24) reviewed for hospice and end of life care. This deficient practice was evidenced by the following: On 04/24/24 at 9:48 AM during the initial tour of the facility, the surveyor observed Resident #24 lying in bed asleep. The resident was accompanied by the hospice aide who provided personal care to the resident at the time of the observation. Review of Resident #24's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to: Alzheimer's disease. Review of the resident's Order Summary Report revealed an order dated 11/01/23, Hospice Eval (evaluation) and Tx (treat). Review of Resident #24's Care Plan revealed an entry dated 11/3/23, with a Focus of Hospice start date: 11/03/23. Hospice care due to end stage of Senile Degeneration (Dementia) Review of Resident #24's Minimum Data Set (MDS), an assessment tool, revealed a Significant Change in Status assessment with an Assessment Reference Date (ARD) of 11/16/23. Further review of the assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated that the resident was severely cognitively impaired. Review of Section O-Special Treatments, Procedures and Programs revealed under subsection K 1., that the resident received Hospice Care while a resident. Further review of the assessment on line Z0500 under Signature of RN (Registered Nurse) Assessment Coordinator Verifying Assessment Completion was signed as completed on 01/04/24. Further review of the assessment revealed that the Certified Clinical Reimbursement Coordinator (CCRC) RN also documented that she completed Section O on 1/4/24, which indicated that the resident received Hospice Care. On 04/29/24 at 11:06 AM, the surveyor interviewed the CCRC who stated that she worked at the facility since February of 2023. CCRC stated that Resident #24's Significant Change MDS Assessment was initiated on 11/16/23, but was not completed until 01/04/24. CCRC stated that the Significant Change Assessment should have been initiated within 14 days of when the resident entered into hospice services. CCRC further stated that there could have been a delay, but she was not able to recall why the assessment was not completed until 01/04/24, 49 days later. CCRC stated that the assessment was accepted by CMS (Centers for Medicare and Medicaid Services) on 01/08/24. CCRC further explained that she worked alone in the building after her co-worker retired in October 2023, and that was why the assessment was completed late, and not within 14 days as required. On 05/01/24 at 10:11 AM, the surveyor interviewed the Director of Nursing (DON) who stated that a Significant Change MDS Assessment should have been entered upon the initial hospice admission date. DON stated that from 11/16/23 through 01/04/24, it was delayed. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, a Significant Change in Status MDS must be completed by the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Review of the facility policy, OPS 183 MDS Remote Completion (Revision Date 12/27/21) revealed the following: .Centers will also follow the RAI Manual Instructions for completing the assessment process. .Purpose: To ensure compliance with the RAI process and timely completion of the MDS. NJAC 8:39-11.2(i)

Based on observations, interview, record review, and pertinent facility documents it was determined that the facility failed to provide appropriate treatment and care, based upon current standards of practice and the resident's comprehensive care plan specifically not securing a urinary catheter drainage bag properly resulting in the bag making contact with the floor. The deficient practice was identified for 1 of 3 (Resident # 15) investigated for Urinary Catheter. The deficient practice was evidenced by the following: A review of Resident # 15's admission Minimum Data Set (MDS; an assessment tool) dated 04/08/2024 revealed that he/she had an indwelling catheter (tube inserted into the bladder to assist in the flow of urine). A review of Resident # 15's Electronic Medical Record (EMR) revealed under Med Diag that he/she was diagnosed with but not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine) and Retention of Urine. A review of Resident # 15's EMR revealed under, Orders to, Empty catheter drainage bag at least once every eight hours to when it becomes 1/2 to 2/3 full every 8 hours. The order revealed a start date of 04/02/2024. A review of Resident # 15's Care Plan located in the EMR revealed a focus, [Resident # 15] requires indwelling foley catheter due to obstructive uropathy. The focus was created on 04/02/2024. The focus revealed an intervention that revealed, Record output and Keep catheter off floor. Both interventions had an initiated date of 04/02/2024. A review of Resident # 15'2 Treatment Administration Record (TAR) located in the EMR revealed the order to Empty catheter drainage bag at least once every eight hours to when it becomes ½ to 2/3 full every 8 hours. The TAR revealed the following dates and times were blank: 4/3 - 1400 (2:00 PM) blank 4/4 - 0600 (6:00 AM) blank 4/11 - 1400 (2:00 PM) blank 4/12 - 0600 (6:00 AM) blank 4/14 - 0600 (6:00 AM) blank 4/15 - 0600 (6:00 AM) blank 4/17 - 0600 (6:00 AM) blank, 2200 (10:00 PM) blank 4/18 - 0600 (6:00 AM) blank 4/19 - 1400 (2:00 PM) blank, 2200 (10:00 PM) blank 4/22 - 1400 (2:00 PM) blank 4/24 - 1400 (2:00 PM) blank 4/26 - 0600 (6:00 AM) blank, 2200 (10:00 PM) blank 4/29 - 0600 (6:00 AM) blank On 04/24/2024 at 10:31 AM during the initial tour of the facility, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the wheels of the bed. On 04/26/2024 at 10:07 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. The urinary catheter drainage bag was not secured too the bed frame. On 04/29/2024 at 09:07 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. On 04/30/2024 at 11:11 AM during an interview with the surveyor, Certified Nurses Aide (CNA) # 1 said that when emptying the urinary catheter drainage bag, she measures and tells the nurse. CNA # 1 confirmed that the nurse documents the TAR. On the same date at 11:28 AM during an interview with the surveyor, the Unit Manager/Registered Nurse # 1 confirmed that the nurse documents in the TAR. On 05/01/2024 at 09:54 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. At that time, CNA # 2 was present in the room. At that time, CNA # 2 referred to Resident # 15's urinary drainage bag and stated, It's all twisted up. The surveyor asked her if it should be on the floor. CNA # 2 replied, No. On 05/01/2024 at 12:14 PM during an interview with the surveyor, the Director of Nursing (DON) replied, No when asked by the surveyor if the urinary drainage bag should be in contact with the floor. Secondly, the DON replied, Infection control when the surveyor asked why the urinary drainage bag should not be in contact with the floor. Also, the DON confirmed that nurses document urinary outputs in the TAR. Lastly, the DON replied, I know they [nurses] empty it but if it's not documented, it's not done . A review of the facility provided document titled, NSH113 Nursing Documentation revised 05/01/23 revealed under the section titled, Practice Standards that, 1. Documentation of nursing care is recorded in the medical record and is reflective of the care provided by nursing staff . A review of the facility provided document titled, Procedure: Catheter: Indwelling Urinary - Care Of revised 02/01/23 revealed, 13. Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor . § 8:39-27.1 (a)

NJ Complaint #159967, #159711, #169655, #170197, Based on interview, review of the Nurse Staffing Report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: On 04/29/24 at 10:30 AM, the surveyor held a Resident Council meeting with six residents in attendance. During the Resident Council meeting the surveyor asked all residents in attendance if they received showers, or assistance with showers. Four of the six residents in attendance told the surveyor that showers were not offered twice weekly (Resident #21, #84. #94, and #122). All were aware of their shower day schedule but stated they do not always receive them because of staffing issues. 1.For the week of Complaint staffing from 10/02/2022 to 10/08/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -10/02/22 had 6.5 CNAs for 111 residents on the day shift, required at least 14 CNAs. -10/03/22 had 8 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/04/22 had 7 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/05/22 had 6 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/06/22 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/07/22 had 8 CNAs for 115 residents on the day shift, required at least 14 CNAs. -10/08/22 had 10 CNAs for 115 residents on the day shift, required at least 14 CNAs. 2. For the week of Complaint staffing from 10/16/2022 to 10/22/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -10/16/22 had 5 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/17/22 had 7 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/17/22 had 5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -10/18/22 had 8 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/19/22 had 8 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/20/22 had 9 CNAs for 120 residents on the day shift, required at least 15 CNAs. -10/21/22 had 8 CNAs for 120 residents on the day shift, required at least 15 CNAs. -10/22/22 had 10 CNAs for 120 residents on the day shift, required at least 15 CNAs. 3. For the week of Complaint staffing from 11/20/2022 to 11/26/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -11/20/22 had 9 CNAs for 114 residents on the day shift, required at least 14 CNAs. -11/21/22 had 7 CNAs for 113 residents on the day shift, required at least 14 CNAs. -11/22/22 had 9 CNAs for 109 residents on the day shift, required at least 14 CNAs. -11/23/22 had 9 CNAs for 109 residents on the day shift, required at least 14 CNAs. -11/23/22 had 6.5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -11/24/22 had 8.5 CNAs to 108 residents on the day shift, required at least 13 CNAs. -11/25/22 had 6 CNAs for 107 residents on the day shift, required at least 13 CNAs. -11/26/22 had 8.5 CNAs for 107 residents on the day shift, required at least 13 CNAs. 4. For the week of Complaint staffing from 12/04/2022 to 12/10/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -12/04/22 had 8.5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/05/22 had 5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/05/22 had 6 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -12/06/22 had 11 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/07/22 had 7 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/08/22 had 9.5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/09/22 had 8 CNAs for 112 residents on the day shift, required at least 14 CNAs. -12/10/22 had 9 CNAs for 111 residents on the day shift, required at least 14 CNAs. 5. For the week of Complaint staffing from 12/10/2023 to 12/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs total staff on 3 of 7 evening shifts as follows: -12/10/23 had 8.5 CNAs for 111 residents on the day shift, required at least 14 CNAs. -12/11/23 had 12.5 CNAs for 110 residents on the day shift, required at least 14 CNAs. -12/11/23 had 6 CNAs to 18 total staff on the evening shift, required at least 9 CNAs. -12/12/23 had 11 CNAs for 110 residents on the day shift, required at least 14 CNAs. -12/12/23 had 7 CNAs to 17.5 total staff on the evening shift, required at least 9 CNAs. -12/13/23 had 9.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/13/23 had 7 CNAs to 16 total staff on the evening shift, required at least 8 CNAs. -12/14/23 had 11 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/15/23 had 10 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/16/23 had 12.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. 6. For the week of Complaint staffing from 12/31/2023 to 01/06/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 2 of 7 evening shifts as follows: -12/31/23 had 8 CNAs for 131 residents on the day shift, required at least 16 CNAs. -12/31/23 had 6 CNAs to 15 total staff on the evening shift, required at least 7 CNAs. -01/01/24 had 7 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/02/24 had 10 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/03/24 had 12 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/04/24 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -01/04/24 had 7 CNAs to 15.5 total staff on the evening shift, required at least 8 CNAs. -01/05/24 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -01/06/24 had 10 CNAs for 132 residents on the day shift, required at least 16 CNAs. 7. For the 2 weeks of staffing prior to survey from 04/07/2024 to 04/20/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shift, deficient in total staff for residents on 1 of 14 evening shifts, deficient in CNAs to total staff on 10 of 14 evening shifts, and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -04/07/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/07/24 had 5 CNAs to 12 total staff on the evening shift, required at least 6 CNAs. -04/08/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/08/24 had 11 total staff for 119 residents on the evening shift, required at least 12 total staff. -04/08/24 had 4 CNAs to 11 total staff on the evening shift, required at least 5 CNAs. -04/09/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/09/24 had 4.5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -04/10/24 had 9 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/10/24 had 4 CNAs to 13.5 total staff on the evening shift, required at least 7 CNAs. -04/11/24 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/11/24 had 5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -04/12/24 had 9.5 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/13/24 had 7.5 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/13/24 had 5.5 CNAs to 15.5 total staff on the evening shift, required at least 7 CNAs. -04/14/24 had 6 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/14/24 had 4 CNAs to 13.5 total staff on the evening shift, required at least 7 CNAs. -04/15/24 had 10 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/15/24 had 5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -04/16/24 had 9 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/16/24 had 8.5 CNAs to 17.5 total staff on the evening shift, required at least 9 CNAs. -04/17/24 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/17/24 had 5.5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -04/18/24 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/19/24 had 13.5 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/20/24 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/20/24 had 7 total staff for 118 residents on the overnight shift, required at least 8 total staff. On 04/30/24 at 10:20 AM, the surveyor reviewed the policy titled, ADLs (Activities of Daily Living) with a revision date of 05/01/23. Under the section titled, Practice Standards, number five indicated that documentation of ADL care is recorded in the medical record and is reflective of the care provided by the nursing staff. ADL care will be documented in real time, as close to the time that the care was provided, and information obtained as possible. ADL care is documented every shift by the nursing assistant. On 04/30/24 at 12:10 PM, the surveyor interviewed CNA #1 (Certified Nursing Assistant) on the subacute unit. CNA#1 told the surveyor that the shower schedules were in the assignment book which included the days and shift for showers. CNA#1 said that the nurse or unit manger tells the CNA which showers were due for the day. On 05/01/24 at 11:11 AM, the surveyor interviewed CNA#4 of the Lighthouse Unit on the first floor. CNA #4 stated residents get showered twice weekly and if one shower was skipped, we would make sure the resident got the second shower later that week. On 05/01/24 at 11:21 AM, the surveyor interviewed CNA#3 on the second-floor unit at the facility. CNA#3 told surveyor that there are times when they are so short staffed that showers are not able to be completed. CNA#3 said she believes it happens on all shifts and if unable to give a shower she would offer a bed bath or a shower in the afternoon. On 05/01/24 at 11:30 AM, the surveyor reviewed the bathing task list for Resident #21 for the month of April. For the month of April, the task list was blank for the first 22 days indicating care was not rendered. The task was signed by staff for 4/23, 4/25, 4/26, and 4/29 by the CNA, indicating the resident had a bath and not a shower. The surveyor reviewed the bathing task list for Resident #94 for the month of April. The resident had received a bath six of the 30 days. It was documented that the resident received a bath and not a shower. The surveyor reviewed the bathing task list for Resident #84. The resident was scheduled for showers on Wednesday and Saturdays on day shift. For the month of April, the only shower documented as completed was on 4/20/24. The other scheduled days were left blank. The surveyor reviewed the bathing task list for Resident #122. The residents task list showed a shower schedule for Sundays and Thursdays on evening shifts. The resident was scheduled for 4/22/24, 4/25/24 and 4/29/24 and they were left blank as not completed. On 05/01/24 at 12:28 PM during an interview with the Director of Nursing (DON) regarding documentation, the DON stated, If it's not documented it's not done. On 05/01/24 at 12:32 PM, when the DON was asked about staffing numbers for the CNAs she stated, I know we are not meeting the numbers. NJAC 8:39-25.2 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, specifically failing to adhere to the minimum time to lather hands during hand hygiene when providing wound care. The deficient practice was observed during wound care for 1 of 2 residents (Residents # 59) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 59's Quarterly Minimum Data Set (MDS; an assessment tool) dated 01/22/2024 revealed that he/she had wounds. A review of Resident # 59's Electronic Medical Record (EMR) revealed under Orders to Cleanse Right heel with wound cleanser. Pat dry. Apply hydrogel fluffed gauze. Cover with ABD, wrap with kling [gauze-style bandage] every day shift for open wound for 14 Days AND as needed. The order was initiated on 04/25/2024. A review of Resident # 59's EMR revealed under Care Plan a focus that Resident # 59 has a documented pressure ulcer to the right heel. The focus was initiated on 04/24/2024. On 04/26/2024 at 10:38 AM, the surveyor obtained permission from Resident # 59 to observe his/her wound care. The wound care was performed by Licensed Practical Nurse (LPN) # 1. At this time, LPN # 1 applied disposable gloves and proceeded to remove the old dressing from Resident # 59's right heel. After that, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene process was 19 seconds. At that time, LPN # 1 applied a new pair of disposable gloves. LPN # 1 then proceeded to administer the hydrogel to 4x4 inch gauze, covered that with the ABD pad followed by wrapping the heel with kling. Afterwards, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene lathering process was 9 seconds. At that time, LPN # 1 applied a new pair of disposable gloves. LPN # 1 then proceeded to applied tape to the kling wrap. Afterwards, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene lathering process was 12 seconds. On the same date at 10:46 AM during an interview with the surveyor, LPN # 1 replied, Yes when the surveyor asked if she felt like she lathered for twenty seconds. At that time, the surveyor asked LPN # 1 if the twenty seconds applied to lathering or the entire process. LPN # 1 replied, Lathering. Twenty seconds but it may take more time. On 05/01/2024 at 12:14 PM during an interview with the surveyor, the Director of Nursing replied, Twenty seconds when the surveyor asked how long should the lathering portion be during hand hygiene. A review of the facility provided policy titled, IC203 Hand Hygiene revised 05/01/23 revealed under, 2. Hand hygiene techniques: that, 2.1 To wash hands with soap and water: Wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers . § 8:39-19.4 (a) 1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to: a) promptly record the removal of a controlled drug from inventory b) maintain accurate accountability of controlled substances within the medication administration carts c) maintain accurate accountability of all controlled medications within the automated medication dispensing system d) accurately document and complete DEA (Drug Enforcement Agency)-222 forms. This deficient practice was identified in 2 of 4 medication carts on 2 of 3 nursing units and for 12 of 12 DEA-22 forms reviewed. This deficient practice was evidenced by the following: 1. On [DATE] at 12:14 PM, the surveyor inspected the Low Hall Garden Unit medication cart with Registered Nurse (RN) #1. When the surveyor requested to inspect the controlled medications RN #1 stated, The count was going to be off (not accurate count) with the Oxycodone (a controlled medication used to treat moderate to severe pain) 5 milligram (mg) immediate release tablets. When the surveyor asked why, RN #1 stated that she felt nervous after she was observed during the medication pass by another surveyor earlier that morning and forgot to sign it out when the medication was removed from the medication cart at approximately 10:30 AM. The surveyor reviewed the declining inventory sheet (DIS) that was issued to Resident #523 and indicated that 24 tablets of Oxycodone Immediate Release 5 mg tablets remained, when only 23 tablets actually remained. RN #1 stated that she knew that she was supposed to sign the medication at the time that it was removed from the medication cart and prepared for administration. On [DATE] at 12:42 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #3 who stated a controlled medication such as Oxycodone should be signed out at the time of administration. RN/UM #3 stated that if a discrepancy were noted at shift change, it would be caught and addressed at that time. Review of Resident #523's active orders revealed an order dated [DATE], for Oxycodone HCL (hydrochloride) oral tablet 5 mg give one tablet by mouth two times a day for chronic generalized pain. Review of the resident's Medication Administration Record revealed that RN #1 documented that she administered the dosage of Oxycodone HCL oral tablet 5 mg to the resident on [DATE] at 9:00 AM. On [DATE] at 12:05 PM, the surveyor obtained a copy of Resident #523's DIS for Oxycodone Immediate Release 5 mg tablet and noted that on [DATE] at 12:00 PM, RN #1 signed the resident's 9 AM scheduled dose of Oxycodone Immediate Release 5 mg tablet as administered, rather than at 10:30 AM, as RN #1 previously stated at the time of the initial observation on [DATE] at 12:14 PM. On [DATE] at 12:38 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when a controlled medication was pulled from the medication cart it must be signed for right away because it was a counted process and may cause the count to be off. DON further stated that if the resident stated that he/she had not received the medication, than the process could be ruined at that time. 2. On [DATE] at 1:02 PM, the surveyor inspected Post Acute Unit (PACU) medication cart #3 with LPN #2. The surveyor reviewed the Shift Count form with LPN #2 who stated that the outgoing nurse must have forgotten to sign the form in the space allotted for Nurse's Signature Going Off Duty this morning. LPN #2 stated that both nurses were required to sign the shift count to indicate that they were both in agreement for the amount of controlled medications that remained in the cart at the time of cart transfer for accountability purposes. LPN #2 stated that if one person did not sign, and the count was wrong, then the person who signed took more responsibility as they failed to ensure the other person signed and agreed upon the count. On [DATE] at 1:33 PM, the surveyor interviewed RN/UM #1 who stated that nurses must sign out on the Shift Count form to ensure that the controlled medication count was right at shift change. RN/UM #1 stated that she checked the book monthly to ensure compliance. RN/UM #1 stated, The oncoming nurse should not accept the medication cart from the outgoing nurse if she did not sign the Shift Count sheet because it was sloppy. RN/UM #1 further stated, The narcotic (controlled substance) count could be wrong, and you know the importance of narcotics. On [DATE] at 1:33 PM, the surveyor interviewed the DON who stated that the oncoming nurse and outgoing nurse were supposed to sign that they received the medication cart in good faith, narcotics were checked, and they were taking the cart and everything was good. DON stated there would be a write up if a shift to shift were not done. DON further stated that they should sign every time a narcotic count was done. 3. On [DATE] at 10:50 AM, the surveyor inspected the Post-Acute Unit (PACU) medication room and the automated medication dispensing system with RN/UM #1 and Licensed Practical Nurse (LPN) #3. RN/UM #1 stated that the night shift and morning nurse counted the controlled medications within the automated medication dispensing system daily and signed the Shift Count book when completed. The surveyor reviewed the book and noted that the book was not routinely signed to indicate that the count was completed daily as described by RN/UM #1. The surveyor observed that the Shift Count was completed on the following dates: [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. February 2024: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. When interviewed at that time, RN/UM #1 stated that the automated medication system Shift Count was reviewed by the Unit Manager who was responsible to ensure that the controlled medication count was completed. RN/UM #1 stated if the Shift Count were not signed, then the count was not done. RN/UM #1 stated that the purpose of the count was to ensure that the medications were in sufficient quantity, were not expired and the count was right to prevent diversion. On [DATE] at 12:38 PM, the DON stated that the automated dispensing medication system count was done every morning by 7-3 nurse that she specifically assigned to do the count on the first cart, with the 11-7 nurse going off on the first cart. DON stated that there were some newly hired nurses who may have missed the education related to the Shift Count. 4. On [DATE] at 12:38 PM, the surveyor interviewed the DON who stated that she worked at the facility for five years. The surveyor reviewed the DEA-222 forms with the DON and questioned why 12 out of 12 forms reviewed did not have Part 5: To be filled in by purchaser and indicated the number of controlled medications received and the date received from the supplier/pharmacy. DON stated that she was not trained to fill in the amount received and copied the previous DON's method of completion. On [DATE] at 10:31 AM, the surveyor interviewed the Pharmacist in Charge (PIC) who stated that on the back of the DEA-222 form it says Part 5 to be filled in on the copy of the original form, and they should keep a copy. On [DATE] at 10:30 AM, in the presence of the survey team, the Administrator was informed that the DEA-222 forms reviewed failed to have Part 5 filled in by the purchaser as required. Review of the Instructions for DEA Form 222 that were available on the back of the form were reviewed and revealed the following: .part 5. Controlled Substance Receipt: 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages furnished on each line item and the date shipped . Review of the facility policy, 6.0 General Dose Preparation and Medication Administration (Revision Date [DATE]) revealed the following: .Administer medications within timeframes specified by Facility policy or manufacturer's information Document the administration of controlled substances in accordance with Applicable Law; . Review of the facility policy, 5.4 Inventory Control of Controlled Substances (Revision Date [DATE]) revealed the following: .Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion (used for purposes not intended by prescriber) at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Review of the facility policy, 5.5 Routine Reconciliation of Controlled Substances (Effective [DATE]) Facility should routinely reconcile controlled substance emergency medications in .Omnicells (automated medication dispensing system) .and comparing the count to the number of emergency doses supplied by the pharmacy to the number of recorded doses removed by facility staff from controlled substance emergency supply . Review of the facility policy, NSG 300 Controlled Drugs: Management of (Revision Date: [DATE]) revealed the following: .Ongoing inventory: A complete count of all Schedule II-IV controlled substances is required at change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations . NJAC 8:39-29.7(c)

Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for the pneumococcal vaccination for 1 (Resident #4) of 5 residents whose MDS assessments were reviewed. Findings included: Reference: Review of the Centers for Medicare and Medicaid Services' [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] User's Manual for Version 3.0, revised in October 2023, indicated Coding Instructions O0300A, Is the Resident's Pneumococcal Vaccination Up to Date? Code 0, no: if the resident's pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. The Manual further indicated Code 2, Offered and declined: resident or responsible party/legal guardian has been informed of what is being offered and chooses not to accept the pneumococcal vaccine. A review of an admission Record indicated the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an admission MDS, with an Assessment Reference Date (ARD) of 08/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The pneumococcal vaccination section (Section O0300B) was coded 2 to reflect the pneumococcal vaccine was offered and declined. Review of Resident #4's immunization record revealed it lacked evidence to indicate the pneumococcal vaccine had been offered and declined. Review of a form titled Pneumococcal Vaccine Informed Consent revealed the form was signed and dated by Resident #4 on 10/05/2023 (the same date as the survey). During an interview on 10/05/2023 at 2:07 PM, the MDS Coordinator revealed she could not find any supportive documentation to show that Resident #4 was offered and declined the pneumococcal vaccine. The MDS Coordinator stated she could not recall where she retrieved the information to answer the questions in section O0300 of Resident #4's admission MDS assessment with an ARD of 08/20/2023. The Director of Nursing (DON) was interviewed on 10/05/2023 at 2:11 PM. She stated the MDS Coordinator was expected to check the medical record for vaccination consent history before answering any related MDS coding questions. The Administrator was interviewed on 10/05/2023 at 1:58 PM. He stated his expectation was for all MDS assessments to be accurate. NJAC: 8:39-11.1

Based on interview, record review, and facility policy review, the facility failed to maintain documentation of eligibility and consent to receive or refusal of the pneumococcal vaccination upon admittance into the facility for 1 (Resident #4) of 5 residents reviewed for immunizations. Findings included: Review of a facility policy titled Pneumococcal Vaccination, with a revised date of 11/15/2022, indicated, Upon admission, obtain the pneumococcal vaccination history of all patients. It further revealed 1.2 Document pneumococcal vaccination history in PointClickCare (PCC) and on the Pneumococcal Consent form under Vaccination History. 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. A review of an admission Record revealed the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of Resident #4's immunization record revealed it lacked evidence to indicate the pneumococcal vaccine had been offered and administered or refused. Review of a form titled Pneumococcal Vaccine Informed Consent revealed the form was signed and dated by Resident #4 on 10/05/2023 (the same date as the survey). During an interview on 10/05/2023 at 11:58 AM, Resident #4 said they were not offered the pneumococcal vaccine upon admission or prior to 10/05/2023. The interim Infection Preventionist (IP) was interviewed on 10/05/2023 at 11:35 AM. She stated Resident #4 was offered and educated about the pneumococcal vaccine upon admission, but there was not any documentation to support this other than todays consent form. The Director of Nursing (DON) was interviewed on 10/05/2023 at 1:29 PM. She stated Resident #4 should have been offered the pneumococcal vaccine upon admission, and if the resident had declined the offer, then documentation of the refusal should have been completed. The Administrator was interviewed on 10/05/2023 at 1:56 PM. He stated he expected all vaccinations to be offered upon admission, including the pneumococcal vaccine, and that all consents should be documented in the resident's medical record. NJAC 8:39-19.4 (a)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) On 03/17/22 at 9:20 AM, the Surveyor toured the second floor unit and observed Resident #69 in bed. The Resident spoke briefly to the surveyor and closed his/her eyes. The Surveyor observed the urinary catheter collection bag was hanging on the door side of the bed. The urinary collection bag contained urine and did not have a privacy cover. On 07/17/22, the Surveyor made the additional observations of Resident #69's urinary catheter collection bag: At 10:14 AM, the urinary collection bag contained visible urine and had no privacy cover . At 12:10 PM, the urinary collection bag contained visible urine and had no privacy cover. At 1:39 PM, urinary collection bag contained visible urine and had no privacy cover. On 03/18/22 at 9:21 AM and 12:19 PM, the Surveyor observed Resident #69 lying in bed with his/her eyes closed. The Surveyor observed the urinary catheter collection bag hanging on the door side of the bed, the privacy cover was pushed up and exposed the urine inside the catheter collection bag. On 03/22/22 at 8:38 AM, the Surveyor observed Resident #69's direct care CNA in the Resident's room after finishing morning care. The Surveyor interviewed the CNA at that time, who stated that she would provide urinary catheter care to Resident #69, and then cover the urinary collection bag with a privacy cover for dignity. The CNA stated there should always be a privacy cover over the bag [urinary collection bag], and she had not worked on 03/17/22 or 03/18/22, and could not speak to why the urinary collection bag was without a privacy cover. On 03/24/22 at 10:58 AM, the Surveyor interviewed the LPN who cared for Resident #69. The LPN stated that the urinary catheter was being used to help promote wound healing and for urinary retention. The LPN stated the catheter would be changed monthly unless there was a problem, catheter care was completed each shift, urine output was measured by the CNAs, and a privacy cover was used for the dignity of the resident. The LPN added that it did not matter if the resident was in bed, in a chair, or in the activities room and that staff should always use a privacy cover over the urinary collection bag. A review of the admission Record revealed Resident #69 had been admitted to the facility with diagnoses which included, but were not limited to, myocardial infarction, hypertensive heart disease with heart failure, Type 2 Diabetes Mellitus, pressure ulcer of the sacral region, and neuromuscular dysfunction of the bladder. A review of the most recent Quarterly MDS dated [DATE], revealed a BIMS of 11/15 which indicated Resident #69 had a moderate cognitive impairment. Section H revealed that the resident had an indwelling catheter. A review of the Medication Review Report revealed an order dated 07/28/21 for a Foley catheter [flexible tube that passes through the urethra and into the bladder to drain urine] 18 FR (French) with a 10 cc (cubic centimeter) balloon to bedside straight drainage. A review of the on-going Care Plan revealed a focus area that the resident required an indwelling catheter due to: Neurogenic bladder (lacking bladder control due to a brain, spinal cord, or nerve condition) and stage 3/4 pressure ulcer in area. Interventions included, but were not limited to, provide privacy and comfort, and provide a privacy bag. A review of the facility provided, Treatment: Considerate and Respectful, revised 07/01/19, included but was not limited to: Policy: centers will promote respectful and dignified care for patients in a manner and in an environment that promotes maintenance or enhancement of quality of life; Purpose: to provide patients the right to a quality of life that supports independent expression, decision making, and respect; Process: 1.9 Demeaning practices: staff will refrain from practices that are demeaning to patients such as: 1.9.1 keeping urinary catheter bags uncovered. The facility administrative staff was made aware of the above concerns on 03/25/22 at 12:56 PM. On 03/28/22 at 11:41 AM, the facility had no further information to provide. NJAC 8:39-4.1(a)(12)(16) Based on observation, interview, medical record review and review of other pertinent documentation, it was determined that the facility failed to ensure resident dignity by failing to ensure a urinary collection privacy cover was in place over the urinary catheter collection bags. This deficient practice was identified for 2 of 4 residents reviewed (Resident #54 & Resident #69) for urinary catheter use. The deficient practice was evidenced by the following: a.) On 03/17/22 at 9:40 AM, during a tour of the facility, the Surveyor observed Resident #54 seated in the Dining Room (DR) with three other residents. The catheter drainage bag was underneath the chair and had a visible amount of urine inside the bag and did not have a privacy cover. On 03/17/22 at 10:36 AM, the Surveyor observed Resident #54 attending an activity in the DR with other residents present. The catheter drainage bag was observed half full with urine and was without a privacy cover. On 03/17/22 at 12:18 PM, the Surveyor, in the presence of another Surveyor, observed Resident #54 in the DR eating with nine other residents present. Both Surveyors observed the Resident #54's catheter drainage bag was visible and contained a large amount of urine. There was no privacy cover observed. On 03/17/22 at 12:21 PM, an interview with the Licensed Practical Nurse (LPN) revealed that Resident #54 was transferred to the floor three months prior and had the catheter. At that time the LPN stated that her role was to check the catheter for leakage, check the urine color, record the urinary output every shift, and ensure that there were no kinks in the tubing. When asked about the catheter drainage bag, she stated, Everybody, especially nurses should ensure that the catheter drainage bag was in a dignity bag [privacy cover]. We can offer a leg bag during the day for privacy, this was the facility's policy and the resident's rights. A review of Resident 54's medical record revealed the following: The admission Record (an admission summary) revealed Resident #54 was admitted to the facility with diagnoses which included, but were not limited to, unspecified kidney failure, autistic disorder, difficulty walking and muscle weakness. Review of the Minimum Data Set (MDS), an assessment tool dated 02/02/22, revealed that Resident #54 was cognitively intact, required total dependence of one staff for toileting and required two persons for assist with transfer. A review of Resident #54's Care Plan (CP) initiated 01/25/22, revealed that Resident #54 had an indwelling catheter in place due to neurogenic bladder (a condition experienced by a person who lacks bladder control due to brain, spinal cord or nerves problems). The CP interventions included: Monitor and record urine output, monitor for signs and symptoms of infection and report to the physician, provide privacy and comfort, keep catheter off the floor. On 03/18/22 at 11:05 AM, the Surveyor interviewed the LPN Unit Manager (LPN/UM) regarding the catheter care. The LPN/UM stated that nurses and Certified Nursing Assistants (CNA) were responsible to ensure the catheter was patent (not blocked), ensure that the resident needed the catheter, and maintain the scheduled urology appointments. The LPN/UM stated that the catheter drainage bag must be in a privacy cover. The LPN/UM stated that the CNAs, or nurses were responsible to place the catheter drainage bag in privacy bag. The UM further stated that she did not want the urine in the catheter to be on display, and all staff should ensure that a dignity bag was in place. On 03/18/22 at 11:18 AM, the Surveyor interviewed the Nurse on the high hall. The Nurse stated that dignity bags were available on the floor in the clean utility room or in central supply. The Nurse escorted the Surveyor to the clean utility room and showed the privacy bags, that were located on the shelf, to the Surveyor . On 03/25/22 at 9:51 AM, the Surveyor conducted an interview with the CNA who cared for Resident #54. The CNA stated that in the morning she would provided catheter care to the resident, ensure there were no kinks in the tubing, empty the catheter drainage bag, secure the catheter drainage bag to the wheelchair and ensure that a dignity bag was over the drainage bag.

Based on interview, review of clinical records and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse to the state survey agency, Department of Health (DOH). This was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/18/22 at 8:55 AM, the Surveyor interviewed Resident #51 who stated that he/she remembered reporting a complaint about a Certified Nursing Assistant (CNA) to the human resources manager (HRM). The resident that stated that he/she reported that the CNA did not provide care to him anymore or since he/she reported it to the administration. The resident stated that the CNA was rude and was talking about him/her in the hallway loudly enough so that he/she could hear him/her. On 03/18/22 at 9:13 AM, the Surveyor interviewed HRM who identified herself as the Workforce Specialist which was the human resources director. The HRM told the surveyor that she remembered about one year ago that Resident #51 reported that he/she did not care for of his/her CNAs. She stated that the previous social worker (SW) investigated the resident's complaint and that the previous SW was not employed by the facility any longer, but that there should be an investigation regarding that complaint. She stated that the resident reported to her that the CNA rushed him/her and talked about him/her to other CNAs in the hallways and that the resident could hear her. The HRM stated that after the investigation, the CNA was restricted from going into Resident #51's room or providing care to him/her. She also stated that the conclusion of this investigation reflected that there was no evidence of abuse and that the resident was reassured that the CNA would not go into the resident room, nor provide care to the resident. The HRM stated that the resident had not reported any recent concerns that he/she was having issues with staff members. On 03/18/22 at 9:28 AM, the Surveyor interviewed the Director of Social Work (DSW) who stated that she would find the investigation that the previous SW conducted for Resident #51's allegations that a CNA was rude and talking about him/her in the hallway so the resident could hear her. She stated that the resident did not inform her of any problems or concerns he/she was having with the staff but that she would go and speak with the resident. The facility admission Record (AR) indicated that Resident #51 was admitted to the facility with diagnoses which included but were not limited to, Multiple Sclerosis (affected the nervous system resulting in physical and mental symptoms), muscle weakness and seizures. The quarterly Minimum Data Set (MDS) an assessment tool dated 02/05/22, reflected that Resident # 51 scored a 15/15 on the basic interview for mental status (BIMS) which indicated that he/she was cognitively intact. Section E of the MDS indicated that the resident did not exhibit any behaviors during this review and required complete care of two staff members for all aspects of activities of daily living. On 03/18/22 at 10:15 AM, the Surveyor reviewed the progress notes which revealed the following information: On 6/22/20 at 15:33 (3:33 PM), a Social Service note revealed the following: The SW met with the resident to discuss his/her behaviors over the weekend related to cursing at the aides and refusing some care. The SW documented that the resident stated that he/she was upset because he/she heard a CNA in the hallway on the weekend. The SW explained to the resident that the CNA was not assigned to him/her and that she was assigned to care for other residents in his/her hall. The documentation reflected that the resident stated, didn't care and didn't want to .even hear her in the hallway .because she talks about me. On 03/28/22 at 9:56 AM, the Administrator (LNHA) and Director of Nursing (DON) confirmed that an investigation was not conducted for the Resident #51's allegation of abuse to the SW on 06/22/20 at 15:33 (3:33 PM). They also confirmed that the allegation was not reported to the state agency NJ DOH. The LNHA provided the surveyor with an investigation and reportable event record (RER) that was conducted on 03/24/22. The facility policy titled, Abuse Prohibition with a revision date of 04/09/21, indicated that the facility center prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the patients' medical symptoms. The center will implement an abuse prohibition program through the following: --Reporting of incidents, investigations, and center response to the results of investigations. The federal definitions: Mental abuse includes but is not limited to humiliation, harassments, threats of punishment or deprivation. Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following: 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) no later than two 2 hours after the allegation is made. 7.9 Failure to report in the required time frames may result in disciplinary action up to and including termination. 9. The CED or designee will: 9.2 Report findings of all completed investigations within 5 working days to the DOH using the state on-line reporting system The facility policy titled, Accidents/Incidents indicated that staff will use the Risk Management System (RMS) to report, review, and investigate all accident/incidents which occurred, or allegedly occurred, on the centers property and involved, a patient who is receiving services. The policy indicated that an incident is defined as any occurrence not consistent with the routine operation of the center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety and security. The licensed nurse will utilize the RMS to report accidents/incidents and assist with completion of timely investigation to determine root cause. The information entered will: -Flow to individualized state reporting forms to assist with completing the state and federal reporting requirements as indicated. Any incident that may be considered an allegation of abuse, neglect, misappropriation of patient property and or crime against an elderly person is managed in accordance with the centers state specific Abuse prohibition policy. 3.4 Notification of state reportable events will be made using the RMS forms except in states that require reporting through the state database. NJAC 8:39-9.4 (f), 13.4

Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to follow the facility Abuse Prohibition policy by failing to thoroughly investigate an allegation of abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/17/22 at 9:49 AM, during the tour the surveyor observed Resident #51 in his/her room in bed who stated that there were nurses and Certified Nursing Assistants (CNAs) in the facility that were mean. Resident #51 stated that last Saturday he/she requested the CNA to change him/her because he/she had a bowel movement (BM). Resident #51 stated that the CNA assigned to his/her care did not change him/her for four hours and he/she was left sitting in BM. Resident #51 stated that he/she did not report this concern, and gave the Surveyor permission to report the concern to the Social Worker (SW). On 03/18/22 at 8:55 AM, the Surveyor interviewed Resident #51 who stated that he/she remembered reporting a complaint about a CNA to the human resources manager (HRM). The resident stated that he/she reported that the CNA did not provide care to him/her anymore or since he/she reported it to the administration. Resident #51 stated that the CNA was rude talked about him/her in the hallway so that he/she could over hear. On 03/18/22 at 9:13 AM, the Surveyor interviewed the HRM who identified herself as the Workforce Specialist which was the human resources director. The HRM told the surveyor that she remembered about one year ago that Resident #51 reported that he/she did not care for one of his/her CNAs. She stated that the previous Social Worker (SW) investigated the resident's complaint and that the previous SW was not employed by the facility any longer, but that there should be an investigation regarding that complaint. She stated that the resident reported to her that the CNA rushed him/her and talked about him/her to other CNAs in the hallways so the resident could hear her. The HRM stated that after the investigation, the CNA was restricted from going into Resident #51's room or providing care to him/her. She also stated that the conclusion of this investigation reflected that there was no evidence of abuse and that the resident was reassured that the CNA would not go into the resident room, nor provide care to the resident. The HRM stated Resident #51 had not reported any recent concerns he/she was having issues with staff members. On 03/18/22 at 9:28 AM, the Surveyor interviewed the Director of SW (DSW) who stated that she would locate the investigation that the previous SW conducted for Resident #51's allegations that a CNA who was rude and talked about him/her in the hallway so the resident could hear over hear. She stated that the resident did not inform her of any problems or concerns he/she was having with the staff but that she would go and speak with him/her. The facility admission Record (AR) indicated that Resident #51 was admitted to the facility with the diagnoses which included, but was not limited to, Multiple Sclerosis (neurological condition affecting physical and mental state) muscle weakness and seizures. The quarterly Minimum Data Set (MDS) an assessment tool dated 02/05/22, reflected that Resident #51 scored a 15/15 on the basic interview for mental status (BIMS) which indicated that he/she was cognitively intact. Section E of the MDS indicated that the resident did not exhibit any behaviors during this review, and Section G of the MDS indicated that Resident #51 required complete care of two staff members for all aspects of activities of daily living (ADLs). On 03/18/22 at 10:15 AM, the Surveyor reviewed the progress notes which revealed the following information: On 06/22/20 at 15:33 (3:33 PM) a Social Service note revealed the following: The SW met with the resident to discuss his/her behaviors over the weekend related to cursing at the aides and refusing some care. The SW documented that the resident stated that he/she was upset because he/she heard a CNA in the hallway on the weekend. The SW explained to the resident that the CNA was not assigned to him/her and that she was assigned to care for other residents in his/her hall. The documentation reflected that the resident stated, didn't care and didn't want to even hear her in the hallway because she talks about me. The resident's Care Plan reflected the following problems: Resident exhibits verbal behaviors and accusatory, towards staff related to: Poor impulse control, History of verbal outbursts directed toward others (e.g., use of abusive language, pattern of challenging/confrontational, verbal behavior), Ineffective coping skills., poor anger management, confabulations, and false accusations towards staff. Date Initiated: 03/05/2019 Created on: 03/05/2019 Resident tends to exhibit sexually inappropriate behavior related to: Female Staff. Date Initiated: 01/08/2020 Created on: 01/08/2020 Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to acceptance of progression of MS as evidenced by Persistent anger/agitation (lashing out at staff, false accusations towards staff) affecting relationships/personal loss/functional changes. Date Initiated: 02/15/2019 Created on: 02/15/2019 On 03/18/22 at 10:23 AM, the Surveyor interviewed the Registered Nurse (RN) who had been employed in the facility since February. The RN stated that when hired she was in-serviced on abuse, infection control, COVID-19 rules, etc. She stated that if a resident had an allegation of abuse (such as verbal, physician, mental, emotional, withholding food or medications, neglect) she would report to supervisor. If I witnessed any abuse, I would intervene to stop the abuse and then I would report. I would always make sure that the resident was safe that's the priority. On 03/18/22 at 10:30 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN) employed since 1989 who stated that she received mandatory training regarding abuse quarterly. She stated that the types of abuse included neglect, physical, verbal, emotional, and financial. The LPN stated that if she witnessed abuse she would remove the resident from the situation, remove the employee from the situation and be suspended until the investigation was completed. The Director of Nursing (DON), SW, Unit Manager (UM), Supervisor, Licensed Nursing Home Administrator (LNHA) would be notified so that an investigation would be completed. The LPN also stated that statements would need to be obtained from the resident, CNA, and all other employees that were involved. The LPN then added that if it was unwitnessed, the facility would have to go back 24 and obtain statements from all employees that cared for the resident, and if there was an alert and oriented roommate, that the facility would obtain a statement from that person, and other alert and oriented residents in the surrounding area to ensure the abuse was not a widespread problem. On 03/18/22 at 10:41 AM, the Surveyor conducted and interview with a CNA what employed at the facility for 8 years. The CNA stated that in-services were conducted 3-4 times per year on abuse, and stated that abuse can be verbal, physical, neglect, and also emotional. The CNA stated that if she ever witnessed abuse, she would make sure that the resident was safe and then would report the abuse. I would report to DON [Director of Nursing] and Supervisor, and if it didn't help, then the ombudsman and state. The CNA stated that speaking about a resident in the hall in a resident's earshot could be considered emotional abuse. On 03/18/22 at 10:51 AM, the Surveyor interviewed the DSW who stated that the Administrator (LNHA) was the abuse officer at the facility. She stated that the facility completed yearly online mandatory training on abuse and all new hires received abuse training. The DSW stated that abuse could be described as verbal abuse, neglect, financial exploitation, mental, involuntary seclusion, or sexual and she stated that if any reports of abuse were reported and depending on the type of abuse with actual injury, that the DON, LNHA and then the police would be notified. The DSW stated that if abuse was witnessed, the following events would occur immediately and included to protect the resident, report to state and an investigation would be initiated. The DSW stated if it was a nurse or a CNA that had direct contact with victim, then she would interview and obtain statements from other residents or CNA's that worked and had contact with the aggressor to find out if the abuse happened to them, or if anyone witnessed anything. The DSW stated this would be done to ensure everyone's safety and she stated she was responsible to interview the residents, and nursing was responsible to interview the staff. The DSW then added that the employee involved would be suspended pending a thorough investigation, and that if there were any unwitnessed signs of abuse the facility would obtain statements from everyone that had contact with the resident which included housekeeping, dietary, CNAs, nurses, etc. On 03/18/22 at 11:11 AM, the Surveyor interviewed the DON who stated that the LNHA was the facility abuse officer. She stated that abuse could be defined as physical, mental, verbal, financial exploitation, sexual, emotional, or mental. She stated that mandatory abuse training was done yearly, and reeducation was provided to staff as needed. She stated that if the staff reported abuse, first and foremost was to protect the resident and make sure the resident was safe. The DON further added that if it was a staff member who was the alleged perpetrator then the staff member would be put on administrative leave pending an investigation. She stated that nursing supervisor would start the investigation and would fill out an incident report (RMS). The DON stated I then start an investigation and report to the DOH, MD [medical doctor] and family. She then stated that she would obtain statements from the staff and the SW was the designee to obtain a statement from the resident and from the roommate and we expand the statements to other residents in the CNA's assignment. The DON also stated that any allegations of abuse would be reported to the Department of Health (DOH) as a reportable event. She further added that if abuse was unwitnessed, statements would be obtained from the resident, the roommate, a full body assessment would be performed and that the resident would be sent to the hospital. She stated that statements would also be obtained from other residents and staff going back 72 hours. The DON reviewed the SW progress note dated 06/22/20 at 15:33 (3:33 PM) with the surveyor and stated I was not the DON at the time of the incident of 6/22/2020 but I would have started an investigation. On 03/18/22 at 11:29 AM, the LNHA stated that he was the abuse officer in the facility. He stated that he ensured all staff knew the abuse policy and that all staff were trained on abuse annually, upon hire, and as needed. He stated that he was ultimately responsible for any abuse issues in the facility. He stated that all employees were trained to report abuse to the supervisors and that when abuse was suspected the staff would know to report to the LNHA. He stated that abuse was any physical, mental, sexual, verbal, misappropriation of funds, retaliation, coercion, isolation of seclusion, or neglect. He stated that if he was notified about any allegations of abuse, he would immediately report to Department of health (DOH) and police (if warranted), Ombudsman, MD, and the family or responsible party. He further added that he would make sure the resident was safe and assessed for any signs of injury. The LNHA stated that all allegations of abuse were taken seriously. He added that the alleged perpetrator would be suspended immediately pending an investigation and that during the investigative process the facility would interview other residents to assure that the issue was not widespread. He stated that a risk management system facility incident report (RMS) would be completed and typically the nurse would fill that out. He stated that the RMS/Incident report was a checklist and guide to ensure everything was covered. The surveyor reviewed the SW progress note dated 6/22/20 at 3:33 PM with the LNHA who stated that an RMS/Incident report should have been completed for the resident's allegation, and that he would investigate to see if he could locate the documentation. The LNHA stated that Resident #51 had a history of being sexually inappropriate with female staff and when the staff refused to perform sexual acts, he/she retaliated against them and tried to get staff fired. He stated that the facility tried to assign male CNAs to the resident's care when available, and have two CNAs present in the resident's room during care because of the resident's allegations against the CNAs. On 03/18/22 at 1:13 PM, the DON stated to the Surveyor that there was no investigation completed into Resident #51's allegation of abuse from 06/22/20 at 3:33 PM. On 03/22/22 at 8:33 AM, the Surveyor interviewed the LNHA who stated that they had to move the CNAs (who the resident heard in the hallway talking about him) assignment around to accommodate the resident so that the resident did not hear the CNAs voice per the incident of 6/22/2020. He stated that the resident continued to complain about the CNA because previously the CNA politely refused sexually advances regarding shaving the residents' private parts. The LNHA further stated that even though a resident had a history of making allegations. The Surveyor inquired to the LNHA what the facility would do if the resident made further allegations and the LNHA stated that they would still investigate. The LNHA stated that he would look into the allegation of 6/22/2020 to see if an investigation was conducted. The LNHA could not provide the surveyor with a completed investigation of an allegation of abuse reported by the resident to a SW on 06/22/2020 15:33 (03:33 PM). On 03/28/22 at 9:56 AM, the LNHA and DON confirmed that an investigation was not conducted for the Resident #51 allegation of abuse to the SW on 06/22/2020 at 15:33 (03:33 PM). They also confirmed that the allegation was not reported to the state agency Department of Health (DOH). The LNHA provided the surveyor with and investigation and reportable event record (RER) that was conducted on 03/24/2022. The facility policy titled, Abuse Prohibition with a revision date of 04/09/21 indicated that the facility center prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the patients' medical symptoms. The center will implement an abuse prohibition program through the following: -Identification of possible incidents and allegations which need to be investigated. -Investigations of incidents and allegations. The federal definitions: Mental abuse includes but is not limited to humiliation, harassments, threats of punishment or deprivation. Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following: 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse has occurred and to what extent. 7.8 The investigation will be thoroughly documented within the RMS and ensure that documentation of witnessed interviews is included. 7.8.1 Conduct interviews using Alleged perpetrator/victim interview record and witness interview record. The facility policy titled, Accidents/Incidents indicated that staff will use the Risk Management System (RMS) to report, review, and investigate all accident/incidents which occurred, or allegedly occurred, on the centers property and involved, a patient who is receiving services. The policy indicated that an incident is defined as any occurrence not consistent with the routine operation of the center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety and security. The licensed nurse will utilize the RMS to report accidents/incidents and assist with completion of timely investigation to determine root cause. The information entered will: -Trigger specific investigation tools based on the type of event and/or injury of the patient. -Any incident that may be considered an allegation of abuse, neglect, misappropriation of patient property and or crime against an elderly person is managed in accordance with the centers state specific Abuse prohibition policy. 4. Follow-up/Investigation. 4.2 the CED or designee will coordinate all investigations and: 4.4 When investigating, the CED, CNE or designee will: 4.4.1 Make every effort to ascertain the cause of the incident or accident. 4.4.3 Investigations will be documented using the appropriate RMS investigation/QA form. 4.4.4 Monitor all aspects of the accident/incident and investigation involving are documented in the RMS. 4.4.7 Complete investigation within 5 working days. NJAC 8:39-9.4 (f), 13.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to update and revise resident Care Plans (CP) to include interventions for: a.) 1 of 3 residents reviewed for pressure ulcers (Resident #11), and b.) 1 of 4 resident reviewed for accidents (Resident #17). This deficient practice and was evidenced by the following: a.) On 03/17/22 at 10:05AM, during the initial tour the Surveyor interviewed Resident #11 in his/her room who stated that he/she did not remember when he/she developed the wound to the right heel. The Surveyor reviewed the clinical record which revealed the following information: The admission Record revealed that Resident #11 was admitted to the facility with diagnoses that included, but were not limited to, venous insufficiency and cellulitis. The admission Minimum Data Set (MDS), an assessment tool dated 12/23/21, revealed Section M (skin Conditions) indicated that there were no pressure ulcers, the resident was at risk for skin breakdown and there were nine arterial ulcers. The MDS also reflected that the resident was cognitively intact and required extensive to limited assistance with activities of daily living (ADLs). The nurse practitioner (NP) progress notes with time of 00:00 and dated 12/19/21, did not reflect that the resident had a right heel pressure ulcer. The Skin Check (V 4) report dated 12/24/21 at 20:52 (8:52 PM), indicated that the resident had bilateral (BLE) wounds. There was no documentation of a right heel pressure ulcer. The skin check included the following interventions: off load/float heels while in bed and observe skin for signs or symptoms of skin breakdown. The NP note dated 12/28/21 at 15:05 (3:05 PM) indicated that there was a change in the resident's condition: skin wound or ulcer. The note indicated that nursing observations, evaluation and recommendations were that while performing dressing changes to the resident bilateral lower extremities noticed an intact fluid filled blister to the right outer heel. The note indicated that the resident denied pain to the right heel and stated that he/she was not aware that the blister was there. The Surveyor reviewed the Clinical Physician Orders (CPO) dated 12/28/21 which indicated that resident #11's heels were to be elevated on pillows at all times while in bed and a CPO dated 12/29/21 reflected an order to apply skin prep to right heel blister every day and evening shift. The Care Plan was reviewed and there was no documentation in the CP regarding the right heel pressure ulcer identified on 12/28/21, and there were no further interventions for right heel ulcer. The Care Plan reflected the following: [Resident #11] exhibits or is at risk for compromised peripheral circulation venous stasis ulcers. Date Initiated: 12/21/21 Created on: 12/21/21 -An intervention for floating heels was initiated 12/21/21. The resident was a risk for skin breakdown related to advanced age, frail fragile skin, limited mobility, poor safety awareness, shear and friction risk, skin lesion and vascular disease. Date initiated: 12/21/21 Created on: 12/21/21 On 03/23/22 at 8:37 AM, the Surveyor interviewed Resident #11 in his/her room who stated that he/she had the wound on the right heel for quite some time. Resident #11 stated he/she could not remember the date or month when he/she developed the wound and stated I think I got it by using my heels to push myself up in bed. Resident #11 stated that he/she wore a special heel pad to the right heel while in bed and had a special mattress. He/she stated that he/she had severe vascular and circulation issues and was going out to see the vascular doctor today and stated that wound care was completed in the evening. On 03/23/22 at 8:52 AM, the Surveyor conducted an interview with the Licensed Practical Nurse (LPN #1) who stated that she had been employed at the facility for six years. The LPN #1`stated that Care Plans (CP) were started upon admission with the focus being on skin, pain and falls. The LPN #1 stated that interventions were added in at that time of admission to either prevent an occurrence or treat a current issue. She stated that the CP had goals and interventions and if a wound developed while in the facility, or was new that a RMS/Change in condition/ Incident report would be initiated so that all disciplines would know that the resident had a new wound. She stated that a CP would be developed immediately with interventions, the physician would be notified, treatment would be ordered, and the family notified unless the resident was alert and oriented and was own responsible party. On 03/23/22 at 8:59 AM, the Surveyor interviewed an LPN #2 who stated that CPs were initiated upon admission with the focus being on falls, wounds, and pain. She further stated that the CP wound also be developed to tailor diagnoses and resident conditions on admission, and interventions would be added to promote care, prevent falls, wounds, and pain. The LPN #2 stated that it would be important to put the CP in because it drove care with all disciplines. The LPN #2 stated that the CP would be updated with a new conditions, such as wounds or when family conferences were held, and when that process was completed in the computer it notified all disciplines to get involved, develop interventions and update the CP. On 03/23/22 at 9:17 AM, the Surveyor interviewed a Registered Nurse (RN) who stated that an RMS (risk Management System) is the facility incident report. If a resident should fall or develop a wound, or if there was a medication error, then this report would be generated in the computer. The RMS would instruct the nurse or person filling out the report to start an investigation and what steps needed to be done according to what the incident was. The RN/UM also stated that a CP with new interventions would be developed for a new wound. On 03/23/22 at 10:29 AM, the Surveyor interviewed the Director of Nursing (DON) who stated that, and incident report should have been completed when the nurse discovered the wound on Resident #11's right heel on 12/28/21. The DON stated that the nurse should have implemented a CP concerning the new heel pressure ulcer but that was not completed. On 03/28/22 at 9:55 AM, the DON confirmed that the CP was not revised to include the development of the right heel ulcer. Surveyor: [NAME], [NAME] b.)Refer to F689 On 03/18/22 at 11:30 AM the Surveyor conducted a record review of Resident #17's electronic medical record. According to the admission Face Sheet, Resident #17 was admitted to the facility with diagnoses which included, chronic obstructive pulmonary disease with exacerbation, anxiety disorder, nicotine dependence and dependence on supplemental oxygen. The Significant Change Minimum Data Set (MDS) dated [DATE] an assessment tool to prioritize residents care revealed that Resident #17 was alert with some confusion. Resident #17 scored 09 out of 00-15 on the Brief Interview for Mental Status (BIMS) indicated a moderate cognitive impairment. A review of Resident #17's Care Plan for smoking initiated 10/23/19, revised 11/21/19 and included the goal that Resident #17 would smoke safely x 90 days per smoking assessment. The interventions included : 1. Inform of and reinforce smoking restriction 2. Inform and remind Resident #17 of smoking areas and times. 3. Ensure that there is no oxygen use in smoking area (s) 4. Monitor Resident #17 compliance to smoking policy. 5. Maintain lighting materials at nurse's station. The Quarterly Smoking Evaluation (SE) dated 10/31/22 and provided by the facility on 03/28/22 at 11:01 AM was not signed by Resident #17. A boxed note on the SE read: Resident #17 did not use oxygen when he/she went out and used oxygen while in the room. According to the facility, Resident #17 was assessed to be an independent smoker and was able to adhere to the facility's policy for smoking. The Surveyor further reviewed the electronic clinical record and noted a Progress Notes dated 02/17/22 timed 6:33 which revealed the following: Staff noticed resident's room smelled like smoke and found two packs of cigarettes with a lighter and a half smoked cigarette in a coffee cup. Resident admitted to smoking in the room while she/he had the nasal cannula on and the O2 concentrator was running. Cigarettes and lighter removed from room and resident counseled on behavior. Supervisor aware . The Care Plan for smoking initiated 10/23/19 and last revised 11/21/19 was not revised to to include interventions after the resident was found smoking in his/her room while wearing oxygen. An interview conducted with the DON on 03/25/22 at 12:50 PM confirmed that Resident #17's CP was not revised after the incident of 02/17/22. On 03/25/22 at 1:30 PM, the Surveyor interviewed the UM and reviewed Resident #17's CP. The UM confirmed the resident's CP had not been updated to include frequent monitoring, monitoring for the presence of paraphernalia in the room and implement room search to prevent recurrence of the behavior. The facility policy titled. Skin Integrity Management with a revision date of 06/01/21 indicated the following information: The policy indicated that the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patient changes and implements revisions to the plan of care as needed. The purpose of the policy is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, promote healing of all wounds. -Identify patient's skin integrity status and need for prevention interventions or treatment modalities through review of all appropriate assessment information. -Develop comprehensive interdisciplinary CP including prevention of wound treatments, as indicated and Implement pressure ulcer prevention for identified risk factors. The facility policy, Person-Centered Care Plan with a revision date of 07/01/19 indicated that the center must develop and implement a baseline person-centered care plan within 48 hours for each patient that included the instructions needed to provide effective and person-centered care that meet professional standards of quality of care. The baseline care plan will ensure that patients who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for patients experiences and preferences. Purpose: is to attain or maintain the patients highest practical physical, mental and psychological well-being, eliminate or mitigate triggers that may cause re-traumatization of the patient, to promote positive communication between patient, resident representative, and team to obtain the patient's and resident representative's input into the plan of care, ensure effective communication and optimize clinical outcomes. The comprehensive person-centered care plan must be developed for each patient and must describe the following: 4.1 Services that are to be furnished. 4.2 Any services that would otherwise be required but are not provided due to the patient's exercise of rights including the right to refuse treatment. 4.3 Any specialized services or specialized rehabilitative services. Care Plans will be: 7.1 Communicated to appropriate staff, patient resident representative, family. 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, an as needed to reflect the response to care and changing needs and goals. NJAC 8:39-11.2 (1), (2), 12.1, 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and review of pertinent facility documentation it was determined that the facility failed to follow standards of practice by failing to accurately document a locked emergency cart. This deficient practice was identified on 2 of 3 units (1st floor subacute unit and 2nd floor long term care unit) and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 9:25 AM, the Surveyor inspected the crash (emergency cart) on the 1st floor. The emergency medication box that was located on top of the cart was locked with a green lock and the emergency cart (EC) was unlocked. The form located on a clipboard on top of the emergency cart titled, Emergency Cart Checklist (ECC) and dated [DATE] had instructions that indicated: nurse should place a yes or no in the box for the cart to be locked. The ECC stated if the cart is unlocked, check each item, replace missing or expired items, initial each item, lock the cart and initial that it was locked. The surveyor observed that there were nurses' signatures located on the ECC which indicated that the emergency cart was locked. On [DATE] 9:35 AM, the Surveyor interviewed the registered nurse (RN) on the 1st floor who stated that the EC had been unlocked as far as she could remember and that there was never a key to the cart. She stated that the nurse on the 11:00 PM to 7:00 AM shift checked the EC and signed the ECC that the items were all in place on the EC and that the cart was locked. She further added that the nurse was also signing the ECC that the cart was locked, however the cart on the 1st floor has never had a key and was never locked. She added that the nurse should not be singing the ECC that it was locked when it wasn't. On [DATE] at 9:42 AM, the Surveyor interviewed the RN #2 on the 1st floor who stated that the EC on the second floor was also not able to be locked and it was covered with a plastic tarp. She added that if the EC on the second floor did not need to be locked then why did the 1st floor emergency cart needed to be locked. On [DATE] at 9:55 AM, three Surveyors observed the EC on the 2nd floor and observed that the medication emergency box was located on top of a cart and was locked. The EC was covered with a pink plastic tarp and could not be locked. The Surveyor interviewed the RN nurse educator (RNE) at this time who stated that she had not been employed at the facility for very long but in her experience the EC should not be locked and should be accessible if needed. The RNE reviewed the ECC in the presence of the surveyor and confirmed that the nurses were signing the ECC that the cart was locked when the EC could not be locked. On [DATE] at 10:36 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the EC should only have items in the cart that was listed on the ECC. She stated that if an item was not on the ECC then it should not be in the EC. She stated that the ECC that was signed by a nurse which indicated that the supplies were all in place on the cart in case there was an emergency and that the cart was locked, but that the ECC was not updated to reflect that the EC was to remain unlocked. She stated that the EC on the second floor could not be locked. On [DATE] at 10:08 AM, the Surveyor interviewed the Director of Nursing (DON) who did not have an explanation as to why the nursing staff on the 11:00 PM to 7:00 AM shift nurses were signing the ECC that the medication cart was being locked when the EC on the first and 2nd floor were not able to be locked. She further added that the staff crossed off the area on the ECC [DATE] regarding the EC being locked but confirmed that they should not be crossing information off facility documents and that they should have communicated to administration that the ECC form was not accurate regarding the locking of the EC. On [DATE] at 10:30 AM, the DON and Licensed Nursing Home Administrator (LNHA) did not provide the Surveyor with any additional information. NJAC 8:39-1.1 (a), 3.1 (a, b) .

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to investigate an incident of unsafe smoking. This deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #17) and was evidenced by the following: On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with his/her eyes open. The Surveyor observed the resident had oxygen (O2) infusing by way of a nasal cannula (tubing used to deliver oxygen, flexible tube that is placed under the nose) that was connected to an oxygen concentrator (an electronic device that removes nitrogen from room air and increases the oxygen concentration). On 03/17/22 at 12:41 PM, the Surveyor observed Resident #17 self-propelling in a wheelchair in the hallway. On 03/17/22 at 12:50 PM, the Surveyor reviewed Resident #17's medical record which revealed the following: The admission Face Sheet (an admission summary) revealed that Resident #17 had diagnoses which included but were not limited to, chronic obstructive pulmonary disease (COPD) with exacerbation (a condition involving constriction of the airways and difficulty or discomfort in breathing), anxiety disorder, nicotine dependence and dependence on supplemental O2. The significant change Minimum Data Set (MDS), an assessment tool dated, 12/31/21, revealed that Resident #17 was alert with some confusion. Resident #17 scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a moderate cognitive impairment. Review of the Progress Notes dated 01/02/22 through 02/01/22, revealed that Resident #17 was alert with periods of confusion. The surveyor reviewed Resident #17's Smoking Evaluation (SE) dated 10/02/19 and 10/31/21. On 03/18/22 at 9:24 AM, the Surveyor observed Resident in bed with his/her eyes closed and oxygen was running via a nasal cannula that was connected to an O2 concentrator. On 03/18/22 at 11:30 AM, the following entry was noted in the electronic medical record (EMR) dated 02/17/22 and timed 06:33: Staff noticed resident's room smelled like smoke and found 2 packs of cigarettes with a lighter and a half-smoked cigarette in a coffee cup. Resident admitted to smoking in the room while [he/she] had the nasal cannula on and the O2 concentrator was running. Resident is very apologetic and states [he/she] won't do it again. Cigarettes and lighter removed from room and resident counseled on behavior. Supervisor aware. On 03/18/22 at 12:40 PM, the Surveyor requested Resident #17's Care Plan (CP) and all investigative reports. The Director of Nursing (DON) provided the surveyor with two fall investigative reports, and she stated there were no other investigations conducted for Resident #17. A review of Resident #17's CP for smoking, initiated 10/23/19, revealed the following under focus: Resident #17 may smoke independently per smoking assessment related to history of smoking. The goal was for Resident #17 to smoke safely X 90 days per smoking assessment with the following interventions: 1. Inform of and reinforce smoking restriction. 2. Inform and remind Resident #17 of smoking areas and times. 3. Ensure that there is no oxygen use in smoking area(s). 4. Monitor Resident #17's compliance to smoking policy. 5. Maintain lighting materials at nurse's station. On 03/22/22 at 12:50 PM, the Surveyor conducted a subsequent interview with the DON regarding any additional investigations for Resident #17. The DON confirmed that there were no additional investigations for Resident #17. On 03/22/22 at 1:10 PM, the Surveyor conducted an interview with a Certified Nursing Assistant who was familiar with Resident #17's routine and had been working at the facility for over 15 years. The CNA revealed that Resident #17 was a former employee. She stated she was not assigned to Resident #17 that day the resident was found smoking. The CNA stated that Resident #17 was a smoker and he/she used to go outside to smoke. On 03/22/22 at 1:12 PM, the Surveyor conducted an interview with a CNA assigned to Resident #17 that day. The CNA revealed that Resident #17 was very sociable, must be encouraged to participate with care, and liked to stay in bed and watched television. The Surveyor inquired to the CNA regarding the facility rules regarding smoking. The CNA stated that she had recalled an incident that happened in Resident #17's bathroom. Resident #17 was found smoking in the bathroom and had been found with a lighter and cigarettes in the room. The CNA stated the Administrator was called and gave a paper to the resident regarding the incident. The CNA indicated that the incident took place on the 11:00 PM-07:00 AM shift. On 03/22/22 at 1:25 PM, the Surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) about Resident #17. The LPN/UM stated the resident was a smoker and was very sick and was hospitalized in December. The LPN/UM stated Resident #17 had not smoked since, and that she was not aware of any incident involving the resident smoking in the room. On 03/22/22 at 1:35 PM, the Surveyor interviewed Resident #17 in his/her room. Resident #17 stated that he/she became very sick a few months ago and had not smoked since. On 03/22/22 at 1:42 PM, the Surveyor, accompanied by another Surveyor, conducted an interview with the Administrator regarding the smoking process at the facility. The Administrator stated that the facility had a smoking policy tied to the corporate policy which included: the designated areas for smoking, smoking times, storage of paraphernalia and lighting materials. The Administrator stated that residents were allowed to keep cigarettes with them and were not allowed to keep lighting materials. The Administrator stated that based on the facility's policy, lighting materials were kept at the front desk. The Surveyor inquired to the Administrator regarding if he had addressed any resident noncompliance with the smoking policy recently. The Administrator stated, No, not recently. The Surveyor further inquired about smoking assessments. The Administrator indicated that smoking assessment were completed by the nursing department. The Administrator provided the facility's smoking policy to the Surveyors. The Administrator stated to both Surveyors that if a resident was caught smoking in a room, or a non-designated area for smoking, an incident report should have been completed. (There was no incident report completed when Resident #17 was found smoking in the room on 02/17/22). On 03/23/2022 at 08:00 AM, the surveyor reviewed the facility provided 24 Hour Summary dated 12/17/21 .The incident regarding Resident #17 found smoking in his/her room was not documented on the 24 Hour Summary report. On 03/23/22 at 10:05 AM, the Surveyor interviewed the DON regarding the smoking incident with Resident #17 that occurred on 02/17/22. The Surveyor inquired to the DON regarding if an incident report was completed when Resident #17 was found smoking in his/her room. The DON stated that an incident report was not completed. She stated that she was not at the facility when the incident occurred and the Assistant Director of Nursing (ADON) who was covering, was new on the role and did not complete an incident report. On 03/23/22 at 11:03 AM, the Surveyor interviewed the Social Worker (SW) regarding the smoking incident with Resident #17. The SW stated that he was informed of the incident by the nurse on the morning of 12/17/2021. The SW stated that Resident #17 was aware that he/she should not be smoking in the room. The SW stated that Resident #17 did not disclose how he/she got the lighter and the cigarettes. On 03/23/22 at 11:23 AM, the Surveyor interviewed the ADON who stated that the nurse smelled the cigarettes, searched the room, and documented and reported the incident. The ADON stated that the cigarettes and the lighter were returned to the Administrator on the morning of 12/17/2021. The ADON stated that she reported the incident to the DON and to the Corporate Office and she was told that it was not a reportable event. The ADON confirmed that she did not interview the resident and did not generate an incident report. The ADON stated that Resident #17 was interviewed by the nurse and the Social Worker after the incident. The ADON indicated that she reviewed the smoking policy with Resident #17 at a later date but could not recall the date, and she did not provide the Surveyor with an entry in the medical record regarding her conversation with Resident #17 regarding the smoking incident. On 03/25/22 at 8:35 AM, the survey team conducted a face to face interview with the LPN who worked on 02/17/22 on the 11:00 PM-07:00 AM shift. The LPN stated that on 02/17/22 she was in the hallway checking on the residents and then she smelled the cigarette smoke by Resident #17's room. The LPN then called to the CNA who confirmed the same. The LPN stated she then entered Resident #17's room and observed two packs of cigarettes, and a lighter on the bedside table. The LPN stated she also observed the remainder of a smoked cigarette in a coffee cup. The LPN stated that she interviewed Resident #17 who admitted that he/she had been smoking in the room, while the oxygen was running that night. The LPN stated that she documented the incident and reported the incident to the Nursing Supervisor and the ADON. The LPN further stated that the next morning the Administrator came into the facility, and she discussed the incident with him. The LPN stated, I was aware that residents could have cigarettes, not a lighter, in the room. That was bad enough, [he/she] had oxygen on if [he/she] lit it [he/she] could ignite the place. The Surveyor inquired to the LPN about any interventions that were put into place after the incident to prevent recurrence, and the LPN indicated she was not sure of any and she was informed by the DON that she should have initiated a change in condition. She told the Surveyors that she notified the ADON and did not have to do anything else. The incident was not entered onto the 24-hour report and there were no monitoring tools put into place. She stated that she notified the ADON and that she did not have to do anything else. When asked about the process on On 03/22/222 at 1:30 PM, the Surveyor interviewed the Administrator regarding the process that should have been followed if a resident was found smoking in his/her room. The Administrator stated that an incident report should have been completed. On 03/23/22 at 1:27 PM, the Surveyor interviewed the front desk staff regarding accountability for the lighting materials. She indicated her role was to provide the lighter upon request, and that the residents were responsible to return the lighter. On 03/24/22 at 9:35 AM, the Surveyor interviewed the Medical Director (MD). The MD stated that he visited the facility several times a week and could be reached at any time. When asked if he was made aware of the smoking incident with Resident #17 on 02/17/22, he indicated that he could not recall if he was made aware. The MD stated that he would have encouraged him/her not to smoke, and residents should not be smoking in the room, it is a fire hazard. On 03/25/22 at 9:30 AM, the Surveyor interviewed the UM regarding Resident #17's behavior. The UM stated that she heard of an incident that happened while she was on vacation. When asked to elaborate she informed the Surveyor that Resident #17 was reportedly smoking in the room. The Surveyor asked her to elaborate on the process of such an incident. The UM stated she would expect that the incident be reported to the Nursing Supervisor on duty, remove the paraphernalia in the room, and ensure that the resident and the roommate were safe. The UM stated I would check the oxygen, ensure that the DON was made aware of the incident and basically follow the chain of command. The UM stated she would initiate an incident report, do a significant change because it was something out of the norm [normal] and it was possible harm. She further stated that if Resident #17 was smoking in the room and there was oxygen and a roommate, there could be an explosion. The UM stated all lighters were held at the front desk and residents were not allowed to have lighting materials in the room. She further stated that she would investigate and would call the family, and she would ask the staff to find out how he/she got the lighting materials. The UM stated I would monitor to ensure it did not happen again. A review of the facility policy titled, Accidents/Incidents dated 06/01/1996 and last revised 11/28/16 revealed the following: The facility will use the Risk Management System (RMS) report, review, and investigate all accidents/ incidents which occurred, or allegedly occurred on Center property and involved, or allegedly involved, a patient who is receiving services. Policy: An accident is defined as any unexpected and unintentional incident which may result in injury, or illness to a resident/ patient. This does not include adverse outcomes are a direct consequence or treatment or care that is provided in accordance with current standards of practice. An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security. The licensed nurse will utilize RMS to report accidents/ incidents and assist with completion of a timely investigation to determine root cause Purpose: Provide standards for review and investigation of accidents/ incidents. To define causative/ contributing factors and institute preventive measures to avoid further occurrences as part of the Quality Assurance Performance Improvement. Process. To meet regulatory requirements for analyzing and reporting accidents/ incidents. Under Assessment it indicated that the nurse would document the accident/incident on the 24-Hour Report. The Policy was not being followed. A review of the facility policy for smoking dated 06/01/1996 last revised 11/202018 documented also the following: Smoking (including electronic cigarettes) will only be allowed in designated areas. Oxygen use is prohibited in smoking areas . The care plan will be updated as necessary. Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. Patient will not be allowed to keep their own lighter, lighter fluid, or matches. The policy was not being followed. NJAC 8:39-27.1 (b)8:39- 33.1 (d)

Based on observation, interview, and document review it was determined that the facility failed to provide foods at the appropriate hot and cold temperatures on 1 of 2 units, and for 1 of 3 Residents reviewed for food (Resident #57). The deficient practice was evidenced by the following: On 03/17/22 at 10:40 AM, Surveyor #1 conducted an interview with Resident #57. The resident stated that the food sat on the trays, there was no temperature control for the food, and the food was cold at times. The Surveyor reviewed the 02/24/22 Resident Council Minutes. Complaints for Food Committee revealed: Food is extremely cold- Not using plate warmers. On 03/22/22 at 12:04 PM, the Surveyor observed the tray-line in progress. At that time, the Surveyor reviewed the lunch meal food temperature log as identified by the Cook. The Surveyor observed that the temperature log was blank in the milk, dessert (peaches) and vegetable (broccoli) was not listed. On 03/22/22 at 12:07 PM, the Surveyor requested a test tray that included the main and alternate entree, milk and dessert. The tray exited the kitchen at 12:10 PM, and the Surveyor was accompanied by the FSD, and arrived on the 2nd floor Garden Unit at 12:13 PM. The Surveyor interviewed the FSD director at that time regarding the appropriate food temperatures for resident service, and the FSD stated that the dessert and cold food should be less than 41 degrees Fahrenheit (F) and hot foods should be served at 145 F or above. The last resident meal tray was passed at 12:21 PM. At that time the FSD and Surveyor proceeded to measure the following food temperatures: FSD Surveyor Breaded Fish: 155.8 F 149F Potato: 146 F 146F Cranberry Meatball: 133 F* 132 F* The FSD stated the meatball should have been at 135 degrees and stated all hot foods should have been the same. Broccoli: 128 F* 121F * Milk: 61.4 F* 61.3F* Peaches: 64.6* 66.2F* On 03/23/22 at 1:01 PM, the Surveyor conducted an interview with the FSD regarding the parameters for meal trays. At that time, the FSD provided the surveyor with a Food and Nutrition Services Meal Assessment Blank Form. The Form revealed the Holding temperature standard for the Entree at 135 degrees F minimum, and cold beverages and dessert should be 41 degrees F maximum. The FSD stated that she would want the milk and juice cold. The Surveyor inquired if the temperature of the should be checked, and the FSD stated 'yes, the milk should be checked. The Food and Nutrition Services Policies and Procedures, Meal Service, Effective Date: 07/01/98 revealed: Policy Meals are served accurately, timely, and at the appropriate temperatures. Process: 1.7, Cold beverages are either kept under refrigeration or are placed on ice with proper drainage., 4. Employees are gathered for pre-service meeting, 4.2, [NAME] or designee takes and records temperatures on Production Worksheets. The Food and Nutrition Services Policies and Procedures, 7.2 Food Service Wuality Indicaotrs, Effective 07/01/98 revealed: 8.1, Food Service Satisfaction: Standard: Patients/Residents will be satisified with their meals. 8:39-17.4(a)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was evidenced for 1 of 7 residents reviewed for immunizations (Resident # 50). The deficient practice was evidenced by the following: On 03/25/22, the Surveyor reviewed Resident #50's medical record. A review of Resident #50's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, Parkinson's Disease (progressive nervous system disorder that affects movement), Chronic Obstructive Pulmonary Disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs) and presence of cardiac pacemaker (small device that's placed in the chest to help control the heartbeat). A review of Resident #50's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/4/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident #50 was cognitively intact. Further review of the MDS reflected that under section O, O0300 Pneumococcal Vaccine (PV) indicated that Resident #50 was not up to date with the PV and that the PV was not offered. A review of Resident #50's Pneumococcal Vaccine Informed Consent reflected that the information was incomplete and the resident's signature was not on the consent. On 03/25/22 at 9:41 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN) regarding Resident #50's PV. The LPN stated that Resident #50 was admitted through the subacute unit and that on admission the nurse did not fill out the form for PV. The LPN then added that when a resident was admitted , the nurse would ask the resident if they had the PV. The LPN stated if the resident was not up to date with the PV then the PV would be offered to the resident. On 03/25/22 at 9:46 AM, the Surveyor interviewed the second floor Unit Manager (UM) regarding Resident #50's PV. The UM stated that she called two facilities that Resident #50 had previously resided in to determine if Resident #50 had received the PV. She added that she did not hear back from either facility, and that she had not followed up with either one. She then stated that Resident #50's Power of Attorney (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) did not know about Resident #50's immunizations and that she would follow up now. A review of the facility provided policy titled, IC601 Pneumococcal Vaccination-Prevnar 13 (PCV13) or Pneumovax (PPSV23) with a revision date of 09/02/20, included the following: Policy: .Centers will provide the opportunity to receive the pneumococcal vaccine to all patients . Purpose: To prevent pneumococcal disease and its complications to patients . Process: 1. Upon admission, obtain the pneumococcal vaccination history of all patients. 1.1 Patient or resident representative may self-report vaccination history. 1.2 Document pneumococcal vaccination history in PointClickCare (PCC). 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medially contraindicated or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. N.J.A.C. 8:39-19.4(i)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to: a.) develop and implement a policy to track and securely document the COVID-19 vaccination status for all staff, and b.) ensure all staff were vaccinated for COVID-19. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services (CMS) QSO-22-07 ALL, dated 12/28/21, included the following: Within 30 days after issuance of this memorandum 2, if a facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. Reference: CMS QSO-22-07 ALL Attachment A included the following: Definitions: . Staff refers to individuals who provide any care, treatment, or other services for the facility and/or its residents, including employees; licensed practitioners; adult students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangements. This also includes individuals under contract or by arrangement with the facility, including hospice and dialysis staff, physical therapists, occupational therapists, mental health professionals, licensed practitioners, or adult students, trainees, or volunteers Facilities have the flexibility to use the tracking tools of their choice; however, they must provide evidence of this tracking for surveyor review. Additionally, facilities' tracking mechanism should clearly identify each staff's role, assigned work area, and how they interact with residents. This includes staff who are contracted, volunteers, or students. Reference: CMS COVID-19 STAFF VACCINATION MATRIX INSTRUCTIONS FOR PROVIDERS included the following: The Matrix is used to identify the vaccination status for all staff. The facility completes this form, including section I, staff name, and columns 1-11, which are described in detail below, or provide a list containing the same information required in the matrix. Unless stated otherwise, for each staff mark an X for all columns that are pertinent. 1. Direct facility hire (DH), Contracted hire (C), or Other (O): Direct facility hires (DH) are employees who are directly hired by the facility. Contracted hires (C) provide care, treatment, or other services for the facility and/or its residents under contract or by other arrangements. Other (O) includes adult students, trainees, and volunteers. On 03/17/22 at 1:00 PM, during entrance conference with the facility the survey team requested the COVID-19 Staff Vaccination Matrix (used to identify the vaccination status for all staff) as per the CMS Entrance Conference Worksheet (guide given to the facility which lists all the documentation the facility must provide to the survey team). On 03/17/22 at 2:10 PM, the Director of Nursing (DON) provided the Surveyor a document titled Staff Vaccination Status for Providers which included the COVID-19 vaccination status of 137 staff. The document included direct hire staff and some contracted staff. The contracted staff included on the document were Therapists, Housekeeping staff, Dietary Staff, Laundry staff, Agency Nursing Staff and Nurse Practitioners. The document did not include contracted hires that provide care, treatment, or other services for the facility and/or its residents under contract or by other arrangements which would include but was not limited to physicians and hospice providers. The document also did not include volunteers that provided services which would include but was not limited to pet therapy. The document included an X to indicate if the staff member received the COVID-19 vaccination and a booster. The document did not include the dates the staff received the doses. The document also included if the staff member was granted an exemption from the COVID-19 vaccination. On 03/22/22 at 10:03 AM, the Surveyor observed a pet therapy dog that had two pet therapy handlers on the second floor with an unsampled resident in a wheelchair. On 03/22/22 at 10:24 AM, the Surveyor reviewed the National Healthcare Safety Network (NHSN) (a data tracking system which provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections) data, that the facility is required to report, for the week ending 03/6/22 which included the following: Staff fully vaccinated 95.8%. On 03/22/22 at 10:57 AM, the Surveyor interviewed the Infection Preventionist (IP) regarding the COVID-19 Staff Vaccination Matrix provided by the DON which did not include all the facility's contracted hires/outside vendors. The IP stated that the facility had physicians that came to the facility but that she did not have them or their vaccination status on her list. She added that the receptionist may have the physicians on her list. The surveyor then asked the IP if she kept track of the vaccination status of any of the hospice providers that came to the facility. The IP stated that she did not keep track of the hospice providers. The Surveyor then asked the IP how she kept track of when staff were due for their next dose of vaccination or their booster dose since there were no dates on the COVID-19 Staff Vaccination Matrix provided by the DON. The IP stated that she had a different COVID-19 Staff Vaccination Matrix that included the dates of the staff's vaccinations and boosters. The surveyor requested a copy of the IP's COVID-19 Staff Vaccination Matrix. The surveyor then asked the IP if she reported the Vaccination status of the facility to NHSN. The IP stated that she was not the person that reported that information. On 03/22/22 at 11:16 AM, the Surveyor interviewed the DON regarding who reported the vaccination status to NHSN. The DON stated that she reported to NHSN and that it asked for the numbers. The Surveyor then asked the DON what the reason was that the COVID-19 Staff Vaccination Matrix did not include contracted hires/outside vendors. The DON stated that it included all staff that work in the building and that she had not included contracted hires/outside vendors. She added that at the front desk the staff asked for a copy of the persons vaccination card when they came in but that she did not know if they were all vaccinated. On 03/22/22 at 1:45 PM, the IP provided the Surveyor a document titled, COVID-19 Vaccine Administration Batch Entry Log which included 156 employees of the facility. The document did not include the titles of the staff or if the staff were direct facility hires, contracted hires or others that would include volunteers. On 03/24/22 at 11:35 AM, the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the vaccination status for all staff. The LNHA stated that he reported to NHSN by filling out a weekly survey. He added that when anyone entered the building that they were screened, and their vaccination status was put in the computer. He then stated that corporate had that information and that they reported it. The surveyor then asked the LNHA if the 137 number that was listed on the first COVID-19 Staff Vaccination Matrix that was provided to the Surveyor included contracted hires/outside vendors. The LNHA stated that 115 of the 137 were staff that were in house. He added that all vendors are vaccinated and that he had to fire the beautician and the fish tank cleaner because they were not vaccinated. On 03/24/22 at 12:49 PM, the Surveyor asked the LNHA to provide a complete COVID-19 Staff Vaccination Matrix that would include contracted staff including pet therapy. The LNHA stated that he could not print the line list. He added that he did not think pet therapy would be included as a contracted hire/outside vendor since they were volunteers and were not paid. On 03/28/22 at 9:57 AM, in the presence of the survey team, the LNHA stated that corporate had the contracted hires/outside vendor list and that corporate handled the submission to NHSN. The surveyor asked the LNHA if there was someone at the facility to make sure the list was conclusive of all staff. The LNHA stated that the receptionist would let him know if there was an issue. The LNHA then stated that they had three vendors with exemptions for the COVID-19 vaccination. The surveyor then asked the LNHA what staff did not have the COVID-19 vaccination or an exemption since what was reported to NHSN was that not all staff had the COVID-19 vaccination or an exemption. The LNHA could not provide that information. The facility did not provide a complete COVID-19 Staff Vaccination Matrix. The facility did not provide documented evidence that the facility had a process to track the COVID-19 vaccination status of all staff which included contracted hires. According to the data reported to the NHSN by the facility, the facility did not have the required 100 % of their staff vaccinated for COVID-19. A review of the facility provided policy titled IC604 COVID-19 Vaccination, with a revision date of 11/15/21, included the following: Policy: Centers will provide the opportunity to receive COVID-19 vaccinations for all doses (this includes dose 1, dose 2, additional dose, booster-not immunocompromised, and any future doses) following Centers for Disease Control and Prevention (CDC) recommendations subject to availability, to patients/residents (hereinafter patient), employees (as defined below), visiting healthcare personnel (as defined below), and visitors (as defined below) Definitions: Employees are defined as full-time and part-time of Center .Visiting Healthcare Personnel (HCP) are defined as medical providers (e.g., physician, NP, PA), contractual workers (e.g., hospice, mental health professionals, lab, x-ray, ambulance personnel, students, trainees, volunteers, etc.) . Purpose: To prevent the spread of SARs-CoV-2 infection and its complications to patients/staff . A review of the facility provided policy titled HR232 Universal COVID-19 Vaccination with a revision date of 3/8/22, included the following: Policy: The Company requires that all personnel are fully immunized against COVID-19 as follows: All center-based personnel or Corporate, Regional, or Divisional personnel who regularly and/or intermittently work in or visit centers . Definitions: Personnel: Employees, Students, Members of the medical staff, Volunteers, Care partners, non-employed caregivers, intermittent providers: Service providers and Contractors. Purpose: To protect the health and safety of patients, employees, personnel and employee family members, and the community from COVID-19 infection. To reduce the risk of transmission of COVID-19 to patients from unvaccinated personnel 1. COVID-19 Immunization:1.6 Students, members of medical staff, volunteers, care partners, non-employed caregivers, Physicians/advanced practice providers (APPs), intermittent providers and contracted personnel must provide proof of vaccination. 2. Corrective Actions: 2.1 Non-compliance with this policy will result in corrective action up to and including termination, termination of a contract/services, or removal from the facility. N.J.A.C. 8:39-5.1(a)

Based on interview, medical record review, and review of facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Activities of Daily Living (ADL's), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50) and was evidenced by the following: On 03/17/22 at 9:50 AM, the Surveyor observed Resident #50 in bed with their eyes closed. On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. The Friend informed the surveyor he had been trying to get Resident #50 a shower for the past two months. The Friend stated that the facility had not been able to accommodate Resident #50's preference for a shower. A Review of Resident #50's medical record revealed the following: The admission Face Sheet (an admission summary) reflected that Resident #50 had diagnoses which included, but were not limited to, Parkinson's disease (a disorder of the central nervous system that affects movement), contracture of the right hand, unspecified lack of coordination and need for assistance for personal care. A review of the Quarterly Minimum Data Set (MDS) an assessment tool dated 02/04/22, revealed that Resident #50 was alert and able to make her/his needs known. Resident #50 scored 14/15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Section G of the MDS assessment which referred to Activities of Daily Living (ADLs), revealed that Resident #50 was totally dependent on staff for all ADLs including bathing. Section E of the MDS which addressed behavior, was coded 0 which indicated that Resident #50 did not exhibit any behavior. Section E 0800 which referred to rejection of care was coded 0 which indicated that Resident #50 was compliant with all care. A review of the on-going care plan for ADL care, included the goal that Resident #50 would improve current level of functioning in bathing, grooming/personal hygiene. The care plan for preferred activities indicated under focus, [Resident #50] stated that it was important that [he/she] had the opportunity to engage in daily routines that were meaningful relative to their preferences. The goal: [Resident #50] will plan and choose to engage in preferred activities was implemented on 11/02/21. Review of the interventions included: It is important to me to choose between a tub bath, shower, bed bath or sponge bath. It is important for me to have family or a close friend involved in discussions about my care. On 03/17/22 at 12:41 PM, the Surveyor interviewed the Licensed Practical Nurse (LPN) regarding the facility shower schedule process. The LPN stated that showers were scheduled during the 700 AM -3:00 PM and 3:00 PM -11:00 PM shifts. The LPN stated the Certified Nursing Assistants (CNAs) were responsible to complete the showers. Upon inquiry to the LPN regarding where the CNAs would document that a shower was provided, she indicated that the CNAs would document on the kiosk (computer system) used by the facility to document ADLs care provided. She further stated that ADLs care can be viewed under the Tasks section of the electronic medical record. On 03/17/22 at 12:49 PM, a review of the CNA's assignment book revealed that Resident #50's shower was scheduled on Tuesday and Friday on the 300 PM - 11:00 PM shift. The Surveyor interviewed one of the CNAs assigned to the unit regarding documentation in the kiosk. The CNA explained the process would be if the task was completed the documentation would be in green, and if the task was not completed, the documentation would be in pink. The CNA reviewed the bathing task for Resident #50 from March 1 through March 17, 2022 with the Surveyor. The documentation was observed in pink, which indicated that the bathing task had not been completed. A further review of the ADLs sheet provided by the facility confirmed that Resident #50 had not received a shower for the past two months. On 03/18/22 at 8:53 AM, the Surveyor observed Resident #50 in bed. Resident #50 was awake and alert and the Surveyor interviewed the resident at that time. The Resident stated stated that he/she had not had a shower for two months and would like to take a shower. On 03/18/22 at 9:58 AM, the Surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that her role was to oversee staff, assist with care, administer medications if the nurse called out, attend care conference with other disciplines and families, rounding with the wound nurse every Thursday, and to communicate with residents and assist with care planning. She further stated that staff would inform her of any complaints, and the family would also inform her of any issues that needed to be addressed. The Surveyor inquired to the LPN/UM regarding Resident #50's request for shower. The LPN/UM acknowledged that she had been informed by the LPN assigned to the low hall of Resident #50's about the request for a shower, and she had informed the 3:00 PM -11:00 PM Nurse. On 03/18/22 at 10:10 AM, the Surveyor interviewed the LPN assigned to the low hall about the process for shower. The LPN stated that the CNA would ask/inform the resident of the shower and if the resident refused, the CNA would inform the nurse, then the nurse would document into the notes that the resident had refused the shower. A review of the Nurse's Notes from 03/01/22 to 03/17/22 failed to indicate that a shower was offered to Resident #50, and refused on the following dates: 02/01/22, 02/04/22, 02/08/22, 02/11/22, 02/15/22, 02/18/22, 02/22/22, 02/25/22, 03/01/22, 03/04/22, 03/08/22, 03/11/22 and 03/15/22. On 03/17/22, a late entry was entered for 03/15/22, which revealed that Resident #50 had refused a shower on 03/15/22 (The resident was not provided with approximately sixteen showers). On 03/18/22 at 10:40 AM, the Surveyor requested the February's ADLs documentation from the LPN/ UM. The Unit Manager and the Assistant Director of Nursing indicated that they could not print the documentation as requested. At 12:55 PM, partial documentation was provided by the MDS Coordinator which confirmed that Resident #50 had not had a shower as scheduled for the last two months. On 03/22/22 at 9:15 AM, the Surveyor observed Resident #50 in bed. An interview with Resident #50 at that time revealed the resident denied refusing a shower on 03/15/22. Resident #50 stated, Of course I wanted to take a shower. On 03/22/22 at 10:09 AM, during an interview with Resident #50 in the presence of the UM, Resident #50 revealed that he/she had not had a shower since he/she had been at the facility. Resident #50 stated, Of course I would like to take a shower. I need a special chair and stated Would that be a scheduled shower? On 03/22/22 at 10:17 AM, the Surveyor reviewed the Nurse's Notes and could not locate documentation that Resident #50 had refused a shower on 03/18/22. The UM confirmed that the Nurse's Notes did note did not reflect that Resident #50 had refused a shower on 03/18/22 as scheduled. On 03/23/22 at 9:36 AM, the Surveyor interviewed Resident #50 and inquired as to how it felt not to having his/her scheduled shower, Resident #50 replied, I felt that was negligence on the part of the nursing home. On 03/28/22 at 9:51 AM, the Survey Team conducted a meeting with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing. The DON stated that when a resident was scheduled to have a shower, the CNA was responsible to communicate with a nurse if the resident refused. A review of the facility provided policy for, Activities of Daily Living revised 06/01/21, stated in part: Based on the comprehensive assessment of a resident, and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living ADL'S activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrate that a change was unavoidable. Activities of daily living (ADLs) include Hygiene-bathing, dressing, grooming, and oral care Purpose: To ensure ADLs are provided with accepted standards of practice, the care plan, and the patient's choices and preferences. Under Practice Standards the following were noted: Patients are assessed upon admission, quarterly, and with a significant change to identify his/her status in all areas of ADLs, risks for decline in any ADL ability to improve in identified ADLs. The care plan will address the patient's ADL needs and goals, including the provision of ADLs if the patient is unable to perform ADLs. A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. ADL care is documented every shift by the nursing assistant. The licensed nurse will document ADL care he/she provided, when applicable. NJAC 8:39- 4.1(a)22

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Advance Directives to ensure a complete and updated Advance Directive was maintained in a resident's medical file, and b.) inform and offer educational material regarding Advance Directives. This deficient practice was identified for 1 of 1 resident (Resident #2) who was reviewed for Advance Directives. The deficient practice was evidenced by the following: On 03/17/22 at 9:43 AM, the Surveyor observed Resident #2 in their room with their spouse. Resident #2 spoke to the Surveyor and was confused at times. A review of Resident #2's medical records revealed the following: The admission Record revealed Resident #2 had been admitted to the facility with diagnoses, which included but were not limited, to dementia without behavioral disturbance, Transient Ischemic Attack (stroke-like attack wherein symptoms resolve within 24 hours), depression, lack of coordination, hyperkalemia (elevated blood potassium), hypertension (elevated blood pressure), abnormal gait and mobility, and major depressive disorder. The most recent Quarterly Minimum Data Set (MDS) an assessment tool, dated 03/11/22, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact, and that family or significant other participated in goal setting. The on-going Care Plan (CP) revealed a focus area that the resident has an established advanced directive initiated 09/04/20 with interventions which included full code (full support provided if a person has no heartbeat or stops breathing); all opportunities for expression of feelings; and inform resident/patient and/or healthcare decision maker of any change in status or care needs. On 03/18/22 at 9:37 AM, the Surveyor reviewed a form located in Resident #2's medical chart. The Resident's name and a note was observed in the upper right-hand corner '9/2/20 Full Code' with no other information filled out and there was no signature. The form indicated to 'circle: DNR [Do Not Resuscitate] DNH [do not hospitalize] DNI [do not intubate]; the form included the following sections to be filled out: 1. Reason for the DNR/DNH/DNI order; 2. Discussion of DNR/DNH/DNI status has occurred with resident - family/responsible party - nursing staff - other; 3.) discussion of DNR/DNH/DNI order has not taken place with family because .; 4.) Intervention aimed at curing the resident or restoring the resident to a better than present state of health are deemed futile, of no medical benefit, and hence medically inappropriate. The dying process is irreversible. Resuscitation to prevent or reverse death, when it occurs , would only impose additional burden and discomfort upon the resident without any reasonable hope of benefit. Therefore, I am ordering a. emphasis on comfort, support and symptom control, b. do not resuscitate, c. do not hospitalize, d. do not intubate, e. the resident is not to be disturbed with tests, unless the information thereby obtainable is expected to be utilized to increase the resident comfort or otherwise benefit the resident, f. additional orders. These orders are based upon a sound medical assessment, after consultation with the resident/responsible party of the resident's condition. On 03/18/22 at 9:46 AM, the Surveyor reviewed the Initial Services Assessment and Documentation form, dated 09/4/20 and documented by the previous Social Worker (SW), which indicated Resident #2 was a DNR do not resuscitate. A review of the Social Services Assessment and Documentation quarterly forms dated 12/04/20, 03/08/21, 06/06/21, 09/07/21, 12/02/21, and 03/13/21, all included but were not limited to the following information: 5. Resident Rights / Healthcare Decision Making / Advance Directives b. Advance Directives (e.g. Living Will, Healthcare Power of Attorney or Healthcare Proxy) in place? NO c. Additional conversation regarding advance care planning provide NO d. opportunity to complete advance directive offered YES e. Separate Healthcare Orders (Physician Order for scope of Treatment, Physician Orders for Life Sustaining Treatment, Medical Order for Life Sustaining Treatment) completed? NO Resident Rights / Advance Directive Comments, g. Use to further elaborate on healthcare decision making [area left blank]. On 03/18/22 at 9:49 AM, the Surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM) on the 2nd floor. The LPN UM stated that a resident's Advance Directive would be documented in the computer, and all updates would be the responsibility of the SW. The LPN UM stated it was important for residents to have Advance Directives so the staff would know what the residents' wishes were. On 03/18/22 at 10:30 AM, the present SW stated that Advanced Directives sometimes would be completed through the admissions department, or if the family wanted to change anything, the facility will have the Nurse Practitioner (NP) address changes along with the SW. The SW stated Advance Directives were important because the resident needed to be able to voice their rights and decisions. The SW stated the Advance Directives would be reviewed every month by the NP or SW. On 03/18/22 at 10:41 AM, the Surveyor reviewed a progress note dated 09/2/20 entered by the NP which revealed Full Code. The progress note revealed she had spoken to Resident #2's daughter on the phone from 11:30 am to 11:47 am and that the daughter was looking for the living will. The NP's progress notes further revealed that in the interim, Resident #2 would be made a Full Code as the daughter tried to locate the Advance Directives or living will documents. On 03/18/22 at 10:48 AM, the Surveyor reviewed the progress notes in Resident #2's medical records and was unable to find any follow up regarding Advanced Directives to date or follow up with the resident's daughter. On 03/22/22 at 9:18 AM, during a follow-up interview, the SW stated Resident #2 was a full code and knew that because he had asked the business office. The SW stated he would have to look for any paperwork regarding the resident's code status or Advance Directives. On 03/22/22 at 9:36 AM, the Director of Social Services (DSS) stated that when a resident was admitted to the facility, social services would ask if they had any Advance Directives. If the resident did not have one, they would be offered to formulate an Advance Directive, and it would be discussed during the quarterly care conference. The DSS added that documentation of the discussion of Advance Directives should be in located in the progress notes because it was important to know what a resident's wishes were. The DSS stated she had no explanation as to why no one had followed up on the Advance Directive for Resident #2. On 03/22/22 at 10:07 AM, the Surveyor attempted to contact Resident #2's daughter. On 03/22/22 at 11:26 AM, the Surveyor attempted to ask Resident #2 about an Advance Directive, wishes or life choices. The resident was confused and was unable to answer. On 03/24/22 at 10:34 AM, the SW stated he would review the file to see if anything was updated in the chart about Advanced Directives. The SW further stated that the process was to ask the family or resident upon admission, and that would be on the UDA [Initial Services Assessment and Documentation] assessment. The SW further stated that the health care decision and Advance Directives would be tracked via the computer system, or there should be a copy in the file. The SW stated when he completed his assessment, that he asked the Resident's daughter and he was unsure of the date. The SW stated he did not document in the medical record and that the assessment was the quarterly assessment. He stated there was no documentation who attended, and the SW was unable to confirm who was at the meeting, or who he spoken to. The SW further stated that the conversation was not documented, and that he would just check off the questions on the assessment form. On 03/24/22 at 11:05 AM, the DSS stated she would review Advance Directives during care conference. She stated that Advance Directives would be addressed during the initial assessment and during care conferences that were done quarterly, and the attendants should be listed in the progress notes. The DSS reviewed the 09/04/20 progress note and acknowledged the note reflected Resident #2 was a DNR, but the following note reflected Resident #2 was a full code. She stated the documentation did not follow up as to when the subsequent Social Worker completed the quarterly assessment, and that the Social Worker listed the resident as not having an Advanced Directive. The DSS stated per the documentation there was no proof that we [the facility] did what we were supposed to do. She stated that copies of the Advance Directive should be kept in the resident's chart, and she had no explanation as to why there was no education or information provided to the resident, or daughter regarding an Advance Directive. On 03/24/22 at 11:33 AM, the Surveyor made a second attempt to contact Resident #2's daughter but there was no answer. A review of the facility provided policy and procedure, Health Care Decision Making revision 3/1/22, revealed Policy: it is the right of all patients / residents to participate in their own health care decision making including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an Advance Directive. Centers must: inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and the patient's option formulate an advance directive; provide a written description of the centers policies to implement advance directives; approach a capable patient who does not have an advance directive upon admission, the patient will be approached by the SW or another designated staff on admission, quarterly, and with change in condition to discuss whether he/she wishes to consider developing an advance directive; inquire with the individual's patient representative if the patient is incapacitated at the time of admission as to whether an advance directive has been complete/executed in accordance with state law; and establish mechanisms for documenting and communicating the patient's choices to the interprofessional team and staff responsible for the patient's care. Advance Care Planning: an ongoing process of communication between patients and their healthcare decision makes to understand, reflect on, discuss, and plan for future healthcare decisions for a time when patients are not able to make their own healthcare decisions. Advance care planning includes two key parts: 1. Face-to-face conversations with physician, healthcare professional and patients or their healthcare decision makers to discuss advance directives and treatment decisions; and 2. Documenting treatment or wishes preferences. Advance Directive: written instruction, such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care. Instructive Directive: Living will or similar state form that is used to document the medical treatment wishes. It serves as information for the family, physician, and/or surrogate decision maker to base health care decisions on the patient's personal desires for treatment. Practice Standards: 1. Upon admission, determine whether the patient has a copy with them, make copies, place in medical record, and notify interprofessional team. 1.1.1.1 request that patient/patient representative bring the documents to the Center [facility] as soon as possible. 1.2 If the patient does not have an advance directive: 1.2.3 provide advance directive information. 2. Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and/or portable medical orders and determine whether the patient wishes to change or continue these instructions. On 03/25/22 at 12:56 PM, the concerns were discussed with the facility. The facility had no additional information to provide. NJAC 8:39-4.1(a)(2)(4), 9.6(a)

3. On 03/17/22 at 10:18 AM, the Surveyor observed Resident #63 sleeping in bed with O2 being administered at 3 liters per minute by nasal cannula tubing which was connected to an O2 concentrator. The Surveyor observed that the nasal cannula tubing was dated 02/27/22. The Surveyor also observed that there was no cautionary signage posted on Resident #63's door to indicate O2 was in use. On 03/17/22 at 12:38 PM, the Surveyor, in the presence of another Surveyor, observed Resident #63 sitting up in the bed without O2 by nasal cannula tubing being administered. The Surveyor attempted to interview Resident #63 who was unable to participate in the interview due to cognitive deficits. The Surveyors observed the nasal cannula tubing, dated 02/27/22, was lying on the floor next to Resident #63's bed. On 03/18/22 at 9:14 AM, the Surveyor observed Resident #63 sleeping in bed with O2 being administered at 3 liters by minute by nasal cannula tubing. The Surveyor observed that the tubing was dated 02/27/22. On 03/18/22 at 9:42 AM, the Surveyor reviewed Resident #63's medical record. A review of Resident #63's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, unspecified dementia, Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing) and hypertension (high blood pressure). A review of Resident #63's quarterly MDS, an assessment tool used to facilitate the management of care, dated 02/14/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #63 was unable to complete the interview. Further review of the MDS indicated that Resident #63's skills for daily decision making were severely impaired. A review of Resident #63's Medication Review Report included the following physician's order: O2 2 LPM via nc (nasal cannula) may titrate (adjust the amount until the desired effects are achieved) up for po <92%, RR (respiratory rate) > 20 or feelings of breathlessness. A review of Resident #63's care plan indicated that the resident did not have a care plan for the use of oxygen. On 03/18/22 at 11:22 AM, in the presence of another Surveyor, the Surveyor asked the LPN #2 to inform the Surveyors what date she observed on Resident #63's nasal cannula tubing. LPN #2 confirmed that the date on the nasal cannula tubing was 02/27/22 and stated that the tubing was usually changed every Saturday on the 11 PM -7 AM shift, and that Resident #63's nasal cannula tubing should have been changed. She added that she always looked at the flow rate of the O2 and that sometimes she looked at the date on the tubing. The Surveyor then informed LPN #2 about the observation that the two surveyors made of Resident #63's nasal cannula tubing on the floor on 03/17/22. LPN #2 stated that if the nasal cannula was on the floor that the tubing should have been changed. The Surveyor then asked LPN #2 if there should be a sign on Resident #63's door that would indicate O2 was in use. LPN #2 confirmed that there was not a cautionary sign on the door and stated that she believed there should be one. On 03/18/22 at 11:33 AM, in the presence of the LPN #2, the Surveyor asked the Unit Manager (UM) of the second floor what date she observed on Resident #63's nasal cannula tubing. The UM confirmed that the date on Resident #63's nasal cannula tubing was 02/27/22 and revealed that the tubing should have been changed. On 03/22/22 at 12:04 PM, the Surveyor interviewed the UM who confirmed that Resident #63 did not have a care plan for O2 use and that Resident #63 should have had one. 4. On 03/17/22 at 9:58 AM, the Surveyor observed Resident #27 sleeping in bed with O2 at 2 lpm by nasal cannula tubing. The Surveyor observed that the nasal cannula tubing was dated 02/27/22. The Surveyor observed that a water bottle that was connected to the O2 concentrator was dated 2/21. The Surveyor also observed that there was not a cautionary sign on Resident #27's door to indicate O2 was in use. On 03/18/22 at 9:25 AM, the Surveyor observed Resident #27 in bed with O2 being administered at 2 lpm by nasal cannula tubing. The Surveyor observed that the tubing was dated 02/27/22. The Surveyor observed that a humidification water bottle that was attached to the O2 concentrator was dated 2/21. The Surveyor interviewed Resident #27 who stated that he/she used the O2 mostly at night but also used it during the day. On 03/18/22 at 11:20 AM, the Surveyor reviewed Resident #27's medical record which revealed the following: The admission Record face sheet reflected that the resident was admitted to the facility with diagnoses which included but were not limited to COPD, Type 2 Diabetes Mellitus (DM) and Major Depressive Disorder. The quarterly MDS, an assessment tool used to facilitate the management of care, dated 01/20/22, reflected that the resident had a BIMS score of 15 out of 15, which indicated that Resident #63 was cognitively intact. The Medication Review Report (MRR) included the following orders: O2 at 2L/min via nasal cannula every shift for COPD; O2 tubing change weekly and label each component with date and initials every night shift every Sunday. The Care Plan, with a created date of 07/30/21, indicated that the resident had a care plan for COPD which included the use of O2. On 03/18/22 at 11:25 AM, in the presence of another Surveyor, the Surveyor asked LPN #2 to explain to the Surveyors date she observed on Resident #27's nasal cannula tubing and water bottle. LPN #2 confirmed that the date on the nasal cannula tubing was 02/27/22 and the date on the water bottle was 2/21. LPN #2 stated that the nasal cannula tubing was usually changed every Saturday on the 11-7 shift and that Resident #27's nasal cannula tubing and water bottle should have been changed. She added that humidity water bottle was changed at the same time the nasal cannula tubing was changed. The Surveyor then asked LPN #2 if there should be a cautionary sign posted on Resident #27's door that would indicate oxygen was in use and LPN #2 confirmed that there was not a sign and believed there should be a sign. On 03/18/22 at 11:34 AM, the Surveyor asked the UM of the second floor what dated was posted on Resident #63's nasal cannula tubing and water bottle. The UM confirmed that the date on Resident #63's nasal cannula tubing was 02/27/22 and the date on the water bottle was 2/26. The UM admitted that the tubing and water bottle should have been changed and added that it should be changed weekly and that it was usually done on Saturday evening and believed that it gets documented. The Surveyor then reviewed Resident #27's Treatment Administration Record (TAR) which indicated that on 03/6/22 and 03/13/22 Resident #27's oxygen tubing was documented to have been changed by the nurse. On 03/18/22 at 12:02 PM, the Surveyor interviewed the UM. The UM stated that the nurses had signed that they changed the tubing but that all she knew was that the date on the nasal cannula tubing did not match what the nurses signed for on the TAR. An interview was conducted with the Director of Nursing (DON) on 03/28/22 at 11:20 AM. The DON stated that the nurses should be checking the flow rate of the oxygen at least every shift. Her expectations were that the oxygen tubing and humidifier bottled would be changed, dated and labeled weekly. A review of the facility provided policy titled Oxygen: Nasal Cannula with a revision date of 06/1/21, included the following: 1. Verify order. 2. Determine appropriate oxygen source and need for humidification by the using the following table . 3. Gather supplies: 3.2 Nasal cannula labeled with date of initial set-up . 3.8 No Smoking-Oxygen in Use sign . 6.Post No Smoking-Oxygen in Use sign on patient's door 10. If humidifier is used: 10.1 Label with date . 11.set the flow rate to the prescribed liter flow . 16. Replace disposable set-up every seven days. Date and store in treatment bag when not in use . N.J.A.C. 8:39-11.2 (b); 27.1(a) Based on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to: a.) administer oxygen per the physician order for 2 of 5 residents sampled for respiratory/oxygen (Resident #36 and Resident #17), b.) ensure that all oxygen supplies were changed, labeled and dated weekly for 4 of 5 residents sampled for respiratory/oxygen, and c.) post cautionary signage to indicate that oxygen therapy was in use for 4 of 5 residents reviewed for oxygen/respiratory (Resident #36, #17, # 63 and Resident #27). The deficient practice was evidenced by the following: 1. On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with eyes open wearing oxygen (O2) by way of nasal cannula (tubing used to deliver oxygen). The O2 was connected to an oxygen concentrator (an electronic device that removed nitrogen from room air and increased the oxygen concentration) that was sitting beside the bed and set to deliver 3.5 liters of oxygen per minute. On 03/18/22 at 9:24 AM, the Surveyor observed Resident #36 resting in bed with his/her eyes closed. Resident #36 was observed wearing O2 by way of nasal cannula. The oxygen was connected to an oxygen concentrator sitting next to the bedside and the concentrator was set to deliver 4.5 liters of O2 per minute. A review of Resident #36's medical record revealed: the resident was admitted to the facility with diagnoses which included but not limited to, chronic obstructive pulmonary disease (COPD), heart failure and dependence on O2. A review of a physician order dated 04/13/19 revealed O2 at 3 liters per minute nasal cannula continuously 18-24 hours daily every shift, O2 tubing change weekly, label each component with date and initials every night shift every Saturday and label each component with date and initials. A review of the Quarterly Minimum Data Set (MDS an assessment tool) dated 01/22/22, revealed that Resident #36 was cognitively intact and required limited assistance with activities of daily living. On 03/18/22 at 11:32 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was not too sure of the setting for the O2 and that she indicated that she checked the oxygen concentrator this morning. On 03/18/22 at 11:35 AM, the Surveyor accompanied by LPN #1 into Resident #36's room only to verify that the O2 was connected to the oxygen concentrator with a flow rate of 4.5 liter per minute. The surveyor observed that the O2 tubing was not labeled with a date and was resting on the floor. The surveyor also observed the humidifier bottle (a medical device used to humidify O2, increases humidity or moisture and decrease dryness) was dated 03/04/22. The Surveyor observed that there was no cautionary signage posted at the door to indicate that O2 was in use. LPN #1 confirmed that the flow rate was set to deliver 4.5 liters per minute and that she would check the physician order and adjust the flow rate. On 03/18/22 at 11:40 AM, the Surveyor conducted another interview with LPN #1 who confirmed that she was responsible for Resident #36 that morning and that the 11:00 PM -7:00 AM shift was responsible to change the O2 tubing and humidifier bottled every Saturday. LPN #1 confirmed that Resident #36's order was to receive O2 at 3 liters per minute. On 03/25/22 at 8:55 AM, the Surveyor interviewed the LPN (LPN #2) who worked the 11:00 PM-07:00 AM shift. LPN #2 stated that she had not been at the facility for the last two weeks and that the other nurse that covered the shift should have changed and dated the O2 tubing. LPN #2 indicated that upon return to work she did not check to ensure that the O2 tubing was changed as it was the facility's policy for the O2 tubing to be changed every week on Saturday. 2. On 03/17/22 at 10:15 AM, the Surveyor observed Resident #17 in bed. Resident #17 had the O2 on and the O2 tubing was dated 03/04/22. The surveyor observed the flow rate set to deliver 3.5 liters O2 per minute. The surveyor observed that there was no cautionary signage posted at the door to inform of O2 usage in that room. The Surveyor reviewed Resident #17's medical record which revealed the following: Resident #17 was admitted to the facility with diagnoses which included but was not limited to, COPD with exacerbation, anxiety disorder and dependence on supplemental O2. A physician order sheet dated 11/28/21 reflected an order for O2 to be delivered at 3 liters per minute via nasal cannula 18-24 hours every shift. The order continued to reveal that O2 tubing was to be changed weekly and that the staff was to label each component with date and initials every shift on every Saturday. On 03/18/22 at 11:42 AM, the Surveyor interviewed the LPN #1 regarding the process for oxygen administration and use of O2. LPN#1 revealed that the nurse should ensure that cautionary signage was posted at the entrance door to inform of O2 being in use and to check the flow rate. She further stated the 11:00 PM - 7:00 AM shift was responsible to change the tubing every Saturday. The LPN admitted that she did not check the date on the O2 tubing. On 03/18/22 at 11:52 AM, the Surveyor observed Resident # 17 in bed, awake and alert with the head of the bed elevated. Resident #17 was receiving O2 by way of a nasal cannula connected to the O2 concentrator next to the bed. The oxygen concentrator was set to deliver 3.5 liters. The O2 tubing was dated 03/04. According the facility policy the O2 was to be changed every Saturday, the oxygen tubing had not been changed for two weeks, and the humidifier bottled was not dated. The surveyor accompanied LPN #1 to Resident #17's room and both the surveyor and the LPN #1 observed that the O2 concentrator was set to deliver 3.5 liters per minute. The nurse then verified the physician's order and adjusted the flow rate to 3 liters per minute as ordered.

Based on observation, interview, review of the medical record and other pertinent facility documentation, it was determined that the facility failed to: a.) consistently communicate information to the dialysis center by failing to document an assessment and pre-dialysis treatment, on the Hemodialysis Communication Record (HCR), per facility policy, for 22 of 35 scheduled dialysis treatments, b.) document an assessment, post dialysis treatment, on the HCR, per facility policy, for 33 of 35 scheduled dialysis treatments, c.) accurately monitor and account for the intake of all fluids administered for a resident with a physician ordered fluid restriction, d.) ensure a physician ordered medication that required additional fluid for administration would not exceed the fluid restriction, and was documented. This deficient practice was evidenced for 1 of 2 resident's reviewed for dialysis (Resident #4) and was evidenced by the following: On 03/17/22 at 11:25 AM, during initial tour, the Surveyor observed Resident #4 lying in bed. Resident #4 stated that he/she received hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood) treatments on Tuesday, Thursday, and Saturday and that he/she had just returned from a hemodialysis treatment. Resident #4 stated that he/she was on a fluid restriction but was unsure of the amount. On 03/18/22 at 10:02 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN #1) regarding Resident #4's fluid restriction and HCR. LPN #1 stated that the total amount of fluid for the day was divided into two totals, one for nursing and one for dietary. She then stated that the nurses would check to make sure there was no water at the resident's bedside, and that nursing would educate the resident about the fluid restriction. She added that sometimes the resident asked for more water. LPN #1 stated that Resident #4 had a communication book that the nurse would fill out prior to Resident #4 leaving for hemodialysis, and the book would go along with Resident #4 to the dialysis center. The LPN #1 added that when Resident #4 returned from the dialysis center the nurse would check the resident's access site (a way to reach the blood for hemodialysis) and vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicated the state of a patient's essential body functions). On 03/18/22 at 10:00 AM, the Surveyor reviewed Resident #4's HCR Binder from 12/24/21 through 03/17/22 which included the following: There was no HCR documented for 12/28/21, 12/30/21, 01/01/22, 01/04/22, 01/6/22, 01/13/22, 01/29/22, 02/01/22, 02/03/22, 02/05/22, 02/08/22, 02/12/22, 02/15/22, 02/17/22, 02/22/22, 03/08/22, 03/15/22 and 03/17/22. There was no pre dialysis treatment assessment documented on the HCR by the facility Licensed Nurse on 01/20/22, 01/25/22, 03/5/22 and 03/8/22. There was no post dialysis treatment assessment documented on the HCR by the facility Licensed Nurse on 12/24/21, 01/8/22, 01/15/22, 01/18/22, 01/20/22, 01/25/22, 02/10/22, 02/19/22, 02/24/22, 02/26/22, an undated form, 03/05/22 and 03/08/22. On 03/22/22 the Surveyor reviewed Resident #4's medical record which revealed the following: The admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (ESRD), Type 2 Diabetes Mellitus (DM), and dependence on renal dialysis. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/12/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's BIMS score indicated that Resident #4 was cognitively intact. The MDS was coded to indicate that Resident #4 received dialysis. The Care Plan (CP), with an initiated date of 09/7/21, indicated the resident was on a 1200 ml fluid restriction. The Medication Review Report included the following physician order: Glycolax Powder (Miralax) (laxative that relieves constipation & softens stools) Give 17 gram by mouth one time a day for constipation (Mix in 4 to 8 ounces [120 to 240 milliliters (ml)] of liquid). On 03/22/22 at 11:52 AM, the Surveyor interviewed Resident #4, and at that time, LPN #2 entered the resident's room with a medicine cup of pills and a plastic cup filled approximately three quarters of water. Resident #4 took one sip of water with the pills and the nurse instructed the resident to take another sip of water. Resident #4 took another sip of water and then LPN #2 took the cup of water and left the resident's room. On 03/22/22 at 12:00 PM, the Surveyor interviewed LPN #2 regarding the process of the HCR. LPN #2 stated when Resident #4 returned from the dialysis treatment the LPN#2 would check Resident #4's vital signs and check the HCR for any communication from the dialysis center. The Surveyor then asked LPN #2 if each section of the HCR should be completed, and if there should be an HCR for each dialysis treatment. The LPN #2 confirmed that there should be a HCR for each dialysis treatment and all three sections should be completed. On 03/22/22 at 12:06 PM, the Surveyor interviewed the second floor Unit Manager (UM) regarding the HCR. The UM stated that the HCR was for communication between the facility and the dialysis center, and the facility received information about the resident's post dialysis weight, and any other recommendations from the dialysis center. She added that there were three sections on the HCR and stated the nurse would complete the pre and post dialysis treatment sections, and that the dialysis center would complete the middle section. The Surveyor then asked the UM if all three sections of the HCR should be completed, and the UM stated that the nurse could either put a note in the computer or fill out the HCR. The Surveyor then asked the UM if there was another place that the facility kept the HCR records. The UM stated that the HCR would be kept in the HCR book or in the resident's physical medical record. The UM then proceeded to review Resident #4's medical record and did not locate the HCR in the resident's chart. At that time, the UM confirmed that there were multiple missing HCR forms and multiple HCR forms that were incomplete. The UM, in the presence of the Surveyor, viewed Resident #4's electronic medical record (EMR). The UM was unable to provide documented evidence that an assessment post dialysis treatment was documented in the EMR for the missing HCR or the missing documentation on the HCR. The UM confirmed that a post dialysis treatment assessment should have been documented. On 03/22/22 at 12:39 PM, the Surveyor observed Resident #4's lunch tray which included 6 oz (180 ml) of coffee. Resident #4 stated that he/she only received limited fluids with his/her meals and that he/she did not drink anything between meals. On 03/22/22 at 12:45 PM, the Surveyor interviewed LPN #2 regarding Resident #4's fluid restriction. LPN #2 stated that Resident #4's total fluid intake was divided between 800 ml from dietary and 400 ml from nursing. The Surveyor then asked LPN #4 the reason she brought a three-quarter cup of water (approximately 180 ml), in for the resident to take his/her medication. At that time, the LPN #2 confirmed the cup was a 9-ounce cup and LPN #2 stated that the resident was in dialysis and did not receive his/her full allotment of fluid for that shift. She added that Resident #4 took 2 sips and that she needed to give the resident fluid to take medications. The LPN #2 did not confirm how much fluid from 2 sips of fluid. On 03/22/22 at 1:33 PM, the surveyor reviewed Resident #4's March 2022 Medication Administration Record (MAR) which included the following physician's order: Monitor Daily Fluid Restriction Total 1,200 ml; 800 Dietary; 400 nursing. every shift for Abnormal labs; which was 200 ml for 7-3 shift, 150 ml for 3-11 shift and 50 for 11-7 shift. Further review included the following: Resident received 280 ml on the 11-7 shift on 03/01/22, 03/02/22, 03/07/22, 03/08/22 and 03/18/22. Resident received 120 ml on the 11-7 shift on 03/03/22. Resident received 180 ml on the 11-7 shift on 03/09/22 and 03/16/22. Resident received 60 ml on the 11-7 shift on 03/10/22. Resident received 360 ml on the 11-7 shift on 03/17/22 and 03/21/22. According to the physician's order, Resident #4 should have received 50 ml on the 11-7 shift. (According to the physician's order, Resident #4 should not have received more than a total of 400 ml from nursing for the day. Resident #4 received 510 ml on 03/17/22, 450 ml on 03/18/22 and 610 ml on 03/21/22). On 03/23/22 at 9:49 AM, the Surveyor interviewed Resident #4 regarding his/her fluid restriction. Resident #4 stated that he/she usually took medications with applesauce. Resident #4 added that if he/she had a nurse that was not his/her usual nurse that the nurse would come in with water. Resident #4 then stated that he/she would only take a small sip of the water. On 03/23/22 at 9:59 AM, the Surveyor interviewed LPN #3 regarding Resident #4's medications and fluid restriction. LPN #3 stated that Resident #4 was on a fluid restriction of 200 ml from nursing on the day shift. She added that Resident #4 received medications several times during the day shift, and that Resident #4 received Miralax in 6 oz (180 ml) of water. On 03/23/22 at 10:20 AM, the Surveyor asked LPN #3 to explain the different times that Resident #4 received medications and how she calculated the amount of fluid that Resident #4 received during the day shift. LPN #3 stated that Resident #4 received Miralax in 6 oz (180 ml) of water at 10 AM and received other pills at the same time. She added that Resident #4 would use the fluid that was with the Miralax to take the pills at that time. She then stated that on days that Resident #4 did not have dialysis the resident received Metoprolol (used to treat chest pain (angina), heart failure, and high blood pressure) at 8:30 AM. She then added that Resident #4 received Neurontin (used to relieve nerve pain) at 2 PM. The Surveyor then asked LPN #3 if Resident #4 had been receiving more than the allowed 200 ml on the day shift. LPN #2 stated that Resident #4 could be receiving more than 200 ml on the day shift. The Surveyor then asked LPN #3 how it was possible for a nurse to document that Resident #4 had only received 60 ml during the day shift if the minimum required fluid that was ordered to be used with the Miralax was 4 oz (120 ml). LPN # 3 confirmed that the minimum documented on the MAR for the day shift would be at least 120 ml. On 03/23/22 at 11:47 AM, the Surveyor interviewed the UM regarding Resident #4's medications and fluid restriction. The UM stated that the physician order divided the amount of fluid that the resident would receive between the nursing department and the dietary department. She added that nursing would use 9 oz (270 ml) cups and the 30 ml medicine cups to calculate the amount given. The Surveyor then asked the UM about Resident #4's physician's order for Miralax. The UM stated that whatever the order had written was what the nurse would provide. She added that if the order was 4 to 8 oz (120 to 240 ml), then the nurse would give at least 4 oz (120 ml) but that it would depend on what the resident's fluid restriction was. The Surveyor asked the UM what amount of fluid was documented on the MAR. The UM stated that only the nursing amount of fluid should be documented on the MAR, and that the dietary amount would not be included in that amount. The Surveyor then asked the UM if the Miralax order of 4 to 8 oz (120 to 240 ml) was appropriate for a resident that was on a fluid restriction and limited to 200 ml on the day shift. The UM stated that the order for Miralax could be adjusted. The Surveyor then asked the UM to view Resident #4's MAR and the amount of fluid that was documented for 03/17/22, 03/18/22 and 03/21/22. The UM confirmed that Resident #4 received more than the 400 ml allotted for those days. The UM stated that Resident #4 was noncompliant with the fluid restriction and added that Resident #4 was alert and oriented and knew of the fluid restriction. The UM stated that Resident #4 could have requested more fluid, and the nurse would have educated Resident #4 but still provided the fluid. The Surveyor then asked the UM if she would expect documentation if the resident would have asked for more fluid and the nurse educated the resident. The UM confirmed that there was no documentation in the EMR to support that the resident was educated and if it happened the nurse should have documented it. The Surveyor then asked the UM how the nurses documented that Resident #4 had received 60 ml on the day shift on multiple days in March 2022 if Resident #4 had received Miralax in 120 ml of fluid on those days. The UM stated that the nurses had not accurately documented the amount of fluid Resident #4 received. On 03/25/22 at 8:43 AM, the Surveyor interviewed LPN #4 who was Resident #4's 11-7 shift nurse and had documented the amounts of fluid that were over the allotted 50 ml on the March 2022 MAR. LPN #4 stated that Resident #4 was noncompliant with the fluid restriction and that the resident would sneak fluid. She added that sometimes the extra fluid she documented was from Resident #4's breakfast tray. The Surveyor then asked LPN #4 if Resident #4 was noncompliant with the fluid restriction during LPN #4's shift, and if she should document the noncompliance in the EMR. LPN #4 confirmed that a note should be documented in the EMR. On 03/28/22 at 10:05 AM, in the presence of the survey team, the DON confirmed that there should be documentation on the HCR filled out by the facility nurse. The DON added that she educated the nursing staff on fluid restriction. A review of the facility provided policy titled, NSG253 Dialysis: Hemodialysis (HD)-Communication and Documentation with a revision date of 6/1/21, included the following: Policy: Center staff will communicate with the certified dialysis facility prior to sending a patient for hemodialysis (HD) by completing the Hemodialysis Communication Record [HCR] .or other state required form and sending it with the patient. The form will also be completed upon return of the patient from the certified dialysis facility. Practice Standards: 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the HCR .and send with the patient to his/her HD facility visit. 2. Following completion of the HD, the dialysis facility nurse should complete the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: 3.1 Review the HD center communication. 3.2 Evaluate/observe the patient; and 3.3 Complete the post-HD treatment section on the HCR . 4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center. 4.1 Document notification of certified dialysis facility regarding return of form or other communication. 5. Maintain the HCR .in the patient's medical record. A review of the facility provided policy titled, NSG216 Fluid Balance, with a revision date of 6/1/21, included the following: When a physician/advanced practice provider (APP) orders a fluid restriction due to specific clinical condition, close monitoring of fluid intake will be provided to maintain adequate hydration. Orders must include volume of fluid permitted during a 24-hour period. Staff will notify the Dietary Department .Dietary will calculate the amount of fluids to be provided on the meal trays. Nursing will calculate the remaining amounts of fluids allotted for each shift. Intake and output will be monitored and documented as follows: . Fluid restriction: Monitor fluid intake; monitor output if ordered. If ordered by physician/APP . 1. Notify staff caring for patient that patient is on fluid restriction. 2. Inform the patient and responsible party of fluid restriction. N.J.A.C. 8:39-27.1 (a)

Based on interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure: a.) a resident was offered a shower on scheduled shower days, and b.) that residents were consistently offered evening snacks. The deficient practice was evidenced by the following: Refer to F561 and F809 The facility failed to: a.) follow the facility policy for Activities of Daily Living (ADLs), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50). On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. The Friend informed the surveyor he had been trying to get Resident #50 a shower for the past two months. The Friend stated that the facility had not been able to accommodate Resident #50's preference for a shower. On 03/22/22 11:00 AM, the Surveyor conducted a Resident Council meeting with five residents. Five out of five residents in attendance stated staffing at night was short with long wait times. On 03/22/22 at 11:06 AM, the Surveyor conducted resident council meeting with five residents. During that time, the Surveyor inquired about HS snacks. All five residents commented that they do not always get offered bedtime snacks and that it would depend on how the staff felt that evening. On 03/25/22 at 9:56 AM, the Surveyor interviewed the Director of Nursing (DON) regarding snack distribution. The DON stated the snacks were the nurses responsibility to ensure the snacks were delivered. The DON stated I never reviewed the logs and the unit managers should have reviewed the logs and I should have but never have. The DON stated we have been short staffed because of Covid. The DON stated without documentation she could not state for certain that the snacks were being provided. Per the New Jersey State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. The facility was deficient in Certified Nurse Aide (CNA) staffing for residents on 14 of 14 day shifts, and was deficient in total staff for residents on 3 of 14 overnight shifts as follows: -02/27/22 had 9 CNAs for 126 residents on the day shift, required 16 CNAs. -02/28/22 had 9 CNAs for 125 residents on the day shift, required 16 CNAs. -03/01/22 had 10 CNAs for 125 residents on the day shift, required 16 CNAs. -03/01/22 had 8 total staff for 125 residents on the overnight shift, required 9 total staff. -03/02/22 had 12 CNAs for 125 residents on the day shift, required 16 CNAs.-03/02/22 had 8 total staff for 125 residents on the overnight shift, required 9 total staff. -03/03/22 had 13 CNAs for 125 residents on the day shift, required 16 CNAs. -03/04/22 had 11 CNAs for 122 residents on the day shift, required 16 CNAs -03/05/22 had 8 CNAs for 122 residents on the day shift, required 16 CNAs. -03/06/22 had 8 CNAs for 124 residents on the day shift, required 16 CNAs. -03/07/22 had 10 CNAs for 124 residents on the day shift, required 16 CNAs. -03/08/22 had 10 CNAs for 122 residents on the day shift, required 16 CNAs. -03/09/22 had 11 CNAs for 121 residents on the day shift, required 16 CNAs. -03/10/22 had 10 CNAs for 121 residents on the day shift, required 16 CNAs. -03/11/22 had 11 CNAs for 120 residents on the day shift, required 15 CNAs. -03/11/22 had 8 total staff for 120 residents on the overnight shift, required 9 total staff. -03/12/22 had 11 CNAs for 118 residents on the day shift, required 15 CNAs. The Facility Assessment Tool revealed: Individual staff assignment, 3.3 Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments. The approach for this center as it relates to direct care staffing is in pattered approaches. NJ requires acuities to be taken into consideration with staffing. We would adjust based upon acuities and census. Discussions are held in staffing meetings about unit staffing. Unit Managers provide updated information on patient needs with nursing management. The scheduler will make adjustments as needed. Discussion on staffing is an on-going task that is discussed several time throughout a given day. Consistent staffing patterns are the ultimate goal with staff assigned patient assignments. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to develop a process to track and perform weekly: a.) COVID-19 testing for staff that did not receive a COVID-19 vaccination, and b.) COVID-19 testing for staff who were not up-to-date with all recommended COVID-19 vaccinations. This deficient practice was evidenced by the following: Reference: CMS QSO-20-38-NH dated revised 09/10/21, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their community transmission level as the trigger for testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site:https://covid.cdc.gov/covid-data-tracker/#county-view. Table 2: Routine testing Intervals by County COVID-19 Level of Community Transmission . Level of COVID-19 Community Transmission: Moderate (yellow); Minimum testing Frequency of Unvaccinated Staff: once a week. The guidance above represents the minimum testing expected. Reference: CMS QSO-20-38-NH dated revised 03/10/22, Facilities should use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site: https://covid.cdc.gov/covid-data-tracker/#county-view. Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission .Level of COVID-19 Community Transmission: Moderate (yellow); Minimum Testing Frequency of Staff who are not up-to-date: once a week. The facility should test all staff, who are not up-to-date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. The guidance above represents the minimum testing expected. Documentation of Testing. Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week), and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test. On 03/17/22 at 2:10 PM, the Director of Nursing (DON) provided the Surveyor a document titled Staff Vaccination Status for Providers which included three staff members that had received a non-medical exemption which indicated they were not required to receive a COVID-19 vaccination. The staff were: a Dietary Aide (DA), a Nurse Practitioner (NP) and a Speech Therapist. On 03/22/22 at 10:57 AM, the Surveyor interviewed the Infection Preventionist (IP) who stated she worked part-time, 20 hours a week. The Surveyor asked the IP what the process was for staff that had an exemption for the COVID-19 vaccination. The IP stated that she tested staff that had an exemption once per week. She added that she was currently not testing all employees because the facility was no longer in an outbreak. On 03/22/22 at 11:16 AM, the Surveyor interviewed the DON who stated that she was aware of one contracted hire/outside vendor that was unvaccinated. She stated the vendor was a NP that came to the facility every Thursday to see residents that had wounds. The Surveyor requested that the DON provide the weekly COVID-19 testing for the unvaccinated NP. On 03/22/22 at 1:45 PM, the IP provided the surveyor the test results for the unvaccinated NP which included the following COVID-19 testing dates and results: 09/24/21 negative 11/30/21 negative 12/7/21 negative 01/11/22 negative 01/25/22 negative 02/22/22 negative (The facility was unable to provide documented evidence that the NP was tested for COVID-19 weekly). On 03/22/22 at 2:05 PM, the Surveyor reviewed the IP's COVID-19 POC (point of care) Testing log book. On 03/14/22 there were 57 handwritten names of staff that were tested for COVID-19. On 03/17/22 there were 3 handwritten names of staff (1 staff that needed a COVID-19 booster) that were tested for COVID-19. On 03/18/22 there was 1 handwritten name of staff that was tested for COVID-19. The IP did not have documented evidence of how she tracked that unvaccinated staff or staff that were not up to date with all recommended vaccines were tested each week. On 03/23/22 at 12:52 PM, the Surveyor interviewed the IP regarding the process of COVID-19 testing. The IP stated that she tested everyone in the building on 03/14/22. She stated that if staff did not work the day that she performed COVID-19 testing, that the staff would come and find her when they returned to work. She stated that typically she performed COVID-19 testing on Tuesdays and Thursdays. She then stated that staff that had an exemption from COVID-19 vaccination, or needed a COVID-19 booster needed to be tested weekly. The Surveyor requested to the IP to review the document of the NP's COVID-19 testing. The Surveyor then asked the IP to confirm that the NP was not tested weekly. The IP confirmed that the NP was not tested weekly. The IP then stated that the NP was told she needed to be tested every week since she had an exemption for the COVID-19 vaccination. The IP stated that if she observed the NP at the facility, that she would test her, or that the NP could refuse if the NP had been tested somewhere else the day prior. The Surveyor then asked if the NP could provide the results from where she had been tested and provide it to the IP. The IP added that the NP was getting tested elsewhere but that the NP did not bring the test results to her. The IP confirmed that the NP should be tested weekly. The Surveyor then asked the IP for at least 4 weeks of COVID-19 testing for the DA. On 03/23/22 at 1:25 PM, the Licensed Nursing Home Administrator provided a copy of the New Jersey Department of Health Communicable Disease Service (NJDOH CDS) COVID-19 Activity Level Report for the week ending March 5, 2022, which included that the region that the facility was in had a moderate (yellow) activity level of COVID-19. On 03/24/22 at 9:20 AM, the IP provided the Surveyor with COVID-19 test results for the DA which included the following: 02/2/22 negative 02/4/22 negative 02/7/22 negative 02/22/22 negative 03/1/22 negative 03/14/22 negative The facility could not provide documented evidence that the DA was tested for COVID-19 the week of 02/14/22 and the week of 03/7/22. On 03/24/22 at 10:23 AM, the Surveyor interviewed the IP regarding the COVID-19 testing for the DA. The IP stated that the DA might not have been here on the day she was performing COVID-19 testing. She added that the DA was good about getting tested. She added that the expectation was that she tried to get all the staff [that required testing] tested on the days that she was at the facility. She added that supervisors test on weekends but that they did not always write the tests in the log book. The Surveyor then asked the IP if she had a process to track that the staff, who were required to be tested, were getting tested weekly. The IP stated that she did not have a roster of the staff to keep track but that she could start doing that. She added that it would be easier moving forward to keep track. On 03/25/22 at 10:15 AM, the Surveyor reviewed the testing log which included an additional staff that was tested on [DATE] (an unvaccinated staff) and two staff that were tested on [DATE] (1 unvaccinated staff and 1 staff that was required to have a COVID-19 booster). On 03/25/22 at 11:56 AM, the DON provided the Surveyor a document titled SONAR Employees due Booster Vaccine. The document was a handwritten list of eighteen employee's names and was dated 03/25/22. The document did not contain the titles of the employees and 12 of the 18 employees listed had a date written next to their name indicating the date their booster vaccine was due to be given. One of the eighteen employees listed had LOA written next to their name. Five of the eighteen employees listed did not have anything written next to their name. The facility could not provide weekly testing for 16 staff that were not up to date with their COVID-19 vaccinations since 03/14/22. On 03/28/22 at 8:47 AM, the Surveyor reviewed the facility provided Time Sheets for the DA which included the following: For the week of 02/14/22, the DA worked 02/14/22, 02/15/22, 02/16/22, and 02/18/22. For the week of 03/7/22, the DA worked 03/7/22, 03/8/22, 03/9/22 and 03/11/22. On 03/28/22 at 10:10 AM, in the presence of the survey team, the DON confirmed that the facility missed one week of testing for the staff that were not up to date with their COVID-19 vaccinations. A review of the facility provided policy titled, IC405 COVID-19, with a revision date of 06/7/21, included the following: Testing for COVID-19: 31. Patients, facility staff, and visitors will be tested according to CMS and state Department of Health requirements and Genesis guidance. 31.1 COVID-19 testing results will be documented. A review of the facility provided policy titled, Screening Tests for Coronavirus-Residents and Staff dated 03/15/22, included the following: Definitions: Up-to-Date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible . Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency. Table Criteria: Test positivity 5%-7.99% and incidence 10-49.99 per 100,000; Descriptive Label: CMS Yellow (Moderate) Testing Frequency for Staff Who Are Not Up-To-Date: Weekly .For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week) and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test. Non-employed facility staff (including non-employed agency staff coming from third-party vendors and working a multi-week contract at a Center) are included in this guidance and must be screened at the same frequency as employed staff (See Table above). This includes full-time independent physicians, APPs, hospice providers, consultants, contractors, .and all others who come into contact with residents and/or staff .Obtaining and Documenting Proof of Testing and Test Result for Non-Employed Staff: The screener must ask for proof of COVID-19 testing performed within the Center's testing frequency per the table below. Non-employed staff are not permitted to enter the Center until proof of negative test is provided, POC is administered with negative result, or PCR specimen is collected .If non-employed staff member refuses testing, do not permit the person to remain in the Center. Center will provide/arrange for alternate care/services. N.J.A.C. 8:39-5.1(a);19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility documentation, it was determined that the facility failed to consistently offer residents HS (hour of sleep) snacks. This deficient practice was identified for 5 of 5 residents (Resident #17, #23, #68, #44, and #25) during resident council meeting and was evidenced by the following: On 03/22/22 at 11:06 AM, the Surveyor conducted resident council meeting with five residents. During that time, the Surveyor inquired about HS snacks. All five residents commented that they do not always get offered bedtime snacks and that it would depend on the staff that evening. On 03/23/22 at 8:09 AM, the second floor Licensed Practical Nurse Unit Manager (LPN UM) stated that the process would be for the evening snacks to be delivered from the kitchen about 6:45 PM to 7 PM. The LPN UM stated some snacks are assigned to certain residents and the other snacks would be offered to the rest of the residents. The LPN UM stated that the Certified Nursing Assistants (CNAs) would either document on the computer or on the Activities of Daily Living (ADL) log if the resident refused or accepted the snack and how much was consumed. On 03/23/22 at 9:15 AM, the Surveyor reviewed all residents [NAME] (the CNA Care Plan to assist with resident needs), the ADL logbook from 03/01/22 through 03/22/22, for all five residents and found the documentation to be incomplete. The Surveyor reviewed the electronic documentation from 03/01/22 through 03/22/22, for HS snacks for all five residents and found the documentation to be incomplete. The documentation reflected the following: Resident #17's [NAME] indicated under Eating to provide with HS yogurt, and PB and J (peanut butter and jelly), and to offer snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 16 of the 22 days in March 2022. Resident #23's [NAME] indicated under Eating; that the resident likes to snack between meals. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 18 of the 22 days in March 2022. Resident #25's [NAME] indicated under Eating; to offer snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 18 of 22 days in March 2022. Resident #44's [NAME] indicated under Eating; to offer additional snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 20 of 22 days in March 2022. Resident #68's [NAME] indicated under Eating; to offer additional snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 21 of 22 days in March 2022. On 03/23/22 at 11:34 AM, a CNA stated her normal shift was 11 AM to 11 PM. She stated the process was that the snacks would be delivered from come the kitchen and that the CNAs should start handing them out to the residents. She further stated the CNAs would document in the computer or the ADL log if a resident refused or accepted the snack and how much was consumed On 03/23/22 at 1:28 PM, the Director of Nursing (DON) provided the surveyor with the task accountability sheets for the five residents who attended resident council. The DON and the Surveyor reviewed the sheets and noted many blanks on all five residents. The DON stated that would indicate that the CNAs did not offer the snacks, and that the task was not done. A review of the facility provided, Meal Service indicated that breakfast starts at 7:15 AM, lunch starts at 11:50 AM, dinner starts at 4:30 PM and snacks between meals at 10 AM, 2 PM, and nightly before bedtime. A review of the facility provided policy and procedure, Snacks, Nourishments, Supplements, and Pantry Stock' revised 06/15/18, included but was not limited to the following information. Policy snacks, nourishments, supplements, and pantry stock are available to complement meal service .Definitions Snack evening snack is planned as part of the menu. Purpose to provide an evening snack for all patients/residents. Process 1. Snacks 1.4 nursing or designated staff offer an evening snack to every patient/resident. 5.2 completed logs are used to assist the facility in problem analysis and resolution. This concern was presented to the facility administration on 03/25/22. The facility had no additional information to provide. NJAC 8:39-17.4(b)

Based on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth and to prevent physical contaminants from entering the food, b.) staff practiced appropriate hand hygiene and restrained hair appropriately, c.) food items were maintained in a manner to ensure they were not used past their use by date, and d.) a process was in place to ensure bottled water was maintained in a manner to ensure the water was not used by a use by date. The deficient practice was evidenced by the following: On 03/17/22 at from 9:32 AM to 11:30 AM, the Surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD), and observed the following: 1. The refrigerated walk-in unit had a dark spot affixed to the interior of the wall by the door, and what appeared as greenish dark stained areas throughout the interior of the walls of the walk-in unit. The FSD stated the spot was a little dirt spot, and the interior was cleaned once per week and that spot was probably missed. A block of opened Swiss cheese was located on a shelf and was wrapped in plastic. The cheese did not contain a use by date. 2. A dietary worker (DW #1) stacked insulated bases on top of one another at the tray line area. The bases appeared visibly wet inside. Upon interview, the DW #1 stated stated that the bases were dry, and she continued to stack them on top of one another. The Surveyor then observed the bases with the FSD, and the Surveyor inquired to the FSD if the the lids were supposed to be dry. The FSD stated they were supposed to be dry and that they were wet nesting. There were 83 insulated bases stacked that were visibly wet inside, and one base had visible debris caked on it. The FSD stated they if the bases were wet, that they won't heat up because the system was a heat on demand system (an insulated base would be inserted into a machine which would assist with maintenance of the food temperature upon meal transport). The Surveyor observed 34/34 insulated lids that were stacked, and visibly wet inside. The FSD stated that the lids/bases were supposed to be stacked sideways to dry them and the staff did not do that. 3. Two ceiling grates and a ceiling heat/air conditioner vent above the tray line area had visible dark dust like debris in the vents and on the ceiling tile adjacent to the vents. The FSD observed the ceiling and stated that maintenance usually cleaned the grate once per month and she was not sure if it was scheduled to be completed. The FSD observed the vents and stated maybe from heat and that it was not okay, absolutely not, the dust could fall onto the food. The FSD stated she was able to contact maintenance if something needed to be cleaned. 4. Two stainless steel shelves affixed to the front of the tray line were visibly soiled with various colored debris underneath the shelves. The FSD stated the shelves were used during the meal service to hold food items. The FSD observed the debris and stated the staff usually wiped the shelves down. The Surveyor inquired as to what the debris was and the FSD stated food splats and responded probably not when the surveyor inquired if the underneath of the shelves was cleaned. The FSD stated it should be cleaned daily. 5. A can opener was affixed to a metal table in the kitchen. The blade appeared visibly worn, and a copious amount metal shavings were visible at the blade area. The Surveyor inquired to the FSD about the can opener blade and the FSD stated the can opener blade was worn. The Surveyor inquired as if it was okay to use the can opener in that condition and she stated it was not okay. The FSD confirmed that the can opener was used that morning to open cans of applesauce, and stated the metal shavings could fall into the food. The plastic type insert that contained the can opener appeared soiled. The FSD removed the insert, and the Surveyor observed a dark sticky in appearance substance, and the FSD stated it's dirty and that the insert was hard to remove. The FSD stated it was probably not cleaned last night. The Surveyor requested a cleaning log from the FSD. The FSD directed the Surveyor to a bulleting board that had A Daily Cleaning Assignment (one sheet for each day of the week) affixed to a bulletin board. The Daily Cleaning Assignment list dated 3/16 revealed the Bottom of the Prep Table number 1 and 2 (Bins included and legs) was signed off and initialed as completed. The underneath of the shelves, and the can opener and base was not listed on The Daily Cleaning Assignment dated 3/16. 6. A steel preparation table had a utensil rack over the table with visible dust like debris affixed to it. The surveyor inquired to the FSD regarding the debris and she stated, it shouldn't be there. The FSD stated she was responsible to monitor the kitchen environment for cleanliness. 7. A reach-in refrigeration unit, #17, contained a 1/2 empty 12 ounce soda bottle. The FSD stated the items were from a staff member, and that personal items should not be kept in that refrigerator. The gasket to the reach-in refrigeration unit was heavily soiled with a dark substance and was ripped. The Surveyor inquired if it had been cleaned, and if the ripped gasket was acceptable. The FSD acknowledged the ripped gasket and stated that the refrigeration unit can loose temperature if the gasket was ripped and it was not okay. She stated the gasket had also not been cleaned. 8. At 10:42 AM, the Surveyor interviewed the Assistant Food Service Director (AFSD), in the presence of the FSD about the observations of the can opener and the process for cleaning it. The AFSD stated that she had used the can opener yesterday, and she had observed shavings on the lid of the tomato sauce can. She stated she had worked at the facility for twenty years and the Surveyor inquired if she had received education about the can opener, and shavings from the can opener. The AFSD stated no. The Surveyor inquired as to the process for cleaning the can opener insert and the AFSD stated it was pretty stuck and it was not always pulled out. The Surveyor inquired to the FSD regarding what should have been done when the AFSD identified there were metal shavings on the can opener and also on the lid of the can. The FSD stated when the can opener blade was dull there was a potential for shavings. The FSD stated I don't have any recent training on the can opener. 9. A stack of black meal trays were located at the beginning of the tray line. The FSD stated the trays were clean. There were 96 wet nested trays, 6 trays with debris on them and 8 trays that were visibly chipped and worn. The FSD confirmed the surveyors observations and stated the chipped trays should not be used because the fiberglass from the trays could potentially get into the food. 10. There were five large cutting boards stacked by the food preparation table. A yellow, two white, one red and one blue cutting board were observed with deep gauges and appeared worn, discolored with imbedded debris. The AFSD and FSD were present and the AFSD stated that food can get stuck and that it was wear and tear. The FSD stated that the 5/5 cutting boards shouldn't be used. 11. A large blender was stored upright on a preparation table. The gasket was soiled with debris. The FSD stated the gasket was not clean. On 03/18/22 at 11:31 AM, the Surveyor conducted a follow-up kitchen observation during the meal service preparation, and the observed the following: 12. A cook (Cook #1) was observed placing frozen dinner rolls on a tray. The cook was wearing a surgical mask on his face, and had facial hair that was visible and not restrained. 13. At 11:38 AM the FSD was observed placing milk on resident meal trays after she exited the tray line to retrieve the milk, adjusted her personal clothing and then touched various tray items without first performing hand hygiene. 14. At 11:40 AM, a staff member was observed in the kitchen at the end of the tray line and had a facial type restraint that did not fully cover the sides of his protruding facial hair. The staff identified himself as a Regional Manager (RM). The surveyor inquired to RM what he was wearing on his face and he stated it was a surgical mask and a beard guard-beard restraint was over it. The Surveyor inquired to the RM if all of the beard should be covered. The RM stated as much as can be for the beard, not the sides. At 12:22 PM, the Surveyor interviewed the FSD regarding if a surgical mask was acceptable to use as a facial hair restraint. The FSD stated no, and the Surveyor inquired to the FSD regarding the policy regarding how much facial hair should be covered, and if it was only for hair at a certain length. The FSD stated she was unsure. 15. At 11:48 AM, the RM was observed assisting moving items at the tray line, while the tray line was in progress, and the RM had visible facial hair that was exposed and was not covered by the beard restraint. 16. At 11:49 AM, [NAME] #1 was observed wearing gloves as he entered the kitchen with a pan of oranges. He then proceeded to wash the oranges and cut the oranges. Upon Surveyor inquiry, [NAME] #1 stated the oranges were to be used to replace the grapes that were on the menu, and he proceeded to provide the oranges to the tray line, and then brought the soiled pan and a strainer back to the dirty area in the kitchen. The [NAME] #1 returned to the tray line wearing gloves, removed the gloves and put on a new pair of gloves, without first washing his hands. The [NAME] #1 then proceeded to cut and serve a grilled cheese sandwich on a resident's meal plate. 17. At 11:57 AM, the FSD was observed on the tray line touching resident meal trays. The phone rang and the FSD exited the tray line to answer the phone opposite of the tray line, then returned to preparing resident meal trays on the tray line without performing hand hygiene. 18. At 12:27 PM, the Surveyor interviewed the FSD regarding when hand washing should be performed. The FSD stated when tasks were changed, or when someone touched their hair of face, that the hands should be washed after. 19. A Dietary Staff (Dietary Staff #2) was observed working in the kitchen and on the tray line with hair protruding from his hair restraint. The surveyor informed the FSD of the observation and the FSD stated that she had bigger hair nets for him and that sometimes he wore them. The FSD proceeded to show the Surveyor the larger sized hair net. 20. The dry food storage room contained a dented #10 can of beans on a rack. The FSD stated the dented can needs to be sent back, because they can get sick from dented cans. The FSD confirmed the can was dented. 21. The dry food storage room contained seven loaves of Texas toast bread, imprinted with a best if used by date of March 16. There was no other use by date located on the loaves and the FSD stated that the bread was used by the best by date. 22. The Surveyor interviewed the FSD regarding the observation made with the [NAME] # 1 preparing the oranges, without washing his hands between tasks. The FSD stated the [NAME] #1 should have washed his hands between clean and dirty. The Surveyor also interviewed the FSD regarding the observation when the FSD exited the tray line to answer the phone and returned to the tray line without washing her hands. The FSD stated I probably should have washed my hands. 23. On 03/22/22 at 12:04 PM, the Surveyor observed the tray-line in progress. The AFSD was observed cutting a sandwich on a very worn, discolored white cutting board that had deep gauges in it that was affixed to the tray line, and then placed the sandwich on a resident meal tray. 24. On 03/23/22 at 9:37 AM, the Surveyor accompanied the Maintenance Director (MD) and observed the storage of the on-site emergency water supply. The MD stated the 5 gallon water containers were stored in various areas and he had 128, 5 gallon water containers. The MD stated he purchased them, inventoried them and that the water would be used for drinking, food preparation, bathing and to flush toilets. An area for water storage was observed with 33, 5 gallon water containers that were stored under the stairwell #1, and an additional water supply was located under a rear stairwell. The 5 gallon water containers stored under the stairwell were observed to be stored directly on the floor. The Surveyor could not ascertain how many bottles were located under the rear stairwell. There water was not stamped or identified with an expiration date. The Surveyor inquired to the MD regarding the process and expiration for the water. The MD stated he did not have a sticker or label on the water for an expiration date, and stated he thought that he had the bottles for about four years. The MD stated that he checked the inventory, but not the expiration. The Surveyor observed the third location for the water which was in a trailer outside the rear of the facility. The trailer was located in the rear of the facility parking lot. There were 51 bottles of water stored in the trailer, there was various debris and dust observed around the bottles and cob-webs observed on the bottles. The bottles were also observed to be stored with various types of mechanical equipment, and 3 large cardboard boxes labeled with a red biohazard (containing blood and regulated medical waste) emblem affixed to the box, and labeled Regulated Medical Waste. The MD then, proceeded to bring a 5 gallon bottle of water and place it on the floor of the trailer, directly next to the hazardous waste. The MD showed the Surveyor the stamp on the 5 gallon bottle of water that was dated 3/31/16 on bottle. The MD stated I guess it has been longer. The Surveyor requested a policy/ information regarding the expiration of the water. At 11:22 AM the MD stated the date on the bottle was the best use date and he would look for a policy. At 12:42 PM, the Surveyor interviewed the FSD regarding the water supply and if beverages are considered food storage. The FSD stated that beverages would be considered part of food storage and the food storage policy would apply. At 1:35 PM, the MD provided the Surveyor with an invoice from 2017 for water and the MD stated he did not know about the water dated 2016, and did not provide any additional information regarding the process for water storage and the expiration date. The Food and Nutrition Services Policies and Procedures Policy, 4.7 Food Handling, effective 07//01/98 revealed: Foods are stored, prepared and served in a safe and sanitary manner., Purpose: To prevent bacterial contamination and possible spread of infections., 2.1. Employees wear disposable gloves when handling food. Disposable gloves are considered a single-use item and are discarded when damaged, soiled and after each use. 2.1.1. Employees must wash hands before putting on disposable gloves . The Food and Nutrition Services Policies and Procedures Policy, 2.2 Personal Hygiene, Effective 07/01/98, revealed: Food and Nutrition Services employees present a neat, clean, professional appearance and wear the uniform that meets the established guidelines of the department., Purpose: To maintain a professional appearance at all times. 7. Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover facility hair of a substantial length., 9. Disposable gloves are singe use and are changes between tasks. The Food and Nutrition Services Policies and Procedures, 5.6 Dry Storage, Effective 07/01/98 revealed: Products stored in dry storage areas are maintained in a safe and sanitary manner. Purpose: To prevent damage, spoilage, contamination, and infestation of products., 1. General Practices: 1.1 All shelves storage racks, and platforms are at least six inches off the floor .,13. Routine cleaning and pest control procedures are followed., 2. 2.2 Food is stored and rotated following first- in-first- out procedures., 2.3 Food stock is dated on the day of receipt. Items that are removed from the original box are individually dated. 2.4 Dented cans that are deemed unusable are separated from stock and clearly marked for return., 2.6 Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and include the use by date . The Food and Nutrition Services Policies and Procedures, 4.6 Hand Washing, Effective 07/01/98 revealed: Hand washing is performed frequently and using correct hand washing technique, Purpose: To minimize the spread of Disease., Process: 1. Handwashing is performed: 1.2, Before putting on disposable gloves to begin a task that involves food; 1.3, During food preparation, as often as necessary to clean soiled hands and exposed portions of arms, 1.7 After contacting any soiled equipment or utensils, 1.8, When moving from one task to another. The Food and Nutrition Services Policies and Procedures, 5.7 Refrigerated/Frozen Storage, Effective 07/01/98, revealed: Food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner, Purpose: To prevent damage, spoilage, and contamination of products. Process: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened. Manufacturer use by dates are used until opened. 1.11 Refrigeration units are kept clean and organized. Cleaning is routinely scheduled and completed. A review of the Facility Job Description for the Dining Services Director/Account Manager revealed: Manages the dining services program in a single site according to [management company] policies and procedures, and federal/state requirements. Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Review of the Emergency Water Supply Policy, provided by the MD on 03/23/22 at 10:00 AM, revealed: Policy: [Facility] will provide a safe and healthful environment for all resident, staff and visitors., Purpose: To establish procedure in the event of a loss of water supply., The following Action Steps will be taken: 8:39-17.2(g)