**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #401653, #401655Based on observation, interview and record review, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 7 residents reviewed for medication management, (Resident #9, #120 & #57), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.On 8/7/2025 at 11:00 AM, during a resident council meeting which included Resident #9 and two surveyors, Resident #9 stated they had not received their pain patch or pain gel that morning. The surveyor reviewed the electronic medical record (EMR) for Resident #9. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; general anxiety disorder, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life), schizoaffective disorder, bipolar type (characterized by the presence of mood episodes, including mania or mixed mania and depression, along with psychotic symptoms such as delusions or hallucinations), pain in left knee and low pack pain unspecified. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/9/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Further review reviewed the resident received a scheduled pain medication regiment. A review of the individual comprehensive care plan (ICCP) revealed a Focus: has (acute/chronic) pain r/t (related to) RHEUMATOID ARTHRITIS; Unspecified osteoarthritis, unspecified site…Date Initiated: 11/2/2023 and included Interventions: Administer analgesia as per orders . Date Initiated: 11/02/2023 Revision on: 1/26/2024 and anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/2/2023. A review of the Order Summary Report (OSR) revealed physician orders (PO) for the following: - Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to left knee topically one time a day for pain Apply 4grams to left knee one time a day, Dated 10/23/24. -Lidocan External Patch (Lidocaine) Apply to Lower Back topically one time a day for Lower Back Pain 4% Lidocaine Patch and remove per schedule; Dated 2/27/25. A review of the August 2025 electronic Medication Administration Record (eMAR) revealed the above POs for the Voltaren External Gel had been signed as administered as ordered on 8/7/25 at 0900 (9:00 AM), site: Lknee (left knee) and the Lidocan External patch had been signed as applied as ordered on 8/7/25 at 0900 by Licensed Practical Nurse (LPN) #1. On 8/7/2025 at 1:55 PM, the surveyor interviewed LPN #1, who stated that she had given Resident #9 all their medications that morning. The surveyor asked if the resident received anything for pain, any gels or patches? LPN #1 responded “Yes, I didn’t put them on yet. I am getting to my treatments now.” She stated the medications were in the treatment cart not the medication cart. LPN #1 reviewed the EMR in the presence of the surveyor and stated all the medications in green meant that they were given. She verified the orders for the Lidocan patch and the Voltaren gel were green, but stated they were not given. The surveyor asked if the physician was informed that the medications were not given, and she stated “I haven’t gotten to it yet. It’s not an important medication so I don’t think anything should be done.” On 08/7/2025 at 2:01 PM, the surveyor interviewed LPN/Unit Manger (LPN/UM) #1, who stated her expectation for a 9 AM medication was the medication could be given an hour before or after the time and if it was within the parameters, it should be given. She stated if a medication was not in the cart, then the nurse should check the backup medications. She verified the Lidocaine patch 4 percent and the Voltaren gel was available in the back up. LPN/UM #1 stated, “I know 100 percent both are in stock in the back up.” She stated if the nurse signed the eMAR for the medication, it meant it was given. The surveyor made LPN/UM#1 aware LPN #1 said she didn’t give the medications, but she signed she did. LPN/UM #1 stated, “It is a medication error and the nurse should be written up for it and a medication error sheet should be done.” On 8/7/2025 at 2:11 PM, LPN #1 informed the surveyor, in the presence of LPN/UM#1, that she had retrieved the medications and reported to the physician that the medications were not given this morning. On 8/7/25 at 2:50 PM, the surveyor interviewed the Director of Nursing (DON), who stated 9 AM medications can be given up to an hour before or up to an hour after. She stated if they (medications) are not given within the time period, then the physician should be called. She further stated if medications were not in the medication cart, the nurse should check the back up system and contact pharmacy. She confirmed if a medication was in green it meant the medication was given at the correct time and that medication should not be signed as given if it was not given. On 8/12/2025 at 2:48 PM, the surveyor, in the presence of the survey team, made the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Nursing (VPN), the DON, and the [NAME] President of Operations aware of the above concerns. 2. The surveyor reviewed the electronic closed medical record for Resident #120. A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Rheumatoid Arthritis (RA) (chronic inflammatory disorder affecting the joints). A review of the resident's electronic medication administration record (EMAR) for November revealed on 11/12/25 a physician’s order dated 11/12/25 for “Voltaren External Gel 1 % (Diclofenac Sodium (Topical) Apply to knees, hands, shoulder topically every shift for arthritis pain apply 4 grams.” The “Night” dose was not administered and was indicated by LPN #2 with the number “5” which corresponded to “Hold/see progress notes.” A review of the resident’s electronic progress notes (EPN) revealed there was no corresponding progress note to correlate with the number “5” for Voltaren gel not being administered on 11/12/25 at night. Further review of the EPN revealed on 11/13/25 at 6:24 AM there was a nursing note from the LPN #2 “Resident alert and oriented. At 5:45 am resident complain [redacted] did not get [redacted] last night medicine writer explain to [redacted] that [redacted] only medication [redacted] take at this time is for GERD (gastroesophageal reflux disease-irritation caused by stomach contents flowing back up into the esophagus), resident get upset saying [redacted] did not get [redacted] evening medication and night medication steroid….” Further review of the EMAR revealed a PO dated 11/13/24 for “Methylprednisolone oral 4 MG (Methylprednisolone) Give 2 tablet by mouth at bedtime for arthritic pain.” There was no time of administration indicated on the EMAR for the evening of 11/12/24. According to an After Visit Summary from an emergency room hospital visit dated 11/11/24, the resident had instructions to start 11/12/24 Methylprednisolone 4 MG tablet, commonly known as Medrol Dosepak, take as directed on package. Indications: pain with history of RA, start tomorrow 11/12/24. On 8/7/25 at 10:00 AM, the surveyor requested from the DON any investigations regarding Resident #120. On 8/12/2025 at 9:20 AM, the surveyor attempted to interview LPN #2 via the telephone and left a voicemail. On 8/12/2025 at 9:55 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the CP for approximately a year. The CP stated that if a medication was not available the nurses should check the backup supply, call the pharmacy provider and call the physician for follow up. The CP added that the nurses cannot just document that the medication was not available. On 8/12/25 at 11:00 AM, the surveyor interviewed LNHA regarding Resident #120. The LNHA was unable to speak to any concerns or investigations regarding Resident #120. On 8/12/2025 at 1:24 PM, the surveyor interviewed the DON, who stated for a new admission there was a backup supply for some medications and there was also the possibility to call an emergency pharmacy if the provider pharmacy could not deliver a medication right away and the provider pharmacy also made multiple deliveries at different times of the day. In addition, the DON stated that medications if brought from home in a prescription vial or properly labelled were verified then the facility would be able to use the medications brought from home. The DON was unable to speak to Resident #120 not receiving their medications on the night of 11/12/24 because she was not the DON at that time. In addition, the DON was unsure if LPN #2 was still employed. On 8/12/25 at 2:48 PM, the survey team met with the LNHA, DON, VPN and [NAME] President of Operations. The DON stated she would expect to see in the progress notes why medications were not administered and any follow up from a physician. The VPN provided a timeline for Resident #120 which indicated Resident #120 was admitted at the end of the day shift on 11/12/25 and “Medications finished around 6:00 pm.” There was no explanation for the evening dose of Voltaren gel not being administered or the PO for Methylprednisolone not being administered the evening of 11/12/25. There was no further documentation provided for Resident #120. 3. On 8/6/25 at 11:30 AM, the surveyor observed Resident #57 in their room with a staff member cleaning out the resident’s personal refrigerator. The surveyor was unable to interview the resident. The surveyor reviewed the electronic medical record for Resident #57. A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, dementia, major depressive disorder, recurrent, in partial remission and gastro-esophageal reflux disease without esophagitis (stomach acid irritates the lining). A review of the most recent comprehensive quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 14 out of 15, indicating that the resident had an intact cognition. A review of the resident's EMAR for August 2025 revealed the following: 1. A PO with a start date of 7/28/25 for “Cefuroxime Axetil Oral Tablet 250 MG (Cefuroxime Axetil) Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 6 days 2 tabs=500 MG. Notify MD (physician) of signs and symptoms adverse reaction.” On 8/1/25 at the time of administration for 1700 (5 PM) indicated the number 9 by LPN #3 which corresponded to “other/see nursing progress notes.” 2. A PO with a start date of 7/29/25 for “Escitalopram Oxalate Oral Tablet 5 milligrams (MG) (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Depression 1 tab=5 MG.” The time of administration was 9:30 AM and on 8/12/25 the medication was not signed as administered and there was the number 9 noted by LPN #4 which corresponded to “other/see progress notes.” 3. A PO with a start date of 7/29/25 for “Pantoprazole Sodium Oral Tablet Delayed release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD 1 tab=40 MG, Do not crush.” The time of administration was 9:00 AM and on 8/12/25 the medication was not signed as administered and there was the number 9 noted by LPN #3 which corresponded to “other/see progress notes.” A review of the electronic progress notes (EPN) for Resident #55 revealed the following eMAR administration notes: 1. On 8/1/25 at 18:29 (6:29 PM) the LPN #3 documented “awaiting delivery” for the Cefuroxime 500 MG dose. 2. On 8/12/25 at 9:02 AM the LPN #4 documented “awaiting delivery” for the Escitalopram 5 MG dose. 3. On 8/12/25 at 9:03 AM the LPN #4 documented “awaiting delivery” for the Pantoprazole 40 MG dose. There were no progress notes regarding the physician being notified. On 8/13/2025 at 11:02 AM, the surveyor interviewed LPN #5 who stated that she was the nurse administering medications to Resident #55 that day but was not here yesterday. LPN #5, in the presence of the surveyor, reviewed the medication cart and removed Escitalopram 5 MG and Pantoprazole 40 MG labelled for Resident #55. LPN #5 stated they were in the bottom drawer of the medication cart. LPN #5 added that sometimes agency nurses do not look for the medications. On 8/13/2025 at 11:25 AM, the surveyor interviewed Resident #55 in their room. The resident stated that the nurses brought their medications and had no concerns. The resident added that they had a lot of medications and was unable to speak to which medications or what times the nurses gave them their medications. On 8/13/2025 at 11:50 AM, the surveyor interviewed the DON, who stated that she would have to educate the nurses who indicated “awaiting delivery” for Resident #55’s medications. The DON stated that Cefuroxime, Escitalopram and Pantoprazole were medications stocked in the back up supply and should have been administered. The DON added that she would expect the nurses to notify a supervisor if a medication was not available and there would be follow up such as getting the medication from the backup system, calling the provider pharmacy, or emergency pharmacy. The DON stated that the goal was to get the medication and administer it and if that was not possible then the physician needed to be notified for follow up. A review of the electronic medication back up supply list reflected that Cefuroxime 250 MG tablets, Escitalopram 10 MG tablets and Pantoprazole 20 MG tablets were available. A review of the facility policy dated as revised April 2019 for “Administering Medications” provided by the DON reflected “Medications are administered in a safe and timely manner, and as prescribed.” In addition, the policy interpretation and implementation included but not limited to; “4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).” NJAC 8:39-11.2(b), 29.2(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 1 of 10 residents (Resident #43) reviewed for tray accuracy during dining and was evidenced by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli. The surveyor observed a sign that hung over the resident's bed which indicated, No Straws and Thickened liquids, do not leave thickener packets with the resident. The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool dated 5/23/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS indicated that the resident required a mechanically altered diet (e.g., pureed food, thickened liquids), and a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and had no identified weight loss or weight gain. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/30/25, that the resident had a swallowing problem r/t (related to) oral dysphagia (difficulty swallowing); I am on Nectar thick liquids. Interventions included: Instruct me to eat in an upright position, to eat slowly, to chew each bite thoroughly, refer for Swallowing Evaluation as needed.A review of the Order Summary Report (OSR), dated as of 3/26/25, including the following Physician's Order (PO):A PO, dated 3/26/25, for a No Concentrated Sweets (NCS) diet Ground texture, Nectar consistency.A review of a Speech Therapy Discharge summary dated [DATE], included: Skill: Interventions Provided: .instruction in no straw precautions.On 8/6/25 at 12:50 PM, the surveyor observed Resident #43 seated in a wheelchair eating independently accompanied by another resident. The surveyor reviewed the resident's meal ticket which indicated, NCS-Ground, Nectar Thick Liquids. Further review of the meal ticket specified, NO STRAW at the bottom of the resident's meal ticket. A straw that was sealed in paper was placed to the left of the resident's meal tray. At that time, Registered Nurse (RN) #1 presented to the resident's table. When the surveyor asked RN #1 why the resident was provided with a drinking straw when the meal ticket specified otherwise RN #1 stated, But, it was not opened. RN #1 further stated that the resident needed to be assisted with meal set up but could feed themselves independently. On 8/7/25 at 11:28 AM, the surveyor interviewed RN #1, who stated that the aides were informed of the resident's care needs and there were signs on the resident's wall in their room which indicated thick liquids, no straw. RN #1 stated that the resident could aspirate (food or fluids get into the airway), so a straw should not have been given to the resident if it specified no straw on the resident's meal ticket. On 8/7/25 at 11:54 AM, the surveyor observed Resident #43 seated in a wheelchair in the main dining room with a drinking straw on his/her place mat. On 8/7/25 at 11:57 AM, the Infection Preventionist (IP) walked over to Resident #43's table and removed the straw from the resident's place mat. When interviewed at that time, the IP stated that he removed the straw from the resident because the resident was on a list of residents who received thickened liquids. On 8/7/25 at 12:00 PM, the surveyor interviewed Activity Aide (AA) #1, who stated that the dietary department put the place mat, napkin and straw on each table. On 8/7/25 at 12:03 PM, the surveyor interviewed the Registered Dietician (RD), who stated that the meal ticket specified no straw if the resident were ordered thickened liquids. The RD further stated that the aide, or the nurse could identify if the ticket specified no straw upon review for tray accuracy and remove it at that time if indicated. On 8/7/25 at 12:08 PM, the surveyor interviewed the Food Service Director (FSD), who stated that the staff usually fed the resident, and the nurse should have noticed the straw at that time. The FSD stated that the resident should not have been provided with a drinking straw because the resident was ordered thickened liquids. The RD who was present at that time, stated that the reason that the resident was not permitted to have a straw had something to do with their swallowing, but she did not know the correct answer. On 8/7/25 at 1:41 PM, the surveyor informed the Director of Nursing (DON) of the concerns with Resident #43 who received a drinking straw on their tray during the lunch meal service on 8/6/25 and 8/7/25, despite the meal ticket indicating No Straw.A review of the facility's undated Tray Accuracy included:.Routine tray line audits to confirm tray accuracy will be conducted by the Food Service Director or designated employee.A review of the facility's Preparing the Resident for a Meal policy, revised September 2010, included: .Review the resident's care plan and provide for any special needs of the resident.NJAC 8:39-17.4(a)1

NJ401661, NJ401667, NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow appropriate infection control procedures during the provision of incontinence care for a resident who was previously identified to have been at risk for recurrent urinary tract infection.This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for bladder and bowel incontinence and was identified by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli.The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: urinary tract infection, site not specified, overactive bladder, other specified noninfective gastroenteritis and colitis (conditions that affect the gastrointestinal tract). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 5/23/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed that the resident was frequently incontinent of urine and was always incontinent of bowel. On 8/6/25 at 10:42 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to eleven residents today and she had not yet provided any care to Resident #43 yet because she planned to give the resident a shower today and the resident required assistance from two staff members to get out of the bed. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, with a revision date of 7/18/25, that the resident had bowel incontinence related to dementia. Interventions included: Check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. Further review of the ICCP included a focus area, with a revision dated of 7/18/25, that the resident was at risk for chronic urinary tract infection related to incontinence. Interventions included: Resolved: Check at least every 2 (two) hours for incontinence. Wash, rinse and dry soiled areas (resolved date 3/19/25), and encourage adequate fluid intake, and monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs and symptoms) of UTI: Frequency, urgency, malaise (a general feeling of discomfort), foul smelling urine, dysuria (painful or difficult urination), fever, nausea and vomiting, flank (side) pain, supra-pubic (lower part of the abdomen above the genitals) pain, hematuria (presence of blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes (date initiated 6/30/25). A review of the Order Summary Report, included the following physician order (PO):A PO dated, 7/24/25, for Macrobid oral capsule 100 MG (milligrams) (Nitrofurantoin Monohyd Macro) Give 1 (one) capsule by mouth two times a day for UTI for 10 (ten) days.A review of an Incident Note dated 7/24/25 at 11:07 PM, indicated that the resident was on Macrobid Oral Capsule 100 MG for UTI for 10 days. No c/o (complaint of) pain or discomfort noted during the shift. PO (oral) fluids encouraged.Safety precautions in place. On 8/6/25 at 11:07 AM, the surveyor observed CNA #1 and CNA #2 as they prepared to assist Resident #43 with incontinence care. CNA #1 stated that she did not know when the resident's brief was changed last. CNA #1 then stated that CNA #2 went to get supplies to change the resident. At that time, CNA #2 returned to the room without any supplies to change the resident. The resident wore a green brief that was opened by CNA #2, who then assisted the resident to turn towards the right side of the bed towards CNA #1. The resident had a small amount of urine and liquid stool in their brief. CNA #2 stated that the stool looked fresh. CNA #2 then proceeded to use the brief to cleanse both the stool and urine from the resident's skin. When the surveyor asked if it were permissible to use the brief to clean the resident with the soiled brief instead of a washcloth CNA #1 stated that it was okay since the resident was going to get a shower anyway. CNA #2 then continued to clean the resident with the soiled brief and prepared the resident to shower. On 8/7/25 at 10:30 AM, the surveyor interviewed CNA #3 who stated that Resident #43 was changed today at 9:30 AM and was not saturated with urine. CNA #3 stated that he obtained all supplies needed before he rendered care to the resident. CNA #3 stated that the facility offered both disposable and washable wash cloths for incontinence care. CNA #3 stated that two wash cloths were needed for incontinence care for a female, and it was important to clean from front to back so that it would not get contaminated. CNA #3 stated that if we used a soiled brief to wipe a resident it was not appropriate for infection control purposes because the resident could get an infection. On 8/7/25 at 11:19 AM, the surveyor interviewed CNA #2 who stated that she used the resident's soiled brief to clean Resident #43's urine and stool because it was there, and CNA #1 wanted to clean the resident in the shower. CNA #2 stated that there were wipes that were not used and the resident was not properly cleaned. CNA #2 further stated that by using the brief to clean the resident instead of a wipe the resident could get an infection. On 8/7/25 at 11:28 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that the aides could have pressed the call bell and called for wash cloths to cleanse the resident. RN #1 further stated that there was a potential for infection because the resident had a history of urinary tract infection. On 8/7/25 at 11:36 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1, who stated that a soiled brief should not be used to do incontinence care because you must use a wet washcloth to clean the resident appropriately. The LPN/UM #1 stated that it could cause an infection if a soiled brief were used instead. The LPN/UM #1 further stated that Resident #43 has had UTIs since day one and had been going to the urologist, but they have not specified the cause of the resident's UTIs. On 8/7/25 at 12:20 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that even if a section of the resident's brief that was not soiled were used to clean the resident it was still soiled and dirty. The IP stated that he would have instructed the aides to wait and get the appropriate supplies to clean the resident because there was a concern for infection, and it could cause a potential UTI. On 8/7/25 at 1:41 PM, the surveyor interviewed the Director of Nursing (DON), who stated that it was not appropriate to use a soiled brief to clean the resident. The DON stated a clean diaper maybe, or a washcloth, wipe or toilet tissue could be used to clean the resident but not a soiled diaper, until the aides showered the resident. The DON stated, A soiled brief was not clean, and it is an infection issue because there was both urine and bowel movement in the diaper and it can cause an infection. The DON stated that the doctor has deemed the resident chronic for UTI. A review of the facility's Urinary Continence and Incontinence-Assessment and Management policy, revised September 2010, included: The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines.A review of a staff in-service that was provided to staff which included CNA #2 on 7/2/25, revealed the following:.Nurses and CNA play a key role in UTI prevention through patient education and promoting healthy habits.Female Patients: Spread the labia majora and wipe down the center, using a clean part of the washcloth for each stroke. Then, clean each side, rinsing and drying the area thoroughly. Finally, have the patient turn on their side to clean the anal area.Male Patients: For circumcised males, start cleaning at the top of the penis and move downwards in a circular motion to the base. For uncircumcised males, gently retract the foreskin before cleaning and remember to reposition it afterward. NJAC 8:39-19.4

The facility failed to ensure the required Minimum Data Set (MDS) assessments were submitted timely as evidenced by 1 of 1 resident reviewed (Resident #66) for a system selected MDS Record over 120 days old. The deficient practice was evidenced by the following: On 02/22/24 at 11:33 AM, the surveyor reviewed the MDS for Resident #66 and interviewed the Licensed Practical Nurse MDS coordinator (MDSC) regarding submission of the MDS. The MDSC stated she was not at the facility at that time and an old medical record system was utilized. The MDSC then viewed an MDS report on the old system and stated the quarterly MDS and discharge MDS did not appear to be submitted and she would research further. On 02/23/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) provided a report for Resident #66's Discharge Assessment scheduled as due no later than 09/14/23 which was Accepted. The Quarterly Assessment stated was Submitted, not accepted per the document, and Transmission date no later than 09/26/23. On 03/05/24 at 1:35 PM, the surveyor informed the LNHA and Director of Nursing (DON) of the MDS concerns. On 03/06/24 at 12:04 PM, the DON provided the surveyor with a Final Validation Report which indicated the record was now Accepted, and Record Submitted Late: The submission date is more than 14 days after Z0500B on this new A0050 equals 1 assessment). NJAC 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, it was determined that the facility failed to ensure that an ongoing activity program was designed to meet the needs of all residents, specifically those who enjoyed outside of the facility trips. The deficient practice was identified for 1 of 2 residents reviewed for activities (Resident #18) and was evidenced by the following: On 02/29/24 at 9:00 AM, the surveyor reviewed the Electronic Medical Record for Resident #18, and reviewed the current Care Plan which did not include a care plan for activity preferences. The annual minimum data set (MDS) dated [DATE] revealed Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status, and was cognitively intact. The Interview for Activity Preferences revealed it was very important to go outside for fresh air when the weather was good. On 02/29/24 at 10:29 AM, the surveyor conducted an interview with Resident #18 who also served as the resident council president. The surveyor asked Resident #18 if the Licesnsed Nursing Home Administator (LNHA) ever conducted a meeting with the residents regarding the changes to the menus. Resident #18 stated he comes, stands there for like five minutes and leaves and stated, no we never had a meeting. Resident #18 then stated, that we used to go on trips, twice per month. Resident #18 stated that he/she informed the LNHA that residents wanted to go on trips and Resident #18 stated that the LNHA informed him/her that the bus was too expensive and it was too expensive for a trip every month. Resident #18 stated that the last trip was in December and that was three months ago, and prior to that the last trip was to the shopping mall. The surveyor reviewed the February 2024 activity calendar posted by activity room. The calendar revealed on 02/13/24 at 11:00 Trip to [restaurant name redacted] - TBD. On 02/29/24 at 10:51 AM, the surveyor interviewed the Activity Director (AD) who stated she had been at the facility for about six months. The surveyor asked the AD if the resident are ever scheduled for trips outside of the facility. The AD stated, the facility would have to hire a company and bills are pending. The AD stated she cannot schedule trips and she was not sure why. The surveyor asked if trips were important to the residents and the AD stated, yes they were important and she spoke with the LNHA and it was at corporate. The AD stated she put a trip on the calendar last month and the transportation company would not come to the facility. The AD showed the surveyor an invoice dated, 08/01/23 for $375.00 for a Recreational Trip. The AD stated she submitted the invoice to corporate on 08/11/23 and 11/21/23 for payment and it has not been paid. The AD stated she is unable to schedule trips and the LNHA did not inform her why the invoice is not getting paid. The AD showed the surveyor the February 2024 where the restaurant trip is TBD [To Be Determined]. On 03/05/24 at 1:35 PM, the surveyor informed the LNHA and Director of Nursing, the presence of the survey team, regarding the concerns about the inability to schedule trips due to the transportation invoice not being paid. The LNHA stated, he paid the bill and trips run on the calendar as TBD. No additional information was provided. NJAC 8:39-7.3(a)(1)(7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, and review of other pertinent documentation, it was determined that the facility failed to ensure residents received pain management consistent with professional standards of practice and physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #75 and #286) reviewed for pain and was evidenced by the following: 1.) On 02/20/24 at 9:31 AM, the surveyor observed Resident #75 lying in bed awake and alert. Resident #75 stated that his/her back had been hurting. He/she stated that Tylenol (medication used to relieve mild to moderate pain) helps some. He/she further stated that he/she used to get a patch on their back but not for a while. A review of the admission Record revealed that Resident #75 had diagnoses which included but were not limited to; repeated falls, muscle wasting and atrophy multiple sites, and cardiac arrhythmia (irregular heartbeat). A review of the Order Summary Report included but was not limited to; a physician's order dated 12/22/23, to observe for verbal/nonverbal signs and symptoms of pain every shift and take action as appropriate. A physician's order dated 01/19/24, Acetaminophen (medication to relieve mild to moderate pain) 325 mg (milligrams) give 2 tablets by mouth every 6 hours as needed for pain. A physician's order dated 01/31/24, Lidocaine (a topical patch to relieve pain) 4% apply to lower back daily. Apply in the morning and remove at bedtime. A review of the Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 12/29/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. A review of the resident-centered comprehensive on-going Care Plan (CP) revealed a focus area at risk for pain with a goal that the resident will not have an interruption in normal activities due to pain through the review date, and interventions that included but were not limited to; administer analgesia and acetaminophen as per orders, anticipate the need for pain relief and respond immediately, monitor/record/report any signs and symptoms of non-verbal pain. A review of the Medication Administration Record (MAR) February 2024 included but was not limited to; the order for the Lidocaine Patch 4%, apply to lower back daily. Apply in the am, remove at bedtime. In the morning for Pain management and remove per schedule. Remove 0859 and Apply 0900. The MAR documented the following: 02/13/24: apply was documented as administered. 02/14/24: was documented as applied and removed. 02/15/24: was documented as apply code 5 which indicated hold/see progress note and remove was documented as completed. The progress note (PN) dated 02/15/24 and timed 12:31 PM, by the Registered Nurse (RN) documented Lidocaine Patch 4%, apply to lower back daily. Apply in am, remove at bedtime in the morning for Pain management and remove per schedule. 02/16/24: apply was documented as code 9 which indicated other/see progress notes and remove was documented as code 2 drug refused. The PN dated 02/16/24 at 14:57 (2:57 PM), revealed OOF (out of facility) not given. There was no documentation that the physician was notified. 02/17/24 and 02/18/24: both indicated both applied and removed. 02/19/24 and 02/20/24: both indicated code 9 for applied and removed. The PN dated 02/19/24 at 11:02 indicated not give, no patch on pt (patient). The PN dated 02/20/24 at 13:22 (1:22 PM), indicated patch oof not given. There was no documentation that the physician was notified. 02/21/24: documented apply and remove as code 5. The PN for 02/21/24 at 8:14 was the only note and documented the order of Lidocaine Patch 4%, apply to lower back daily. Apply in the am, remove at bedtime in the morning for Pain management and remove per schedule. There was no documentation that the physician was notified. 02/22/24: documented apply as code 2 and removed as administered. The PN dated 02/22/24 that at 16:39 (4:39 PM) the resident complained of back pain rated 10 out of 10 and that Acetaminophen 325 mg 2 tablets was administered. There was no documentation indicating why the Lidocaine patch had not been applied. There was no documentation that the physician was notified. 02/23/24: documented apply as code 3 which indicated absent from home with meds (medications) and removed as administered. There was no PN dated 02/23/24 to document the reason why the resident had not been administered the Lidocaine patch. There was no documentation that the physician was notified. 02/24/24: documented apply and remove code as 9. The PN dated 02/24/24 at 8:10 AM, indicated Patch OOF (out of facility), not given. There was no documentation that the physician was notified. 02/25/24: documented apply and remove as code 9. The PN dated 02/25/24 at 8:29 AM, indicated Patch OOF, not given. There was no documentation that the physician was notified. On 02/23/24 at 7:42 AM, the surveyor and the resident's direct care Registered Nurse (RN) were in Resident #75's room. The resident asked about pain and stated it was a 9 (pain scale up to 10 as the worst) in his/her back. Stated he/she was supposed to be getting a patch for his/her back. The RN and surveyor exited the room. The RN stated the patches were house stock and asked another staff member to get the house stock Lidocaine patches. On 02/23/24 at 11:37 AM, the surveyor went to the residents room and was informed the Lidocaine patch had not yet been applied to the residents back. On 02/26/24 at 8:30 AM, the surveyor observed the resident sitting up in bed. The resident stated he/she was still not having his/her Lidocaine patch applied every morning and that the staff keep telling him/her they were trying to get it and meanwhile I am in agony here. On 02/26/24 at 8:32 AM, RN #2 who was caring for the resident stated he had been borrowing Lidocaine patches from the other unit. RN #2 and the surveyor looked through the medication cart and confirmed there were no Lidocaine patches. On 02/26/24 at 9:24 AM, the RN Unit Manager (RN UM) was questioned about the inconsistency of the application of the Lidocaine patch for Resident #75. The RN UM asked about lidocaine patch not consistently being applied. The RN UM stated the facility should be getting a delivery of patches today I know. I don't know why he/she has not been getting the Lidocaine patch. She further stated that the staff should have been calling the physician about missing medication, but the resident's Lidocaine patch was house stock. On 02/26/24 at 9:36 AM, the Director of Nursing (DON) in the presence of the survey team, confirmed that if house stock medications were missing and the resident was not being administered the ordered medication, the staff should call the physician and obtain a onetime order for something similar. The DON stated he was not sure if there was a policy and procedure. He further stated that the Lidocaine patch should be in the facility house stock but if not, the physician should be called, and that call should be documented in the resident's medical record. The DON stated it was important to call the physician, so a resident does not miss their prescribed medication. On 02/26/24 at 12:15 PM, during a telephone interview in the presence of the survey team, the ordering physician stated she was never made aware by anyone at the facility that the resident was not getting the Lidocaine patch consistently. I am absolutely positive nobody let me know about that. I could have addressed it. A review of a PN by the Nurse Practitioner dated 02/26/24 at 13:38 (1:38 PM), included but was not limited to; the resident was seen due to pt's (patients) complain of worsening weakness with increased lower back pain. The PN documented to cw (continue with) the Lidocaine patch and Tylenol PRN (as needed). On 02/27/24 at 8:24 AM, the surveyor observed Resident #75 awake sitting up in bed and smiling. When asked how he/she was feeling, Resident #75 stated, thank you so much. I got my patch yesterday and today already. The nurse promised I would get it as ordered every day. It takes the edge off and helps me to do my exercises to get strong. I'm so happy about it. b.) On 02/20/24 10:15 AM, the surveyor observed Resident #286 lying in bed awake and alert with an orthopedic boot on the right lower leg. Resident #286 stated he/she broke his/her ankle and lower tibia (bone in the leg). Resident #286 stated he/she had told the staff he/she was previously on Percocet (narcotic pain medication) 7.5 milligram (mg) for pain not the 5/325. He/she stated the staff informed him/her that the 7.5 mg had been ordered last Wednesday, he/she waited all week but it never came. Resident #286 stated that staff told him/her the order was never put in. A review of the admission Record revealed that Resident #286 had diagnoses which included but were not limited to; unspecified fracture of right lower leg, hypertensive (elevated blood pressure) heart disease, osteoarthritis, and muscle wasting and atrophy multiple sites. A review of the admission MDS dated [DATE], included but was not limited to; a BIMS of 15 out of 15 which indicated the resident was cognitively intact. Section J-Health Conditions documented the resident had frequent pain. A review of the comprehensive resident-centered on-going CP included but was not limited to; a focus area of has acute pain related to ankle fracture with one goal that the resident will verbalize adequate relief of pain to cope with incompletely relieved pain through the review date, and interventions which included but were not limited to; administer analgesia as ordered, anticipate need for pain relief and respond immediately, and evaluate the effectiveness of pain interventions, alleviating of symptoms, and resident satisfaction with results. A review of the Order Summary Report revealed a physician's order dated 02/13/24 Percocet (narcotic pain medication) 5-325 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, discontinue once 7.5/325 dose arrives. A review of the resident's paper medical chart revealed a prescription by the physician dated 02/14/24 for Percocet 7.5/325 mg give 1 tablet every 6 hours PRN (as needed) for pain. A review of the Treatment Administration Record (TAR) dated February 2024, revealed pain monitoring which began 02/14/24 when the Percocet 7.5/325 mg was ordered. The TAR revealed the following elevated resident pain ratings from 0 (no pain) to 10 (worst pain): 2/15/24: 9; 2/16/24: 8; 2/17/24: 7; 2/21/24: 8; 2/23/24: 8. The TAR documented the previous physician's order Percocet 5/325 mg give 1 tablet every 4 hours as needed for moderate to severe pain. The medication was requested and administered as follows: 2/14/24: with a pain rating of 7 and the recheck indicated I ineffective, a second dose with a pain rating of 7; 2/15/24: twice with a pain rating of 8; 2/16/24: three times once with a pain rating of 9 and the additional two with a pain rating of 7; 2/17/24: four times twice with a pain rating of 8, one with a pain rating of 7, and one with a pain rating of 6; 2/18/14: three times, two with a pain rating of 8; 2/19/24: four times, three with a pain rating of 7 and one with a pain rating of 8; 2/20/24: twice with a pain rating of 7; and 2/21/24: once with a pain rating of 8. The facility provided TAR dated 2/1/24 through 2/29/24, failed to document the physician's order dated 2/14/24 for the Percocet 7.5/325 mg. A review of the facility provided Progress Notes (PN) dated 2/13/24 through 2/22/24, included but was not limited to; date 2/21/24 at 16:36 (4:36 PM) Oxycodone-Acetaminophen (Percocet) 7.5/325 mg administered for pain level 8. Date 2/21/24 at 20:52 (8:52 PM) Percocet 7.5/325 mg administered for pain level 7. Date 2/22/24 at 1:10 AM Percocet 7.5/325 mg administered for pain level 7. Date 2/22/24 at 11:41 Percocet 7.5/325 mg pain scale not noted. Date 2/22/24 at 16:10 (4:10 PM) Percocet 7.5/325 mg for pain scale 7. A review of the PNs ranging from 2/13/24 through 2/21/24 when the resident received the first dose of Percocet 7.5/325 mg, failed to document any contact with the physician or the facility pharmacy to determine why the medication ordered on 2/14/24 had not arrived or to inform the physician the resident was not getting the prescribed higher dose of pain medication. On 02/22/24 at 8:49 AM, the Registered Nurse Unit Manager (RN UM) stated the process when a prescription was received was to write the order, put it in the computer and it goes to the pharmacy. She further stated, We don't know when pharmacy gets the order. If it is in the morning or if they get in in afternoon. The RN UM stated that medications were delivered within 24 hours and that the staff would sign for the delivered medications. When asked about the Percocet 7.5/325 mg order from 2/14/24, she stated the Percocet was ordered for the 7.25 mg, but the pharmacy never sent it. We would check every day but actually got it days later. The RN Um stated the communication with the pharmacy would be documented in the electronic medical record. The RN UM stated she had contacted the pharmacy, but the surveyor was unable to find documentation in the electronic medical record. On 02/22/24 at 9:20 AM, the Director of Nursing (DON) stated the process for a written prescription would be to fax it to the pharmacy, a confirmation page of the may or may not be kept but the staff would write a note in [the electronic medical record] that the script (prescription) was faxed. We may get the medication overnight or the next day. When asked about how the facility would track medications sent to the pharmacy to ensure they were received and delivered, the DON stated if the medication was not delivered, he would be notified. He further stated that if the medication does not arrive, the staff would call the pharmacy. The DON stated that communication would be documented in the electronic medical record and the staff should call the physician. The DON stated that within 24 hours the medication should be delivered to the facility. On 02/22/24 at 9:44 AM, the RN UM provided a PN dated 2/21/24 at 9:07 AM, created on 2/22/24 at 8:58 AM, regarding call to pharmacy. The PN documented she had spoken to the pharmacy x3 (three times). The PN documented the pharmacy stated the Percocet 7.5/325 mg had not been sent because the resident had an order for Percocet 5/325 mg. This RN explained that the 5/325 is to remain until the 7.5/325 arrives so patient continues to have pain coverage. Pharmacist stated understanding and said that the order would go out on the next run. On 02/22/24 at 9:50 AM, during a telephone interview in the presence of two surveyors, the facility pharmacist stated the Percocet 7.5/325 mg was initially sent to the pharmacy 2/14/24 and was sent out to the facility on 2/21/24. The pharmacist stated the resident was on Percocet 5/325 mg and the pharmacy was trying to confirm which order the physician wanted because the Percocet 5/325 mg was also written on 2/14/24. The pharmacist stated it should not typically take that long. Because we received both scripts 2/14/24, but we did not get a call from the facility until the 20th from [name redacted RN UM] asking why the Percocet 7.5/325 mg had not been sent. The pharmacist stated that at that time, she confirmed which medication was to be provided, and sent out the Percocet 7.5/325 mg on the 21st. The Pharmacist stated, there were no other phone calls from anyone at the facility regarding the clarification. A review of the Packing Slip confirmed that Resident #286's Percocet 7.5/325 mg tablets were delivered on 2/21/24. On 02/22/24 at 10:10 AM, Resident #286 stated, I finally got the correct 7.5/325 and it doesn't alleviate all the pain, but it takes it down at least a notch from the other medication (5/325). On 02/22/24 at 10:12 AM, the residents direct care RN stated she was familiar with the resident. The RN stated, the resident tells her he/she has pain and the resident asked for a higher dose of Percocet, so the doctor wrote it. If the medication wasn't delivered, we would call pharmacy. She stated she worked 2/14/24 and she faxed the prescription for the Percocet 7.5/325 mg. The RN stated she called the pharm to tell them to use the Percocet 7.5/325 mg. She stated, I work part time, so I wasn't here for a while to know that the medication did not arrive. She stated the resident was complaining he/she was in pain and that was why I got the doctor to see him/her. She stated she did not document that she called the pharmacy to clarify the order that day. On 02/23/24 at 10:23 AM, during a telephone interview in the presence of the surveyors, Resident #286's physician was asked if he was aware that the Percocet 7.5/325 mg that was ordered on 2/14/24, had not been delivered until 2/21/24. The physician stated that on 2/19/24 he was made aware and that the clarified order was just put in at that time. The physician confirmed that no staff attempted to clarify the order with him prior to 2/19/24 regarding the 2/14/24 order. A review of the facility provided, Pain Assessment and Management policy and procedure dated revised 3/20, included but was not limited to; Purpose: to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and need that address the underlying causes of pain. Guidelines: 1. Commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management defined as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes: a. assessing the potential for pain; b. recognizing the presence of pain; 3. Developing and implementing approaches to pain management; f. identifying and using specific strategies for different levels and sources of pain; and h. modifying approaches as necessary. Assessing Pain: 1.a. history of pain and its treatment. 3. Discuss with the resident or representative his/her goals for pain management and satisfaction with the current level of pain control. Implementing Pain Management Strategies: 2. Pharmacological interventions may be prescribed . 3. The physician and staff will establish a treatment regimen based on: c. current medication regimen. Documentation: 1. Document the reported level of pain with adequate detail (ex: enough information to gauge the status of pain and effectiveness of interventions) as needed and in accordance with the pain management program. A review of the facility provided, Administering Medications policy and procedure revised 4/19, included but was not limited to; 4. Medications are administered in accordance with prescriber orders. A review of the facility provided, Unavailable Medication dated 1/1/23, included but was not limited to; Policy: it is the facility policy to administer medications as ordered by a physician/NP (Nurse Practitioner). Procedure: 3. The nurse will notify the physician/NP that the ordered medication is not available for administration as ordered. 5. The physician/NP will provide orders to address the unavailability of the ordered medication . 6. The nurse will communicate with the pharmacy to ensure that the physician ordered medications have been appropriately ordered from the pharmacy. A review of the facility provided, Medication Orders and Receipt Recor revised 04/07, included but was not limited to; Policy: . document all medications that are ordered and received. Interpretation: 1. the charge nurse will maintain medication order . records. 2. the medication order . record shall contain d. order dae; e. name and title of person placing the order; g. the date and quantity received. 3. The DON will designate individuals to be responsible . NJAC 8:39-27.1(a)(c)3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and document review, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to ensure a) resident requests for water were honored, b) meals were served in a dignified homelike manner without the use of disposable dishware, c) consistently communicated with residents by their preferred name and not label residents as feeders, d) staff did not speak in a foreign language in the presence of the residents, e) staff conducted personal phone calls during resident interactions, and f) all residents were provided with privacy curtains. The deficient practice was identified during a resident council meeting held with six residents, and evidenced during a survey conducted from 02/20/24 through 03/06/24, and affected all residents who resided on 2 of 2 resident units. The deficient practice was evidenced by the following: On 02/23/24 at 11:14 AM, the surveyor held a resident council meeting with six residents. The following concerns were expressed: -6 of 6 Residents stated the Certified Nurse Aides (CNAs) were so loud in the hallway, that the residents were awoken to laughing and giggling in the early morning hours and late at night. -3 of 6 Residents stated they waited anywhere from thirty minutes to one hour for the CNAs to respond to the call bells. Two of six residents stated staffing is terrible 3:00 PM -11:00 PM and 11:00 PM -7:00 PM. -2 of 6 Residents stated they waited thirty minutes to one hour for assistance and sometime longer, one resident stated, they leave me wet for hours sometimes and double diaper me, which I don't ask them to. -1 of 6 Residents stated, my roommate will use the call bell and the CNAs will come in and turn it off without addressing the concern. -1 of 6 Residents stated, they did not have to call for help because they did everything themselves and stated, they need to hire more people though. -5 of 6 Residents stated that shower times were not honored, the staff changed the schedule without notification, and they by pass my showers sometimes, or the aids will ask me if I want to shower at 11:00 PM and that's just too late. -6 of 6 Residents stated that staff are always talking in different languages around us and sometimes they are talking on the phone while taking care of us, staff are always on their phones while working, either talking or texting. Surveyor #5: 1. During the initial tour on 02/20/24 at 9:30 AM, Surveyor #5 observed Resident #1 sitting in the bed. The resident responded to the surveyor's greetings then asked for a drink of water. The surveyor informed the resident to activate the call light. The resident informed the surveyor that there was no call light. The surveyor did not observe a call light attached to the bed or near the resident. The surveyor exited the room and, observed a CNA in the hallway and informed the CNA that the resident requested water. The CNA, in the presence of the resident, stated It is a repetitive behavior, [he/she] always asked for water, [he/she] had Alzheimer's. The surveyor informed her again that the resident requested water and the CNA repeated, it is a repetitive behavior, [he/she] had Alzheimer's. The CNA did not, engage the resident, check the cup on the bedside table to ensure there was water in the cup, or provide the resident with a fresh cup of water. The surveyor then asked the CNA to send the nurse into the room. The Director of Nursing (DON) entered the room and the Resident stated that he/she would like a drink of water. The cup on the bedside table was empty and Resident #1 did not have a water pitcher in the room. The surveyor informed the DON of the observations and the DON stated that he would address the issue. 2. On 02/23/24 at 8:30 AM, the surveyor observed that Resident #1 received their breakfast meal on paper plates with disposable silverware. On 02/26/24 at 12:15 PM, the surveyor observed Resident #1 on the lunch meal on paper plates with disposable silverware. On 02/27/24 at 8:30 AM, the surveyor observed Resident #1 being served the breakfast meal on a paper plate with a plastic cup and plastic silverware. The surveyor escorted the DON to the room and inquired about the rationale for serving the meal with disposable dinnerware. The DON stated that the resident had a behavior of destroying dishware. On 02/27/24 at 10:30 AM, the surveyor reviewed Resident #1's Comprehensive Care Plan and could not locate any documentation regarding that the resident was disruptive and that all meals should be served on disposable dinnerware with plastic utensils. On 03/05/24 at 8:30 AM, the surveyor observed Resident #1 eating the breakfast meal on disposable plates and using plastic cutlery. The surveyor then interviewed the CNA who delivered the meal confirmed that the resident received all meals on disposable dinnerware, she could not provide the date when the order was written. A review of the meal ticket delivered with the tray confirmed that all meals were to be served on disposable dinnerware and cutlery. A review of the Progress notes from 12/05/23 to 03/04/24 did not reflect any behavior of destroying dishware as stated by the DON. The progress notes documented that the resident would refuse medications and care. The psychiatric progress notes dated 01/05/24 documented the following: [Resident #1] was currently stable on treatment. On evaluation, was calm and cooperative. Has the tendency to be aggressive at times, but no recent behaviors were reported by the nursing staff. On 03/06/24 at 8:45 AM, the surveyor observed that Resident #1 received their breakfast meal on a paper plate with plastic utensils. The facility was unable to provide documentation of any behavior which warranted the use of disposable dinnerware for the resident. Surveyor #1: 2. On 02/20/24 at 12:12 PM, the surveyor toured the 200 unit during the meal service. The surveyor observed 18 residents eating in the small dining room and 4 of 18 were eating on colored paper plates that were rested on the metal warming pellet. The residents were also using plastic silverware and plastic cups for beverages. The surveyor asked a CNA why residents were using disposables and the CNA stated, infection control. The surveyor proceeded to tour resident rooms on the high side of the 200 unit and observed Resident #61, Resident #45, and Resident #49 also eating off of paper plates, beverages were in disposable cups and were using plastic utensils. The surveyor asked Resident #45 if they received paper plates often, and Resident #45 stated, yes, they always give me paper plates, plastic also. The surveyor observed Resident #36 was being assisted with the meal in the resident's room by a CNA. The resident's meal was also served on paper plates and was assisted with plastic utensils. The surveyor asked the CNA why paper plates and plastic were used. The CNA stated, no idea, and this was not the first time. On 02/20/24 at 12:24 PM, the surveyor then proceeded toward the low side of the 200 unit and observed the meals served on paper plates and plastic utensils on the resident meal trays. The surveyor asked another CNA why the paper plates were being used and the CNA stated, probably not enough plates. The surveyor observed an unsampled resident in room [ROOM NUMBER] eating the meal off of a paper plate and using plastic utensils and a plastic cup for the beverage. On 02/20/24 at 12:42 PM, the surveyor entered the kitchen and interviewed the Food Service Director (FSD) regarding the resident meals served on paper plates. The FSD stated, we ran out of plates. The surveyor asked how long and the FSD stated maybe a week. The surveyor asked the FSD if it was acceptable to serve resident meals on paper plates and he stated, no, it is not. Surveyor #1 then asked why the residents were eating with plastic utensils and the FSD stated, same thing, short. On 02/21/24 at 11:57 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and asked if it was dignified to have residents eat from paper plates and use plastic utensils. The LNHA stated it was not okay to use paper plates and plastic utensils. Surveyor #1 asked the LNHA why that was, and he stated not as homelike. On 02/22/24 at 8:11 AM, the surveyor observed the breakfast meal cart brought to the 200 unit, and staff pulled out a meal tray from the meal cart in front of room [ROOM NUMBER], and began loudly speaking to another staff member in a [foreign language]. The staff member was across the hall by the other resident rooms. The surveyor asked the staff about the observation and the staff stated, I was talking to her in a [foreign language], and stated it was the Activity Director (AD). The staff that she was speaking to stated, we talk often in [a foreign language]. The surveyor interviewed the AD who stated that she needed to speak to the housekeeper in a [foreign language] and was aware they should not speak in another language. On 02/22/24 at 8:17 AM, during the same observation, the surveyor heard staff referring to a resident while outside of room [ROOM NUMBER] as a feeder, then entered room [ROOM NUMBER] with another staff. The Licensed Practical Nurse, Unit Manager (LPNUM) was at the meal cart at the time and the surveyor asked her what a feeder was. The LPNUM stated it was people that needed help [to eat the meal]. The surveyor asked was feeder a usual term that was used and the LPNUM stated, yes. The surveyor asked the LPNUM if she was ever trained to not use that term and she stated, no. The LPNUM then asked the surveyor what the appropriate term was that she should use. On 02/22/24 at 8:39 AM, the surveyor observed a male CNA distribute multiple meal trays on the high side of the 200 unit, including to room [ROOM NUMBER]. A female CNA then pointed to meal trays, and identified several residents by saying this one is a a feeder, and that one is a feeder to the male CNA. Other residents were in close proximity in the small dining room awaiting the meal distribution. On 02/22/24 at 9:38 AM, the surveyor interviewed the Registered Nurse Unit Manager Staff Educator (RNUM) and asked about any education provided to staff regarding dignity. The RNUM stated that was completed by social services. The surveyor asked the RNUM if a resident could be called a feeder. The RNUM stated, we don't use feeder, it is rude. The RNUM then stated, that is a big one, that is old, no one is supposed to be using that anywhere, it is a dignity issue. On 02/22/24 at 9:42 AM, the surveyor asked the RNUM if staff could speak a foreign language in the presence of the residents. The RNUM stated, no, that is dignity as well. They [the residents] need to know what is being said in their home. On 02/22/24 at 10:38 AM, the surveyor interviewed the DON who stated he has worked at the facility for four months. The surveyor asked the DON if the staff could a speak foreign languages around the residents, and identify and point at residents then identify them as feeders. The DON stated, they are not supposed to do that, or speaking a foreign language. The DON then stated, feeder, that is not supposed to be used at all, that is a dignity issue. The DON stated, it was not okay to point, not good. On 02/23/24 at 11:39 AM, Surveyors #1 and #5 were in the main hallway between the activity room and the dining room and observed a staff in a lab coat pushing Resident #79 in the wheelchair with his right hand, was holding a cellular phone in his left hand and conducted a phone call on speaker while he pushed the resident into the dining room. Surveyor #1 interviewed then the staff who identified himself as Registered Nurse (RN). The surveyor asked him if he typically conducted a phone call on speaker phone while he wheeled a resident with the other hand. The RN stated, no, that is not normal behavior, I was on my break and stated Resident #79 needed to be watched. On 02/26/24 at 10:02 AM, the surveyor interviewed the DON regarding if was acceptable for staff to take a personal phone call while caring for residents. The DON stated, no, it is not acceptable, everyone was trained on that. On 03/01/24 at 11:06 AM, the surveyor entered the activity room while residents were at the main table, coloring and watching television. At the same table the with the residents, an activity staff (AS) was talking on a cellular phone. The AS hung up the phone and the surveyor asked if she should be on the phone while she is with the residents in an activity. The AS stated, It was my heart doctor. Surveyor #3: On 02/20/24 at 11:09 AM, during environmental rounds of the Unit 200, the surveyor observed privacy curtains were missing for both window and door bed (Resident #59 and Resident #335). On 02/22/24 at 9:41 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who stated that the purpose of curtains in a resident's room was to provide privacy. She further stated that all residents should have a curtain to provide privacy and for dignity. If a curtain was missing, then the maintenance should be notified, and a new curtain be replaced. On 02/22/24 at 11:00 AM, the surveyor observed the privacy curtains were still missing from both residents' beds. At that time, the maintenance technician (MT) was observed replacing the curtains on window bed. Resident #59 was not in the bed and Resident #335 was observed lying in his/her bed. The surveyor interviewed the MT who stated that he was not sure how long the privacy curtains had been missing but he was just putting them back up now. The MT further stated that the curtains were sent out to a private company to be cleaned and the facility did not have on site laundry services. On 02/22/24 at 11:04 AM, the surveyor interviewed the Director of Maintenance (DM) who stated that the privacy curtains were taken down a couple days ago because they were stained and were sent out to a private company to be cleaned. The DM further stated I did not have any backup curtains to put up when these curtains were sent out to be cleaned. We need to put an order in to get more curtains. On 02/22/24 at 11;23 AM, the surveyor interviewed the CNA who was assigned to both Resident #59 and #335. He stated that Resident #59 needed total assistance with all activities of daily living (ADLs) and transferred to a wheelchair with minimal assistance. Resident # 335 needed minimum assistance with ADLs and could ambulate to the bathroom with supervision. The CNA stated that I think the curtains were missing for about 2 days. It is important for residents to have curtains for their privacy. A review of the electronic medical record (EMR) revealed that Resident #335 was admitted with diagnoses including but not limited to schizoaffective disorder, adjustment disorder, and mood disorder. The Quarterly Minimum Data Set (MDS), as assessment tool, dated 01/26/24 reflected that Resident #335 had severe cognitive impairment, minimum/moderate assistance with ADLs and could ambulate 10 feet in the room with supervision. A review of the electronic medical record (EMR) revealed that Resident #59 was admitted with diagnoses including but not limited to Dementia, schizoaffective disorder, and major depressive disorder. The Annual Minimum Data Set (MDS), as assessment tool, dated 01/31/24 reflected that Resident #59 had severe cognitive impairment, maximum assistance with ADLs and moderate assistance for transfers. A review of the facility policy titled, Dignity, Revised February 2021 revealed a Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are c. provided with a dignified dining experience. 6. Speak respectfully to residents at all times, including addressing the by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. A review of the policy titled, Resident Rightslast revised February 2011, indicated the following: Employees shall treat all residents with kindness, respect and dignity. The resident shall exercise his or her rights as a resident of the facility and as a citizen of the Unites States. Be supported by the facility in exercising his or her rights. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. NJAC 8:39-4.1(a) 12

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) On 02/20/24 at 10:01 AM, during a tour of the 100 unit of the facility, Resident #76 was observed awake and alert in bed watching television. Surveyor #2 attempted to speak to the resident, but English was not [his/her] primary language. The resident was able to convey that [he/she] had been at the facility for a few months. A review of the admission Record revealed that Resident #76 had diagnoses which included but were not limited to; traumatic subarachnoid hemorrhage (bleeding into the brain); alcohol abuse; traumatic brain injury; and cognitive communication deficit. A review of the admission MDS dated [DATE], included but was not limited to; Section B0700 2 which indicated the resident sometimes understood by others and B0800 2 which indicated the resident sometimes understands others. Resident #76 had a BIMS of 00/15 which indicated severely cognitively impaired. Section C1310 Signs and Symptoms of Delirium documented 2 behavior present, fluctuates for inattention. Section D0100 should mood interview be conducted? indicated 0 No - resident rarely/never understood. Section N Medications documented that yes resident received antipsychotics on a routine basis; no Gradual Dose Reduction (GDR) had been attempted; and no GDR has not been documented by a physician as clinically contraindicated. A review of the Physicians Order Summary Report, active orders as of 03/01/24, included but was not limited to; a physician's order dated 01/10/24, for Seroquel (an antipsychotic) 25 milligrams (mg) give 1 tablet by mouth in the evening for psychosis. The Order Summary Report did not include any target behaviors for the resident. A review of the consulting pharmacy, Nursing Summary Report dated 01/11/24, included but was not limited to; a pharmacy recommendation to identify and monitor the behavior being exhibited for the use of Seroquel regarding Resident #76. There was no documented evidenced that the recommendation was followed with the physician or dated to indicate it had been completed by the facility. A review of the psychiatric evaluation Progress Note (PN) dated 01/12/24, included but was not limited to; Medication: Seroquel 25 mg (Psychosis). Plan: 1. Always consider supportive interventions . redirection, support, reassurance, comfort measures, reduced stimulation, expression of feelings, family involvement. Treat medical issues. On 03/05/24 at 9:07 AM, Surveyor #2 interviewed the DON and the Registered Nurse Unit Manager (RN UM) of the 100 unit. The RN UM accessed Resident #76's on-going comprehensive Care Plan and acknowledged psychosis was not listed nor were there any measurable goals or interventions. The DON stated that the purpose of a comprehensive Care Plan was so that the entire staff would know how to treat the resident. When asked what would be expected to monitor for a resident with psychosis, the DON stated behaviors. When asked where the staff would know where to find the target behaviors for the resident, the DON did not reply. The RN UM stated I guess it should be in the Care Plan. I don't know. A review of the resident-centered on-going Care Plan had no documented evidence of a focus area of psychotropic medication for psychosis or target behaviors; no measurable goals; no interventions; and did not list psychosis as a diagnosis. The facility had no additional information to provide. d) On 02/27/24 at 8:15 AM, Surveyor #2 observed the breakfast meal ticket for Resident #32. The meal ticket showed Allergies: eggs, turkey, chicken, citrus. A review of the admission Record revealed Resident #32 had Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. A review of the Physician's Order Summary Report dated 02/27/24, documented Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. A review of Task record (a Certified Nursing Assistant guide to care for the residents) included Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. A review of the Physician's Assistant Progress Note dated 02/20/24, documented Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. A review of the Registered Dietitian's Progress Note dated 01/22/24, revealed Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. A review of the resident-centered on-going comprehensive Care Plan for Resident #32 listed Allergies Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillins (an antibiotic), citric acid, melon. The Care Plan had no documented evidence to include a focus area for the medication allergies of Erythromycin and Penicillins to include measurable goals, possible side effects, and interventions. The Care Plan had no documented evidence to include a focus area for the food allergies of Eggs, Egg-derived products, citric acid, and melons to include measurable goals, possible side effects, and interventions. A review of the facility provided, Director of Nursing Services job description undated, included but was not limited to; Care Plan and Assessment Functions: assist in the development of preliminary and comprehensive assessments; develop a written care plan (preliminary and comprehensive) that identifies the resident's problems/needs, indicates the care to be give, goals to be accomplished, and which professional service is responsible for each element of care; review nurses' notes to determine if the care plan is being followed; and review and revise care plans and assessments as necessary. A review of the facility provided, Nurse Supervisor job description undated, included but was not limited to; Purpose: . to ensure that the highest degree of quality care is maintained at all times. Care Plan and Assessment Functions: participate in the development of written preliminary and comprehensive assessments of the needs of each resident; participate in the development of a written care plan that identifies the problems and needs of the residents, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care; and review the resident care plans for appropriate goals, problems, approaches, and revisions based on needs. A review of the facility provided, Care Plan-Baseline policy revised 3/2022, included but was not limited to; Policy Statement: to meet the resident's immediate health and safety needs, developed for each resident within forty-eight hours of admission. Interpretation and Implementation: 1. To include instructions needed to provide effective, person-centered care that meets professional standards of quality care and must include the minimum healthcare information needed to properly care for the resident including but not limited to; a. initial goals; b. physician orders; c. dietary orders. 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. The baseline care plan is updated as needed to meet the resident's needs. A review of the facility provided, Care Plan, Comprehensive Person-Centered policy revised 3/2022, included but was not limited to; Statement: . includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Interpretation and Implementation: 3. The care plan interventions are derived from a thorough analysis of the information gathered in the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. c. stated goals upon admission and desired outcomes; d. builds on resident's strength; and e. reflects recognized standards of practice for problem areas and conditions. 10. When possible, interventions address the underlying source of the problem areas, not just symptoms or triggers. The facility failed to follow their policies. NJAC 8:39-11.2; 27.1 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individualized resident-centered comprehensive care plans with measurable goals: a) to integrate approaches for a resident with a history of aggression and exhibited behaviors, b) for a resident with a history of falls including falls with injury, c) and interventions for a resident who had a history of psychosis, and d) for a resident with allergies. This deficient practice was identified for 4 of 18 residents (Resident #1, #5, #76, and #32) reviewed for Care Plans (CP) and was evidenced by the following: a. On 02/20/24 at 12:34 PM, Surveyor #1 observed Resident #1 in bed with the lunch tray on the bedside table. The lunch tray was covered with a plastic wrap and the resident was eating off of disposable dinnerware and with disposable cutlery. The surveyor left the room and observed the Director of Nursing (DON) in the hallway. Surveyor #1 inquired regarding the resident being served on disposable dinnerware and cutlery. The DON informed the surveyor that the resident had behavior of being aggressive and destroyed dishware and had a CP for the behavior. A review of Resident #1's medical record revealed: The Physician Orders sheet (POS) for March 2024 reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's disease and schizophrenia. The POS reflected that the resident was receiving Depakote (a mood stabilizer) and Zyprexa (an antipsychotic) for schizophrenia. A review of the resident's comprehensive care plan did not include that the resident had behavior of being aggressive and was to have all meals served on disposable dinnerware and cutlery. The Care plan dated 01/23 indicated that the resident had behaviors of yelling and cursing, and had not exhibited the behavior since last revised on 01/02/23. A gradual dose reduction of Zyprexa was done on 10/27/23 in the absence of the Target Behavior (delusions and hallucinations). Review of the January 2023 Medication Administration Record (MAR) behavior monitoring and interventions sheet provided by the facility, indicated that the resident was receiving these medications for the target behaviors of delusions and hallucinations. Behavior monitoring reports were provided for 1/2024, 2/2024, and there were no behavior monitoring sheets provided for being aggressive or destroying dishware. During the survey from 02/20/24 to 03/05/24, Surveyor #1 observed the resident during four separate observations being served on disposable dinnerware with disposable cutlery. On 02/23/24 at 9:23 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated that Resident #1 preferred to stay in bed. The resident would refuse care at times but did not exhibit any aggression towards staff. At that time the, CNA stated that the resident had always been served on disposable dinnerware and cutlery. On 02/26/24 at 9:08 AM, the surveyor observed the resident being served again on disposable dinnerware and cutlery. The surveyor accompanied the DON to the room and inquired about the rationale for the resident being served all meals on disposable dinnerware and cutlery. The DON stated that the resident had a behavior of destroying dishware and the concern had been addressed on the CP. On 02/26/24 at 11:30 AM, the surveyor interviewed the Licensed Practical Nurse /Unit Manager (LPN/UM) who stated she has worked at the facility for a while. She confirmed that the resident had been served on disposable dinnerware and cutlery and was cared plan for the behavior. At that time, the LPN/UM and Surveyor #1 looked at the resident's Psychiatry Progress Notes and noted that the Target Behaviors mentioned were delusions and hallucinations. Review of the Monthly Psychotropic Review reflected that the Target Behaviors being monitored were delusions and hallucinations (not destroying dishware). The resident did not have a care plan in place which addressed aggression and being disruptive. The LPN/UM was unable to speak to the resident being disruptive or if the resident had a care plan for being served on disposable dinnerware and cutlery. The LPN/UM was unable to provide documented evidence of a care plan for the behavior. On 03/05/24 at 11:43 AM, the surveyor conducted a second interview with the DON regarding Resident #1 being served on disposable dinnerware and cutlery during the survey. The DON confirmed that the behavior was addressed on the CP. The surveyor reviewed the care plan with the DON and noted that the behavior of throwing trays and utensils was added on 03/01/2024 (after the surveyor's inquiry). When inquired of the purpose for the care plan, the DON stated that there should have been a CP to reflect the resident's current status with measurable goals and interventions. b. On 02/28/24 at 8:35 AM, the surveyor observed Resident #5 in the room and observed a large yellow and purple bruise that extended from the top of the forehead to the right jaw area and had blue bruises to both wrists. A visitor was in the room and informed the surveyor that the resident fell on [DATE] and had been transferred to the hospital and returned to the facility last night (02/27/24). A review of Resident #5's Face Sheet (admission summary) reflected that Resident # 5 was readmitted to the facility from another long term care facility, with diagnoses which included but were not limited to; Mood disturbance and anxiety, fracture of unspecified part of neck of left femur, subsequent encounters for closed fracture with routine healing and need for assistance with personal care. The Quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #5 had severe cognitive impairment. Resident #5 received a score of 05 out of 15 on the Brief Interview for Mental Status (BIMS.) Surveyor #1 reviewed the history and physical dated 09/08/22, which revealed the resident had a history of falls. The resident fell at home and sustained a fracture of the left hip. The resident underwent surgery to repair the fracture and was admitted for rehabilitation. The surveyor reviewed the care plan which did not address a focus related to or any interventions to prevent further falls. The comprehensive care plan dated 09/08/22, reflected that the resident falls risks were not addressed for the current admission dated 09/08/22. Resident #5 was discharged home on [DATE] and readmitted to the facility on [DATE], following an ORIF (Open Reduction Internal Fixation) surgical intervention to repair a left hip fracture. Resident #5 sustained a fall out of bed on 09/11/22 at 2:12 PM. The Certified Nursing Assistant documented: Heard somebody screaming, upon entering the room, observed the resident lying on the floor. I called the nurse. The nurse documented: I asked the resident what happened. The resident stated, I wanted to walk. I assessed the resident. The resident had a hematoma to the right forehead, the resident complained of right shoulder pain. Following the fall of 09/11/22, Resident #5 was referred to Physical Therapy who made the following recommendations: Continue with physical and occupational therapy. Patient will need: Bed alarm, Chair Alarm for safety. Patient education to call for assistance as needed. There was no documented evidence that the interventions were implemented, on the Care Plan, per the recommendations made by Physical Therapy (PT). There was no Care Plan developed after, on 09/15/22, the resident reported pain in the left ankle and joints of left foot. The physician ordered an X-Ray of the left foot. Resident #5 was diagnosed with a non displaced fracture of medial malleolus of the left tibia. On 02/26/24 at 10:00 AM, the Assistant Director of Nursing (ADON) indicated that the resident had a care plan in the current Electronic Medical Record (EMR) system. The ADON could not provide a Care Plan for the prior falls. The surveyor reviewed a care plan provided by the ADON, dated 11/02/23 for falls identified as Risk for falls. The goal was Resident #5 will be free from injury through the target date of 01/31/24. Interventions included: Anticipate and meets my needs. Be sure my call light is within reach and encourage me to use it for assistance a needed. Bed alarm when in bed. initiated 11/10/23. Line of site when out of bed. initiated 02/02/24. On 02/26/24 at 10:30 AM, Surveyor #1 reviewed with the DON the recommendations made after the fall of 09/11/22, regarding the Physical Therapy recommendations. The DON stated that he could not comment on the interventions not being implemented as he was not working at the facility at that time. On 03/05/24 at 1:04 PM, the surveyor reviewed the falls incidents and the care plan with the Licensed Nursing Home Administrator (LNHA) and he could not comment on the omission of the interventions from the care plan. The LNHA stated that the nursing department was to implement the recommendations.

Deficiency Text Not Available

2) On 03/05/24 at 8:34 AM, Surveyor #2 walked onto the 100 unit of the facility. Surveyor #2 observed Resident #78 awake sitting up in bed with [his/her] call light down the side of the bed, and on the floor out of reach of the resident. At that time, CNA #2 was in the hall. CNA #2 acknowledged Resident #78's call bell was inaccessible and stated that the call bell should be within reach of the resident in case the resident needed help. A review of the admission Record revealed that Resident #78 had diagnoses which included but were not limited to; weakness, dementia, muscle wasting, and difficulty walking. A review of the resident centered on-going Care Plan (CP) included but was not limited to; a focus area dated 1/21/24, Safety General with interventions which included safety measures to reduce the risk of fall. A focus area dated 1/21/24, at risk for falls related to gait/balance problems, unaware of safety needs with interventions which included be sure my call light is within reach and encourage me to use it for assistance as needed. 3) On 03/05/24 at 8:38 AM, Surveyor #2 observed, on the 100 unit of the facility, that Resident #288 was awake, alert and sitting up in bed. Surveyor #2 knocked and entered the room and observed the call bell handing off the side of the bed and on the floor out of reach of the resident. At that time, Surveyor #2 asked Resident #288 if [he/she] had a call bell if [he/she] needed to call for the staff for help. Resident #288 replied, I don't know. Where would it be?. Resident #288 was moving both hands over the covers on [his/her] bed. On 03/05/24 at 8:35 AM, CNA #3 was in the hallway and Surveyor #2 asked for her assistance in the resident's room. CNA #3 entered the room and acknowledged the call bell out of the resident's reach. CNA #3 stated, I'm sorry I did not see your call bell on the floor. CNA #3 stated that all residents need to be able to reach their call bells in case of an emergency. A review of the admission Record revealed that Resident #288 had diagnoses which included but were not limited to; age related osteoporosis (weakened bone strength), difficulty walking, and dementia. A review of the resident centered on-going Care Plan included but was not limited to; a focus area dated 2/27/24 to receive physical and occupational therapy services for ADL (activities of daily living) tasks, functional mobility, and ambulation related to muscle weakness and difficulty walking. Intervention included balance, gait training, ADL re-training, and therapeutic exercises. A review of the 01/26/24, Minimum Data Set (MDS) an assessment tool to facilitate resident care, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 00/15 indicating Resident #32 was severely cognitively impaired. Section GG Functional Abilities documented that Resident #288 was either dependent or required substantial/maximal assistance from staff for picking up objects; hygiene, toileting, bathing, dressing, rolling left and right; sit to lying; lying to sitting on the side of the bed; sit to stand; chair/bed transfer; toilet transfer; and walking. On 03/05/24 at 8:55 AM, the Director of Nursing (DON) was made aware of the inaccessible call bells. The DON stated that the CNAs should ensure call bells were in place and within reach for the residents. A review of the facility provided, Certified Nursing Assistant job description, undated, included but was not limited to; Purpose: provide residents with daily nursing care and services in accordance with the resident's assessment and care plan. Functions: perform all tasks in accordance with established policies and procedures. Answer resident calls as promptly as feasible. Ensure residents who are unable to call for help are checked frequently. Check residents routinely to ensure that personal care needs are being met in accordance with their wishes. A review of the facility provided, LPN (Licensed Practical Nurse) job description, undated, included but was not limited to; Purpose: to supervise the day-to-day nursing activities performed by CNAs and other personnel and to provide direct nursing care to the residents. Functions: make rounds on your unit/shift to ensure that assigned CNAs and other personnel are performing their work assignments. Ensure residents who are unable to call for help are checked frequently. A review of the facility's policy titled, Answering the Call Light dated 2001, last revised 03/2023 indicated the following: Purpose The purpose of this procedure is to ensure timely response to resident's requests and needs. General Guidelines Upon admission and periodically as needed, explain and demonstrate use of call light to the resident. Ask the resident to return the demonstration. Be sure that the call light is plugged in and functioning at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Steps 3 of the procedure revealed the following: If assistance is needed when you enter the room, summon help by using the call signal. The policy was not being followed. NJAC 8:39-31.8 (c)9 Complaint NJ 161569, NJ 169440 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident call bells were accessible. This deficient practice was identified for 3 of 18 residents (Residents #1, #78 and #288) reviewed for the call bells and was evidenced by the following: 1) During the tour of the facility on 02/20/24 at 10:04 AM, Surveyor #1 observed Resident #1 sitting in the bed. The resident responded to the surveyor's greetings then asked for a drink of water. The surveyor informed the resident that she was just a visitor and not staff and instructed the resident to activate the call light. The resident informed Surveyor #1 that [he/she] did not have a call light. The surveyor looked on the bed and on the floor and did not observe a call light. The surveyor left the room and observed a Certified Nursing Assistant (CNA) #1 in the hallway. The surveyor asked CNA #1 to activate the call light. The CNA was unable to locate the call light. The surveyor asked the CNA to send the nurse to the room. The Director of Nursing (DON) entered the room with another CNA. The surveyor asked the DON to activate the call light. The DON looked on the bed and on the floor and could not locate the call light. After searching the room, the call light was noted on the other bedside table blocked by the privacy curtain and out of the resident's reach when the resident was in bed. The DON retrieved the call light and placed it on the resident's blanket. Upon inquiry the DON stated, the call light should be accessible to all residents. Review of the care plan for Resident #1 dated 11/02/23, included a problem area of being at risk for falls due to poor safety awareness, behaviors and use of psychotropic medications. Two of the listed approaches included for staff to keep the call bell within reach and encourage the resident to use the call bell for assistance as needed. On 03/05/24 at 8:29 AM, Surveyor #1 entered the room and observed Resident #1 in bed. The breakfast tray was on the bedside table and emptied. Resident #1 asked the surveyor if [he/she] could have more food. The surveyor asked the resident to activate the call light. The resident stated, I do not have a call light. The surveyor left the room and observed the DON in the hallway. Surveyor #1 accompanied the DON to the room where we both observed that Resident #1's call light was not accessible. The call light was observed behind the night stand and out of the resident's reach. On 03/05/24 at 8:45 AM, the surveyor asked the DON who was responsible to ensure that the call light was accessible to the residents. The DON stated,everyone, the nurses and the CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #s NJ 152910, 152911, 159956 Based on observation, interview and document review, it was determined that the facility failed to ensure that all residents were treated with respect and dignity by ensuring the facility acted promptly to respond to ongoing residents grievances affecting quality of life by failing to consistently and uniformly address grievances regarding: a) ensuring residents had consistent access to their personal needs account funds (PNA), b) food complaints identified on 02/28/2022 when the resident council was alerted to the menu being changed to kosher style, and c) the menu not being posted, not having access to menus to select meal choices and the repetitiveness of the menu. This deficient practice was identified by 6 of 6 residents who attended a resident council meeting and affected all residents who resided on 2 of 2 units. The deficient practice was evidenced by the following: Refer to: 567F and 568F On 02/20/24 at 9:41 AM, during the initial tour of the kitchen with the Food Service Director (FSD), the surveyor asked if the kitchen was a kosher kitchen and the FSD stated it was kosher style. On 02/20/24 at 12:07 PM, during the tour of the facility, the surveyor observed a large bulletin board affixed to the wall and labeled, Daily Menu, with five empty slots. The board was in the central area of the 200 unit. The surveyor observed a Licensed Practical Nurse (LPN) and asked where the menu would be posted. The LPN stated the menu was not posted. On 02/20/24 at 1:30 PM, the surveyor received the 81-page facility admission Agreement provided by the Licensed Nursing Home Administrator (LNHA) as part of the entrance documents. A review of the document revealed 3. Services Provided: a. Services Included in the Daily Basic Rate. The facility agrees to provide the following basic services, all of which are included in the daily basic rate: (i) Board, including food and drink that is palatable, attractive, and at a safe and appetizing temperature, drinks consistent with Resident needs and preferences and in quantities sufficient to maintain Resident hydration, therapeutic or modified diets, as prescribed by a physician or other licensed health professional, and menus meeting the nutritional needs of Residents in accordance with established national guidelines, taking into account religious, cultural, and ethnic needs of the Resident groups, that accommodates Resident allergies, intolerance's, and preferences. Food shall be stored, prepared, distributed, and served in accordance with professional standards for food service safety. (The kosher style menu was not included as part of the admission Agreement) On 02/21/24 at 11:17 AM, the LNHA provided the surveyor with a copy of the current four-week menu cycle. Upon review, the surveyor observed that the breakfast meals listed only Vegetarian Sausage Links as a breakfast item three times per week, no pork products were listed on the menu and chicken was listed as a lunch entrée on 21 of 28 days and fish as a dinner entree 23 out of 28 days. On 02/23/24 at 6:36 AM, the surveyor again toured the kitchen, and the breakfast meal was in progress. The surveyor interviewed the [NAME] regarding what the kosher style menu was. The cook stated, we don't have pork, meat and dairy together and no meat for breakfast. The [NAME] stated the kosher style menu started about 1-1/2 years ago and it changed with the new owners that wanted that kind of menu. The cook stated, we used to have bacon and sausage all of the time and now we don't have it. The surveyor asked about the chicken that was observed in the walk-in refrigerator. The cook stated, there is quite a lot of chicken on the menu. On 02/23/24 at 6:43 AM, the FSD entered the kitchen, and at 6:48 AM, the surveyor asked the FSD if he created the menus and he stated that they came from a company. The surveyor asked the FSD to explain what a kosher style menu was. The FSD stated, it is kosher style, and he was not sure why it was changed. The surveyor asked the FSD if he met with the residents regarding the menu. The FSD stated he attended a Food Forum meeting at the resident council. The surveyor asked the FSD to provide any meeting minutes or documentation regarding what was discussed at the meeting. The FSD stated he had none to provide. The surveyor asked the FSD if he was provided with anything in writing, including meeting minutes that he had to respond to or change regarding resident menu concerns. He stated, I'm not handed anything regarding meeting minutes. On 02/23/24 at 11:14 AM, a surveyor conducted a resident council meeting with 6 residents. All 6 of 6 residents stated that they were made aware that the meals are from a kosher style kitchen, and they do not have any pork products. The resident's confirmed that they used to get pork products but only get vegetable sausage now. All six residents confirmed that they have asked for pork products before, and the facility told them it is a kosher style kitchen, and they only serve chicken and fish mostly. One resident stated they would only get chicken and they don't ask for pork products because they won't get them, and all 6 of 6 residents confirmed that menus have not been provided to review or make selections. The surveyor asked the residents about their PNA account and 6 of 6 residents stated they were not able to access their PNA when they want. All six residents confirmed they were only allowed to remove $ 25.00 at a time. Resident #10 stated they always say they have to go to the bank for it, and the money goes to fast. The resident also stated that you can't get it when you want it or need it, they say they have to get someone to go to the bank to get the cash, and the person responsible doesn't drive. Resident #25 stated, I can't get my money right away, I also have to wait like everyone else. Resident #18 stated, when I say I need money, they say we don't have it or some [NAME] [exploitive redacted] excuse that they can't. Main excuse they use is that they are too busy. Resident #30 stated, they still owe me $ 25.00; I've been to [Human Resources Director's] office seven times and she told me yesterday she would bring it to me and still haven't seen it. I will be going to her office today. Resident #17 stated, I never receive my money on time either and they only give $25 at a time. Resident #49 stated, when I first came here in [date redacted] I asked for money, and they told me no. I used to have it in [Facility Name Redacted] and they would give me $50.00 every month. When I went, they said I don't have an account. I have not received any money since I've been here. An unidentified resident stated, there was no receipt provided when getting any money and only $25.00 increments allowed at a time. The LNHA provided the surveyor with the following Resident Council Meeting Minutes which revealed: -02/28/22; 20 Residents in attendance. Dietary: New Business: [Staff name redacted] met with residents to explain the new kosher style menu and to give them copies of the week's rotation. Residents voiced their concerns with the new diet and many of the substitutes. [Resident name redacted] stated that most residents don't want kosher and that she is speaking for them not herself. The other residents present did not confirm this. [Staff name redacted] said she would ask about the possibilities of substitutes and get back to them. They came back and said she was told she may give milk at the evening meals but that she could not do anything about pork or bacon. The residents voiced having the option of switching lunch to meat and dinner to dairy. Administrator: Our new Administrator introduced himself and took questions mostly concerning the new menu. He left to inquire to the owners about their concerns. He came back shortly after to tell the council that they will make any allowances they require such as milk in the evenings and cheese for hamburgers. The Administrator confirmed that if the general consensus of the residents was to switch the menu, we most definitely can. We agreed to convene next meeting to go over any concerns. -There were no Resident Council minutes provided for a 3/2022 meeting, and no follow- up regarding reconvening with the Administrator to review concerns regarding the menu. - 04/25/22; 17 Residents in attendance. Dietary: Past Issues: Residents are happy with meat served at the midday meal (No response included regarding the concerns about the menu change to a kosher style menu). -05/31/22; 19 Residents in attendance. Past Issues: Residents would still like a menu posted somewhere. Response: [New Food Service Director] will post them on the wall to the right as everyone enters the dining room .Residents are reminded that if they would prefer they can order from the always menu: chicken, hot dogs, burgers and grilled cheese. (No response included regarding the concerns about the menu change to a kosher style menu, or posting the menu). -06/27/22;19 Residents in attendance. Dietary: New Business: Food Committee meeting to review the menu just prior to this meeting. Residents state they love the new spring/summer menu that just started on June 19th. (No Food committee meeting minutes attached, and no response included regarding the concerns about the menu change to a kosher style menu or posting the menu). -There were no Resident Council minutes provided for a 07/22 meeting, (No response included regarding the concerns about the menu change to a kosher style menu or posting the menu). -08/31/22; 20 Residents in attendance. Dietary: Past Issues: No past issues mentioned. (No response included regarding the concerns about the menu change to a kosher style menu or posting the menu.) New Business: Food committee meeting prior to this meeting. Resident stated too much chicken is on the menu and the Food Service Director agreed and will make changes. -09/19/22; 13 Residents in attendance. Past Issues: Residents are requesting a daily menu so they can choose what they would like to eat. (This is a repeat concern, there was no follow-up to the Food Service Director confirming there was too much chicken on the menu and no response included regarding the concerns about the menu change to a kosher style menu or posting the menu.) -10/24/22; 12 Residents in attendance. Dietary: Past Issues: Resolved (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: Dietary Director has left, will have Food Forum when a new director is hired .Residents are requesting daily menus (Repeat concern without resolution). Residents would like to be aware of other alternatives they may choose from. -11/22/22; 7 Residents in attendance. Dietary: Past Issues: Residents would like weekly menus delivered to them. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: New Dining Director was introduced. Residents asked about a breakfast meat and Dining Director told them they can do turkey bacon or sausage. Residents would like to be aware of other alternatives they may choose from (Repeat concern without resolution). -12/23/22; 6 Residents in attendance. Dietary: Past Issues: Residents requesting winter menu. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: New Dining Director was introduced. Residents asked about a breakfast meat and Dining Director told them they can do turkey bacon or sausage. Residents would like to be aware of other alternatives they may choose from. (Repeat concern without resolution). -01/30/23; 11 Residents in attendance. Dietary: [left blank] Past Issues: Winter menu still not finalized. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or the winter menu). -02/27/23; 9 Residents in attendance. Dietary: They are waiting too long for missing items. -03/28/23; 13 Residents in attendance. Concerns: Dietary: better. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu). Administration: There is a need for PNA (personal needs account) money to be available on weekends. -04/25/23; 10 Residents in attendance. Dietary: Resident would like sausage and bacon added to the menu for breakfast. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu). Administration: Not listed and there was no follow-up regarding the concern regarding PNA money not being available on the weekends. 05/23/23; 6 Residents in attendance. Activities: Resident requesting trip to a restaurant. Also want to make sure they receive money before going. Dietary: Coffee is sometimes not hot enough. Patient requesting for variety other than fish or chicken (no resolution-repeat complaint nine months prior). Residents are requesting turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu) 06/26/23; 8 Residents in attendance. Dietary: No Concerns: (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). Administration: No follow-up regarding the concern regarding PNA money not being available on the weekends. Residents were informed that we are in the process of switching to a new company with the goal of improving our service. 07/31/23; 6 Residents in attendance. Dietary: Notes of Resident preferences were recorded by Dietary Director. Residents liked the summer menu. (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -08/31/23; 10 residents in attendance. Dietary: Food is cold sometimes. Food forum was held, and resident's preferences will be honored. (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -09/31/23; 11 Residents listed in attendance. Dietary: Concerns: No concerns, Food forum was held and resident's preferences will be honored. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -10/31/23; 20 Residents listed in attendance. Dietary: Concerns: Food forum was held and resident preferences made, new food company has been contracted to improved food quality. Response: Residents are looking forward to new recipes and new culinary experiences. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken ( and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). -11/28/23; 16 Residents listed in attendance. Dietary: Resident chose the menu for the holidays, went over new items in the menu and requested their preferences. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. 12/26/23; 15 Residents listed in attendance. Dietary: No issues, food has improved, residents shared their preferences, and there are no complaints. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken [identified 16 months prior] on the menu, and not receiving a menu.) No follow-up regarding the concern regarding PNA money not being available on the weekends. 1/30/24; 14 Residents listed in attendance. Dietary: .occasionally food is not warm enough .(No follow up for cold coffee and food [repeat complaint] No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not receiving a menu.) No follow-up regarding the concern regarding PNA money not being available on the weekends. On 02/26/24 at 1:09 PM, interviewed the Food Service Director (FSD) regarding the facility menu development. The FSD stated he is not responsible with the menu development; a company provides the menu. I asked the FSD who signs off on the menu to ensure it meets the residents needs and is nutritionally adequate and he stated, I am not sure. I asked the FSD to elaborate on the kosher style menu, and he stated it started about two years ago, I am not sure, and I don't know why. The FSD stated, it wasn't always kosher. On 02/26/24 at 1:26 PM, the surveyor interviewed the LNHA about facility policies and procedures. The LNHA stated they are reviewed on an annual basis. The surveyor asked the administrator when the menu was changed to kosher style and he stated, I believe it was changed a few months ago, I don't know exactly when it was changed. The surveyor asked the LNHA regarding the company who was responsible for the menu development per the FSD. The LNHA stated he was not sure if the contract for the menu company was still in effect. On 02/29/24 at 9:51 AM, the surveyor interviewed, in the presence of the surveyor team, the Registered Dietitian [NAME] President (VPRD) Of Clinical Services for the Consultant Dietitian Company. The VPRD stated she was responsible for the clinical nutrition for the residents. The surveyor asked what her menu functions were and she stated we don't create the menu, and we don't do menu development, but we review it. She stated, I look to make sure there is a variety and to make sure there is different fruits and vegetables and entrees. Asked the VPRD to provide information regarding if chicken should be served 7 days per week. The surveyor asked if she attended resident council and she said the FSD will attend and and if there are concerns that are brought up in resident council we can make adjustments to the menu. The surveyor asked about the menu and she stated it was a kosher style menu. The surveyor asked about the kosher style menu and the VPRD stated it does not have meat served with dairy and they don't serve pork or shellfish. The surveyor asked if the residents were notified if the menu was changed to kosher style. The VPRD stated, I believe normally, they do notify the residents if they implement a kosher style menu. The surveyor asked if the menus should be posted for the residents and the VPRD stated, yes, for the residents. On 02/29/24 at 10:29 AM, the surveyor conducted an interview with Resident #18, who served in the role as the Resident Council President (RCP). The surveyor asked the RCP how the meals were, and the RCP stated the quality went down. The surveyor asked about receiving pork breakfast meats. The RCP stated, we don't get it anymore, we don't get any bacon. The RCP stated we get vegetable sausage and it [exploitive redacted]. The RCP stated that grits used to be on the menu also, and they no longer provide them. The surveyor asked the RCP if the facility provided anything in writing when the menu was changed to no longer include pork products, and the RCP stated, no. The surveyor asked the RCP if the council decided to not allow any residents to take out $25.00 at a time from their PNA. The RCP stated, no, we never decided on only $25.00, no, that was not our decision, not ever!. The RCP stated even when he/she was not the RCP, that he/she still attended the Resident Council and stated, we want all our money. Asked if all the money was available, no, we cannot get it, maybe $15.00 or $25.00 at a time. The surveyor asked if a receipt was provided when a transaction was made. The RCP stated, no, never, we barely get the money, and if you don't get the money and the Human Resources Director (HRD) goes home, you are [exploitive redacted] out of luck! The RCP stated, they don't have money on the weekends, they used to have money. The RCP stated, there is no money on the weekends, none, [NAME], [NAME] ever. The RCP stated that the HRD sometimes doesn't have money during the week either. The surveyor asked if the LNHA ever conducted a meeting with the residents regarding the changes to the menus. The RCP stated, he comes, stands there for like five minutes and leaves and stated, no we never had a meeting. The surveyor asked the RCP if a menu was provided to make selections and the RCP stated, we would have to ask for it, it is not distributed and it should be left at the nurses station. On 02/29/24 at 1:27 PM, the surveyor conducted a follow up interview with the VPRD. The VPRD stated there is no kosher policy and stated residents could request anything. The surveyor asked is that including pork and bacon, and she stated she cannot speak to that. The VPRD did not provide any information regarding why there is chicken often 7 days per week on the menu. On 02/29/24 at 1:41 PM, the surveyor interviewed the LNHA and DON, in the presence of the survey team. The surveyor asked if bacon was provided to the residents, and the LNHA stated only if a resident asks they can provide bacon. The surveyor asked about the admission agreement, not specifying a kosher style menu. The LNHA stated, a resident can ask and there are no, non-kosher items on the menu. The surveyor asked, are there any pork products in the kitchen and the LNHA stated, no. On 03/01/24 10:00 AM, the LNHA, in the presence of the survey team, provided the surveyor with the Resident Council minutes from 05/31/22 and stated that in the minutes it was documented that if the general consensus was to switch the menu, we most definitely can. The LNHA also provided five random food receipts for unidentified bacon and stated that the bacon was for people who requested it. The LNHA did not provide any documented evidence that the concerns were addressed with the resident council. On 03/01/24 10:52 AM, the surveyor observed an Always Available Menu posted on a bulleting board on the 200's unit. The Menu Please notify our dietary food service department if you prefer and of the alternate options below. Included for Breakfast- French Toast, Scrambled Eggs, Hard Boiled Egg, Assorted Cold Cereal, Hot Cereal of the Day; Bacon, sausage, or any alternate breakfast meats were not listed, and were not listed for Lunch or Dinner. On 03/01/24 at 10:56 AM, the surveyor interviewed the Social Worker (SW) regarding the grievance process. The SW stated if she received the grievance, she would fill out a grievance form and then provide it to the department head and notify the staff. The surveyor asked about grievances at resident council. The SW stated she would sit in on Food Forum, it would be when the residents in attendance would discuss their food preferences, and the Activity Director handled that process. On 03/01/24 at 11:30 AM, the surveyor interviewed the AD about the Food Forum. The AD stated that would be held right before resident council and conducted by the FSD. The surveyor asked if she would receive a copy of the minutes from the Food Forum. The AD stated, no it was a note thing and the FSD would review the always available menu. The surveyor asked the AD if the residents brought up that they wanted pork breakfast meats. The AD stated the FSD told the residents they could have turkey sausage. The surveyor asked the AD if the FSD had ever informed the residents that they could select pork bacon and the AD stated, no the FSD would tell the residents that they could request turkey bacon. The AD confirmed that there were no documented minutes for the Food Forum. On 03/05/24 at 11:10 AM, the surveyor interviewed the LNHA in the presence of the survey team. The surveyor asked if the LNHA documented responses regarding resident grievances. The LNHA stated he did not document responses to resident grievances and that would be the social worker's responsibility. On 03/05/24 at 1:35 PM, the survey team conducted a pre-exit conference with the Director of Nursing (DON) and LNHA. The surveyor reviewed the above concerns. On 03/06/24 at 11:55 AM, the LNHA, provided the surveyor with a Resident Council Concern Form dated 10/24/23. Concern was crossed out and listed was proposing plant-based sausage, cheese blend souffle, residents expressed personal preferences, introducing turkey pastrami, kielbasa, turkey burgers and soup will be added, brisket, tortellini Alfredo. Another form was dated 02/01/23 and was for a specific resident for coffee all meals and another resident would like bacon (type not indicated), Resolution: Resident would receive coffee all meals and other resident would start receiving (unidentified) bacon for breakfast. The LNHA did not provide any information regarding responding to the documented resident council concerns. There LNHA provided eight pages of a handwritten documents titled Daily PNA Disbursements with handwritten resident names and 16 highlighted names/dates that the LHNA stated were weekends. The highlighted amounts revealed, $1.00- $25.00 amounts and 1 of 16 named had a documented $50.00 amount. No additional information was provided. Review of the Resident Rights policy Revised February 2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: u. voice grievances to the facility . v. have the facility respond to his or her grievances . NJAC 8:39-4.1(a)(8)(9)(10)(33)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review it was determined that the facility failed to ensure that a system was in place for residents to receive their Personal Need Account (PNA) funds without restrictions, ensure that the residents had access to at least $50.00 which would be provided the same day it was requested, and ensure a system was in place which included receipts provided to residents to confirm disbursement. The deficient practice effected all residents who maintained PNA funds who resided in the facility. The deficient practice was evidenced by the following: Refer to 565F On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance more than $50.00 who were listed as Expired [deceased ] under Status. On [DATE] at 1:22 PM, the surveyor interviewed the HRD who confirmed that she handled the PNA money for the resident's accounts during the week. She clarified and stated, during the week, the residents will come find her and on the weekends the residents would obtain money from the activity staff. She stated that if the resident's requested large amounts that the resident's would give her notice. The surveyor asked why there were expired residents with PNA balances which included Resident #237 who expired [DATE] and had a balance of $724.11 and Resident # 236 who expired on [DATE] and had a balance of $153.23. The HRD stated she did not know about the people who were expired, and she did not close the account. The HRD stated a remote business office handled the accounts and they were in [another state]. The surveyor asked the HRD if statements were provided to the residents for their PNA accounts. The HRS stated that she printed and mailed out statements. The surveyor asked if she had a type of form, or document that she sent to the residents. She stated no, and could not provide proof that statements were sent to the residents and she did not document when statements were mailed out. The surveyor asked the HRD if she opened PNA accounts and she stated, she did not open, or close accounts and she would reach out to the remote business office about the closed accounts. On [DATE] at 11:14 AM, a resident council meeting was held with 6 residents (Resident #10, #17, #18, #25, #30, #49) who all confirmed that they are not able to access their PNA money when they want it. The surveyor asked the residents about their PNA account and 6 of 6 residents stated they were not able to access their PNA when they want. All six residents confirmed they were only allowed to remove $ 25.00 at a time. A resident stated, they only allow you to pull out $ 25.00 at a time and they always say they have to go to the bank for it, and the money goes to fast, the resident also stated that you can't get it when you want it or need it, they say they have to get someone to go to the bank to get the cash, and the person responsible doesn't drive. Another resident stated, I can't get my money right away, I also have to wait like everyone else. Another resident stated, when I say I need money, they say we don't have it or some [NAME] [exploitive redacted] excuse that they can't. Main excuse they use is that they are too busy. Another resident stated, they still owe me $ 25.00; I've been to [Human Resources Director's] office seven times and she told me yesterday she would bring it to me and still haven't seen it. I will be going to her office today. Another resident stated, I never receive my money on time either and they only give $25 at a time. The resident continued and stated, when I first came here in [date redacted] I asked for money, and they told me no. I used to have it in [Facility Name Redacted] and they would give me $50.00 every month. When I went, they said I don't have an account. I have not received any money since I've been here. Another resident stated, there was no receipt provided when getting any money and again confirmed only $25.00 increments were allowed at a time. A review of Resident Council minutes provided by the Licensed Nursing Home Administrator revealed on [DATE]; 13 Residents were in attendance, and the concerns included, There is a need for PNA money to be available on weekends. The Resident Council minutes were reviewed through [DATE] and there was no documented resolution to the residents' concern with PNA availability on the weekends. On [DATE] at 10:29 AM, the surveyor conducted an interview with the Resident Council President (RCP). The surveyor asked the RCP if the council decided as a group to not permit any of the residents to take out more than $25.00 at a time from their PNA account. The RCP stated, no, we never decided on only $25.00, no, that was not our decision, not ever!. The RCP stated even when he/she was not the RCP, that he/she still attended the Resident Council and stated, we want all our money. The surveyor then asked if all the money was available upon request, no, we cannot get it, maybe $15.00 or $25.00 at a time. The surveyor asked if a receipt was provided when a transaction was made. The RCP stated, no, never, we barely get the money, and if you don't get the money and the Human Resources Director (HRD) goes home, you are [exploitive redacted] out of luck! The RCP stated, they don't have money on the weekends, they used to have money. The RCP stated, there is no money on the weekends, none, [NAME], [NAME] ever. The RCP stated that the HRD sometimes doesn't have money during the week either. On [DATE] at 1:17 PM, the surveyor conducted a follow-up interview with the HRD. The surveyor asked exactly how the process of the PNA funds was managed on the weekends, how much money was maintained and was there a log system to log the disbursements and provide receipts. The HRD stated it was the same process as during the week and the activity staff had cash on hand and they used a sheet to keep track. The HRD stated the amount varied. The surveyor asked the HRD if residents ever told her that there was no money available on the weekends and the HRD stated the residents are told to ask the activity staff on the weekends for PNA money. The surveyor reiterated and asked if there was a policy for the PNA and how much money is kept on site to ensure there is weekend availability. The HRD stated a lot of the residents would come to her on Friday and stated, we don't have a policy. She did not elaborate on any amount available for the residents, and stated residents are told they can ask activity staff. The surveyor asked how the resident would ask for money and the HRD stated, there is a very specific and actual process. The surveyor asked if there were regulations regarding handling the residents PNA and the HRD stated I wouldn't say I have a regulation. The surveyor asked the HRD how long she was responsible for the PNA and she stated she doesn't know when she took it over. The surveyor asked what the purpose of the PNA was and the HRD stated, at any given point in time, to make sure there is enough money. The HRD stated that when the old activity director was there, the resident council decided on $25.00 as being the amount that any resident was allowed to withdraw on the weekends so there would be enough money at the facility to be distributed to all of the residents. She further stated, to her recollection it was discussed at resident council and the surveyor asked if something was provided in writing to the residents regarding the PNA rules and the HRD stated stated that everything regarding the PNA process was relayed to the residents verbally. The HRD stated if resident requested a log sheet was used and she showed the surveyor a couple of documents. The surveyor requested the log sheets for the past six including the weekends. The HRD stated it was a running list and she would have to look through all of the sheets. On [DATE] at 1:29 PM, the surveyor reviewed the list of the PNA balances in the presence of the HRD. The surveyor reviewed the PNA balances and asked the HRD if the Resident #10, who was listed with a PNA balance, could retrieve money from their PNA account on the weekends. The HRD stated it was not very frequent that residents ask for money on the weekends, and stated Resident #10 would come during the week and ask for money. The HRD showed the surveyor log sheets and stated they generally give me this back [log sheets]. The HRD stated that the residents decided what a reasonable request of what they can take out from their PNA accounts would be, to make sure there was enough money for all. The surveyor specifically asked for the weekend PNA logs and the HRD stated, I don't know if I have six months of logs, but that is the thing, we are not processing withdrawals on the weekend. On [DATE] at 10:51 AM, the surveyor interviewed the Activity Director (AD). The AD stated she has been there for 6 months. The surveyor asked if the activity staff provided PNA funds on the weekends. The AD stated the HRD usually gives it on Friday, and her staff would provide it on the weekends. The AD stated in the past there was a restriction that residents could only take out $15.00 at a time from their PNA. On [DATE] at 11:10 AM, the surveyor interviewed an Activity Staff (AS #1) regarding the PNA. The AS #1 stated she hands out PNA funds on the weekends. AS #1 stated that the HRD provided $40.00- $50.00 total for weekend distribution, but the HRD stated that she would distribute the money on Friday for the residents who wanted money for the weekend. The AS #1 stated that the HRD instructed her the she can give out $20.00 maximum and usually we have them sign a PNA sheet, and it would be with the HRD. The PNA sheet would have the amount that was given. The surveyor asked if there was a book or receipt that was provided to the residents when they withdrew money. The AS #1 stated, no, we don't have a booklet or a receipt book, no we don't have that. The surveyor asked if residents ever said that they needed more money on the weekends and she stated, once in a blue moon. When asked if she ever ran out of money to provide to the residents, she stated, usually we don't, and the surveyor asked if she was provided with a policy or something in writing regarding the PNA process. The AS #1 stated nothing in writing was provided to her. On [DATE] at 12:35 PM, in the presence of the survey team, the HRD provided the surveyor with three Daily PNA Disbursement sheets with highlighted dates that were identified as weekends. The surveyor informed the HRD that staff stated they were instructed to disperse $20.00 on the weekends to the residents. The HRD stated that sometimes it would be more than that. The HRD stated there is no set amount of money to leave with the staff for the weekends. I don't have any proof of the amount of money that is available at any given moment. I hand the staff a bag with money in it, but it is not a set amount. The HRD stated there was no policy in writing regarding how the PNA was handle on the weekends. The surveyor asked about the expired residents who had PNA money. The HRD stated the remote business office informed her that they must contact a family member or Medicaid, otherwise it can be distributed to the next of kin. The surveyor asked the HRD to provide additional information on the resident who were expired, some over one year, and still had PNA funds held by the facility. The Daily PNA Disbursements handwritten sheets that were provided from the HRD were dated [DATE] through [DATE], and six months were not provided as requested. The sheets revealed: [DATE] one resident name with an amount of $25.00 was listed, and the Resident Signature section was left blank; [DATE] three residents names were listed, with $25.00, $15.00 and $10.00 as amount listed and no individual signatures next to each name was documented. There was one disbursement on [DATE] for $10, with a scribble under name and no resident signature. On [DATE] and [DATE] there was one resident with $15 and another with $25.00 with a signature/initials next to the amount, and one disbursement on [DATE] for $15.00 with a notation in the signature column. There was no disbursement greater than $25.00 on the highlighted weekends, and the remaining amounts ranged mostly from $2.00 to $25.00. On [DATE] at 2:01 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing, in the presence of the team, of the findings related to the PNA, including the resident council concerns. The surveyor asked the LNHA how resident's get their money. The LNHA stated they go to the HRD. The surveyor asked the LNHA how much money the residents can request and the LNHA stated, whatever they need, we try to give them, and $50.00 is what they get. The surveyor asked for a policy and the LNHA stated, I don't have a policy. The surveyor asked the LNHA if he was aware of a limit of money that the residents could withdraw, and he stated, I've never heard of it. The surveyor asked if the resident should receive quarterly PNA statements, and he stated they should be provided with quarterly statements. On [DATE] at 11:48 AM, the survey team conducted an exit conference with the LNHA, Director of Nursing, and [NAME] President of Operations (VPO) and Nursing (VPON) from a management company. The LNHA provided eight Daily PNA Disbursements handwritten sheets which now included sheets from [DATE] through [DATE] and stated that the areas highlighted proved that money was available and the VPO added the regulation did not state that they needed to cover all the residents money in the facility. No further information was provided regarding a documented process or policy for PNA disbursements, what is done when resident's expire and PNA money is left, or in response to the resident's documented concerns. Review of the Resident Rights policy Revised February 2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: r. manage his or her personal funds (if he wishes). NJAC 8:39-4.1(a)(9)(10)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to have a system in place to ensure all residents who had the facility manage Personal Needs Account (PNA) funds were provided with a quarterly statement. The deficient practice effected all resident who had PNA funds and was evidenced by the following: Refer to 565F and 567F. On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance more than $50.00 who were listed as Expired [deceased ] under Status. On [DATE] at 1:22 PM, the surveyor interviewed the HRD who confirmed that she handled the PNA money for the resident's accounts during the week. She clarified and stated, during the week, the residents will come find her and on the weekends the residents would obtain money from the activity staff. She stated that if the resident's requested large amounts that the resident's would give her notice. The surveyor asked why there were expired residents with PNA balances which included Resident #237 who expired [DATE] and had a balance of $724.11 and Resident # 236 who expired on [DATE] and had a balance of $153.23. The HRD stated she did not know about the people who were expired, and she did not close the account. The HRD stated a remote business office handled the accounts and they were in [another state]. The surveyor asked the HRD if statements were provided to the residents for their PNA accounts. The HRS stated that she printed and mailed out statements. The surveyor asked if she had a type of form, or document that she sent to the residents. She stated no, and could not provide proof that statements were sent to the residents and she did not document when statements were mailed out. The surveyor asked the HRD if she opened PNA accounts and she stated, she did not open, or close accounts and she would reach out to the remote business office about the closed accounts. On [DATE] at 2:01 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing, in the presence of the team, of the findings related to the PNA, including the resident council concerns. The surveyor asked the LNHA about the PNA process which included if there was a policy and the LNHA stated, I don't have a policy. The surveyor asked if the resident should receive quarterly PNA statements, and he stated they should be provided with quarterly statements. On [DATE] at 11:48 AM, the survey team conducted an exit conference with the LNHA, Director of Nursing, and [NAME] President of Operations (VPO) and Nursing (VPON) from a management company. No further information was provided regarding PNA statements. Review of the Resident Rights policy Revised February 2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: r. manage his or her personal funds (if he wishes). NJAC 8:39-4.1(a)(9)(10)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review it was determined that the facility failed to have a process in place to ensure that within 30 days of a resident's death the facility conveyed, the resident's funds, and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate. This deficient practice occurred for 6 of 6 expired residents identified with a current Personal Needs Account balance (Resident #236, #237, #238 and 3 unsampled residents) and was evidenced by the following: On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance who were listed as Expired [deceased ] under Status. The Expired residents included: 1. Unsampled Resident (UR #1); Expired [DATE] with a Current Balance $100.15. 2. UR #2; Expired [DATE] with a Current Balance $50.07 3. UR #3; Expired [DATE] with a Current Balance $50.07 4. Resident #236; Expired [DATE] with a Current Balance $153.23 5. Resident #237; Expired [DATE] with a Current Balance $724.11 6. Resident #238; Expired [DATE] with a Current Balance $100.16 On [DATE] at 1:22 PM, the surveyor interviewed the HRD regarding the PNA funds and she confirmed that she handled the PNA money for the resident's accounts. The surveyor asked why there were expired residents with PNA balances which included Resident #237 who expired [DATE] and had a balance of $724.11 and Resident # 236 who expired on [DATE] and had a balance of $153.23. The HRD stated she did not know about the people who were expired, and she did not close the accounts. The HRD stated a remote business office (RBO) handled the accounts and they were located in [another state]. The surveyor asked the HRD if she opened PNA accounts and she stated, she did not open, or close accounts and she would reach out to the RBO about the closed accounts. On [DATE] at 8:46 AM, the LNHA provided the surveyor with a copy of an email that the LNHA stated was from the HRD regarding the surveyor questions. The email dated [DATE] revealed I am writing to respond to your request for specific information regarding how interest is calculated for your resident accounts. When an individual account is closed mid-period, the interest accrued through that date is calculated and posted on the same day the account is closed. On [DATE] at 8:56 AM, the surveyor interviewed the HRD in the presence of the survey team, regarding the copy of the email that was provided and the surveyor had not received any information about how the expired resident's PNA was managed. The HRD stated that she contacted the RBO and asked about the PNA for the expired residents. The HRD stated she was told that paperwork from family was needed and that was what she was told. The HRD stated, I didn't push them for specific information and was unable to confirm if the RBO was handling the process or if she was responsible for any part of it. On [DATE] at 12:38 PM, the surveyor conducted a follow up interview with the HRD regarding expired resident PNA accounts. The HRD stated that the RBO had to contact the next of kin to be able to disperse the money. The surveyor asked what happened and what was done and requested a policy for management of PNA. On [DATE] at 2:01 PM, the survey team conducted a pre-exit interview with the LHNA and Director of Nursing (DON). The surveyor discussed the above findings with the LNHA and when asked about a PNA policy he stated, I don't have a policy. On [DATE] at 1:57 PM, the survey team conducted the exit convergence with the LHNA, DON, [NAME] President of Operations and Nursing from a management company. No information regarding the expired resident PNA accounts was provided. NJAC 8:39-4.1(7)(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 169440 Based on observation and interview it was determined that the facility failed to have a system in place to ensure all resident rooms and common areas were maintained in a clean, sanitary and homelike manner, and resident equipment was maintained in good condition. The deficient practice was observed throughout the 200 unit and was observed by the following: On 02/20/24 at 10:26 AM through 11:15 AM, surveyor #1 observed the following on the 200 Unit: -room [ROOM NUMBER], Resident in bed, a gray chair next to the bed was visibly stained on the seat cushion, the bed and bed frame appeared rusted, the bedside table had chips, and the privacy curtain was visibly soiled. -room [ROOM NUMBER] A, There was no handle on the middle drawer of the door side bedside table. Bed frame appeared rusty, and a male Certified Nurse Aide (CNA) entered room with a burgundy recliner chair that had a ripped arm rest and was for resident use. -room [ROOM NUMBER], The resident was in bed and the bedside curtain and wall by the bed was visibly soiled and stained. -room [ROOM NUMBER], The wall by the air conditioner was cracked, the A-bed nightstand was chipped, and ceiling over the bed was stained with brown splatter. -room [ROOM NUMBER], The wall area above the air conditioner was cracked, rusted in appearance bedside table base (door bed), the privacy curtain was visibly soiled, the dresser and walls were also visibly chipped. -room [ROOM NUMBER], Both privacy curtains were stained and an Unsampled resident was in B bed. The resident stated the privacy curtains were not cleaned and also observed dust above the bed headboard. -room [ROOM NUMBER], An Unsampled resident was in a low bed which was visibly chipped on the wood frame. There were splatters on the wall and on the privacy curtain, and there was a hole in the wall behind the bed. -room [ROOM NUMBER], Resident #42 on top of the bed and there was a ripped/broken area on the wall by the television. On 02/21/24 at 11:25 AM, two surveyors (Surveyor #1 and #2) conducted a tour with the Licensed Nursing Home Administrator (LNHA) and observed the following: -room [ROOM NUMBER], The ceiling tile was stained and appeared to be buckling. The surveyors asked the LNHA if he had completed environmental rounds in the building. The LNHA stated he made rounds daily and would look at the fire extinguishers and look if call lights were going off. The surveyors asked the LNHA if the rounds were documented and he responded, no. -room [ROOM NUMBER], Both privacy curtains were visibly stained, and the LNHA acknowledged needs to be cleaned. The wood bed board was visibly chipped and rough. The surveyor pointed to the chipped/ rough areas on the furniture, and the stained curtains and asked the LNHA if that was okay, and the LNHA stated it's not okay. -room [ROOM NUMBER], The wall had an exposed screw under the television, and the wall closest to the resident had visible splatter on it. -room [ROOM NUMBER], The gray chair in the room remained stained, the curtains remained soiled, and the furniture was in the same condition as observed on 02/20/24. -room [ROOM NUMBER], The walls were chipped in several areas, the furniture had chipped areas and the privacy curtains were soiled. -room [ROOM NUMBER], As observed on 02/20/24, the bed frame remained visibly rusted and there was a now a ripped sheet on the bed. This was pointed out to the LNHA who stated, moving forward we will fix broken furniture. -room [ROOM NUMBER], The wall area on both sides of the room were visibly scuffed. -room [ROOM NUMBER], The resident was in bed. There was an edge hanging off the bedside table, the air conditioner remained cracked above the unit and the curtain remained soiled as observed on 02/20/24. -room [ROOM NUMBER], The dresser was worn, walls remained scratched, dust remained above the furniture and the privacy curtains remained stained in the same manner that was observed on 02/20/24. -room [ROOM NUMBER], The resident was in bed, the ceiling had splatter type stains above the resident along with the curtain. The nightstand dresser edge was hanging off and in the direction toward the resident. -room [ROOM NUMBER], The bedside table was visibly rusted in appearance, the privacy curtains were soiled, there was a hole in the wall above the dresser, the door frame was rusted. -room [ROOM NUMBER], The bed frame had a loose piece on the frame and a visibly soiled privacy curtain. -room [ROOM NUMBER], There was a large loose piece from the bed frame, the foot board and dresser handle were missing. On 02/20/24 from 11:05 AM through 11:15 AM, surveyor #4 observed the following on the 200 Unit: - room [ROOM NUMBER], Missing paint and scrapes on the wall by the door bed, and a black stain on the privacy curtain between the two beds. -room [ROOM NUMBER], A blind missing form one pane (2 window pane), no privacy curtain for door and window bed. On 02/21/24 at 11:57 AM, the surveyor asked the LNHA what the expectations were for the privacy curtains and rooms. The LNHA stated, It should have a curtain in every room and be clean, the expectation was it should be perfect. On 02/21/24 at 12:13 PM, the surveyor asked about the observed conditions and asked the LNHA were there any pending environmental projects. The LNHA stated, the new company took over in May [2023]. The LNHA stated it was a work in progress, and we do our best and did not provide any specific information regarding the observed conditions or pending projects. On 02/22/24 at 12:37 PM the LNHA informed the surveyor that 4-5 rooms had been painted on the 200 Unit. The surveyor asked the LNHA if there was any reason the rooms were not painted prior to the tour conducted with two surveyors the previous day. The LNHA stated, no real reason we were focusing on the 100 unit. On 02/26/24 at 8:37 AM, Surveyor #1 toured the 200-unit day room/dining room and observed three residents were eating breakfast at that time. There was a film over the window to the outside which was ripped and partially obstructed the view. The floor was very soiled in the area where the wall met the floor and had various debris and crumbs. There were marks throughout on the walls and there was a hole in a closet type door behind a resident table. The surveyor interviewed an activity staff (AS) member who was in the room and asked if the area looked clean. The AS stated no, that is housekeeping. On 02/26/24 at 8:42 AM, the ceiling in the hallway outside of the same day room/dining room was visibly stained with multiple splatters. On 02/26/24 at 10:50 AM, Surveyor #1, interviewed the LNHA regarding the continued observations. The LNHA stated, he's getting to it [maintenance] and no further explanation was provided. On 02/27/24 at 8:14 AM, two wheelchairs outside the area between room [ROOM NUMBER] and 211 One was blue and had a black seat cushion, which was heavily soiled and stained, along with the black cushion leg support. The second was black leather like chair with a ripped back and seat, and was visibly soiled. Both were labeled with resident's names. On 02/27/24 at 8:23 AM, the mechanical lift in the hallway was visibly soiled, rusted and the padding was ripped. On 03/05/24 at 1:35 the survey team conducted a meeting with the LNHA and the Director of Nursing and presented the above concerns. On 03/06/24 at 11:48 AM, the LNHA, Director of Nursing, [NAME] President of Operations and Nursing from a Management company did not offer any additional information and the LNHA stated, we share the same goal and strive to do our best and we have to work better on it. Next survey we will do better. NJAC 8:39-4.1(a)11; 31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) On 03/05/24, Surveyor #2 reviewed the admission Record for Resident #233 which had diagnoses which included but were not limited to; unspecified dementia, and hemiplegia and hemiparesis affecting left non-dominant side. A review of the Order Summary Report failed to include an order for showers or bathing. A review of the quarterly MDS dated [DATE], included but was not limited to; the resident required substantial/maximal assistance for shower/bathe. A review of the CNA tasks documentation dated Feb-24, included but was not limited to; ADL-Bathing= assist of one person indication that on 2/6, 2/8, 2/9, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15, 216, 2/25, 2/26, and 2/27/24, the staff documented 8,8. The code description for 8,8 indicated that bathing either self-performance or support provided did not occur. The resident had been out of the facility 2/18-2/22/24. This indicated that 12 of the 19 days Resident #233 was in the facility, [he/she] was not provided with bathing/shower. The facility provided three shower review sheets dated 2/8, 2/12, and 2/15, which indicated the resident had a bed bath. This resulted in Resident #233 not being provided a bath or shower for 9 of the 19 days [he/she] was in the facility in February 2024. A review of the facility provided, Certified Nursing Assistant Job Description undated, included but was not limited to; Purpose: to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. Personal Nursing Care Functions: Assist residents with daily dental and mouth care. Assist residents with bath functions (bed bath, tub, or shower). Keep residents dry. Assist residents with bowel and bladder functions. Keep incontinent residents clean and dry. Check each resident routinely to ensure personal care needs are being met. A review of the facility's policy titled, Activities of Daily Living (ADL), Supporting last revised 03/2018 provided by the facility on 02/26/24 timed 02:00 PM, indicated the following: Policy statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) Residents who are unable to carry out activities of daily living independently, will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Under policy interpretation and implementation #6 it is stated, Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. On 03/05/24 at 1:30 PM, the above concerns were discussed with the administrative staff and were asked to provide any additional information on the exit day. On 03/06/24 at 8:38 AM, Surveyor #1 interviewed the Assistant Director/Nurse Educator, (ADON) responsible for orientation and in-services at the facility. The ADON stated that she was not aware that the CNAs were still using double incontinent briefs on the residents. The ADON stated that 2 months ago the issue was brought to their attention and the staff was in-serviced. Some staff were suspended. When inquired if any follow up was done to verify compliance she stated, No. The policy was not being followed. NJAC 8:39-4.1 (12) NJAC 8:39-27.2(g) (h) NJAC 8:39-4.1 (12) NJAC 8:39-27.2(g) (h) Complaints NJ #s: 159956, 161569, 165971, 169440 Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure that Activities of Daily Living Care (ADLs) was consistently provided to residents by failing to a.) provide appropriate incontinent care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38 #50, #51 #53 #55); and b.) provide residents with scheduled showers (Resident #233 and #80). This deficient practice occurred for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, and 1 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 02/23/24 at 11:14 AM, a resident council meeting was held with 6 residents which revealed that 1 of 6 stated they leave me wet for hours sometimes, and double diaper me, which I don't ask them to. On 02/20/24 at 9:16 AM, upon entrance to the facility, the survey team observed a strong odor of urine that permeated into the facility's lobby. a) On 02/23/24 at 6:15 AM, Resident #51 was observed in bed was saturated with urine and was observed wearing double briefs. Two CNAs assisted in the presence of the Licensed Practical Nurse (LPN) and confirmed that some of the residents wore double incontinent briefs. When inquired if all the residents consented to have two briefs on, the CNA stated that the residents that could not consent to the extra pad inside the incontinent brief, the staff would just put them on. The CNA stated that residents who were labeled as heavy wetters, the facility provided the extra pad to be used. A review of the admission Summary revealed that Resident #51 was admitted to the facility with diagnoses which included but were not limited to, Anemia, Unspecified Dementia, and anxiety. The Annual Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care reflected that Resident #51 was severely cognitively impaired. Resident #51 scored 06 out of 15 on the Brief Interview for Mental Status (BIMS). Section GG of the MDS which addressed personal hygiene reflected that Resident #51 required maximum assistance from staff with ADLs. The Comprehensive Care Plan initiated 11/02/23 had a focus for limited physical mobility related to weakness, decline in performing ADLs, decrease in balance and coordination. The resident's care plan did not have a focus for ADLs self-care performance deficit, or any care plan related to wearing two incontinence briefs. b) On 02/23/24 at 6:22 AM, Surveyor #2 was on the 200-unit high hall. CNA #2 was present and stated that the rooms in that area were on her assignment and that the incontinent care had been completed. On 02/23/24 at 6:31 AM, the LPN stated the staff would use two incontinent briefs for residents during the night. She stated the resident would either request two or if they can not request them, the staff would use two anyway. On 02/23/24 at 6:39 AM, Surveyor #2 was standing outside of Resident #32's room door and there was a strong urine odor. CNA #2 was in the hall and confirmed the odor was present. CNA #2 and Surveyor #2 entered the room and pulled the privacy curtain. CNA #2 began to perform incontinent care. At that time, it was observed that the resident had on two incontinent briefs saturated with urine. On 02/23/24 at 8:23 AM, Surveyor #2 interviewed Resident #32 about wearing double incontinent briefs. Resident #32 stated that the staff never asked [him/her] about using two incontinent briefs and that he/she never asked to use two incontinent briefs. A review of the admission Record revealed Resident #32 had diagnoses which included but were not limited to; legal blindness, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, and lack of coordination. A review of the quarterly MDS dated [DATE], included a BIMS of 09/15 which indicated moderately impaired cognition. The MDS indicated the resident required substantial/maximal assistance for toileting hygiene. The resident-centered comprehensive on-going care plan included but was not limited to; a focus area of functional ability performance deficit with ADL tasks. c) On 02/23/24 at 6:30 AM, the surveyor observed Resident #23 in bed. When asked the CNA to check the resident, the CNA replied, I just provided incontinence care to the resident. The CNA and surveyor then observed the resident was wearing two incontinent briefs, and both briefs were soiled with feces and urine. The CNA declined to comment on the last time the resident was cared for. On 02/23/24 at 7:00 AM, the surveyor interviewed another CNA who worked the 11:00 PM-7:00 AM shift regarding the term, heavy wetters. The CNA stated that all the residents who were heavy wetters wore two briefs, and the facility provided the incontinent briefs that were applied inside the first incontinent brief. When inquired about who instructed them on applying the double incontinent briefs on the residents, the CNA stated that the resident was care planned to have the double briefs on and declined to comment further. Review of medical record revealed: The admission Summary revealed Resident #23 was admitted to the facility with diagnoses which included but were not limited to; Unspecified Dementia, without behavioral disturbance, irritable bowel syndrome without diarrhea, history of falling. The Quarterly Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care, reflected that Resident #23 had severe cognitive impairment (BIMS 00) and required extensive assistance from staff with Activities of Daily Living (ADLs). The Care Plan (CP) initiated on 12/12/23, revealed that the Resident had a focus for bowel incontinence. Intervention included but was not limited to provide pericare after each incontinent episode. Wearing double incontinent briefs was not listed as a documented intervention on the CP as stated by the CNA. The form Task Schedule (TS) for February 2024 under Personal Hygiene, showed no documentation to indicate that Resident #23 was provided with Personal Hygiene care for 15 days out of the 29 days. The facility could not provide documentation for the discrepancy. On 02/26/24 at 11:30 AM the Task schedule reflected that Resident #23 received incontinence care at 10:38 PM on 02/23/24. d) On 02/23/24 at 6:40 AM, the CNA checked Resident #50 for incontinence care. The surveyor observed that Resident #50 was wearing two incontinence briefs which were both saturated with urine. The CNA stated, the resident was a heavy wetter, and all heavy wetters wore two briefs. It is on the care plan. Review of the medical record revealed: The admission Face Sheet (an admission summary), Resident #50 was admitted to the facility with diagnoses which included but were not limited to: Unspecified dementia and schizophrenia. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 12/08/23 reflected that Resident #50 had severe cognitive impairment (BIMS 00) and was dependent on staff with Activities of Daily Living (ADLs). The Care Plan (CP) initiated on 11/02/23, revealed the Resident had a focus for Functional Ability Performance Deficit related to ADL tasks. Interventions included but were not limited to: Encourage the resident to participate to the fullest extent possible with each interaction. There was nothing documented regarding placing two incontinent briefs on the resident per the CNA. e) On 02/23/24 at 6:49 AM, the surveyor observed Resident #55 wearing two incontinent briefs which were both saturated with urine. The CNA stated that the resident was a heavy wetter and wore double brief. The CNA further added that the facility provided the second brief which the facility referred to as liners. Review of the medical record revealed: Resident #55 had diagnoses which included but were not limited to: Schizophrenia and localized osteoporosis. The Annual Minimum Data Set (MDS) dated [DATE] reflected that Resident #55 was severely cognitively impaired (BIMS 00) and was totally dependent on staff for ADLs. The Comprehensive Care Plan reflected a Focus for communication problem related to cognition and Alzheimer's disease. The goal was for the staff to anticipate all needs. The care plan did not address how the resident personal care will be met. The Task form provided by the Assistant Director of the Nursing (ADON) where the CNA documented the time incontinence care was provided, was left blank for 15 days during the February month. On 02/23/24, the day of the tour, incontinence care was documented as provided, at 2:16 AM, then 2:37 PM (12 hours later), and 9:24 PM (9 hours later). On 02/23/24 at 11:15 AM, during an interview with the Unit Manager she stated that the CNA would provide incontinence care to dependent residents at the beginning of the shift and prior to exit the shift. f) On 02/23/24 at 7:54 AM, during a random care tour with the CNA, Resident #31 was observed wearing two incontinent briefs which were both saturated with urine. The CNA informed the surveyor that the resident was a heavy wetter and needed two incontinence briefs to be worn. Review of the medical record revealed: Resident #31 was admitted to the facility with diagnoses which included but were not limited to: muscle weakness, chronic obstructive pulmonary disease, muscle wasting and atrophy. According to the Quarterly Minimum Data Set (MDS), an assessment tool, dated 02/11/24, Resident # 31 was moderately cognitively impaired. Resident #31 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) and was dependent on staff with Activities of Daily Living (ADLs). The Care Plan (CP) initiated on 11/01/23, showed that the Resident had Functional Ability Performance deficit related to decline in functional status due to weakness. Intervention included but was not limited to encourage the resident to participate to the fullest extent possible with each interaction. There was no documented intervention to utilize two incontinence briefs. g) On 02/23/24 at 10:17 AM, during the care tour, Surveyor #1 observed Resident #53 was saturated with urine and was observed wearing double incontinent briefs. The CNA again stated that the resident was a heavy wetter. Review of the medical record revealed: Resident #53 was admitted to the facility with diagnoses which included but were not limited to; Muscle Weakness, need for assistance with personal care. According to the Quarterly MDS dated [DATE], Resident #53 had severe cognitive impairment (BIMS 00) and required extensive staff assistance with ADLs. The Care Plan (CP) created on 11/02/23, revealed that the Resident had muscle weakness and required increased ADL assistance. Interventions included but were not limited to: Anticipate and meet the resident's needs. There was no documented intervention to wear two incontinent briefs. The form Task under Personal Hygiene, showed no documentation to indicate that Resident #53 was assisted with Personal Hygiene for 18 out of 29 days for February.On 02/23/24 at 12:01 PM, the surveyor performed a care tour with the assigned CNA. Resident #22 was sitting at the edge of the bed, and the sheet was yellow stained. The resident's clothing and the incontinent brief were saturated with urine. The CNA stated that he provided care to the resident in the morning, the time was not provided. The CNA did not mention that the resident refused or was combative with care. h) On 02/26/24, during a subsequent observation at 8:38 AM, the surveyor observed the resident in the room attempted to get dressed and the breakfast tray was noted on the bedside table. An strong odor of feces permeated the room. Resident #22 then attempted to put their pants on, and the incontinent brief was saturated with urine and balling in the front preventing the resident from pulling on their pants. The surveyor asked the resident to activate the call light. The resident stated that they would not come. The surveyor went to the hallway and asked a random CNA to assist. The CNA confirmed that she served the breakfast tray and did not realize that the resident needed to be changed. At the surveyor request, the resident was checked for incontinence. The resident was soiled with urine and feces and was wearing double briefs. The CNA stated that she did not provide care yet to the resident. The CNA stated that the double incontinence briefs were from the night shift. Review of the medical record revealed: Resident #22 was admitted to the facility with diagnoses which included, but were not limited to; Multiple Sclerosis, unspecified osteoarthritis, and unspecified dementia. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #22 had severe cognitive impairment. Resident #22 scored 05 out of 15 on the Brief Interview for Mental Status) BIMS. Resident #22 required extensive staff assistance with ADLs. The Care Plan (CP) created on 11/02/23 failed to address the resident ADLs needs. The care plan revealed that the resident had a behavior of refusing care. There was no documented intervention to utilize two incontinence briefs. i) On 02/26/24 at 9:30 AM, the surveyor observed Resident #38 sitting at the edge of the bed and attempted to stand up. The LPN had the medication cart next to the resident's door. A strong urine odor was permeated at the door entrance. The LPN acknowledged that the resident was a high fall risk and needed to be changed. The LPN informed the surveyor that the CNA was not available to change the resident yet, she was at the door to ensure that the resident did not fall. The LPN did not make any attempt to change the resident. The surveyor left the room and informed the Unit Manager of the observations. The Unit Manager and another CNA provided incontinence care to the resident. During incontinence care, the surveyor observed that Resident #38 was saturated with urine and their clothing was also saturated and needed to be changed. Review of the medical record revealed: Resident #38 was admitted to the facility with diagnoses which included but were not limited to: malignant neoplasm of pituitary gland, and unspecified dementia. According to the Quarterly MDS dated [DATE], Resident #38 had severe cognitive impairment and required extensive staff assistance with ADLs. The Care Plan (CP) had a focus for falls related to poor safety awareness. One of the interventions was for staff to anticipate all needs. j) On 02/26/24 at 9:17 AM, Surveyor #1 and #3 met with Resident #18 regarding care concerns that Resident #18 stated were addressed with the Director of Nursing. Resident #18 stated that incontinence care was not provided in a timely manner and incontinence care was to be provided every 2 hours but was not being done. The resident could not provide the specific date and time but stated that on one occasion she requested to be changed at 2:00 PM and did not get changed until 7:00 PM. The resident confirmed the use of the double briefs and stated that some times it was allowed because it was known that the staff would not provide incontinence care every two hours. Resident #18 further stated that this issue had been discussed with the DON. The surveyor then asked the resident if they would be able to recount the same story in the presence of the DON. The resident agreed to discuss the concerns with the DON in the room. The surveyor then accompanied the DON to the room and the resident recounted the same story and stated, he told me he was going to take care of it. The DON confirmed that the concern had been brought to his attention and was addressed. Surveyor #1 asked Resident #18 how that made him/her feel to have to wait and the resident stated, I don't like it. A review of Resident #18's medical record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Muscle weakness, peripheral vascular disease and multiple sclerosis. The surveyor reviewed the resident clinical record. The Quarterly Minimum Data Set, dated [DATE] reflected that Resident #18 had intact cognition. Resident #18 was alert and able to make their needs known. Resident #18 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). The Comprehensive Care Plan initiated 11/03/23 reflected a focus for bowel incontinence related to lack of mobility. One of the interventions was to provide incontinence care after each episode. There was no documented intervention to utilize two incontinence briefs. On 02/26/24 at 9:28 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) and inquired if wearing two briefs was on the CNA instructions care card. The LPNUM stated, no that residents should be changed every two hours. On 02/26/24 at 9:41 AM, in the presence of the survey team. The surveyor asked the DON what are the expectations regarding providing incontinence care to the residents? The DON stated the moment I was made aware of the double diapers, I suspended employees, however the DON did not respond to why the surveyor observed the ongoing use of two incontinence briefs. The surveyor asked about using an incontinent brief and inserting a separate large liner inside the brief. The DON stated he was aware about the liner being put inside an incontinent brief. The DON then stated, if a lady is requesting a liner inside the brief, it was okay. On 02/26/24 at 9:45 AM, during an interview with the DON, he revealed that the concern with Resident #38 was brought to his attention and the LPN was in-serviced. The DON further stated that all licensed staff can provide incontinence care. 02/26/24 at 9:47 AM the surveyor asked if Resident #18's complaints were followed up and the DON, stated everyone knows that changes should be done every two hours, and everyone knows their jobs. The surveyor asked if the supervisor was addressed regarding the resident complaints. The DON stated the supervisor checked on staff, by making rounds and talking to nurses. On 02/26/24 at 11:20 AM, the surveyor interviewed Resident #31 regarding incontinence care received at the facility. The resident stated that incontinence care was not provided in a timely manner. The surveyor asked the resident if she requested to have double briefs on, the resident stated that she did not request to have double incontinence briefs on. On 02/26/24 at 12:30 PM, the surveyor interviewed a CNA on the high side of the 200's Unit. The CNA confirmed that incontinent care was provided at the beginning and at the end of the shift. Resident who were considered as heavy wetters wore two briefs to prevent their clothing from being wet when they attended activities. On 02/27/23 at 11:15 AM the surveyor interviewed the Social Worker (SW) regarding the resident's concerns. The SW informed the surveyor that she was aware and assisted Resident #18 with filing a grievance. The SW also stated that she had discussed the issue with the DON and the team in morning meeting. The surveyor reviewed the grievance book and verified that the concern with incontinence care was addressed. k) On 02/26/24 at 10:30 AM, Resident #6 informed the surveyors that he/she also had some concerns that he/she would like to address. Resident #6 expressed their frustration over not receiving incontinence care in a timely manner. When he/she asked to be changed if the roommate did not ask to be changed, he/she would not be changed. Resident #6 stated, for example, on Sunday 02/25/24 he/she asked to be changed and the CNA kept walking back and forth in the hallway and ignored their request. The resident stated, It took a lot from me to open my mouth I was really in bad shape, I let her have it. That was not right that I have to sit in my excrements for hours. By the time I was provided with incontinence care I was sore. I had to open my mouth. I felt neglected. Review of the medical record revealed: Resident # 6 was admitted to the facility with diagnoses which included but were not limited to: unspecified severe calorie malnutrition, pressure ulcer sacral region, muscle waiting and atrophy. The admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care, reflected that the resident cognition was intact. Resident #6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). The Comprehensive Care Plan dated 01/03/24 had a focus for Functional Ability Performance Deficit. The intervention was to observe for possible reversible cause such as reconditioning. The care plan did not include how the resident would be assisted with ADLs care. While in the room, Resident #6 informed the surveyors that she also had some concerns that she would like to address. Resident #6 expressed their frustration over not receiving incontinence care in a timely manner. When he/she asked to be changed if the roommate did not ask to be changed she would not be changed. The form Task Schedule (TS) for February 2024 under Personal Hygiene, showed missing documentation to indicate that Resident #6 was assisted with Personal Hygiene for 11 days during the month. On 02/25/24 the Task was not signed to indicate when incontinence care was provided as indicated by Resident #6 2: a) On 02/21/24, Surveyor #1 reviewed the closed medical record for Resident #80. Resident #80 was noted as not receiving their scheduled showers or a bed bath specifically on 01/27/23 and 02/10/23. The record also noted not receiving their scheduled shower on 02/21/23 and 02/24/23. On 02/21/24 at 8:15 AM, Surveyor #1 requested the shower log for review. The LPN/UM indicated that there was no shower log for the designated time. The UM/LPN revealed that the shower time aligned with the skin assessment. All residents were scheduled for shower and skin assessment x 2 weekly. On 02/21/24 at 10:59 AM, the Director of Nursing (DON) stated that he implemented the shower log book in January. Prior to January 2024, the CNAs were documenting showers in the computer. The surveyor requested the entries from the computer to verify that residents received their shower as scheduled, none were provided. The surveyor reviewed the Treatment Administration Record (TAR) for January 2023. The TAR revealed that skin assessments were scheduled to be performed weekly and was checked as being done, on 01/03, 01/10, 01/17 and 01/24/2023. The TAR did not reflect that Resident #80 received a shower on 01/27/23. A review of the February 2023's TAR reflected that Resident #80's skin check was ordered weekly and was done on the following dates: 02/07/23, 02/14/23 and 02/28/23. The skin assessment was not signed for 02/10/23, 02/21/23 and 02/24/23 to reflect that Resident #80 received a shower on those days. On 02/29/24 at 10:35 AM, Surveyor #1 interviewed the LPN/UM regarding Resident #80. The LPN/UM stated Resident #80 was very difficult to care for on shower days. The resident had poor trunk control and had to be transferred on a shower bed. After showers, Resident #80 requested staff to spend time drying their hair. The process was long and the staff had other patients to care for. The Interdisciplinary Team decided that the Resident would have one shower on the 7:00 AM-3:00 PM shift and one shower on the 3:00 PM-11:00 PM shift. The LPN/UM did not provide the Interdisciplinary Notes for review. There was no documented evidence in the clinical record which reflected that Resident #80 received a shower on the 3:00 PM-11:00 PM shift. On 02/27/24 at 8:50 AM, Surveyor #1 conducted an interview and a care tour with a CNA who had been at the facility for over 4 months. During the care tour, the resident was observed wearing double incontinent briefs. When inquired regarding who instructed her to use double incontinent briefs on the residents, the CNA replied clearly, I was instructed to apply the double brief during orientation. On 02/27/24 at 10:30 AM, the surveyor conducted an interview with the Registered Nurse (RN) assigned to the low side of the 200's Unit. The RN stated that ADLs provided to the residents were documented in the computer by the CNAs every shift. On 02/27/24 at 11:25 AM, the surveyor asked the CNA to show the surveyor the ADL documentation on the computer. The CNA was unable to show the documentation. On 02/29/24 at 11:05 AM, the surveyor interviewed the DON in the presence of the team. The DON revealed again that the facility did not have a process in place to ensure showers were given on assigned days prior to January 2024. The DON went on to state, for example, the resident's family would complain about their loved ones not receiving showers and there was no documentation to verify that the residents received their showers on their scheduled days. He implemented the shower log in January 2024. On 02/26/24 at 10:06 AM, an interview with the Unit Secretary in charge of Central supply, revealed that the facility asked her to order the incontinent briefs that the CNAs referred to as a PAD. On 02/26/24 at 11:00 AM, Surveyor #1 and Surveyor #2 accompanied the Unit Secretary to the storage room and verified that the facility stored multiple boxes of the briefs at the lower level of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #s NJ 152905, 152910, 152911, 159956, 161569, 165971, 160660, 169440 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient and competent staff were available to a) provide appropriate incontinence care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38, #50, # 51, #53 and #55), b) provide residents with scheduled showers (Resident #80 and #233), and c) ensure all residents were treated in a dignified manner. This deficient practice was identified for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, expressed by 6 of 6 Residents who attended a Resident Council meeting, and affected all residents on 2 of 2 units. This deficient practice was evidenced by the following: Refer to 677F, 690H On 02/23/24 at 11:14 AM, the surveyor held a resident council meeting with six residents. The resident's expressed the following concerns: -3 of 6 Residents stated they waited anywhere from 30 minutes to one hour for the Certified Nurse Aides (CNAs) to respond to the call bells. Two of six residents stated, staffing is terrible 3:00 PM -11:00 PM and 11:00 PM -7:00 PM. -2 of 6 Residents stated they waited 30 minutes to 1 hour for assistance and sometime longer, one resident stated, they leave me wet for hours sometimes, and double diaper me, which I don't ask them to. -1 of 6 Residents stated, my roommate will use the call bell and the CNAs will come in and turn it off without addressing the concern. -5 of 6 Residents stated that shower times were not honored, the staff changed the schedule without notification, and they by pass my showers sometimes, or the aids will ask me if I want to shower at 11:00 PM and that's just too late. -6 of 6 Residents stated that Staff were always talking in different languages around us and sometimes they are talking on the phone taking care of us, staff are always on their phones while working, either talking or texting. a) On 2/22/23 at 10:20 AM, Surveyor #1 observed Resident #53 with an incontinence brief balled up in front of him/her. Surveyor #1 observed Resident #53 was wearing two incontinent briefs that were both saturated with urine. CNA #1 stated resident was a heavy wetter and required two incontinent briefs. On 2/23/23 at 6:00 AM, the survey team entered the facility and aided by CNA #2, performed a random care tour on the 200's Unit. The following was observed: Surveyor #1 observations: On 2/23/23 at 6:15 AM, the surveyor observed Resident #51 was wearing double incontinent briefs saturated with urine. On 2/23/24 at 6:30 AM, the surveyor observed Resident #23 was wearing double incontinent briefs that were soiled with feces and urine. On 2/23/24 at 6:40 AM, the surveyor observed Resident #50 was wearing double incontinent briefs saturated with urine. On 2/23/24 at 6:49 AM, the surveyor observed Resident #55 was wearing double incontinent briefs saturated with urine. On 2/23/24 at 7:54 AM, the surveyor observed Resident #31 was wearing double incontinent briefs saturated with urine. On 2/26/24 at 11:20 AM, the surveyor interviewed Resident #31 regarding incontinence care. The resident stated that incontinence care was not provided in a timely manner. On 2/22/23 at 10:20 AM and on 2/23/24 at 10:17 AM, the surveyor observed Resident #53 was wearing double incontinent briefs saturated with urine. On 2/23/24 at 6:39 AM, Surveyor #2 was standing outside of Resident # 32's room and there was a strong odor of urine. CNA #2 was in the presence of Surveyor #2 and confirmed the odor. At that time, CNA #2 performed care in the presence of the surveyor who observed Resident #32 was wearing double incontinent briefs. On 2/23/24 at 12:01 PM, the surveyor observed Resident #22 sitting at the edge of the bed, and the sheet was yellow stained. The resident's clothing and the incontinent brief were saturated with urine. The CNA stated he/she provided care to the resident in the morning, the time was not provided. The same resident was observed on 2/26/24 at 8:36 AM and was wearing double incontinent briefs that were soiled with urine and feces. The CNA informed the surveyor that the double incontinent briefs were from the night shift, and that she had not yet provided incontinence care to the resident. On 2/26/24 at 9:17 AM, Surveyors #1 and #3 interviewed Resident #18 regarding care concerns. Resident #18 stated that incontinence care was not provided in timely manner and incontinence care was to be provided every two hours, but was not being done. The resident stated that on one occasion she requested to be changed at 2:00 PM and did not get changed until 7:00 PM. The resident confirmed the use of double briefs and stated that sometimes it was allowed because it was known that the staff would not provide incontinence care every two hours. Resident # 18 further stated that this issue had been discussed with the Director of Nursing (DON). Surveyor # 1 asked Resident # 18 how that made him/her feel to have to wait for incontinence care to be provided, and resident stated, I don't like it. On 2/26/24 at 9:28 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) and confirmed the residents should not be wearing double briefs and should be changed every 2 hours On 2/26/24 at 9:30 AM, the surveyor observed Resident #38's clothing and person were saturated in urine. A Licensed Practical Nurse positioned at the resident's door informed the surveyor that the CNA was not available to change the resident yet, and she was at the door to ensure that the resident did not fall. On 2/26/24 at 10:30 AM, Resident # 6 informed the surveyors that he/she also had some concerns. Resident #6 expressed their frustration over not receiving incontinence care in a timely manner. Resident #6 stated on Sunday 02/25/24 he/she requested to be changed and the CNA ignored his/her request. The resident stated, It took a lot from me to open my mouth. I was really in bad shape, I let her have it. That was not right that I have to sit in my excrements for hours. By the time I was provided with incontinence care I was sore. I had to open my mouth. I felt neglected. b) On 2/21/24 the surveyor reviewed closed medical record for Resident # 80. Resident #80 was not provided with a shower or bed bath on 01/27/23 and 2/10/23. Resident #80 was not provided with a scheduled shower on 2/21/23 and 2/24/23, and did not receive a shower on 2/27/23, 2/10/23, 2/21/23 and 2/24/23. On 2/29/24 at 10:35 AM, the surveyor interviewed the LPN/UM regarding Resident #80. The LPN/UM stated that Resident #80 was very difficult to care for due to poor trunk control and had to be transferred on a shower bed. The LPN/UM recalled the resident and stated, the resident requested staff to spend time drying their hair which was a long process, and staff had other patients to care for. On 3/5/24, the surveyor reviewed the CNA task documentation dated Fed-24 [February] , which revealed that Resident #233 was not provided with bathing/shower for 12 of 19 days. c. On 02/22/24 at 8:11 AM, the surveyor observed the breakfast meal cart brought to the 200 unit, and staff pulled out a meal tray from the meal cart in front of room [ROOM NUMBER] and began loudly speaking to another staff member in a [foreign language]. The staff member was across the hall by the other resident rooms. The surveyor asked the staff about the observation and the staff stated, I was talking to her in a [foreign language], and stated it was the Activity Director (AD). The staff that she was speaking to stated, we talk often in [a foreign language]. The AD stated that she needed to speak to the housekeeper in a [foreign language] and knew they should not speak in another language. On 02/22/24 at 8:17 AM, during the continued observation, the surveyor heard staff referring to a resident while outside of room [ROOM NUMBER] as a feeder, regarding the meal tray, then went with another staff into room [ROOM NUMBER]. The Licensed Practical Nurse, Unit Manager (LPNUM) was at the meal cart and the surveyor asked her what a feeder was and the LPNUM stated it was people that needed help. The surveyor asked was that a usual term that was used and the LPNUM stated, yes. The surveyor asked the LPNUM if she was ever trained to not use that term and she stated no. The LPNUM then asked the surveyor what the appropriate term was to use. On 02/22/24 at 8:39 AM, the surveyor observed a male CNA distribute multiple meal trays on the high side of the 200 unit, including to room [ROOM NUMBER]. A female CNA then pointed to meal trays, and identified several resident meal trays by saying this one is a a feeder, and that one is a feeder to the male CNA. Residents were in close proximity in the small dining room at tables awaiting the meal distribution. On 02/22/24 at 9:38 AM, the surveyor interviewed the Registered Nurse Unit Manager Staff Educator (RNUM) and asked about any education provided to staff regarding dignity. The RNUM stated that was completed by social services. The surveyor asked the RNUM if a resident could be called a feeder. The RNUM stated, we don't use feeder, it is rude. The RNUM then stated, that is a big one, that is old, no one is supposed to be using that anywhere, it is a dignity issue. On 02/22/24 at 9:42 AM, the surveyor asked the RNUM if staff could speak a foreign language in the presence of the residents. The RNUM stated, no, that is dignity as well. They [the residents] need to know what is being said in their home. On 02/22/24 at 10:38 AM, the surveyor interviewed the DON who stated he has been at the facility for four months. The surveyor asked the DON if the staff could a speak foreign languages around the residents, and identify and point at residents identified as feeders. The DON stated, they are not supposed to do that or speaking a foreign language. The DON then stated, feeder, that is not supposed to be used at all, that is a dignity issue. The DON stated, not okay to point, not good. On 02/23/24 at 11:39 AM, Surveyors #1 and #5 were in the main hallway between the activity room and the dining room and observed a staff in a lab coat pushing Resident #79 in the wheelchair with his right, and was holding his cellular phone in his left hand and conducted a phone call on speaker while he pushed the resident into the dining room. Surveyor #1 interviewed the staff who identified himself as Registered Nurse (RN). The surveyor asked him if he typically took a phone call on speaker and wheeled a resident with the other hand. The RN stated, no, that is not normal behavior, I was on my break and Resident #79 needed to be watched. On 02/26/24 at 10:02 AM, the surveyor interviewed the DON regarding if it is ever acceptable for staff to take a personal phone call while caring for residents. The DON stated, no, it is not acceptable and everyone was trained on that. On 03/01/24 at 11:06 AM, the surveyor entered the activity room while residents were at the main table, coloring and watching television. At the same table the residents were at, an activity staff (AS) was talking on a cellular phone. The AS hung up the phone and the surveyor asked if she should be on the phone with the residents and the AS stated it was her heart doctor. It was determined that the facility failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. This was evident in Certified Nursing Assistant (CNA) staffing for 14 of 14-day shifts reviewed. Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. For the 2 weeks of Complaint staffing from 02/20/2022 to 03/05/2022, the facility was deficient in CNA staffing for residents on 5 of 14 day shifts as follows: -02/20/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -02/24/22 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. -02/25/22 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. -02/28/22 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs. -03/04/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. 2. For the 2 weeks of Complaint staffing from 09/04/2022 to 09/17/2022, the facility was deficient in CNA staffing for residents on 9 of 14 day shifts as follows: -09/05/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -09/06/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -09/11/22 had 6 CNAs for 55 residents on the day shift, required at least 7 CNAs. -09/12/22 had 6 CNAs for 55 residents on the day shift, required at least 7 CNAs. -09/13/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. -09/14/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. -09/15/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. -09/16/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. -09/17/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. 3. For the 2 weeks of Complaint staffing from 10/16/2022 to 10/29/2022, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts as follows: -10/16/22 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs -10/20/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/21/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/22/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs -10/23/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/25/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/26/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/27/22 had 6 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/28/22 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs. -10/29/22 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. 4. For the 2 weeks of Complaint staffing from 11/06/2022 to 11/19/2022, the facility was deficient in CNA staffing for residents on 1 of 14 day shifts as follows: -11/11/22 had 7 CNAs for 61 residents on the day shift, required at least 8 CNAs. 5. For the week of Complaint staffing from 11/27/2022 to 12/03/2022, the facility was deficient in CNA staffing for residents on 1 of 7 day shifts as follows: -12/01/22 had 6 CNAs for 54 residents on the day shift, required at least 7 CNAs. 6. For the 2 weeks of Complaint staffing from 12/18/2022 to 12/31/2022, the facility was deficient in CNA staffing for residents on 4 of 14 day shifts as follows: -12/18/22 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs. -12/21/22 had 5 CNAs for 55 residents on the day shift, required at least 7 CNAs. -12/22/22 had 5 CNAs for 55 residents on the day shift, required at least 7 CNAs. -12/27/22 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. 7. For the week of Complaint staffing from 01/22/2023 to 01/27/2023, the facility was deficient in CNA staffing for residents on 3 of 7 day shifts as follows: -01/22/23 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs. -01/24/23 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs. -01/27/23 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs. 8. For the 4 weeks of Complaint staffing from 02/05/2023 to 03/04/2023, the facility was deficient in CNA staffing for residents on 25 of 28 day shifts as follows: -02/05/23 had 7 CNAs for 63 residents on the day shift, required at least 8 CNAs. -02/06/23 had 7 CNAs for 63 residents on the day shift, required at least 8 CNAs. -02/09/23 had 6 CNAs for 63 residents on the day shift, required at least 8 CNAs. -02/10/23 had 7 CNAs for 66 residents on the day shift, required at least 8 CNAs. -02/11/23 had 6 CNAs for 65 residents on the day shift, required at least 8 CNAs. -02/12/23 had 7 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/14/23 had 7 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/15/23 had 7 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/16/23 had 7 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/17/23 had 7 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/18/23 had 6 CNAs for 64 residents on the day shift, required at least 8 CNAs. -02/19/23 had 6 CNAs for 62 residents on the day shift, required at least 8 CNAs. -02/20/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -02/21/23 had 7 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/22/23 had 6 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/23/23 had 7 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/24/23 had 6 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/25/23 had 6 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/26/23 had 6 CNAs for 61 residents on the day shift, required at least 8 CNAs. -02/27/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -02/28/23 had 5 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/01/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/02/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/03/23 had 6 CNAs for 63 residents on the day shift, required at least 8 CNAs. -03/04/23 had 6 CNAs for 63 residents on the day shift, required at least 8 CNAs. 9. For the 2 weeks of Complaint staffing from 03/19/2023 to 04/01/2023, the facility was deficient in CNA staffing for residents on 11 of 14 day shifts as follows: -03/19/23 had 6 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/20/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/21/23 had 6 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/22/23 had 7 CNAs for 62 residents on the day shift, required at least 8 CNAs. -03/23/23 had 7 CNAs for 61 residents on the day shift, required at least 8 CNAs. -03/24/23 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs. -03/25/23 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs. -03/26/23 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. -03/28/23 had 6 CNAs for 58 residents on the day shift, required at least 7 CNAs. -03/29/23 had 5 CNAs for 58 residents on the day shift, required at least 7 CNAs. -03/30/23 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs. 10. For the 2 weeks of Complaint staffing from 07/23/2023 to 08/05/2023, the facility was deficient in CNA staffing for residents on 6 of 14 day shifts as follows: -07/23/23 had 8 CNAs for 71 residents on the day shift, required at least 9 CNAs. -07/24/23 had 7 CNAs for 71 residents on the day shift, required at least 9 CNAs. -07/25/23 had 8 CNAs for 71 residents on the day shift, required at least 9 CNAs. -07/26/23 had 7 CNAs for 71 residents on the day shift, required at least 9 CNAs. -07/29/23 had 8 CNAs for 71 residents on the day shift, required at least 9 CNAs. -07/30/23 had 8 CNAs for 71 residents on the day shift, required at least 9 CNAs. 11. For the week of Complaint staffing from 09/10/2023 to 09/16/2023, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: -09/11/23 had 8 CNAs for 83 residents on the day shift, required at least 10 CNAs. -09/12/23 had 9 CNAs for 82 residents on the day shift, required at least 10 CNAs. -09/13/23 had 9 CNAs for 81 residents on the day shift, required at least 10 CNAs. -09/14/23 had 9 CNAs for 81 residents on the day shift, required at least 10 CNAs. -09/16/23 had 9 CNAs for 80 residents on the day shift, required at least 10 CNAs. 12. For the 2 weeks prior to survey from 02/04/2024 to 02/17/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -02/04/24 had 7 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/05/24 had 6 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/06/24 had 4 CNAs for 72 residents on the day shift, required at least 9 CNAs. On this day, the facility provided only half of the minimum allowed CNA staff to provide resident care. -02/07/24 had 5 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/08/24 had 5 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/09/24 had 6 CNAs for 73 residents on the day shift, required at least 9 CNAs. -02/10/24 had 6 CNAs for 73 residents on the day shift, required at least 9 CNAs. -02/11/24 had 6 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/12/24 had 5 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/13/24 had 4 CNAs for 74 residents on the day shift, required at least 9 CNAs. On this day, the facility provided only half of the minimum allowed CNA staff to provide resident care. -02/14/24 had 5 CNAs for 72 residents on the day shift, required at least 9 CNAs. -02/15/24 had 4 CNAs for 72 residents on the day shift, required at least 9 CNAs. On this day, the facility provided only half of the minimum allowed CNA staff to provide resident care. -02/16/24 had 7 CNAs for 75 residents on the day shift, required at least 9 CNAs. -02/17/24 had 7 CNAs for 75 residents on the day shift, required at least 9 CNAs. On 02/27/24 at 12:32 PM, the surveyor interviewed the Staffing Coordinator (SC) who stated that she was aware of the mandaory staffing requirements of 8 residents to 1 CNA on day shift, 10 residents to1 direct care staff on evening shift and 14 residents to 1 direct care staff on night shift. When asked if she was able to meet these requirments, the SC stated No, we fall short. NJAC 8:39-27.1(a)

Based on interview and review of pertinent documentation, it was determined that the facility failed to ensure the designated licensed Director of Nursing (DON) worked on a full-time basis as DON to oversee the care of all residents in the facility. This deficient practice was evidenced by the following: On 02/21/24 at 11:34 AM, the DON stated that the previous facility Infection Preventionist (IP) was a corporate nurse who was covering multiple facilities. He stated that the facility had been interviewing candidates for the IP position, but they did not have enough experience or wanted a lot of money so he had been also performing the job as IP. On 02/22/24 at 11:02 AM, the DON in the presence of the survey team, confirmed his job was to be the full-time DON, but he was also working as the facility IP. On 03/05/24 at 10:44 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, stated that the DON assumed the responsibilities of the Infection Preventionist (IP) for the facility a few months ago in the fall. The LNHA stated he was responsible to oversee the DON as the DON and as the facility IP. He further stated that he would discuss with the DON IP what was going on in the facility but none of the discussions were documented. The LNHA confirmed that the DON was hired to work a scheduled 40-hour week. A review of the facility provided, Director of Nursing Services job description undated, included but was not limited to; Purpose: primary purpose is to plan, organize, develop, and direct the overall operation of the Nursing Service Department . to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority: delegated the administrative authority, responsibility, and accountability for carrying out your assigned duties. Functions: Assist the Infection Control Coordinator Acknowledgment: . agree to perform the tasks outlined in the job description The facility failed to ensure the full-time, 40-hour work schedule for the DON was dedicated to the responsibilities of the DON and not the IP to ensure the highest degree of quality of care is maintained at all times. NJAC 8:39-25.1(a)

Complaint # NJ # 160660 Based on observation, interview and document review it was determined that the facility failed to serve hot and cold foods at an appetizing temperature for 4 of 4 hot food items, 2 of 2 cold food items and for 6 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 02/22/24 at 8:44 AM, the last meal tray was tested for temperature by two surveyors utilizing a calibrated thermometer and the Food Service Director (FSD). The resident meal was labeled a Chopped Diet. Hot food items: -Chopped French Toast; FSD- 90 degrees Farenheight (F), Surveyor-88 F. -Sausage; FSD- 89 F, Surveyor -90 F. -Hot Cereal; FSD-132 F, Surveyor-129 F. -Coffee; FSD- 124 F. The surveyor asked the FSD what the hot food temperature should be, and he stated 140 F or above. Cold food items: -4 ounces skim milk; both 51 F -4 ounces orange juice; FSD-54 F The surveyor asked the FSD what the cold food temperatures should be, and he stated cold should be 35 F or below. The surveyor asked if the food temperatures were in appropriate range and he stated, unfortunately not. On 02/23/24 at 11:14 AM, a surveyor conducted a resident council meeting with six residents and 6 out of 6 residents stated the food was cold and the food sat too long in the hallway before the staffed passed out the trays. The Food Temperatures and Holding Policy, undated revealed: Hot food should arrive at the resident above 135 F. It is recommended to leave the kitchen at a much higher temperature. Cold food should arrive at the resident below 41 F. It is recommended to leave the kitchen at a much lower temperature. Soup and Hot Beverages. A minimum of 150 F is preferred while not exceeding a too high and dangerous temperature. 8:39-17.4(a)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review it was determined that the facility failed to ensure a) foods were stored properly and labeled with a use by date, b) equipment was maintained in a clean and sanitary manner, and c) hair restraints were appropriately worn to prevent the spread of potential infection or food borne illness. The deficient practice was evidenced by the following: On 02/20/24 from 9:41 AM through 10:15 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: The walk-in refrigerator contained: -A package of undated meat was in a plastic -type wrap, stored in a metal pan, on a shelf and was covered with aluminum foil. The FSD stated, sometimes they throw on a use by date and stated it was pulled from the freezer on 02/17/24 and it's beef stew for tomorrow. -A large metal pan of chicken thighs was next to the container of meat, had a plastic covering on it with a handwritten label Chicken Pulled 2-17-24 and did not contain a use by date. -A yellow carton labeled Frozen Egg Product, Keep Frozen, was on a shelf with 5 other cartons of the same product. The opened carton had a manufacturer Sell by date stamped 11/20/2024. There was no open date or use by date on the item. The surveyor asked the FSD about the expiration of the product and he stated 14 days. The surveyor then asked how you would know that, and he stated, we are supposed to put an open and label the use by date. The surveyor observed that the carton was stamped in red, Thawed product stored at 40 degrees or below should be used within 5 days (Not 14 days as per the FSD). The FSD stated we are going to toss it, we don't know when it was opened, the carton is clearly labeled should be used within 5 days. -There was a box that contained whole raw eggs that was stored on a middle shelf. The FSD stated the eggs were supposed to be on bottom shelf because they were raw eggs. -There was a large, ten-pound container of potato salad with a manufacture label, packed on 01/04/24 there was no use by date on the product or expiration date. At that time the surveyor asked the FSD if there is a special type of menu used by the facility and he stated, the menu was Kosher style. - A 5-pound container of cottage cheese had a manufactures stamp on the container Sell by [DATE] and a sticker from the vendor dated 1/10/24. The surveyor requested the use by date from the FSD and he stated, it doesn't have a use by date. -A rack containing burgundy resident meal trays was observed stacked up to 6 in a slot, and there were ten large slots and multiple rows. The surveyor asked the FSD to remove several of the trays which were visibly wet and dripping. -The can opener affixed to the table was visible soiled by the blade and the base. The FSD stated, it needs to be washed. On 02/22/24 at 8:25 AM, during a subsequent kitchen observation, and during the tray line, which was in progress for the breakfast meal, the surveyor observed a female staff in the kitchen who was actively working in the kitchen and was throwing out spice containers, then removed buckets of sanitizer. The unidentified staff was not wearing a hair covering containing all her hair and the front portion was out. The surveyor went to the FSD who was prepping trays and observed that the cook was plating food, and the beard restraining did not cover all of his facial hair. The surveyor asked the FSD at that time if he had noticed the cook's exposed facial hair and he stated, he did not. On 02/23/24 at 7:18 AM, during a tour of the 1st floor with the Registered Nurse, the pantry refrigerator was observed as non-functioning. On 03/05/24 at 1:35 PM, the surveyor informed the Administrator of the findings, and no additional information was provided. A review of the following policies revealed: Food Preparation and Service Policy, Last Update: February 2021 revealed 7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food; The Policy for Hairnets and [NAME] Snoods, Last Update: March 2023 revealed How to wear a hairnet properly, 1. Hair net should cover the hair and the ears. 2. All hair should be restrained within the net. 3. Hair restraints must be worn by every worker entering any of the kitchen areas, even those workers with shaved heads. Procedure for beard snoods, 1. Fit the beard snood over the nose with the elastic over the ears, 2. Secure the hairnet with the closure at the front, 3. Once the hairnet is secured, no hair should be exposed. Food Receiving and Storage Policy, Last Update: February 2021 revealed: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date)., 11. Food shall be discarded as per any labeling instructions and policy upon supervisor inspection to prevent spoilage. 16. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods. NJAC 8:39-17.2(g)

Based on observation, interview and document review it was determined that the facility administration failed to ensure policies, procedures and effective systems were implemented to maintain each resident's highest practicable physical, mental, and psychosocial well-being by failing to ensure a) a resident with documented food allergies were provided with appropriate food items, b) that appropriate and timely incontinence care was provided to dependent residents, c) residents were treated with dignity and respect, d) residents were consistently provided with physician ordered medications, e) interventions were implemented to prevent falls for a resident with frequent falls with history of fractures, residents received appropriate incontinent care to limit urinary tract infections, f ) resident council grievances were addressed, e) residents resided in a homelike environment, g ) resident's had unrestricted access to their Personal Needs Accounts, h) transportation was available to ensure outside trips were scheduled, i) the facility maintained a comprehensive emergency preparedness program, j) infection control program contained the required antibiotic stewardship and infection surveillance components to prevent the spread of infection, k) administration self identified areas for improvement and developed quality assurance plans, and l) staffing levels were adequate to meet resident needs. The deficient practice affected 2 of 2 resident units and was evidenced by the following: Refer to: EP #s 1, 7, 18, 25, 31, 36, 37, 39; F550E, F565F, F567F, F568F, F584F, F677F, F679D, F689G, F690H, F725F, F742H, 806J, 865F, 880F On 02/20/24 at 11:19 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Nursing (VPON) from a management company. The surveyor was informed that the VPON was from the company that was looking to purchase the facility. The surveyor asked if any renovations were in progress and the LNHA stated, just cosmetic on the 100's unit. When asked who was the Infection Preventionist, the DON stated, he took over doing that and has been at the facility for four months. On 02/27/24 at 10:51 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the Medical Director regarding the identified concerns with Resident #32 who had a documented egg allergy who received and consumed eggs. The surveyor informed the Medical Director that the LNHA was made aware regarding the Immediate Jeopardy situation regarding the kitchen serving the eggs although the meal ticket for Resident #32 identified the egg allergy, then the nurse who failed to read the ticket for the documented allergies and then served the meal to Resident #32. The Medical Director confirmed that should not have happened, and he had not been made aware of specifics. The surveyor informed the MD regarding the survey teams finding regarding multiple resident who were saturated with urine, were wearing double briefs and the survey team's findings regarding substandard quality of care. The MD stated the facility did not make him aware of the incontinence care concerns, he would want the DON involved with that, and the Certified Nurse Aide's involved should be disciplined. On 03/05/24 at 10:39 AM, the surveyor conducted an interview with the LNHA in the presence of three surveyors. The surveyor showed the LNHA a copy of his Job Description and he confirmed his date of hire was 06/13/22. The surveyor asked the LNHA who the governing board of the facility was and the LNHA stated the management company operated the facility. The surveyor asked when that changed and the LNHA stated, I don't know exactly, but he reported to the management company. The LNHA said he was hired by the former owner and doesn't remember when it changed. The surveyor asked if he communicated with the management company [i.e governing board]. The LNHA stated he reported to the Chief Operating Officer for the management company. The surveyor asked the LNHA what was his role in the infection control program. The LNHA stated that the Infection Preventionist was now the DON's responsibility. The surveyor asked the LNHA if he had been aware that antibiotic stewardship was not being completed and he stated, he was not aware. The surveyor asked the LNHA if antibiotic stewardship was important and the LNHA stated, it was important, because it keeps track of residents with infections. The surveyor asked when the Infection Preventionsist role transferred to the DON and he stated, I do not recall exactly. The surveyor asked how the LNHA ensured that the DON fulfilled the antibiotic stewardship functions and the LNHA stated, we discussed it from time to time. The surveyor asked the LNHA were the discussions documented and the LNHA stated, no, he could not recall the last time he had that discussion. The surveyor asked the LNHA if he should have been aware that antibiotic stewardship was not being completed and he stated, yes, he should have know he was not doing it. The surveyor asked the LNHA about the environmental concerns observed on 02/21/24 with two surveyors on the 200 unit which included, but was not limited to; holes in walls in resident rooms, broken furniture with jagged edges and multiple soiled privacy curtains. On 02/21/24 at 11:25 AM, the surveyor asked the LNHA about completion of daily rounds to which the LNHA stated he had not documented environmental rounds. The surveyor asked the LNHA what was his role to identify the concerns that were pointed out during the environmental tour. The LNHA stated, the big picture of the room looked like it should and I will pay closer attention to those small items, if I missed things, I miss things. The surveyor asked should the areas have been identified and he stated, yes. The LNHA stated we did a lot of painting on the 100 side, we are moving slowly. On 03/05/24 at 10:54 AM, the surveyor asked the LNHA if he interacted with the MD. The surveyor reviewed the concerns identified during the survey, which included, lack of appropriate incontinence care provided to residents and asked the LNHA if he had reviewed concerns with the medical director. The LHNA stated, we discuss various issues. When asked if documented, he stated, no documentation. On 03/05/24 at 10:55 AM, the surveyor asked the LNHA how often did he meet with different departments. The LNHA stated he attended morning meeting every day, regarding anything of significance that day. The surveyor asked the LNHA if staffing was reviewed and did the LNHA think staffing was adequate. The LNHA stated most of the time. The surveyor asked the LNHA if staffing was adequate, should the survey team have identified multiple residents wearing double briefs and did you investigate the concerns. The LNHA stated, I personally didn't document [regarding being aware of staff using double incontinence briefs on residents.] The surveyor asked the LNHA if you identified the concern, should it have happened again, no, we took are hard stance on it, we discussed it. The surveyor asked, if it was the same staff using double briefs on residents and the LNHA stated, I don't believe so, I don't recall. The surveyor asked the LNHA if the facility utilized a risk management program for investigations, and the LNHA stated, I believe we have one, I am not sure of the details. The surveyor asked the LNHA if he reviewed accident and incident reports and the LNHA stated, yes to make sure all steps are followed for an investigation, and what and why something happened. The surveyor asked does the LNHA ensure that any specific interventions are appropriate and implemented and he stated that would be determined with nursing. The surveyor asked how would know if fall interventions are effective, and the LNHA stated, if the person doesn't fall again. The surveyor asked if interventions were documented, and the LNHA stated, yes it should be. On 03/05/24 at 11:10 AM, the surveyor showed the LNHA a signed job description and he confirmed it was his, and his start date was 06/13/22. The surveyor asked the LNHA how does the facility ensure that the resident funds are managed properly. The LNHA stated, to make sure that enough funds are available as necessary, I am not sure it is a policy. The surveyor asked the LNHA do you oversee that process and the LNHA stated, yes. The surveyor asked if he communicated with the Human Resources Director (HRD) regarding if funds were available and it is documented. The LNHA stated, no. The surveyor asked do they discuss how much money is available at the facility, and without any specifics offered, he stated, enough to meet the residents needs. Reviewed concerns brought up in resident council, including receipts to residents when money was removed. The LNHA stated, if they [resident] request a receipt than they can get that as well. On 03/05/24 at 1:35 PM, the survey team conducted a meeting with the LNHA and DON to again, review concerns identified during the survey conducted from 02/20/24 through 03/06/24 which included, but was not limited to, the following concerns: -The lack of a comprehensive, accurate emergency preparedness program. - Resident #5's multiple falls, falls with fractures and lack of interventions to prevent further falls. - On 02/23/24 at 6:15 AM, two surveyors observed multiple residents with double incontinent briefs, were saturated with urine. - Failure to treat residents with dignity and respect on multiple observations for multiple days, serving residents meals on paper plates and disposable silverware for meal service, labeling residents, speaking a foreign language in the presence of residents, and taking personal phone calls while caring for residents. - Failure to perform hand hygiene during meals, no antibiotic stewardship or infection surveillance. -Failure to follow up on resident council concerns for over one year regarding changing the menu to kosher style, and repetitive menus, failure to provide menus. -Lack of outside trips due to not paying the transportation bill, re -Resident Personal Needs Funds limited, no process, no policy, no oversight. -Resident rooms with damaged furniture, walls, equipment, and soiled areas including privacy curtains. On 03/06/24 at 11:03 AM, the LNHA, in the presence of the [NAME] President of Nursing and [NAME] President of Operations from the management company, along with the survey team, stated to the survey team: It has been a challenging two weeks, and we know we share the same goal to strive to do our best and we have to work better on it. Next survey we will do better. The signed LNHA Job Description, dated 06/13/22 revealed: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards,, guidelines, and regulations that governs nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times. Administrative functions: Plan, develop, organized, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Make written and oral reports/recommendations to the governing board concerning operation of the facility. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Safety and Sanitation: Ensure that the building and grounds are maintained in good repair. Review accident/incident reports (e.g., falls, injuries of an unknown source, abuse, etc.). Monitor to determine the effectiveness of the facility's risk management program. Resident Rights: Ensure that the resident's rights to fair and equitable treatment, self determination, individuality, privacy, property and civil rights, including the right to wage complaints are well established and maintained at all times. Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident and family as appropriate. Ensure that resident funds maintained by the facility are managed in accordance with current federal and stated regulations and that appropriate accounting records are maintained. NJAC 8:39- 5.1(a); 9.2(a)

Based on interview and record review, it was determined that the facility failed to ensure that medical record access was provided in a timely manner during an on-site survey conducted from 02/20/24 through 03/06/24. The deficient practice was evidenced the following: On 02/20/24 11:19 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Nursing (VPON) from a management company. The VPON stated the management company was the company that was purchasing the facility. The surveyor asked about the electronic medical record (EMR) system the facility utilized and the LNHA stated they have a new EMR since November 2023. The surveyor asked if the facility still had access to records prior to the November 2023 and he stated, the facility still has access and the information was imported into the new system. On 02/21/24 at 11:21 AM, the facility provided the survey team with a tablet and was informed that the EMR access for medical records prior to 11/2023 would need to be accessed using the tablet to access the prior EMR. On 02/22/24 at 11:10 AM, the surveyor asked the LHNA, in the presence of the survey team regarding why the facility did not have immediate access to the medical records prior to 11/2023. The LHNA stated he was unsure why the facility did not have access to the records and stated, he was unaware that was needed, no one looked for it. The LNHA stated, there was one person in the facility that is familiar with the old EMR system and if she cannot assist the survey team and provide the requested information, the LNHA will have to contact the former EMR company. On 02/23/24 9:59 AM, which was day four of the survey, the survey team met with the LNHA and DON regarding the following medical records that have been requested and not yet provided: Resident #45's medication and treatment administration records for March and April, 2022. All accidents and incidents from 2022 and all physician orders from 2022; Resident #19's physician orders, care plan and medication and treatment administration records from 2022; Resident #54's physician orders from 2022 and Resident #51's 2022 complete medical record. NJAC 8:39-35.2(k)

Based on observation, interview, and document review, it was determined that the facility's Quality Assessment and Assurance Committee (QAPI) failed to ensure the facility self- identified areas for improvement including environmental concerns, resident care related concerns, the Antibiotic Stewardship Program and adverse events. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F550F, F565F, F567F, F584F, F677E, F689G, F690H, F742H, F806J, F890G 1.) During a tour of the 200 unit on 02/20/24 and 02/21/24, the surveyors observed several rooms with broken furniture, soiled privacy curtains, missing privacy curtains, dust in rooms and air conditioners cracked. On 02/21/24 at 11:25 AM, two surveyors (Surveyor #1 and #2) conducted a tour with the Licensed Nursing Home Administrator (LNHA) and observed the broken furniture, soiled privacy curtains, missing privacy curtains, cracked air conditioners. The LNHA stated that he made environmental rounds daily but did not document the rounds. On 02/21/24 at 12:13 PM, the surveyor asked about the observed conditions. The LNHA stated, the new company took over in May [2023]. The LNHA stated it was a work in progress, and we do our best and did not provide any specific information regarding the observed conditions. 2.) On 02/23/24 at 11:14 AM, a surveyor conducted a resident council meeting with 6 residents. All 6 of 6 residents stated that they were made aware that the meals are from a kosher style kitchen, and they do not have any pork products. The residents confirmed that they have asked for pork products before, and the facility told them it is a kosher style kitchen, and they only serve chicken and fish mostly. The residents also had concerns about the menus being posted and the variety of foods on the menu. On 02/26/24 at 1:09 PM, a surveyor interviewed the Food Service Director (FSD) who stated he was not responsible with the menu development; a company provides the menu. When asked who signs off on the menu to ensure it meets the residents needs and is nutritionally adequate, the FSD stated, I am not sure. The FSD stated the kosher style food started about two years ago, I am not sure, and I don't know why. The FSD stated, it wasn't always kosher. On 02/26/24 at 1:26 PM, the surveyor interviewed the LNHA who stated he was not sure if the contract for the menu company was still in effect. When asked about the Kosher style food, the LNHA stated, I believe it was changed a few months ago, I don't know exactly when it was changed. The surveyor interviewed the Resident Council President (RCP) who stated the facility never conducted a meeting with the residents regarding the changes in the menus. The RCP further stated that menus were not provided to the residents. The LNHA provided the survey team with the following Resident Council Meeting Minutes from 02/28/22 through 01/30/24. Each month the residents voiced concerns about kosher style food, no pork products, the variety of food items or menus changes with no follow up noted from the facility. 3.) During Resident Council meeting, 6 of 6 residents stated they were not able to access their Personal Need Account (PNA) when they want. The residents expressed concerns that only a limited amount of money was accessible on the weekends. On 02/29/24 at 2:01 PM, the surveyor informed the LNHA and Director of Nursing (DON), in the presence of the team, of the findings related to the PNA, including the resident council concerns. The surveyor asked the LNHA how resident's get their money. The LNHA stated the residents go to the Human Resource Director (HRD) for their PNA money. The LNHA stated that he was not aware of a limited amount of money the residents could withdraw and he does not have a policy. The LNHA provided the survey team with the following Resident Council Meeting Minutes from 02/28/22 through 01/30/24. On 03/28/23, the residents expressed concerns about the need for PNA money to be available on weekends. The following monthly resident council meeting minutes did not address the PNA money. 4.) On 02/22/23 at 8:15 AM, Surveyor #1 observed Resident #53 wearing two incontinent briefs that were both saturated with urine. On 02/23/24 at 6:15 AM, Surveyor #5 completed an incontinence care tour with a Certified Nursing Assistant (CNA) and 8 residents did not receive appropriate incontinence care, personal care hygiene and observed wearing two incontinent briefs. Resident #51 who was observed wearing 2 incontinent briefs saturated with urine and had a history of Urinary Tract Infections. On 02/26/24 at 9:30 AM, the surveyor observed Resident #38 during incontinence care who was saturated with urine and their clothing was also saturated and needed to be changed. On 03/06/24 at 8:38 AM, the surveyor interviewed the Assistant Director/Nurse Educator, (ADON) responsible for orientation and in-serviced at the facility. The ADON stated that she was not aware that the CNA were still using double briefs on the residents. The ADON stated that 2 months ago the issue was brought to their attention and the staff was in-serviced. Some staff were suspended. When inquired if any follow up was done to verify compliance she stated, No. 5.) On 02/29/24 at 10:11 AM, the Director of Nursing Infection Preventionist (DON IP) provided the Antibiotic Stewardship Program (ASP) policy and procedure and provided July 2023 ABP and August 2023 ABP. A review of the Antibiotic Stewardship Program revealed that the facility was not using a system for routine feedback reports and tracking measures of outcome surveillance related to antibiotics as per facility policy and national standards. On 03/05/24 at 10:44 AM, the LNHA in the presence of the survey team, stated he was unaware that the ASP was not being completed by the DON IP. The LNHA stated that he should have been aware, and that the ASP was important for the facility to be able to track infections and how the residents respond. The LNHA stated there was no documentation of any conversations between him and the DON IP, but that he should have known the ASP was not being conducted. 6.) A review of Resident #5's medical records revealed the resident sustained 13 falls from 09/11/22 through 02/25/24, including falls with injuries on 09/11/22, and the comprehensive care plan was not updated after the falls. On 03/05/24 at 8:47 AM, the DON provided the fall timeline with no interventions, the causal factor was not identified and the care plan for 2022 could not be located. The DON further stated that he started working for the facility on 10/18/23 and could not account for the missing documents. On 03/05/24 at 11:04 AM, during a pre-exit meeting held with the survey team and current facility Licensed Nursing Home Administrator (LNHA), the DON and Executive Nursing Management, the surveyor reviewed the concerns regarding Resident #5's multiple falls, including fall with major injury and the Comprehensive Care Plan not updated after the falls. The administrator added that the nursing department was responsible to review the recommendations and implemented them. On 03/06/24 at 1:30 PM the facility did not provide any additional information regarding Resident #5. 7.) A review of the medical records for Resident #19 and Resident #76 revealed that the residents were not administered antipsychotic medications in March 2022 as ordered by the physician which resulted in a crisis emergency transfer for both residents. There was no documentation of the reason the medications were held or that the attending physician was notified. The surveyor interviewed a Licensed Practical nurse (LPN) and the Psychiatric Mental Health Nurse Practitioner (PMHNP) who both stated that the physician should have been notified of any missed doses of medication and the reason should be documented in the medical records. On 03/05/24 at 1:35 PM, the surveyor presented the above concerns to the DON and LNHA in the presence of the survey team. On 03/06/24 at 11:03 AM, the [NAME] President of Operations and Nursing for the management company, the DON and LNHA met with the survey team and no additional information was provided regarding the above concerns. On 03/06/24 at 10;24 AM, the surveyor interviewed the LNHA who confirmed the QAA/QAPI policy dated 02/01/22 that was given to the survey team was the only policy used at present. The LNHA stated quarterly QAA meetings included all department heads, the DON, Medical Director, Infection Preventionist (IP), pharmacy consultant and lab consultants. The LNHA said that prior to a quarterly QAA meeting, there would be a meeting and each department was requested to bring an issue they would like to work on, and each department had a QAPI tool/form to fill out. These issues also included any family or residents' concerns, and we would address them. The LNHA stated that the facility knows if the corrective actions that were implemented were effective and improvement occurred when each department would bring their results to the QAA meeting, and the group would discuss if ongoing investigation was needed. The surveyor asked the LNHA if the QAA committee was aware of any of the concerns presented to the facility by the survey team. The LNHA stated only the issue with double briefs. The LNHA provided the surveyor with the QAPI binder and confirmed the current QAPI's were as follows: 1. Staffing- the activities department staffing 2. Dietary- kitchen sanitation, temperature logs of the dishwasher and preventing food born illnesses. 3. Rehabilitation- certification documents should be signed timely. 4. MDS (Minimum Data Set) working on timely MDS. 5. Advance Directives (AD)- making sure all residents have an AD on file. 6. Weight loss-residents who had weight loss in the last few months. On 03/06/24 at 11:01 AM, the LNHA provided the surveyor three QAPI's he had found in his computer from the prior LNHA of the facility. The QAPIs included the following: 12/29/22- hand hygiene not being performed while passing trays. 05/15/23- Holes in the MAR's and TARS's (Medication and Treatment Administration Records) 07/21/23-Medications not being obtained timely form the pharmacy. A review of the above QAPI's did not have any ongoing tracking/reporting or resolution. When asked if the QAA was currently working on these QAPI's, the LNHA stated No. A review of the QAA/QAPI binder, dated 2022 through 2023 provided by the LNHA, revealed no reporting from the Infection Preventionist on the ASP or infection tracking and trends. When asked if the QAA Committee reviewed adverse events and reportable events, the LNHA said yes they should be reviewed in the meeting. A review of the following policies revealed: Quality Assurance and Performance Improvement (QAPI), dated 02/01/22, polices were intended to ensure the facility develops a plan that described the process for conducting QAPI/QAA activities, such as identifying and correcting the quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. The policy will include; 1. QAPI Program/Plan 2. QAPI/ QAA Improvement Activities 3. QAA Committee QAA Committee, dated 02/01/22, revealed that the QAA will develop and implement plans of action to correct identified quality deficiencies: regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements. The QAPI policy, dated 02/01/22, reflected that the facility will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes and care and quality of life. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirement of this section. This may include but is not limited to systems and reports demonstration systematic identification, reporting, investigation, analysis, prevention of adverse events; and documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities. It must address all systems of care and management practices, include clinical care, quality of life, and resident choice, an utilize the best available evidence to define the measure indicators of quality and facility goals that reflect processes of care and facility operations. The QAPI policy did not include a Policy/Procedure for 2. QAPI/QAA Improvement Activities. NJAC 8:39-33.1(a)(b)(c)(e); 33.2 (a)(b)(c)(d)

Based on interview and the review of pertinent facility documentation, it was determined that the facility failed to have the a.) the Medical Director (MD) and the Infection Preventionist (IP) present for one (1) of four (4) quarterly Quality Assurance Performance Improvement (QAPI) meetings and b.) Infection Preventionist (IP) report on the Infection Prevention and Control Program (IPCP) for four (4) out of four (4) QAPI meetings reviewed. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: a.) On 03/06/24 at 9:17 AM, the surveyor reviewed the last four (4) quarterly sign in sheets for the QAPI meetings. The sign in sheet dated 04/18/23 did not include the signature of the IP and the sign sheet dated 07/08/23 did not include a signature that the MD was in attendance. The 10/17/23 and the 01/17/24 sign in sheets were missing the IP's signature. On 03/06/24 at 10:24 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged that the IP signature was missing on 04/18/23 and the MD's signature was missing on 07/08/23. On the 10/17/23 and 01/17/24 QAPI sign in sheets, the LNHA stated that the Director of Nursing (DON) was the acting IP at that time. On 02/27/24 at 10:51 AM, during a telephone interview with the MD in the presence of the surveyors, the MD stated that he had just become MD in January 2024 and only attended one QAPI meeting. b.) On 03/06/24 the LNHA provided the surveyor with the QAPI book dated 2022-2023 for the last four quarters. The surveyor reviewed each quarterly minutes and notes and there was no documentation from the IP reporting on the Infection Prevention and Control Program (IPCP) including infection surveillance, tracking of infections and antibiotic stewardship. On 03/06/24 at 11:01 AM, the surveyor reviewed the QAPI binder dated 2022-2023 with the LNHA. The LNHA confirmed that that the QAPI quarterly meetings did not contain any documentation from the IP regarding, including antibiotic stewardship and infection trends. A review of the facility provided, Infection Control, Prevention and Surveillance Plan dated 03/01/23, included but was not limited to; Policy: The Infection Prevention and Control Plan (IPCP) consists of the IPCP policy and procedures and the Antibiotic Stewardship program. 2. Oversight - meets quarterly and report to QAPI (Quality Assurance and Performance Improvement) committee. A review of the facility's policy and procedure titled QAA (Quality Assessment and Assurance) Committee, dated 02/01/22, revealed that the facility must maintain a QAA committee consisting at a minimum of a. the DON, b. the Medical Director of his/her designee, and c. at least three other members of the facility's staff at least one of who must be the administrator, owner, a board member or other individual in a leadership role. The policy did not include the IP must attend the quarterly meetings. On 03/06/24 at 10:24 AM, the LNHA confirmed this was the only QAA policy at that time. NJAC 8:39-19.4(d)(g); 23.1(3); 33.1(b)

4. On 02/20/24 at 10:46 AM, Surveyor #2 toured the facility and observed the ice machine located by the nursing station on the 200-unit. The surveyor observed the plastic ice scoop holder on the side of the ice machine was visibly soiled with a black substance on the bottom corner and the bottom of the holder with the ice scoop in direct contact. At that time, the unit secretary was at the nurse's desk. The unit secretary confirmed the ice scoop holder with the ice scoop resting in it was visibly soiled with the black substance. The unit secretary stated she would clean the ice scoop and ice scoop holder at night but that she would try to clean it at least twice a day. The unit secretary stated, oh no that has to be washed. It's dirty and the residents could get something from the scoop in direct contact with the soiled holder. The facility was made aware of the concern and provided a policy. 5. On 02/20/24 at 11:50 AM to 11:59 AM, Surveyor #2 observed the lunch meal being served on the 100-unit. The Certified Nursing Assistant (CNA) #2 was observed not performing HH before and after delivering meal trays to rooms 102, 101, 103, 104, 109, 111, 112, 113, 114 Door, 114 Window and assisted opening juice, 117, and 118. On 02/20/24 at 12:01 PM, CNA #2 stated the process for meal delivery was to verify the right resident, right diet, and to clean the residents hands. When asked about staff HH, CNA #2 stated she was not required to perform HH during meal delivery unless she touches something like a call bell in the room. On 02/23/24 at 6:39 AM, on the 200-unit, Surveyor #2 observed CNA #1 perform hand washing. CNA #1 applied soap and washed her hands entirely under running water for 12 seconds. CNA #1 administered incontinent care to a resident while wearing gloves. Next CNA #1 disposed of the wet two incontinent briefs and used the same gloved hands to pick up a pillowcase to put on the residents pillow that was under the residents head. Surveyor #2 asked about the process and CNA #1 stated she should not have been using dirty gloves to put a clean pillowcase on the residents pillow. CNA #1 removed her gloves, entered the bathroom, applied soap, and washed her hands entirely under the running water for 13 seconds. CNA #1 put the new pillowcase on the pillow. Next CNA #1 went into the bathroom to wash her hands again. She applied soap and washed her hands entirely under the running water for 11 seconds. On 02/23/24 at 7:54 AM, on the 100-unit, Surveyor #2 observed the medication administration task. The Registered Nurse (RN) completed administering medication to a resident and entered the bathroom to wash her hands. The RN applied water and soap and next washed her hands entirely under the running water for 13 seconds. When asked about the process for handwashing, the RN stated to apply soap, and apply friction for 20-30 seconds, and rinse your hands. When made aware of her handwashing only for 13 seconds, the RN did not offer an explanation. The Director of Nursing (DON) was made aware of the hand hygiene observations and was asked to provide any staff education regarding hand hygiene. On 02/23/24 at 11:37 AM, the DON provided the following Handwashing Observations which included: water temperature checked before beginning; hands wet applying a good amount of soap; front and back of hands properly scrubbed for at least 20 seconds; hands rinsed without touching any surface; hands properly dried with paper towel; faucet turned off with new paper towel; and paper towel properly discarded. The Handwashing Observations revealed the following: CNA #2 had a Handwashing Observation dated 01/31/23, which documented yes for all procedure steps. CNA #1 had a Handwashing Observation dated 02/06/23, which documented yes for all procedure steps. RN had a Handwashing Observation dated 07/05/23, which documented yes for all procedure steps. A review of the facility provided Nutritional Services policy and procedure dated 09/12/22, included but was not limited to; Policy: maintain the ice machine, scoop, and storage container in a sanitary manner to minimize the risk of food hazards. The scoop and storage container will be cleaned once each day. Procedure: 7. Wash and sanitize the ice scoop at least once a day in the dishwasher and air dry. 8. Store the ice scoop in a clean container. A review of the facility provided, Handwashing/Hand Hygiene policy and procedure revised 08/19, included but was not limited to; Statement: the facility considers hand hygiene the primary means to prevent the spread of infection. Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. 7. use an alcohol-based hand rub or alternatively soap and water for: B. before and after direct resident contact. I. after contact with a resident's intact skin. am. after removing gloves. p. before and after assisting a resident with meals. 9. The use of gloves does not replace hand washing or hand hygiene. This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare -associated infections. Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacture to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off faucet. 5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. The facility failed to follow their policies. NJAC 8:39-19.4(a)(l) Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow infection control practices to prevent the spread of potential infection by a) storing dirty meal trays apart from clean, not yet served, resident meals trays on 1 of 2 units; b) adhering to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 1 of 1 residents reviewed (Resident #31); c.) ensuring the ice scoop and ice scoop container were clean for 1 of 2 units; and d.) ensuring staff performed appropriate hand hygiene (HH). The deficient practice was identified on 2 of 2 units and evidenced by the following: 1. On 02/22/24 at 8:35 AM, Surveyor #1 went to the 200 Unit to observe the breakfast meal. The surveyor observed a facility's staff exited a room with an uncovered dirty tray with the remaining of the food not eaten and placed the tray on the food cart with the other breakfast trays that had not yet been served. The surveyor remained in the hallway and observed a Certified Nursing Aide (CNA) removed the dirty tray from the food cart at 8:40 AM. On 02/22/24 at 8:47 AM, the surveyor followed the CNA who disposed of the dirty tray at the nursing station. During an interview with the CNA, the CNA stated, the tray is contaminated and should be separated from the other trays. On 02/22/24 at 8:58 AM, the staff was identified as the Activity Director (AD). The surveyor interviewed the AD who stated that she had been working at the facility for 7 months. She usually assisted with the breakfast meal in the morning. She confirmed that she removed the dirty tray from Resident #1's room and placed the tray on the food cart. The surveyor then asked the AD what is the process when you removed a dirty tray from a resident room. The AD stated after you removed the tray you have to dispose of the tray properly and washed your hands. The dirty tray should not be placed with other trays that had not been served. The AD further stated, for infection control, you have to avoid spreading infection to other residents and the environment. The AD stated she received in-service education on infection control during orientation. 2. During the care tour on 02/23/24 at 6:43 AM, the surveyor entered Resident #31's room and observed Resident #31 lying in bed. Surveyor #1 observed the Nebulizer mask directly placed on the bedside table touching the Nebulizer machine surface on top of the night stand. The CNA provided incontinence care to the resident and left the room. On 02/23/24 at 7:15 AM, Surveyor #1 returned to the room and observed the Nebulizer mask (used for breathing treatments) still on the bedside table, not contained and exposed to the environment. The surveyor accompanied the Licensed Practical Nurse (LPN) who worked the 11:00 PM -7:00 AM shift to the room. Upon inquiry the LPN informed the surveyor that the 3:00 PM -11:00 PM left the Nebulizer mask on the table. The LPN added that she did not realize that the Nebulizer mask was on the the bedside table during the night. The LPN added that the Nebulizer mask should have been placed inside a plastic bag when not in use to prevent infection. On 02/23/24 at 11:15 AM, review of the medical record reflected that Resident #31 was admitted to the facility with diagnoses which included, but were not limited to chronic obstructive pulmonary disease, acute and chronic respiratory failure. A review of the Physician's Order Sheet (POS) for February 2024 revealed the following orders for Resident #31: Ipratropium/Albuterol solution 1 unit, inhale every 6 hours as needed for wheezing. 3. On 02/23/24 at 6:30 AM, the surveyor performed a random care tour with a Certified Nursing Assistant (CNA) #1. The CNA donned (put on) gloves, draw the curtain, checked the resident's incontinent brief and observed that the resident had double briefs on which were saturated with urine and feces. The CNA provided incontinent care to the resident, removed the gloves, went to the bathroom and performed hand hygiene under running water for 13.6 seconds. The surveyor asked the CNA if she received in-service education on hand hygiene, she stated,yes. A review of the CNA's file confirmed receipt of in-service education on hand hygiene on 01/31/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #159556 Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) 1 of 1 resident (Resident # 51) was reviewed for reoccurring Urinary Tract Infections (UTI), and b.) a facility-wide implementation of the Antibiotic Stewardship program, which included a system for routine feedback reports and tracking measures of outcome surveillance related to antibiotic use was followed, as per facility policy and national standards. This deficient practice was evidenced by the following: 1.) On 02/21/24 at 11:01 AM, the surveyor observed Resident #51 awake and alert sitting in his /her wheelchair in dining room eating lunch. A review of the Electronic medical record (EMR) revealed the following physician's orders (PO) and corresponding progress notes: On 11/15/23, a PO for Keflex (an antibiotic used to treat bacterial infections) 500 mg (milligram) 1 capsule orally three times a day for Extended Spectrum. Beta-Lactamase (ESBL- enzymes produced by some bacteria that may make them resistant to some antibiotics) for 7 days. A nurses note dated 11/15/23 at 11:44 PM, reflected that the resident was started on an antibiotic for UTI treatment. On 12/26/23, a PO for Macrobid (an antibiotic used to treat UTI's)100 mg give 1 capsule by mouth. A review of 12/26/23 Nurse Practitioner's (NP) note revealed that Resident #51 had a UTI that was positive for two organisms and was currently being managed with Macrobid. On 01/03/24, a PO for Levaquin (an antibiotic) 250 mg tablet, 1 tablet by mouth once daily for 7 days. A nurses note dated 01/02/24 revealed that Resident #51 had an intermittent reproductive cough, the doctor was notified and an order for Levaquin, cough medicine and a chest Xray was obtained. A NP note, dated 01/04/24 at 1:20 PM, revealed that the resident had Methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used) in the urine, was on isolation precaution and was currently being managed with Levaquin, and was previously on Macrobid. On 02/28/24 at 9:29 AM, the Director of Nursing/Infection Preventionist (DON/IP) provided a timeline of Resident #51's UTI's from 2022-2023 which revealed the following: 06/17/22-MD ordered Ciprofloxacin 500 mg twice a day for 5 days (an antibiotic commonly used for UTI's). 10/18/22-Resident admitted to the hospital with a UTI. 11/28/22-.Whit blood cell's (WBC's) elevated, order to collect urine culture and sensitivity (UA C&S) then start Cipro 500 mg twice a day for 5 days. 12/01/22- Urine culture positive for ESBL and infection disease consult ordered. 12/2/22- the Cipro was discontinued and IV antibiotic Invanz (an antibiotic used to treat a wide variety of bacterial infections)1 gram every 24 hours times 3 days was ordered for ESBL in the urine and osteomyelitis of the left great toe. 12/19/22 admitted to the hospital with colitis (an infection in the colon) 12/22/22-readmitted to the facility on Cipro 500 mg twice a day for 5 days for a UTI. 03/28/23- Urine culture positive, resident received Rocephin (an antibiotic used to treat many bacterial infections) 1 gm times one dose. 04/18/23 resident was admitted to the hospital after a fall and admitted with a UTI. 04/26/23 resident readmitted to facility with a UTI and an order for Invanz 1 gm IM (intramuscular) times one dose. 06/11/23- urine culture positive for ESBL, Macrobid 100 mg twice a day times 7 days ordered. 08/04/23 urine culture positive, Rocephin 500 mg twice a day for 6 days ordered. 11/14/23-Keflex 500 mg three times a day for 7 days for UTI 12/22/23- Cipro for UTI 12/25/22 Cipro discontinued and Macrobid started. A review of the Electronic medical Record (EMR) revealed that Resident #51 was admitted to the facility with diagnosis including but not limited to: Type 2 diabetes mellitus, dementia, overactive bladder, urinary tract infection (UTI), acquired absence of left great toe and coronary angioplasty implant and graft (a treatment used to widen and open narrowed or blocked arteries supplying your heart muscle). The Annual Minimum Data Set (MDS), as assessment tool, dated 11/30/23, revealed that Resident # 51 had severe cognitive impairment, needed maximum assistance for toileting hygiene, always incontinent of urine, had a UTI in the last 30 days and non-ambulatory. On 02/29/24 at 12:31 PM, the DON/IP provided the Antibiotic Stewardship binder dated January 2022-September 2023. The Antibiotic Stewardship binder revealed a [name redacted] Infection Surveillance Checklist completed for Resident # 51 UTI's for the following: 02/08/23 reflected that the UTI criteria was met, 06/11/23 did not indicate the UTI criteria was met or not met and 07/29/23 reflected that the UTI criteria was NOT met. There were no [name redacted] Infection Surveillance Checklist completed for Resident #51 UTI's that were documented in the UTI timeline or EMR as referenced above. The DON/IP provided the surveyor with an untitled print out of residents who were ordered antibiotics for the follow months: December 2023, January 2024, and February 2024. The untitled print out revealed Resident #51 was started on the antibiotic Cipro on 12/23/25 and completed Cipro on 12/25/23 for MRSA in the urine. Resident #51 was ordered Macrobid 100 mg on 12/26/23 and completed on 01/02/24 for a UTI. There was no [name redacted] Infection Surveillance Checklist completed or reviewed for Resident #51. The untitled print out of residents who were ordered antibiotics for January 2024 revealed Resident #51 started Levaquin on 01/3/24 and completed on 01/09/24 for an Upper Respiratory infection. There was no [name redacted] Infection Surveillance Checklist completed or reviewed for Resident #51. 2.) On 02/21/24 at 8:24 AM, the DON stated that he had been working as the Infection Preventionist (IP) also for about two months. On 02/21/24 at 11:34 AM, the surveyor was in the DON's office. The DON stated one of his responsibilities included the Antibiotic Stewardship Program (ASP) and that it depends on the day to determine how much time would be spend on IP or on being DON. He stated that he would review the electronic medical records (EMR) daily to see if a resident was ordered an antibiotic. He would review how long the order was for, if it was affective, and the staff would document daily during the antibiotic use and three days after the antibiotic was discontinued. The DON stated that he followed the facility policy and the Centers for Disease Control and Prevention (CDC) guidelines. The facility used a [name redacted] Criteria for Infection Surveillance Checklist. On 02/29/24 at 10:11 AM, the DON IP provided the ABP policy and procedure and provided July 2023 ABP and August 2023 ABP which was documented by the previous IP nurse. The information was as follows: July 2023 listing included 12 residents. The column to document onset-end date was incomplete for all 12 residents. The column to document culture/X-ray failed to document on four of the 12 residents. The column to document meets criteria failed to document on all 12 of the residents. The column to document outcome failed to document on 11 of the 12 residents. The facility failed to implement the [name redacted] Criteria for Infection Surveillance Checklist for three of the 12 residents, failed to complete the checklist for two of the nine residents, and failed to document that five were reviewed. The facility provided a Point Prevalence of Antibiotic Use (07/01/23-07/31/23), printed on 09/11/23 which included but was not limited to; 30 residents listed with end dates in July 2023; drug class with percentage of the use of that drug class; the residents name; status in or out of house; medication name; the directions for use; diagnosis; and start and end date. The report failed to include a diagnosis for 13 of the 30 residents. August 2023 listing included six residents. The column to document onset-end date was incomplete for all six residents. The column to document symptoms/infection was left blank for one resident. The column to document meets criteria was left blank for all six residents. The column to document outcome was left blank for five of the six residents. The [name redacted] Criteria for Surveillance Checklist was not provided for one of the six residents. The [name redacted] Criteria for Surveillance Checklist for three residents documented criteria not met and the three residents were ordered antibiotics, and five of the checklists were not reviewed. There was no Point Prevalence of Antibiotic Use for the month. September 2023 was an untitled print out of 12 resident names, date started (no end dates), the medication name, a site of infection with two of the 12 residents left blank, symptoms with 12 of 12 residents left blanks, pathogen with one of 12 left blank, community/health care associated with eight of 12 left blank, and comments with all 12 residents left blank. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the 12 residents, and no outcome results for any of the 12 residents. October 2023 was an untitled print out of 10 residents, date started (no end dates), the medication name, site of infection for nine of the 10, symptoms were blank for all 10 residents, pathogen was blank for one of the 10 residents, community/health care associated was blank for four of the 10 residents, and the comments were blank for all 10 residents. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the 10 residents, and no outcome results for any of the 10 residents. November 2023 was an untitled print out of 11 residents, date started (no end dates), the medication name, site of infection for seven of the 11 residents, symptoms were blank for 10 of the 11 residents, pathogen was blank for five of the 11 residents, community/health care associated was blank for two of the 11 residents, and comments was blank for nine of the 11 residents. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the 11 residents, and no outcome results for any of the 11 residents. The DON/IP was responsible for the following ABT stewardship tracking which included but was not limited to the following; December 2023 was an untitled print out of 19 names, date started (no end dates), the medication name, site of infection was blank for two of the 19 residents, symptoms were blank for eight of the 19 residents, pathogen was blank for six of the 19 residents, and comments were blank for 18 of the 19 residents. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the 19 residents, and no outcome results for any of the 19 residents. January 2024 was an untitled print out of eight residents, date started, date completed, medication name, site of infection, symptoms with blanks for two of the eight residents, pathogen with blanks for seven of the eight residents, and comments were blank for eight of the eight residents. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the 10 residents, and no outcome results for any of the 10 residents. February 2024 was an untitled print out of five residents, date and end date, medication name, site of infection, symptoms were left blank for four of the five residents, pathogen, community/health care associated was blank for one of the five residents and comments was left blank for five of the five residents. There was no Point Prevalence of Antibiotic Use for the month, no [name redacted] Criteria for Surveillance Checklist completed or reviewed for any of the five residents, and no outcome results for any of the five residents. On 02/29/24 at 11:22 AM, the DON stated that it was his responsibility to track down any antibiotics, to determine if they were affective, and to discuss the antibiotics with the physicians. He stated that excessive use of an antibiotic could lead to other things. The DON stated the process was to use the [name redacted] Criteria checklist with the algorithm and that ideally the corresponding test results would be included. The DON stated that it was his responsibility to ensure the algorithm and checklist were correct. The DON stated the checklist would be reviewed at morning meeting. He further stated that I haven't been able to check on them [Antibiotic Stewardship] for a while. On 03/05/24 at 10:44 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, stated he was unaware that the ASP was not being completed by the DON IP. The LNHA stated that he should have been aware and that the ASP was important for the facility to be able to track infections and how the residents respond. The LNHA stated there was no documentation of any conversations between him and the DON IP, but that he should have known the ASP was not being conducted. On 03/06/24 at 8:03 AM, the Registered Nurse Unit Manager (RN UM) stated that the process for tracking infections was that if there were orders for antibiotics, they would be in the resident's Medication Administration Record (MAR). She stated that there were no other tracking methods for any other infections. A review of the facility provided, Infection Control Nurse job description undated, included but was not limited to; Purpose: to ensure that an effective infection control program is maintained at all times. Responsibilities: plan, develop, organize, implement, evaluate, coordinate, and direct the infection control program in accordance with current rules, regulation, and guidelines that govern in nursing care facilities. Functions: ensure that laboratory support is available, including microbiological and serological services. Prepare monthly summaries of resident and personnel infections, the corrective actions taken, and the results of the corrective actions. A review of the facility provided, Infection Control-Antibiotic Stewardship dated 03/01/23, included but was not limited to; Intent: to support the judicious use of antibiotics in accordance with State and Federal regulations and national guidelines. Procedure: 1. Establish protocols for prescribing antibiotics in accordance with national guidelines and treatment protocols. 2. Establish algorithms for appropriate diagnostic testing (example obtaining cultures) for specific infections. 3. Summarize antibiotic use on a quarterly basis and use the data to evaluate adherence to antibiotic prescribing protocols and appropriate diagnostic testing protocols. 4. Provide an antibiogram annually to medical staff to support prescribing practices. 5. Document dose, duration, and indication for all antibiotics prescribed. A review of the facility provided, Infection Control, Prevention and Surveillance Plan dated 03/01/23, included but was not limited to; Policy: The Infection Prevention and Control Plan (IPCP) consists of the IPCP policy and procedures and the Antibiotic Stewardship program. Mission and Goals: focus on both employee health and resident care practices; the prevention of adverse outcomes such as healthcare associated infections, optimizing antibiotic use and fostering evidenced-based decision making. 2. a. proactively preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. b. initiating proper measures to limit exposure to pathogens or their spread from identified sources of contagion . c. collecting, analyzing, and trending data and instituting corrective actions. 4. optimize the use of antibiotics to meet resident specific needs per the Antibiotic Stewardship Program. Scope: based on the latest recommendations from the CDC. Components include. 6. Antibiotic Stewardship: specific elements as defined by the CDC. Committee Oversight: 2. a. meets quarterly and report to QAPI (Quality Assurance and Performance Improvement) committee. 3. a. provides oversight for improvement and sustainability of infection prevention and control and the antibiotic stewardship practices and outcomes. Authority: 1. d. generate and review data such as infection rates and antibiotic resistance rates. e. monitors and reports the antibiotic use to meet resident needs. IP responsibilities: culture surveillance; route surveillance; antibiotic drug resistant management; and antibiotic stewardship oversight. Antibiotic Use Protocols and Systems: elements of antibiotic stewardship including: d. monitoring and tracking, e. reporting. f. documenting. Evaluating: regularly review and analyze antibiotic use data, including data from drug regimen reviews. Antibiotic Stewardship measurement is critical to identify opportunities for improvement and assess the impact of improvement efforts. Reference: CDC Core Elements of Antibiotic Stewardship of Nursing Homes, dated 09/07/23. https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html A review of the CDC Core Elements of Antibiotic Stewardship of Nursing Homes, dated 09/07/23, included but was not limited to; 4. Does the facility have policies to improve antibiotic prescribing/use? Developed facility specific algorithm for diagnostic testing for specific infections; reviews antibiotic agents listed on the medication formulary. 5. Developed reports summarizing the antibiotic susceptibility patterns; implemented an antibiotic review process or time out. 9. Does the facility provide specific reports on antibiotic use and outcomes with clinical providers and nursing staff? Measures of outcomes related to antibiotic use; report of facility antibiotic susceptibility patterns with the last 18 months; personalized feedback on antibiotic prescribing practices to clinical providers. The above information was presented to the facility on [DATE]. The facility had no additional information to provide the survey team. NJAC 8:39-19.4(d)(g); 27.1

Deficiency Text Not Available

Based on observation, interviews, and other facility documentation, it was determined that the facility failed to ensure that kitchen staff were properly trained and capable of performing assigned duties to maintain proper kitchen sanitation and prevent food-borne illness. This deficient practice was evidenced by: During the initial tour of the kitchen on 11/17/21 from 09:47 AM until 10:34 AM, the surveyor observed the following in the presence of the Director of Dining Services (DDS): During an interview with the surveyor at 10:16 AM, the DDS stated that a high temperature dish machine was utilized, and the required wash temperature was 150 degrees or higher and the required final rinse temperature was 180 degrees. The surveyor reviewed the Dish Machine Temperature log for the month of November 2021 which revealed that the required rinse temperature of 180 degrees was not met during all recorded breakfast and lunch washes from 11/1/21 through 11/16/21 and only met the rinse requirement during dinner on 11/01/21, 11/03/21, and 11/08/21. Review of the October 2021 Dish Machine Temperature log revealed that the required rinse temperature of 180 degrees was not met during the recorded breakfast readings from 10/01/21 through 10/31/21 and was only met during the recorded lunch readings on 10/03/21, 10/09/21,10/17/21, 10/24/21 and during the recorded dinner readings on 10/01/21 10/03/21, 10/04/21, 10/07/21, 10/11/21, 10/12/21, 10/13/21, 10/14/21, 10/15/21, 10/16/21, 10/17/21, 10/18/21, 10/20/21 and 10/25/21 through 10/31/21. At that time, the DDS stated that she was responsible to review the Dish Machine Temperatures and when she last reviewed it a couple of days ago, she did not notice that the final rinse temperatures were recorded at values less than 180 degrees as required. She further stated that the dishes were not sanitized if the final rinse temperature of 180 degrees was not met. During an interview with the surveyor at 10:19 AM, The Dietary Aide (DA) ran the dish machine to demonstrate function in the presence of the surveyor and the DDS. He stated that the wash temperature should be 158 degrees and the final rinse temperature should be 189 degrees. He stated that the rinse cycle usually ran at 172 degrees. When the surveyor asked if the dishes were sanitized when the final rinse cycle was 172 degrees he stated, Yes, because the water got hot and burned. The DA stated that the dishes were sanitized if the final rinse cycle measured 172 degrees. He stated that the dish machine went down a couple of months ago and he received an in-service on dish machine usage and function at that time. The DA then ran the dish machine and stated that the wash temperature was 162 degrees, and the final rinse was 172 degrees. At that time, the surveyor observed that the final rinse temperature was 192 degrees and was not accurately identified by the DA who instead reviewed the rinse temperature, instead of the final rinse temperature value. When interviewed, the DA stated that final rinse was not being recorded, and the rinse tank temperature which preceded the final rinse cycle, was recorded instead when he completed the Dish Machine Temperature log. During an interview with the surveyor on 11/19/21 at 12:33 PM, the DDS stated that she should have paid more attention to the dish machine temperature logs. She stated that she confirmed that the staff recorded rinse temperature on the Dish Machine Temperature logs for the month of October and November 2021 instead of the final rinse temperatures as required. She stated that she phoned the repair technician previously when the temperature readings were observed to be low, and the technician determined that the dish machine met the required temperatures for sanitization. She stated that competencies were not done with the Dietary Aides for dish machine use and related documentation. She further stated that she had not yet conducted employee in-services to confirm that the Dietary Aides knew how to properly check the dish machine temperatures since 11/17/21 when the surveyor observed the dish machine function. During an interview with the surveyor on 11/23/21 at 9:34 AM, the Licensed Nursing Home Administrator (LNHA) stated that though the DA had an in-service related to pot washing and dishwashing on 09/21/21, he should have had a competency done upon hire. She stated that the DDS also should have reviewed the Dish Machine Temperature logs daily to ensure that the dish machine functioned properly. Review of the Dishwashing Policy (reviewed 02/20/2017) revealed the following: Use the steps in the following procedure to instruct and demonstrate to staff for training purposes. Procedure: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. A. High Temp dishwashers (wash 150, rinse 180) .If temperature does not meet requirements for a high or low temp machine as noted above .alert your DDS and/or the maintenance director for further instruction . Director of Dining Services will spot check dish machine temperature log to assure proper sanitizing of dishes. NJAC 8:39-17.2(g) and 19.7(d)

Based on observations, interviews, and review of facility documentation, it was determined the facility failed to a.) maintain medications with appropriate labeling and b.) maintain a clean, orderly medication cart for 2 of the 3 carts observed on 2 of 2 nursing units. This deficient practice was evidenced by the following: On 11/18/21 from 11:19 to 11:54 AM, in the presence of the Registered Nurse (RN) #1, the surveyor observed the following in the medication cart labeled B on the 100 unit: 1. In the first row of the second drawer, there were two yellow oval tablets, one pink oval tablet, one large white oval tablet, one small white oval tablet, and one white round tablet which were unwrapped and unmarked. There was also paper debris. 2. In the third row of the second drawer, there was one large pink oval tablet, seven white oval tablets, six small white round tablets, one small pink oval tablet, two pink round tablets, one green round tablet, and two yellow oval tablets which were unwrapped and unmarked. There was also paper and foil debris. 3. In the fourth row of the second drawer there was one large white tablet, three yellow oval tablets, one blue oval tablet, three white round tablets, two white oval tablets, and one peach round tablet which were unwrapped and unmarked. There was also paper and foil debris. During an interview with the surveyor at that time, RN #1 stated the nurse cleaned the medication cart when they started their shift and that the loose medications should not have been in the drawer. RN #1 further stated that the unit manager should be notified and that the medications would be destroyed using the drug buster so that they were not given to a resident. On 11/18/21 from 12:32 to 01:08 PM, in the presence of RN #2, the surveyor observed the following in the medication cart for the 200 unit: 1. In the first row of the second drawer, there were two white round tablets, one peach round tablet, and one blue half tablet which were unwrapped and unmarked. There was also debris. 2. In the second row of the second drawer, there were two white round tablets, one peach round tablet, and one peach half tablet which were unwrapped and unmarked. There was also paper and foil debris. During an interview with the surveyor at that time, RN #2 stated it was the nurse's responsibility to clean the cart each shift and that she was unsure why the pills were loose in the drawers and that she would destroy them in the drug buster. RN #2 further stated it was important to account for all of the medications for each resident and to correctly refill the cart when medications were received from the pharmacy. Review of the facility's policy titled Medication Storage in the Facility, dated 8/28/2007, included but was not limited to; Procedure 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices. Medications are kept in these containers. 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy .14. Medication storage areas are kept clean, well-lit, and free of clutter . NJAC 8:39-29.4(a),(h)

Based on observation, interview and review of the medical record, it was determined that the facility failed to provide skin protective device as ordered for the prevention of pressure ulcers. This deficient practice was identified for 1 of 2 residents reviewed, Resident #61 and was evidenced by the following: The admission Face Sheet (AFS) dated 12/10/2019, reflected that Resident #61 was admitted to the facility with the medical diagnoses of Atherosclerotic heart disease, Hypertension, Hypothyroidism and Malignant Neoplasm of an unspecified site. The quarterly Minimum Data Set (MDS) an assessment tool dated 10/30/19, indicated that Resident # 61 had severe cognitive deficits and required complete care with all aspects of activities of daily living (ADL's). The MDS also reflected that Resident #61 had one or more unhealed pressure areas and was at risk for developing pressure areas. On 1/6/20 at 10:32 AM, the surveyor observed Resident # 61 sitting in his/her wheelchair with just socks on their feet. Both the resident's heels were lying directly on the foot rest of the wheelchair. The resident was not able to be interviewed secondary to severe cognitive deficits. The Physician Order Form (POF) documented an order dated 12/10/19 that Resident #61 was to have heel booties to both heels at all times and to remove only for AM and PM care every shift. The Care Plan (CP) dated 2/7/19 indicated that Resident #61 had a stage 3 pressure ulcer on the left heel. The CP intervention dated 12/10/19 was that heel booties were be applied to both Resident #61's heels at all times every shift and to remove for AM and PM care. There was also another intervention on the CP dated 8/26/19, that Resident #61 heels were to be off loaded (medical term for relieving pressure on a part of the body). On 01/06/20 at 12:11 PM and 1:30 PM, the surveyor observed Resident #61 sitting in the dayroom with no heel booties on and both heels were lying directly on the hard surface of the wheelchair's foot rest. The Wound Care Assessment (WCA) form dated 1/3/2020, documented that Resident #61 had pressure wound on the left heel healing stage 3 with a size of length 0.7 cm x width 0.5 cm x depth 0.1. The WCA also indicated that the resident had a right heel pressure wound that healed. The POF dated 1/4/2020 documented treatment orders for betadine to be applied to the left heel daily and a treatment order dated 1/3/2020 for skin prep to be applied to the right heel and leave open to air. The Treatment Administration Record (TAR) contained signatures by the nursing staff on 1/6/20 on the 7-3 shift that heel booties were in place. The surveyor did not observe heel booties on the resident at that time. On 01/07/20 at 09:20 AM, the surveyor observed Resident # 61 sitting in the activities room with only socks on their feet. The heel boots that were ordered by the physician were not on the resident. The resident's heels were lying directly on the hard surface of the foot rest and were not being off loaded to prevent pressure to the heels. On 01/07/20 at 10:49 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that Resident # 61 required total assist with ADL's and had a pressure wound on the left heel that was receiving treatments. The LPN also stated that preventive measure included multipodus (floats the heel to enhance blood circulation vital to healing by eliminating friction or pressure on the back of the foot) boots at all times. I'm not sure why the multipodis boots were not on the resident yesterday, but it was my understanding that the boots were being laundered and since the boots are specialty boots, we don't have extra boots available. She admitted that the residents heels should not be lying directly on the hard surface of the foot rests and that something else should have been put in place to offload the residents heels if the multipodus boots were not available. On 01/07/20 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident is at risk for breakdown or has actual breakdown and the ordered preventive device was not available then an alternate device was to be utilized to offload pressure. If the boots weren't available then a pillow or something should have been utilized to prevent pressure to the residents heels. The facility policy titled Wounds with a revised date of 12/2019, indicated that during wound care treatments, the nurse will observe the condition of the wound bed and surrounding area to assure the area is clean and appropriate treatment is being done. The nurse will observe to assure that the following interventions have been consistently implemented on their shift to include: -Adequate pressure relieving devices. -Appropriate and timely repositioning and incontinence care. -Assessment for the presence of any pain. NJAC 8:39-27.1 (e)

Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to follow fall prevention interventions as written on the resident's plan of care. This deficient practice was identified for 1 of 6 residents (Resident #86) reviewed for falls and accidents and was evidenced by the following: The admission Face Sheet (AFS) dated 6/26/2017, indicated that Resident # 86 was admitted to the facility with the medical diagnoses of Hypertension, Dementia and Muscle Weakness. The significant change Minimum Data Set (MDS) an assessment tool dated 11/20/19, reflected that the resident had severe cognitive deficits and required complete care with all aspects of activities of daily living (ADL's). The MDS also reflected that Resident # 86 had a fall which resulted in a injury since the prior MDS assessment. The Care Plan (CP) dated 11/29/19 documented that Resident #86 was at risk for falls. An intervention to reduce the resident's risk for falls dated 6/26/17 was that the Resident #86 had a bed alarm and a chair alarm and staff was to check for their placement and function every shift. The Physician Order Form (POF) dated 6/26/17 documented an order for a bed alarm and chair alarm and for staff to check for their placement and functioning every shift. On 1/6/20 at 1:10 PM, the surveyor observed Resident # 86 sitting up in the geri-chair (reclining chair). The surveyor did not observe a chair alarm on Resident #86's chair. The Treatment Administration Record (TAR) documented a physicians order for a bed alarm and chair alarm and to check for their placement and function every shift. There was nursing check mark on 1/6/20 at 10:00 AM that indicated that the alarm was in place and functioning on the resident's bed and chair, however the alarm was not observed on the resident's chair or bed by the surveyor. On 01/07/20 at 09:32 AM, the surveyor observed the resident in bed and again did not observe an alarm on the resident's bed. On 01/07/20 at 10:22 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident did not have a bed alarm or wheelchair alarm and did not know how long he/she did not have one. The CNA also indicated that the resident was at risk for falling. On 01/07/20 at 11:01 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that Resident # 86 had one alarm which was transferable to the bed or to the wheelchair depending on where the resident was. The LPN also stated that the chair alarm should be on the residents chair since the resident was up in the geri-chair. The LPN accompanied the surveyor to the residents room and found the alarm in the back of the residents drawer and indicated that the pad was missing for the chair alarm. The LPN admitted that this was a problem and that the alarm should have been on the residents chair and would find out why it was not. On 1/9/2020 at 1:00 PM during the exit conference with the Director of Nursing (DON) and Administrator, there was no additional information provided. The facility policy titled Bed and Chair Alarms and dated 8/7/2019, indicated that if a resident is found to be at risk for fall/accident a plan of care will be initiated by the Interdisciplinary team (IDCP) to prevent such accidents/incidents. The policy also indicated that bed/chair alarms are one device used in prevention of accidents/incidents and that they may be used alone or in conjunction with other interventions as identified on the plan of care. The unit manager or designee will be responsible for proper placement and functioning of all alarms and making sure they are in place by making rounds. NJAC 8:39-27.1 (a)

Based on observation, interview and record review it was determined the facility failed to monitor medication refrigerator temperatures to ensure safe medication storage. This deficient practice found in one of two medication storage refrigerators and was evidenced by the following: On 01/07/20 at 10:54 AM, the surveyor inspected the medication room on Unit One in the presence of the unit Licensed Practical Nurse (LPN). During the medication room inspection the surveyor inspected the medication refrigerator. The refrigerator temperature registered 36 degrees at time of inspection. In the refrigerator were eight insulin vials, one insulin pen and three bottles of residents' prescription eye drops. All medications were unopened. The surveyor asked the LPN the process of monitoring refrigerator temperatures and the LPN stated it was done daily by the night shift staff and written on a log. The surveyor then asked to see the refrigerator logs. The LPN gave the surveyor the logs for November 2019, December 2019, and January 2020. For the month of November, 15 days out of the month the temperatures were not checked. In December, for nine days of the month the temperatures were not checked. In the month of January there were three days the temperatures were not checked. The surveyor asked the LPN why the temperatures were not checked on those days and the LPN stated, it was probably agency nurses. On 01/07/20 at 11:15 AM, the surveyor asked the LPN what the process would be if the refrigerator temperatures were out of range. The LPN told the surveyor that maintenance is called to come check the refrigerator and the medications would be removed. On 01/07/2020 at 12:30 PM, the Director of Nursing (DON) provided the surveyor with the policy titled Medication Storage in the Facility. The policy had an effective date August 28, 2007 and the area for a review or revision date was blank. The DON could not provide a reviewed or updated policy. Number 11 under the procedures section indicated that medications requiring refrigeration or temperatures between 36 and 46 degrees Fahrenheit are kept in the refrigerator with a thermometer to allow temperature monitoring. The DON also gave the the surveyor a policy titled Medication Storage and Labeling with a date initiated of 06/2016. The policy did not address refrigerated medications. The surveyor asked the DON how often the refrigerator temperatures are checked and the DON said once a day. On 01/09/20 at 12:08 PM, the surveyor requested to see the monthly pharmacy audits of medication storage from the Director of Nursing. The DON provided the surveyor with a Monthly Nursing Station Review that was completed by the Pharmacy Consulting Company. The audit was dated December 13, 2019. In the section titled Refrigerator, the temperature okay area was marked No. NJAC 8:39-29.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of medical records and other pertinent facility documentation, it was determined that the facility failed to follow professional standards of clinical practice by a.) not providing topical medication as ordered by the physician for Resident #26, and b.) not providing skin protective devices as ordered by the physician for Resident #86, 2 of 22 residents reviewed and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a.) On 1/06/20, the surveyor observed Resident #26 in their room sitting in a wheelchair. The resident informed the surveyor he/she was supposed to be receiving a fungal powder each day so he/she could wear a prosthetic device and ambulate. According to the Resident Face Sheet, Resident #26 was admitted to the facility on [DATE], with the medical diagnoses including Major Depressive Disorder, Epilepsy, Chronic Pain Syndrome and Acquired Absence of Left Leg Above Knee (amputation). The annual Minimum Data Set (MDS), an assessment tool dated 12/19/19, indicated Resident #26 was cognitively intact, required none to limited assistance with activities of daily living (ADL's), did not ambulate in the room or in the corridor with ADL's and was currently receiving physical therapy. The surveyor reviewed the resident's electronic treatment administration record (eTAR) which revealed an order dated 12/11/2019 for Nystatin, apply to groin daily (bedtime) at 9:00 PM. The eTAR indicated the powder was signed as given each evening beginning on 12/11/19 and through 1/6/20 by 6 different second shift nurses. On 1/7/20 at 11:51 AM, the surveyor requested the nurse on duty show evidence of the medication on the treatment cart. The nurse was unable to locate the medication on either treatment cart. On 1/7/20 at 12:07 PM, during a follow up interview with Resident #26, the resident told the surveyor he/she had spoken with both the regular day and evening nurse, requesting the medication. Resident #26 also revealed having a conversation with the nurse practitioner last week. Resident #26 revealed the Nurse Practitioner (Advanced Practice Nurse (APN)) stated, How can they (the nurses) be charting for something you don't have? The powder never arrived. On 1/7/20 at 12:14 PM, during a telephone interview, the APN confirmed the order for the fungal powder and indicated that the facility told her the powder was in stock. The APN further revealed after the resident made her aware the medication was not being administered, she informed a nurse who reordered the medication. The APN indicated she did not document on the medication concern because her, focus was on a different topic. On 1/7/20 at 12:30 PM, the UM indicated if the medication was in stock, it would be on the treatment cart. The UM confirmed the reorder in the eTAR. On 1/8/20 at 12:31 PM, The Regional Corporate QA Nurse (RCQAN) told the surveyor the Nystatin was not received because the order required clarification. The RCQAN also stated that staff should not have been documenting that medications were being given if they were not. The surveyor reviewed a collection of statements received by the Director of Nursing beginning on 1/7/20 and through 1/9/20. The surveyor reviewed 5 statements obtained from the nursing staff. Four of the five statements confirmed the nurses signed for a medication they did not provide to the resident and was followed up with documentation by the DON indicating the facility would be following up with disciplinary action. The fifth statement indicated the nurse did not recollect what happened. On 1/8/20 at 1:50 PM, the surveyor reviewed a statement by the UM which revealed the facility was unable to obtain a clarification order from the pharmacy. The UM confirmed the order didn't go through because the order didn't specify powder or cream. The UM indicated the order has been clarified and the medication was received. b.) The admission Face Sheet (AFS) dated 6/26/2017, indicated that Resident # 86 was admitted to the facility with the medical diagnoses of Hypertension, Dementia and Muscle Weakness. The significant change Minimum Data Set (MDS) an assessment tool dated 11/20/19, reflected that Resident #86 had severe cognitive deficits and required complete care with all aspects of activities of daily living (ADL's). The MDS also reflected that Resident #86 was at risk for developing pressure ulcers and skin injuries. The Physician Order Form (POF) dated 5/28/18, reflected an order to apply Geri-sleeves (protective skin sleeves) to both lower extremities when out of bed to wheelchair for skin protection on the day shift and evening shift and a physician's order dated 8/7/18 to apply Geri-sleeves to both arms in the AM and to remove during the night shift and evening shift. On 01/06/20 at 11:57 AM, the surveyor observed the resident sitting up in the Geri-chair (reclining chair). resident #86 did not have protective skin sleeves on their arms and legs as ordered by the physician. The resident was unable to be interviewed due to severe cognitive impairment. The Care Plan dated 11/29/19, indicated that the resident was at risk for skin tears and that the resident's skin would remain intact and free from tears and bruising. On 5/28/18 an intervention was put into place to apply Geri-sleeves to both lower extremities when out of bed to wheelchair for skin protection on both the day shift and evening shift. On 1/7/20 at 9:35 AM, the surveyor entered Resident # 86's room and observed the Certified Nursing Assistant (CNA) providing care to Resident # 86. The surveyor interviewed the CNA at this time and the CNA stated that there were no devices that he was aware of that needed to be applied to the resident. The CNA directed the surveyor to interview the nurse about what devices the resident was ordered to wear. On 1/7/20 at 10:45 AM, the surveyor observed Resident # 86 sitting up in the Geri-chair in the activities room. The resident was not wearing any protective Geri-sleeves on their arms or legs as ordered by the physician. The surveyor did not observe any skin impairments on the arms or legs at this time. On 01/07/20 at 12:07 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident was at risk for skin tears and should be wearing protective sleeves on his/her arms and legs. The LPN accompanied the surveyor to the resident's room and located the protective sleeves in a tied bag in the resident's drawer. The LPN stated that the CNA should have put the protective sleeves on the resident and that it was difficult to make sure that every staff member was doing their job. The LPN then stated that it was the nurses responsibility to assure that the protective sleeves were applied to the resident. The Treatment Administration Record (TAR) reflected a physicians order for Geri-sleeves to be applied to both lower and upper extremities when the resident was out of bed to the wheelchair for skin protection on both the day shift and evening shift. A copy of the TAR was provided to the surveyor on 1/7/19 at 12:48 PM. There was no nursing signature that the Geri-sleeves were applied even though the resident was out of bed in the Geri chair at that time. On 1/19/2020 at 1:00 PM, during the exit conference with the Director of Nursing (DON) and the Administrator, no other additional information was provided to the surveyor. The facility policy titled Fragile Skin Protection dated 8/8/19 indicated that if a resident is found to be at risk for skin impairment a care plan will be initiated to prevent such incidents as bruising and skin tears. Geri-sleeves and long sleeve shirts and long pants will be used as initial interventions. They may be used alone or in conjunction with other interventions to prevent skin breakdown. The unit manager or designee will be responsible for proper placement of these interventions during shift rounds. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a manner to prevent foodborne illness. This deficient was practice was evidenced by the following: On 01/06/20 at 09:56 AM, the surveyor, who was accompanied by the Food Service Director (FSD), observed the following: 1. On a foil tray on the bottom open shelf of the snack prep area, there was a sleeve of five-ounce cold cups and a pack of eight-ounce cups. Both packages were open and exposed to air. The dietary aide indicated the items were open when he got to the area and the items should be wrapped when not in use. The dietary aide disposed of the items. 2. Next to the snack prep area, there was an uncovered stand mixer that was not in use. There was visible debris on the mixer as well as particles within the mixing bowl. The FSD indicated the mixer hadn't been used in months and revealed the mixer should be covered when not in use. 3. There was visible debris on the seasoning shelves in the hot cooking area, a package of open and undated elbow macaroni, an open and undated 11-ounce package of coconut flour, a bottle of multi-purpose foaming decarbonate and concentrated oven cleaner on its side in the corner of one of the shelves that was leaking onto the shelf, a single pack dinner roll the FSD described as, Covered in mold with an expiration date of 4/10/19 and 2 hot dog rolls in a 12 pack package, open and exposed to air, with an expiration date of 12/31/19. The FSD described the shelves as having debris on them and indicated bread should be stored in a cold dry storage room. The FSD removed the bottle of cleaner and discarded the breads and open packages at that time. The Chef, who was in the cooking area, revealed he hadn't seen the cleaner and chemicals should not be stored near food. 4. On the bottom shelf of the prep area of the hot cooking area was a sleeve of foam bowls, plastic lids, and five three compartment plates open and exposed to air. The FSD discarded these items. 5. The double sets of doors leading from the kitchen to the dry storage area were visibly soiled. The main door to the dry storage area was soiled with dried brown drips under the doorknob. 6. There were 3 stacks of large coffee filters in the dry storage area, open and exposed to air, 1 stack was on a shelf below someone's baseball cap hanging on the shelf post. There was a lid open on a flour bin with an open unlabeled 25 lb flour sack contained within. The FSD disposed of the open flour. The FSD stated the container should be closed when not in use and the flour sack should be labeled once opened. There were two packs of ziti noodles and two packs of orzo noodles on a shelf on a storage rack that were undated. On the shelf above them, was a 5 lb bag of ziti noodles, open and exposed to air which was not dated. In the can goods section, there was a 6 pound 10-ounce can of marinara sauce with a dent in the seam and a 6 pound 11-ounce can of pineapple tidbits with a dent in the seam. The FSD revealed there should be no dented cans mixed in the can area because there is a separate area for dented cans located in the hallway. 7. In the walk-in refrigerator on the bottom shelf on a storage rack, there was a 20-pound bag of chicken drumsticks and a 10-pound bag of boneless chicken. Both were undated. The FSD indicated it should be dated to thaw and disposed of them. 8. The surveyor observed black spots in the bottom of the ice scoop holder. The FSD described the spots as, Debris. There was additional black debris on the inside of the ice machine on an edge directly above the ice storage compartment. The FSD stated he would have the scoop and holder cleaned and stated that maintenance was responsible for maintaining the ice machine. The surveyor returned to the kitchen on 01/08/20 and observed the FSD in the hot cooking area without a hair net or beard net. He said he entered the kitchen through the rear entrance and there were no nets at that entrance. The FSD put on a hair net and beard net at that time. The surveyor reviewed the policy titled, Dating and Labeling Policy, with a revised date of 11/2019, which revealed opened food items must be sealed and dated upon use. The policy further revealed not labeled or expired items must be discarded immediately. The surveyor reviewed the policy titled, Chemical Storage & Equipment Safety Policy, with a revised date of July 2019, which revealed chemical items must be kept away from food items and any kitchen items that might come in contact with residents' meals and chemicals should not be set next to food items or other place other than the designated area. The policy further revealed equipment should be covered after being cleaned and sanitized. The surveyor reviewed the assignment titled, 530-130 AM COOK Cleaning Daily assignment, and, 1130-730 PM COOK Cleaning Daily assignment, both with a revised date of May 2019, which revealed both assignments were responsible to wipe down shelving under the prep area and to ensure all products were labeled and dated. The surveyor reviewed the schedule titled, Cleaning list schedule for the Dietary Department, with a revision date of September 2019 which revealed all work areas and equipment surfaces must be cleaned daily at the end of each shift. The surveyor reviewed the policy titled, Personal Items Policy, with a revision date of June 2019 which revealed personal items were not permitted in the kitchen, chemical room or dry storage area and should be kept in the employee locker room. The surveyor reviewed the policy titled, Dented Can Policy, with a revision date of September 2019 which revealed canned goods should be checked in on arrival for dents and dented cans must be stored in the designated dented can area. The surveyor reviewed the policy titled, Policy on ice machine Sanitation, with a revision date of October 2019 which revealed ice scoop holders would be removed, On a regular basis, for cleaning and ice machines would be serviced by maintenance, On a regular need basis upon identification of dirt or malfunctions. The surveyor reviewed the policy titled, Policy on hairnet and [NAME] guard use, with a revision date of September 2019, which revealed dietary must wear a hairnet, When working in the kitchen at all times, and people with facial hair must wear a beard net when entering the kitchen. NJAC 8:39- 17.2(g)