Based on observation, interviews, record review and review of pertinent facility documents, it was determined that the facility failed ensure that a Registered Nurse (RN) documented a resident's assessment after a fall occurred. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #10). Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/03/25 at 10:26 AM, the surveyor observed Resident #10 in bed. The resident stated they fell yesterday. The surveyor reviewed the medical record for Resident #10. A review of the admission Record (an admission summary) reflected the resident had diagnoses which included but not limited to; age related osteoporosis and mild cognitive impairment. A review of a comprehensive Minimum Data Set, an assessment tool used to facilitate the management of care, reflected the resident had a Brief Interview for Mental Status of 7 out of 15, which indicated the resident had a severely impaired cognition. A review of the Nursing Note dated 2/23/2025 at 7:02 PM, reflected that Resident #10 sustained a fall on 2/23/2025 at 6:30 PM. This note was entered by Licensed Practical Nurse (LPN) #1. There was no documented evidence in the Electronic Medical Record (EMR) that a Registered Nurse (RN) assessed the resident after Resident #10 sustained a fall. A review of the facility's Incident/Accident Report including the facility's Incident Investigation Worksheet, both dated 2/23/2025, were completed and signed by LPN #1. On 4/07/25 at 1:50 PM, LPN #1 stated the nurse assigned to a resident who sustained a fall completed all incident documentation. He further stated, when the Unit Manger/RN assessed the resident, they don't document the assessment. On 4/07/25 at 2:04 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team. She stated when the RN assessed the resident, the RN and or supervisor would not document anything on the incident/accident report or in the EMR regarding their assessment. She stated, They must do the assessment, but they do not document on any separate form. She further added that residents who sustained a fall should be assessed by the RN to determine if there was any complication or injury from the fall. A review of the facility's policy Fall Assessment and Management with a revised date of 10/2024, did not reflect that a RN was required to document resident's assessments after sustaining a fall. A review of an undated facility Job Description titled Registered Nurse, included duties and responsibilities for supervision of direct care provided to residents by CNAs and LPNs. NJAC-8:39-5.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) an apical heart rate (pulse heard on the chest) was obtained before the medication Digoxin (a medication used to treat heart failure or rhythm problems) was administered by one (1) of three (3) nurses and b.) required vital sign parameters for a medication were obtained in a timely manner by one (1) of three (3) nurses who administered medications to two (2) of five (5) residents, (unsampled Residents #2 and #140), during the medication administration observation. The deficient practices were 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 4/4/25 at 8:47 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing medications for unsampled Resident #2. LPN #1 stated that there was a physician's order (PO) for Digoxin and would have to obtain an apical pulse. On 4/4/25 at 9:04 AM, LPN #1 stated that she was going to the nursing station to get a stethoscope to perform the apical pulse. On 4/4/25 at 9:06 AM, the surveyor observed LPN #1 return to the medication cart, enter unsampled Resident #2's room and hold the resident's wrist for 60 seconds. LPN #1 then stated that the pulse was 76 and was able to administer the Digoxin. The surveyor had not observed LPN #1 return with a stethoscope or use a stethoscope on unsampled Resident #2 to obtain the heart rate. On 4/4/25 at 9:19 AM, the surveyor interviewed LPN #1, at the medication cart, who stated she did not have her stethoscope with her. LPN #1 acknowledged that an apical pulse was obtained by using a stethoscope and listening to the heartbeats for 60 seconds. LPN #1 also acknowledged that what she had done with unsampled Resident #2 was a radial (arm) pulse. LPN #1 stated I should have taken an apical pulse for Digoxin. On 4/4/25 at 11:46 AM, the surveyor interviewed the Unit Manager (UM)/Registered Nurse (RN) who stated that Digoxin requires a pulse to be taken before administering the medication. UM/RN #1 added the pulse required for Digoxin was to be obtained by using a stethoscope on the chest to listen to the heartbeats for 60 seconds, which was an apical pulse. On 4/7/25 at 8:48 AM, the surveyor interviewed the Director of Nursing (DON) who stated that it was mainly her responsibility for staff education. The DON stated that the nurses were to take an apical pulse prior to Digoxin administration and that required using a stethoscope. The DON also stated that the Consultant Pharmacist (CP) has done inservices on medication administration and agency nurses may not attend if they were not working. On 4/8/25 at 8:58 AM, the surveyor interviewed the CP via telephone who stated the nursing standard of practice was to take an apical pulse with a stethoscope for 60 seconds before administering Digoxin. The CP added that he thought that was a national standard and that recommendation should be on the electronic medication administration record (EMAR). A review of an inservice dated 10/4/24 for Pharmacy: Medpass provided by the DON, who stated the CP had performed the inservice, reflected Be prepared- Stethoscope, blood pressure machine, glucometer -clean and operational. In addition, the inservice indicated Examples of meds (medications)with specific timing parameters included, but not limited to HOLD Digoxin (Lanoxin) Full 60 second apical pulse. Further review of the sign-in sheet revealed that LPN #1 had not attended the inservice. The surveyor reviewed the medical record for unsampled Resident #2. A review of the EMAR revealed a PO dated 1/9/2019, for Digoxin tablet 125 MCG (micrograms) Give 1 tablet by mouth in the morning every Mon (Monday), Wed (Wednesday), Fri (Friday) for A.Fib (atrial fibrillation- an abnormal heart rhythm) DAILY A/P (apical pulse)-HOLD IF A/P = 60 or below. On 4/9/25 at 9:28 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON and Infection Preventionist (IP)/Registered Nurse (RN). The DON acknowledged that a radial pulse cannot be taken for Digoxin. The DON added that agency nurses received an orientation packet the first time they were scheduled to work at the facility which included medication administration instructions and guidelines to follow. The DON acknowledged that LPN #1 should have obtained an apical pulse. A review of manufacturer specifications indicates for an assessment of Digoxin by a healthcare professional Monitor apical pulse for 1 full minute before administering. 2. On 4/4/25 at 9:30 AM, the surveyor observed LPN #2 preparing to administer medications to unsampled Resident #140. LPN #2 stated that the resident's blood pressure (BP) was 169/80 and was allowed to administer the resident's Doxazosin (a medication used to treat high BP) according to the PO. LPN #2 explained that the PO indicated to hold Doxazosin if the systolic BP (SBP) was less than 100 and unsampled Resident #140's SBP was 169 so she could administer the medication. The surveyor had not observed LPN #2 obtain a BP. On 4/4/25 at 9:39 AM, the surveyor interviewed LPN #2, who stated unsampled Resident #140's BP was taken earlier. LPN #2 showed the surveyor the electronic profile for unsampled Resident #140 which indicated an entry dated 4/4/25 at 7:07 AM of a BP of 169/80. LPN #2 further explained that her usual routine was to take BPs when she did her rounds when she came onto her shift which was 7 AM. LPN #2 added BP results were electronically recorded and she would use those during the medication pass. In addition, LPN #2 stated that unsampled Resident #140 was at the facility as a sub-acute resident, meaning that the resident would not be staying for long term care and would be going home. The surveyor reviewed the medical record for unsampled Resident #140. A review of the EMAR revealed a PO dated 3/28/25 for Doxazosin Mesylate Tablet 2 MG (milligrams) Give 1 tablet by mouth every 12 hours for htn (hypertension-high BP) HOLD BP BELOW 100. May cause dizziness or lightheadedness. On 4/4/25 at 12:07 PM, the surveyor interviewed UM/RN #2, who stated that usually the nurses checked BP results between 7 AM and 9 AM, before going out on a medication pass. The UM/RN #2 added that a BP taken at 7 AM could be used to determine if a medication had instructions to be held with specific parameters and was being administered at 9 AM as long as the BP that was taken at 7 AM was within range. UM/RN #2 further explained that if a BP was taken at 7 AM and was low, then the nurse should recheck before administering the medication but if the BP was normal then the nurse does not need to recheck. On 4/7/25 at 8:48 AM, the surveyor interviewed the DON, who stated that it was mainly her responsibility for staff education. The DON stated the nurses could take parameters such as BP for all their residents during rounds and then start the medication pass or could take the parameters before they were preparing the medications for administration. The DON explained that it was the nurse's preference and further explained if the nurse were to take parameters such as a BP and a medication had a hold order then the BP would have had to be taken within an hour. The DON further explained that when there was a PO to hold a medication according to specified BP parameters, she did not want the nurses to put the medication in a cup ready to administer until the BP was taken. The DON added that a BP taken within an hour of being administered was reasonable for a hold order. On 4/8/25 at 8:58 AM, the surveyor interviewed the CP, via telephone, who stated when a medication had specific hold orders then ideally the parameters should be taken just before administering the medication. The CP added it would be reasonable to allow 30 minutes to 1 hour before a medication was administered to be acceptable to determine if the medication was to be administered according to the hold order. The CP added that if a nurse took a BP at 7 AM for a resident and then was administering a medication that had a hold order at 9AM for the resident, the 7 AM BP should not be used to determine whether the medication should be administered. A review of an inservice dated 10/4/24 for Pharmacy: Medpass provided by the DON, who stated that the CP had performed the inservice, reflected Timing of medication Administration -HOLD -take BP or pulse immediately before pouring medication. Further review of the sign-in sheet revealed that LPN #2 had attended the inservice. NJAC 8:39-11.2 (b); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/3/25 at approximately 9:00 AM, upon entry into the building, the DON informed the survey team that the facility was currently in an outbreak and recommended all visitors wear a mask covering. The DON offered surgical masks that were at the receptionist desk. In addition, the DON offered the surveyors a different style of mask covering that she was wearing. The DON added that all staff were to wear a mask covering in patient care areas. At that time, the surveyor observed at the entry doorway on a wall, near the visitor electronic sign-in machine, posted signage All Visitors: The facility is currently on a COVID (coronavirus disease) outbreak investigation. We are performing contact tracing and testing per CDC/NJDOH (New Jersey Department of Health). On 4/4/25 at 8:47 AM, during the morning medication administration pass, the surveyor observed Licensed Practical Nurse (LPN #1) at the medication cart who stated that she was performing her morning medication pass. The surveyor observed LPN #1 wearing a surgical mask with her nose exposed, the top of the surgical mask was below her nose and over her mouth. On 4/4/25 from approximately 8:47 AM to 9:19 AM, the surveyor observed LPN #1 prepare and administer 11 medications to unsampled Resident #2, which included obtaining a blood pressure, pulse, administering an inhaler and eye drops. On 4/4/25 at 9:45 AM, the surveyor interviewed LPN #1, who stated she was an agency nurse and worked at the facility approximately once or twice a month. LPN #1 also stated that she was aware that the facility currently had a requirement that all staff wear masks. She stated she wore a surgical mask every time she worked anyway. LPN #1 added that she always wore her mask with her nose exposed because I have a big nose. LPN #1 added that it was difficult to fit her nose in the mask. A review of signage Facemask Do's and Don'ts for Healthcare Personnel that was placed on walls throughout the facility indicated When wearing a facemask, don't do the following: Don't wear your facemask under your nose or mouth. On 4/9/25 at 9:28 AM, the survey team met with the LNHA, the DON and the IP/RN. The DON stated that the nurses should be wearing a mask covering which was tight fitting. The DON acknowledged that the staff were required to wear mask coverings over their nose and that a surgical mask could be pulled above the nose and had an area that could be pinched to adjust covering the nose. The DON added the facility provided different styles of mask coverings, in addition to surgical masks, which may feel more comfortable in accommodating covering the nose area. The DON referenced her mask that she was wearing which was a KN95 (a mask that filters at least 95% of particles of size down to 3 microns in diameter) mask which had a different angle of nose covering. On 4/9/25 at 11:30 AM, the surveyor interviewed the DON, who stated the local health department had advised her to institute facility wide masking as source control when she had reported a case of COVID at the facility. The DON added she had a checklist that was reviewed when they report to the local health department. A review of the Outbreak Management Checklist for COVID-19 (coronavirus disease of 2019) in Nursing Homes and Other Post-acute Care Settings dated 4/2/25 provided by DON reflected that source control measures were implemented on 4/2/25. The checklist indicated CDC recommends implementing source control for persons residing or working on a unit or area of the facility experiencing a SARS (severe acute respiratory syndrome)-CoV-2 (coronavirus that caused COVID-19) or other outbreak of respiratory infection; . N.J.A.C. 8:39-19.4(a) 2. On 04/08/25 at 10:31 AM, the surveyor observed CNA #2 don PPE, which included a gown, gloves, a N95 respirator mask, and a face shield, enter Resident #54's room. The surveyor observed signage on the door for TBP: Contact Precaution/ Droplet Precautions: STAFF PLEASE USE PPE: N 95, eye shield, gown and gloves. The surveyor observed a trach can located in the hallway labeled PPE trash. At 10:37 AM, CNA #2 exited the resident's room and entered the hallway wearing the above mentioned PPE. He removed his gloves and discarded them into the PPE trash can. He removed his gown and face shield in the hallway and placed them into the PPE trash can in the hallway. On 04/08/25 at10:40 AM, the surveyor interviewed CNA #2, who stated the resident was on TBP for COVID (a highly contagious disease caused by the coronavirus SARS-CoV-2) and acknowledged the signage posted at the doorway. CNA #2 stated the PPE trash bin was outside in the hall and that was why he removed and discarded his gown and face shield in the hallway. The surveyor reviewed the medical record for Resident #54. A review of the AR revealed the resident had diagnoses which included but was not limited to; Multiple Sclerosis (a chronic autoimmune disease that affects the central nervous system (brain and spinal cord) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities). A review of the OSR revealed a PO dated 4/02/2025, for COVID Transmission Based Precaution (CONTACT & DROPLET PRECAUTIONS). On 04/08/25 at 1:13 PM, in the presence of the survey team, the LNHA, the DON, and the IP/RN were made aware of the above concerns. A review of the facility policy Donning and Doffing date revised 10/2024, included The facility will follow the CDC guidelines on proper donning and doffing of appropriate PPE to prevent the spread of infection. The policy further included, Discard all PPE in the waste receptacle situated outside of the room. The DON also provided the surveyor the CDC guidance on how to safely remove PPE as an attachment to the facility policy, which reflected the following Remove all PPE before exiting the patient room . Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that a.) two Certified Nurse Aides (CNA) on 2 of 4 Units ([NAME] and [NAME]) caring for Residents #54 and #340, removed (doffed) personal protective equipment (PPE) appropriately, and b.) 1 of 3 nurses wore their facemask properly on 1 of 4 units ([NAME]) caring for Resident #2, and in accordance with the Center for Disease Control (CDC) Guidance. This deficient practice was evidenced by the following: 1. On 4/03/25 at 11:57 AM, the surveyor observed CNA #1 enter Resident #340's room who was on transmission-based precautions (TBP) [process that is implemented to prevent the spread of infections]. CNA #1 was wearing a surgical mask and donned (put on) a gown, gloves and face shield prior to entering the room. She carried the food tray in the room and assisted the resident with setting up the lunch tray. CNA #1 removed and discarded her gloves in the room and exited the resident's room into the hallway with the gown and face shield on. She removed her gown and face shield in the hallway and placed the gown and face shield in the trash can located in the hallway labeled PPE trash. On 4/03/25 at 12:03 PM, the surveyor interviewed CNA #1 who stated the resident was on TBP for the flu and acknowledged the signage posted at the doorway. In the presence of CNA #1, the surveyor observed two signs posted at the resident's doorway. One sign indicated the type of TBP, which was contact and droplet precautions. The second sign described the required and appropriate procedure to don and doff PPE. CNA #1 stated the PPE trash bin was outside in the hall and that was why she removed and discarded her gown and face shield in the hallway. The surveyor reviewed the medical record for Resident #340. A review of the admission Record (AR) [an admission summary] reflected that the resident had diagnoses which included but was not limited to; Influenza, asthma, and malignant neoplasm (cancer) of the ovary, peritoneum (lining of the abdominal cavity), lung and large intestine (history of). A review of the Order Summary Report (OSR), reflected a physician's order (PO) dated 4/02/2025, for Influenza (Seasonal Influenza) . Observe Contact & Droplet Precautions every shift for 7 days. On 4/07/25 at 10:46 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) related to TBP. She stated that when staff exited a TBP room, they should remove their PPE outside the room in the hallway and discard the contaminated PPE into the designated PPE trash bin located outside of the room in the hallway. The IP/RN further stated, Staff is supposed to remove their PPE outside of the residents room. On 04/08/25 at 1:13 PM, the Licensed Nursing Home Administrator (LNHA), the DON, and the IP/RN were made aware of the above concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents' bathing choice of a daytime shower was provided for (2) two of (6) six residents (Resident #10 and #61) reviewed for choices during a resident council meeting on 4/19/23. This deficient practice was evidenced as follows: On 4/19/23 at 10:38 AM, a resident council meeting was conducted with six residents who resided on the [NAME] unit. During that meeting six of six residents expressed that residents required the most assistance during the 7 AM - 3 PM shift, and that at times it was difficult to get showered. Two of the six residents stated that they were scheduled to receive a shower that morning but were unable to be showered since they were told that the unit was short staffed. Record Review for Resident #10: Review of the admission Record reflected that the resident had diagnoses that included but were not limited to; heart failure, morbid obesity, generalized muscle weakness, and a right leg above knee amputation. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. It also indicated that the resident required physical assistance with bathing. Review of the Care Plan indicated to provide the resident with a shower as scheduled and PRN (as needed) dated 7/9/22. Review of the Order Summary Report, reflected a physician's order (PO) dated 7/8/22 for Shower resident as scheduled every day shift every Wed, Sat. Review of the April 2023 electronic Treatment Administration Record (eTAR) reflected the above corresponding PO, which indicated that on 4/19/23 (Wednesday) and 4/22/23 (Saturday) there was an electronic signature by the Registered Nurse (RN) #1 coded as 9 and an electronic signature by RN #2 coded 9; respectively. The eTAR chart code 9 signified Other / See Progress Notes. Review of the residents Progress Notes dated 4/19/23 at 3:32 PM documented by RN #1 reflected, Shower resident as scheduled every day shift every Wed, Sat, shower not applicable - thorough bed bath given. It further reflected an entry dated 4/22/23 at 9:29 AM documented by RN #2 that Shower resident as scheduled every day shift every Wed, Sat, na [not applicable]. Review of the Certified Nursing Assistant (CNA) Care Plan dated 1/5/23, reflected to provide a shower to the resident every Wednesday and Saturday day shift. Review of the April 2023 Nursing Assistant Documentation Record revised date August 2019, reflected that the resident received a Bed Bath on the 7 AM - 3 PM shift on 4/19/23 and 4/22/23, and a shower on the 3 PM - 11 PM shift on 4/22/23. Record Review for Resident #61: Review of the admission Record reflected that the resident had diagnoses that included but were not limited to; right side hemiplegia and hemiparesis (weakness to possible paralysis) following a cerebral infarction (stroke) and generalized muscle weakness. Review of the Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. It also indicated that the resident required physical assistance with bathing. Review of the Care Plan indicated to provide the resident with a shower as scheduled and PRN dated 12/30/20. Review of the Order Summary Report, reflected a PO dated 2/22/21, for Shower resident as scheduled every day shift every Wed, Sat. Review of the April 2023 eTAR reflected the above corresponding PO, which indicated that on 4/19/23 (Wednesday) and 4/22/23 (Saturday) there was an electronic signature by RN #1 coded as 9 and an electronic signature by RN #2 coded as 9; respectively. Review of the residents Progress Notes dated 4/19/23 at 3:28 PM documented by RN #1 reflected, Shower resident as scheduled every day shift every Wed, Sat. Shower not applicable - thorough bed bath given. It further reflected an entry dated 4/22/23 at 10:30 AM documented by RN #2 that Shower resident as scheduled every day shift every Wed, Sat. na. Review of the CNA Care Plan dated 1/5/23, reflected to provide a shower to the resident every Wednesday and Saturday day shift. Review of the April 2023 Nursing Assistant Documentation Record revised date August 2019, reflected that the resident received a Bed Bath on the 7 AM - 3 PM shift on 4/19/23 and Partial Care on 4/22/23. On 4/19/23 at 12:18 PM, the surveyor interviewed CNA #1 who stated that each CNA on the [NAME] unit were assigned 12 residents this shift cause we were short. She further stated that they were unable to provide showers because we were short staffed, I have to help on the [NAME] unit. On 4/19/23 at 12:27 PM, the surveyor interviewed the Nurses Aide (NA) who stated that he was supposed to provide a shower to Resident #10, but I couldn't give the resident a shower because they were missing an aide on the [NAME] unit, and we have to help out. On 4/19/23 at 12:30 PM, the surveyor interviewed Resident #10 who acknowledged that the NA was supposed to provide him/her a shower on the 7 AM - 3 PM shift and that he told the resident that morning that the facility was short of aides, and he cannot give a shower today. On 4/19/23 at 12:39 PM, the surveyor interviewed RN #1 who had administered medications on the [NAME] unit that day. She stated that she was aware that the aides were unable to provide showers because they were short staffed. She provided the surveyor a copy of the [NAME] Unit Assignment sheet for the 7 AM - 3 PM shift dated 4/19/23. A review of the 4/19/23 7 AM- 3 PM unit assignment sheet for the [NAME] unit revealed the NA was assigned to 11 resident's, CNA #1 was assigned to 12 resident's and CNA #2 was assigned to 12 residents. On 4/19/23 at 12:47 PM, the NA provided the surveyor with his working assignment sheet for that day. He stated that the residents whose names were circled required showers this day. The circled names included Resident #10. On 4/19/23 at 12:49 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) assigned to the [NAME] and [NAME] units. She stated that she was aware that the units were short staffed and were unable to provide showers. She stated that there were three aides scheduled for the [NAME] unit and three aides scheduled for the [NAME] unit. The RN/UM further stated that an aide on the [NAME] unit called out and was unable to be replaced. She provided the surveyor with a copy of the [NAME] Shower Schedule, which reflected that Resident #10 and #61 should have received showers on Wednesday and Saturday on the 7 AM - 3 PM shift. In addition, the RN/UM stated that the resident census for both the [NAME] and [NAME] units were each 29 for a total of 58 residents to five aides (a ratio of 11.6 residents to one aide). On 4/20/23 at 9:03 AM, the surveyor interviewed Resident #10 who stated that he/she had not received a shower yesterday. On 4/20/23 at 9:13 PM, the surveyor interviewed Resident #61 who stated that he/she had not received a shower yesterday. On 4/27/23 at 9:03 AM, the surveyor interviewed Resident #61 who stated that he/she had not received a shower again on Saturday 4/22/23. The resident stated that the unit was short staffed and that he/she had not received a shower until the day shift yesterday (4/26/23). On 4/27/23 at 10:31 AM, the surveyor interviewed Resident #10 who stated that he/she had not received a shower again on Saturday 4/22/23. The resident stated that the unit was short staffed and that he/she had not received a shower until the day shift yesterday (4/26/23). On 4/27/23 at 10:45 AM, the surveyor interviewed the RN/UM assigned to the [NAME] and [NAME] units in relation to staffing and resident showers during the 7 AM - 3 PM shift on 4/22/23. She acknowledged that the units were short staffed that day shift. She provided the surveyor with a copy of the [NAME] Unit Assignment sheet for the 7 AM - 3 PM shift for 4/22/23 which reflected that Assignment 3 had to be Split. In addition, the RN/UM provided the surveyor with a copy of the [NAME] Unit Assignment sheet for the 7 AM - 3 PM shift for 4/22/23. This reflected that CNA #1 was scheduled to work Assignment 1 which reflected that she was assigned to 10 residents plus an additional two residents from the [NAME] unit Split assignment. CNA #3 was scheduled to work Assignment # 2 and was assigned to nine residents plus an additional two residents from the [NAME] unit Split assignment, and CNA #4 was scheduled to work Assignment #3 and was assigned to nine residents plus an additional two residents from the [NAME] unit Split assignment. The RN/UM stated that the resident census on the [NAME] unit on 4/22/23 was 28 and 29 on the [NAME] Unit for a total of 57 residents to five aides (a ratio of 11.4 residents to one aide). She stated that there was accountability for bathing on the eTAR as well on the Nursing Assistant's Documentation Record. The RN/UM further clarified that the coding on this sheet indicated S = Shower; BB = Bed Bath and PC = Partial Care which she explained meant the washing of hands and face. In addition, she stated that she was unaware that the units were short staffed on 4/22/23. She provided the surveyor a copy of the April 2023, CNA Care Plan and the Nursing Assistant Documentation Record's for both Resident #10 and #61. On 4/27/23 at 1:00 PM, the surveyor interviewed RN #2 who stated that she worked the 7 AM - 3 PM shift on 4/22/23, on the [NAME] unit and acknowledged that the [NAME] and [NAME] units were short staffed since a nurse aide called out and an Assignment on the [NAME] unit had to be split. She further stated that staff were unable to provide showers to the residents on the [NAME] unit due to the fact that they were short staffed. On 4/27/23 at 1:10 PM, the surveyor interviewed CNA #1 who stated that she worked the 7 AM - 3 PM shift on 4/22/23, on the [NAME] unit. She further stated that the CNAs on her unit were assigned to assist in the care of residents on the [NAME] unit which was short staffed by one CNA that day. CNA #1 stated that they were unable to provide showers to the residents on the [NAME] unit due to fact that they were short staffed. On 4/27/23 at 1:36 PM, the surveyor interviewed CNA #5 who stated that he worked the 7 AM - 3 PM shift on 4/22/23, on the [NAME] unit. He further stated that they were short staffed and were unable to provide showers to the residents that day. On 5/2/23 at 11:32 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that she was aware of the minimum required staffing ratios and acknowledged there should be one CNA to eight residents on the 7 AM - 3 PM shift. The LNHA and DON acknowledged that the facility does not consistently meet the minimum staffing ratios. On 5/3/23 at 12:56 PM, in the presence of the LNHA and the survey team, the DON acknowledged that both Resident #10 and #61 were not provided showers during the 7 AM - 3 PM shift on 4/19/23 and 4/22/23, due to staffing shortages and that showers were their preference. In addition, she provided the surveyor with the supporting documentation at 1:30 PM. Review of the facility policy Showers with a revised date of 11/2022, indicated that all resident's will be offered showers twice a week and that showers will be scheduled and adjusted according to resident's preference. Review of the facility policy ADL - Activities of Daily Living with a revised date of 4/2023, indicated that It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. It further indicated that this is based on the comprehensive assessment of a resident and should be consistent with resident's needs and choices and this included Hygiene - bathing. Review of the facility policy Staffing with a revised date of 4/2023, indicated that Certified Nursing Aides are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. It further indicated that concerns relative to facility staffing should be directed to the Administrator or his/her designee. NJAC 8:39-4.1(a) 3,12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure the safety of the residents by allowing staff to shower residents in a non-resident certified area on 1 of 4 units. This deficient practice was evidenced by the following: On 4/17/23 at 11:25 AM, the surveyor toured the [NAME] Unit. On that same day at 11:40 AM, the surveyor observed a door held open via a magnet off the [NAME] unit. On 4/17/23 at 11:54 AM, the surveyor observed the same door open and attached to the magnet latch. At that same time, the Director of Nursing (DON) stated, the rooms beyond this door are rooms that were converted into staff aide rooms and there is a kitchen and a bathroom beyond the door. She further stated, it's an employee overnight area, an extension. At that same time, the Licensed Nursing Home Administrator (LNHA) stated, this area is not nursing home use. He further stated, it is hard to get staff, and this was a wonderful opportunity to get staff. The LNHA stated that the facility was cited in the past the citation was that there had to be a fire wall separating non-residential living area from the resident area. He stated that the door was a fire door and that the facility implemented a fire wall to separate the residential from non-residential living areas. On 4/17/23 at 12:15 PM, three surveyors in the presence of the DON and LNHA observed the door leading into the non-residential living quarters held open via a magnetic latch. At that same time, the LNHA stated that beyond this door is a residential area that nurse staff reside in, no residents are beyond this area and the rooms are not included in the facility's licensed beds of 136. On that same date and time, the surveyors observed a shower room beyond the door immediately to the left. The DON and the LNHA stated that the shower room was being used to shower nursing home residents. On 4/17/23 at 12:45 PM, the surveyor interviewed a Registered Nurse (RN) on the [NAME] unit who confirmed that the residents were showered in the shower room beyond the door in the non-resident section of the nursing home. The RN showed the surveyor the shower room and stated, this is the room where they shower the residents. On that same day at 12:50 PM, the surveyor interviewed a Certified Nursing Assistant (CNA) who also showed the surveyor the same shower room and confirmed that the staff were showering the nursing home residents in the non-resident section of the nursing home. On 4/17/23 at 12:53 PM, the LNHA and DON acknowledged and confirmed that there was a shower room across room [ROOM NUMBER] on the unit. The LNHA stated, the reason why this shower room isn't used because the other shower room is larger but effective immediately the other shower room past the fire door will be closed. On 5/02/23 12:45 PM, the survey team met with the LNHA and DON and discussed the above findings. On 5/3/23 at 12:30 PM, the LNHA and DON stated that the nursing home residents were showered under staff supervision and residents did not independently access or use the shower room in the non-resident section of the nursing home. The DON stated that all staff were in-serviced not to utilize that shower room for resident use and that the door leading to the shower room was locked. NJAC 8:39-31.4(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to report a bruise of unknown origin to the New Jersey Department of Health (NJDOH) as required for 1 of 13 residents (Resident #55) reviewed for abuse. This deficient practice was evidenced by the following: On 4/24/2023 at 12:25 PM, a review of Resident #55's Incident/Accident report dated 12/06/2022, revealed that on 12/06/2022 at 06:50 PM, the resident was noted to have a purplish discoloration below the left eye, on the eye bag area, medial side. No skin opening, surrounding skin intact; no swelling noted. The incident report indicated that Resident #55 was alert and oriented and able to verbalize needs, but not aware of how he/she sustained the bruise. The resident's medical doctor (MD) and family were notified of the incident. Further review of Resident #55's incident report indicated that the resident's condition before the incident was normal and that the exact location of the incident was the resident's room. The incident report included a diagram of the location of the bruise and a description and measurement of the bruise, which revealed a purple discoloration below the left eye bag corner measuring 1.5 cm [centimeters] x 1 cm. The incident report also included three (3) staff investigative statements as follows: 1) One statement from a Certified Nursing Assistant (CNA #1) on evening shift dated and signed on 12/06/2022, indicated that Resident #55 was on her assignment the day of the incident 12/6/2022, and the statement indicated the following: During the start of my evening shift at 03:00PM, I did my rounds and was taking vital signs of all my resident's including Resident #55, but at that time I didn't see any purple discoloration below his/her left eye yet, then around 06:50 PM the nurse informed me about the purple discoloration below the resident's left eye because someone reported to her and then I checked Resident #55 and I saw the purple discoloration below his/her left eye. 2) A second statement from (CNA #2) on night shift signed and dated 12/16/22 (10 days after the incident), did not indicate if Resident #55 was on (CNA#2's) assignment on the date of the incident of 12/6/2022. The night shift (CNA #2) statement revealed that the resident was in bed and (CNA#2) changed the resident. (CNA#2) documented, I do not record. 3) A third statement from (CNA#3) on day shift signed and dated 12/14/22 (8 days after the incident), indicated that Resident #55 was on his assignment the date of the incident 12/6/2022. The statement indicated the following: I saw the patient sleeping on bed. I helped the patient served and set-up the breakfast tray. I helped the patient do the AM care and get [him/her] dressed. I helped [him/her] to put in the bathroom. I didn't saw any bruises in [his/her] face. Further review of the Staff Investigative Statements of Resident #55's incident report revealed there was no documented statement from the nurse that notified CNA#1 of the bruise observed under the left eye of the resident, or any documented statements from other direct care staff for Resident #55 on the date of the incident 12/6/22. In addition, there were no statements included in the investigation from Resident #55, other residents on the same unit as Resident #55, or any ancillary staff who may have had contact with the resident. A review of the Corrective Action section of Resident #55's incident report indicated that the resident might have bumped his/her eye somewhere while bending and touching hard objects, and that the resident tends to open cabinets and closets without staff assistance. This section also revealed that the resident's care plan was ongoing for skin fragility and there was no evidence of abuse. On 4/24/2023 at 12:36 PM, the surveyor reviewed the medical record for Resident #55. A review of the admission Record face sheet (an admission summary) reflected that the resident had a readmission date of 10/01/21 and had diagnoses which included, major depressive disorder, unspecified dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/31/23, reflected that the resident had a brief interview for mental status (BIMS) score of 07 out of 15, indicating severe cognitive impairment. Section G, for Functional Status, of the MDS revealed that the resident needed one personal physical assistance for dressing, bathing, transfers, bed mobility, and toileting, and setup assistance only for eating. A review of the resident's individualized care plan with an initiated date of 1/25/2022, reflected a focus area that the resident had a potential for bruising due to aging, impaired cognition, medication use (aspirin), and skin fragility. The resident was able to self-propel in wheelchair and had episodes of being resistive with care. Interventions included to monitor the resident's overall mood and behavior which may put him/her at risk for bruising. A review of a Licensed Practical Nurse (LPN) nursing progress note dated 12/7/2022 at 01:33 PM, indicated that at 6:50 PM, Resident #55 was noted to a have purplish discoloration below his/her left eye. The resident was not aware of how he/she sustained the bruise, and the physician and Resident #55's son was notified of the injury. On 4/24/23 at 01:20 PM, the surveyor observed Resident #55 alert sitting in a wheelchair in the dining room at a table with three other residents shuffling a deck of playing cards. The resident looked at the surveyor when his/her name was called, but did not respond to the surveyor questions. An activity staff person standing next to the table with the residents stated that Resident #55 was very hard of hearing and refused to wear his/her hearing aid. The surveyor attempted to interview the resident, but the resident would not respond to the surveyor inquiries. On 4/24/23 at 02:26 PM, the Director of Nursing (DON) stated that all resident's accident/incident reports are discussed at the facility's monthly fall committee meetings. The DON stated that there are no minutes kept from the fall committee meetings and explained that the process was that we bring the incident reports to the meeting to discuss, and then will add right on the incident sheet any added discussions or interventions. On 4/25/23 at 09:00 AM, the DON stated that the process for investigating an incident was that whoever discovered or was involved with an incident would report to the nurse in charge who would then initiate an incident report, interview the resident, and notify the family and the physician. CNAs (Certified Nursing Assistants) would tell the nurse and then the nurse would report findings to the DON and the Licensed Nursing Home Administrator (LNHA). She stated, if it was an injury of unknown origin, then the facility would investigate further. We would collect 24-hour statements, including the rehabilitation team, activities, Therapy Director, then would discuss the incident in the morning meetings and the LNHA would be notified. The DON added that she would document the summary of what was discussed and would give the investigations to the Medical Director to review. The DON stated for an injury of unknown origin, she would extend statements for more then 24 hours. She further stated, for a skin tear or bruise, she would look at a resident's past history, their medical record, and question family members regarding resident's past history. She stated if a resident had a 1 cm bruise, she would come up with a reason for the bruise. Or if a resident had a history of bruising or a black eye, will extend the investigation. The DON added that if an injury is suspicious for abuse, if there is a pattern of an injury, or if unknown bruise, she would initiate notification to the DOH (Department of Health) and the Ombudsman within 24 hours. The DON added that if the investigation was ongoing, then she would report in 48 hours. On 4/25/23 at 09:47 AM, the DON informed the surveyor that there were no reportable accident/incidents for December 2022 and January 2023. On 4/25/23 at 11:11 AM, the surveyor reviewed Resident #55's incident report in the presence of the the DON. The surveyor asked if the injury was reported to the NJDOH? The DON stated that the incident occurred on 12/6/22, and was not reportable because the size of the bruise was only 1.5 cm x 1 cm, showing the surveyor on a measuring tool, and because of the location of the bruise being below the left eye bag. The DON revealed that after discussion and investigation, it was decided that Resident #55's bruise was not related to abuse. On 5/04/23 at 09:22 AM, the surveyor reviewed the Facility's Investigating and Reporting policy with a revised date of 5/2022, which included the following: a) Regardless of how minor an occurrence may appear, including injuries of unknown origin, it must be reported to the department supervisor as soon as such an occurrence is discovered or when information of an occurrence is learned; e) Refer to the Abuse or Neglect policy for procedure in the event of an actual or possible resident abuse or neglect situation. The surveyor then reviewed the facility's Resident Abuse, Neglect and Exploitation of Resident & Property Policy with a revised date of January 2023. The policy did not include a specific reference as to how the facility would address an injury of unknown origin. The policy indicated to refer to the Facility's Accident/Incident policy. On 5/04/23 at 10:59 AM, in the presence of the survey team, the surveyor asked the DON and LNHA what does it mean when the Accident/Incident policy indicated to refer to the Abuse policy in the event of a possible resident abuse? And where in the Abuse Policy was injury of unknown origin addressed? The LNHA stated that they follow the state form that lists types of abuse and refer to the Incident policy for investigating and when to report. The DON stated that we follow the reportable event form and answer the questions to determine if an injury of unknown origin could be abuse and continue with the investigation process to obtain statements from staff. The surveyor asked the DON and LNHA if Resident #55's injury should have been reported? The DON stated that it was not reported because it was concluded that the injury was not abuse. The LNHA stated that we did not report because it did not fit the category of reporting. NJAC 8:39-9.4(f)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a bruise of unknown origin on 12/6/22. This deficient practice was identified for 1 of 13 residents (Resident #55) reviewed for abuse and was evidenced by the following: On 4/24/2023 at 12:25 PM, a review of Resident #55's Incident/Accident report dated 12/06/2022, revealed that on 12/06/2022 at 06:50 PM, the resident was noted to have a purplish discoloration below the left eye, on the eye bag area, medial side. No skin opening, surrounding skin intact; no swelling noted. The incident report indicated that Resident #55 was alert and oriented and able to verbalize needs, but not aware of how he/she sustained the bruise. The resident's medical doctor (MD) and family were notified of the incident. Further review of Resident #55's incident report indicated that the resident's condition before the incident was normal and that the exact location of the incident was the resident's room. The incident report included a diagram of the location of the bruise and a description and measurement of the bruise, which revealed a purple discoloration below the left eye bag corner measuring 1.5 cm [centimeters] x 1 cm. The incident report also included three (3) staff investigative statements as follows: 1) One statement from a Certified Nursing Assistant (CNA #1) on evening shift dated and signed on 12/06/2022, indicated that Resident #55 was on her assignment the day of the incident 12/6/2022, and the statement indicated the following: During the start of my evening shift at 03:00 PM, I did my rounds and was taking vital signs of all my resident's including Resident #55, but at that time, I didn't see any purple discoloration below his/her left eye yet, then around 06:50 PM, the nurse informed me about the purple discoloration below the resident's left eye because someone reported to her and then I checked Resident #55 and I saw the purple discoloration below his/her left eye. 2) A second statement from (CNA #2) on night shift signed and dated 12/16/22 (10 days after the incident), did not indicate if Resident #55 was on (CNA #2's) assignment on the date of the incident of 12/6/2022. The night shift (CNA #2) statement revealed that the resident was in bed and (CNA#2) changed the resident. CNA #2 documented, I do not record. 3) A third statement from (CNA #3) on day shift signed and dated 12/14/22 (8 days after the incident), indicated that Resident #55 was on his assignment the date of the incident 12/6/2022. The statement indicated the following: I saw the patient sleeping on bed. I helped the patient served and set-up the breakfast tray. I helped the patient do the AM care and get [him/her] dressed. I helped [him/her] to put in the bathroom. I didn't saw any bruises in [his/her] face. Further review of the Staff Investigative Statements of Resident #55's incident report revealed there was no documented statement from the nurse that notified (CNA#1) of the bruise observed under the left eye of the resident, or any documented statements from other direct care staff for Resident #55 on the date of the incident 12/6/22. In addition, there were no statements included in the investigation from Resident #55, other residents on the same unit as Resident #55, or any ancillary staff who may have had contact with the resident. A review of the Corrective Action section of Resident #55's incident report indicated that the resident might have bumped his/her eye somewhere while bending and touching hard objects, and that the resident tends to open cabinets and closets without staff assistance. This section also revealed that the resident's care plan was ongoing for skin fragility and there was no evidence of abuse. On 4/24/2023 at 12:36 PM, the surveyor reviewed the medical record for Resident #55. A review of the admission Record face sheet (an admission summary) reflected that the resident had a readmission date of 10/01/21 and had diagnoses which included, major depressive disorder, unspecified dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/31/23, reflected that the resident had a brief interview for mental status (BIMS) score of 07 out of 15, indicating severe cognitive impairment. Section G, for Functional Status, of the MDS revealed that the resident needed one personal physical assistance for dressing, bathing, transfers, bed mobility, and toileting, and setup assistance only for eating. A review of the resident's individualized care plan with an initiated date of 1/25/2022, reflected a focus area that the resident had a potential for bruising due to aging, impaired cognition, medication use (aspirin), and skin fragility. The resident was able to self-propel in wheelchair and had episodes of being resistive with care. Interventions included to monitor the resident's overall mood and behavior which may put him/her at risk for bruising. A review of a Licensed Practical Nurse (LPN) nursing progress note dated 12/7/2022 at 01:33 PM, indicated that at 6:50 PM, Resident #55 was noted to a have purplish discoloration below his/her left eye. The resident was not aware of how he/she sustained the bruise, and the physician and Resident #55's son was notified of the injury. On 4/24/23 at 01:20 PM, the surveyor observed Resident #55 alert sitting in a wheelchair in the dining room at a table with three other residents shuffling a deck of playing cards. The resident looked at the surveyor when his/her name was called but did not respond to the surveyor questions. An activity staff person standing next to the table with the residents stated that Resident #55 was very hard of hearing and refused to wear his/her hearing aid. The surveyor attempted to interview the resident, but the resident would not respond to the surveyor inquiries. On 4/24/23 at 02:26 PM, the Director of Nursing (DON) stated that all resident's accident/incident reports are discussed at the facility's monthly fall committee meetings. The DON stated that there are no minutes kept from the fall committee meetings and explained that the process was that we bring the incident reports to the meeting to discuss, and then will add right on the incident sheet any added discussions or interventions. On 4/25/23 at 09:00 AM, the DON stated that the process for investigating an incident was that whoever discovered or was involved with an incident would report to the nurse in charge who would then initiate an incident report, interview the resident, and notify the family and the physician. CNAs (Certified Nursing Assistants) would tell the nurse and then the nurse would report findings to the DON and the Licensed Nursing Home Administrator (LNHA). She stated, if it was an injury of unknown origin, then the facility would investigate further. We would collect 24-hour statements, including the rehabilitation team, activities, Therapy Director, then would discuss the incident in the morning meetings and the LNHA would be notified. The DON added that she would document the summary of what was discussed and would give the investigation to the Medical Director to review. The DON stated that for an injury of unknown origin, she would extend statements for more then 24 hours. She further stated, for a skin tear or bruise, she would look at a resident's past history, their medical record, and question family members regarding the resident's past history. She stated, if a resident had a 1 cm bruise, she would come up with a reason for the bruise. Or if a resident had a history of bruising or a black eye, she would extend the investigation. The DON added that if an injury is suspicious for abuse, or there is a pattern of an injury, or if unknown bruise she would initiate notification to the DOH (Department of Health) and the Ombudsman within 24 hours. The DON added that if the investigation is ongoing, then she would report in 48 hours. On 4/25/23 at 09:47 AM, the DON informed the surveyor that there were no reportable accident/incidents for December 2022 and January 2023. On 4/25/23 at 10:38 AM, the Unit Manager (UM) stated that if she discovered a skin tear, bruise, or an abrasion on a resident, she would investigate to find out what occurred for that particular skin issue, obtain 24-hour look back statements, and initiate an incident report. The UM added that if an injury was suspicious for abuse, then would immediately notify the DON and LNHA and they would do a more extensive investigation. On 4/25/23 at 11:11 AM, the surveyor reviewed Resident #55's incident report in the presence of the DON. The surveyor asked the DON to clarify the date of the incident, how did the facility rule out abuse regarding the resident's left eye bruise? The surveyor also asked if the injury was reported to NJDOH? The DON stated that the incident occurred on 12/6/22 and was not reported because of the size of the bruise was only 1.5 cm x 1 cm, showing the surveyor on a measuring tool, and because of the location of the bruise being below the left eye bag. The DON further stated that Resident #55 was very mobile and bends down a lot. The resident would go in his/her drawers and open his/her closets without the assistance of staff, was on a blood thinner, and had a history of seasonal allergies. The DON revealed that after discussion and investigation, it was decided that Resident #55's bruise was not related to abuse. On 5/03/23 at 12:37 PM, in the presence of the survey team, the DON stated, We discuss incidents every day at our morning meetings and then come up with an intervention. The DON further explained that the investigation would not be completed when discussing at the morning meetings in case there are updates or additional statements. It's an ongoing investigation. We don't ask residents for statements. It is not in the policy. We ask the resident what happened. It's a verbatim statement from the nurse. The DON provided additional information and stated that the Fall Committee concluded that Resident #55's bruise may have been sustained while bending, touching hard objects including room closet, and cabinet on his/her own. The DON added that the injury may have been sustained by rubbing his/her eyes with the mask on (had metal strip by nose bridge) since resident had seasonal allergies and is on an antihistamine. The DON explained that the presentation of the bruise was not consistent with forced-inflicted injury since the discoloration was localized at 1.5 cm x 1 cm without any signs of swelling. The DON added that Resident #55's bruise presentation if force inflicted would be more pronounced since the resident was on an anticoagulant. The DON revealed that the team concluded that the incident was without evidence of abuse and was deemed not reportable. The DON and LNHA could not speak to if any of the alert and oriented residents on the same unit and being cared for by the same staff as Resident #55 were interviewed, and if any other direct care staff or ancillary staff were interviewed. On 5/03/23 at 02:11 PM, the surveyor interviewed CNA #1 who stated that the signs of resident abuse could be bruising, scratches, crying or even if a family member was yelling at a resident. The CNA #1 added that the staff knows the residents well and could see if something looks suspicious like a new bruise or marking on the resident's skin. The CNA #1 further stated that she would immediately tell the nurse and start writing the incident report. The assigned nurse would assess the resident, notify the DON, and then the DON would get statements from other residents and staff. CNA #1 was unable to recall Resident #55's incident of 12/6/22. On 5/04/23 at 09:22 AM, the surveyor reviewed the Facility's Investigating and Reporting policy with a revised date of 5/2022, which included the following: 1. Reporting of incidents/accidents: a) Regardless of how minor an occurrence may appear, including injuries of unknown origin, it must be reported to the department supervisor as soon as such an occurrence is discovered or when information of an occurrence is learned; e) Refer to the Abuse or Neglect policy for procedure in the event of an actual or possible resident abuse or neglect situation . 4. Investigative action: a. The Nursing Supervisor and/or Department Head shall conduct an immediate investigation of the occurrence and take corrective action to prevent a re-occurrence if appropriate . 10. All injuries of Unknown Origin Incident Report will include statements from all direct caregivers during the past 24 hours. The surveyor reviewed the facility's Resident Abuse, Neglect and Exploitation of Resident & Property Policy with a revised date of January 2023, which included the following: D. Supervisor to complete supervisory Investigate report with interviews and written statement from all persons involved, including the resident, if possible, investigate three prior shifts . H. All written statements and documentation are to be completed within 48 hours and maintained under separate file cover in the DON's office. The policy did not include a specific reference as to how the facility would address an injury of unknown origin. The policy indicated to refer to the Facility's Accident/Incident policy. On 5/04/23 at 10:59 AM, in the presence of the survey team, the surveyor asked the DON and LNHA what does it mean when the Accident/Incident policy indicated to refer to the Abuse policy in the event of a possible resident abuse? And where in the Abuse Policy was injury of unknown origin addressed? The LNHA stated that they follow the state form that lists types of abuse and refer to the Incident policy for investigating and when to report. The DON stated that we follow the reportable event form and answer the questions to determine if an injury of unknown origin could be abuse and continue with the investigation process to obtain statements from staff. The DON verified that the incident was not reported because it was concluded that the injury was not abuse. The LNHA added that we did not report because it did not fit the category of reporting. The DON and LNHA could not provide any additional documentation regarding Resident #55's incident report of 12/6/22. NJAC-8.39-4.1(a)5; 9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to a.) ensure a treatment was administered in accordance with a physician order and in accordance with professional standards of practice, and b.) accurately document skin assessments. This deficient practice was identified for 1 of 2 residents (Resident #1) reviewed for wound care. The deficient practice was evidenced by the following. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. 1.) On 4/17/23 at 11:48 AM, a surveyor observed Resident #1 lying in bed in their room. Resident #1 stated he/she can feed his/herself and that he/she felt good. A review of the admission Record revealed Resident #1 had been admitted to the facility on [DATE], with diagnoses which included but were not limited to hypertensive (elevated blood pressure) heart and chronic kidney disease with heart failure, unspecified protein-calorie malnutrition, muscle weakness, edema, and abnormalities of gait and mobility. A review of the telephone order dated 4/19/23 at 16:13 (4:13 PM) revealed [name redacted] (medicine that removes dead tissue from wounds) ointment 250 unit/gm (gram) to sacral area topically every day shift for wound after cleansing with saline, cover with dry dressing. A review of the Order Listing Report, provided by the facility on 5/3/23, included but was not limited to an order dated revision 4/20/23 for [name redacted] (medicine that removes dead tissue from wounds) ointment 250 unit/gm (gram) to sacral area topically every day shift for wound after cleansing with saline, cover with dry dressing. On 4/21/23 at 10:30 AM, a surveyor accompanied the Registered Nurse Unit Manager (RN/UM) to observe the wound care treatment on Resident #1. The surveyor observed the RN/UM prepare for the wound treatment. The RN/UM obtained a bottle of Dakin's solution a cleaning agent (a diluted solution of sodium hypochlorite and other ingredients typically used as an antiseptic) which was labled with an unsampled resident's name and did not belong to Resident #1. The RN/UM was about to use the Dakin's solution labled with the unsampled resident's name on it for Resident #1's treatment. At that time the surveyor requested the RN/UM review the wound treatment order prior to proceeding with the treatment. At that time, the RN/UM and the surveyor reviewed the wound treatment order which indicated the wound was to be cleaned with saline (a mix of sodium chloride and water which can be used to clean wounds). The RN/UM confirmed she had the wrong wound treatment cleaning agent and that the Dakin's solution did not belong to Resident #1. A review of the facility provided, [name redacted] wound care services report, dated 4/19/23, included but was not limited to Plan: Start: cleanse site with normal saline which had a black handwritten line through normal saline. There was also an adjacent handwritten note dated 4/24/23, correction: ¼ strength Dakin's solution. The correction was made after the wound treatment observation on 4/21/23. A review of the facility provided, Dressing Change (Clean Technique), dated 3/7/23, included but was not limited to the RN/UM being deemed competent to 1. Review physician order for wound cleansing and treatment. A review of the facility provided, 'Med-Pass Evaluation, dated 11/4/22, included but was not limited to the RN/UM being deemed competent to administer the correct medication. A review of the facility provided, Dispensing of Medication, revised 1/23, included but was not limited to 7. Facility will utilize resident's own medication. On 5/4/23 at 11:00 AM, during an interview with the survey team, the Director of Nursing acknowledged the incorrect wound treatment by the RN/UM. 2.) A review of the admission Record further revealed that Resident #1 had an additional diagnosis dated 2/22/23, of pressure ulcer of sacral region, stage 3. A review of the facility Progress Notes (PN) date range from 1/27/23 through 2/18/23 contained no documented evidence of any pressure injury (intact damage to the skin or underlying soft tissue) or pressure ulcer (open ulcer with appearance depending on the staging of the ulcer and may be painful). A review of the facility provided Daily Skilled Notes included but was not limited to the following: Dated 2/11/23 at 22:08 (10:08 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/12/23 01:36 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns . Dated 2/12/23 14:30 (2:30 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/13/23 03:34 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/13/23 10:07 (AM), day shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/13/23 16:53 (4:53 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/14/23 05:04 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/14/23 15:32 (3:32 PM), day shift. D. skin 1. Skin WNL (within normal limits). Dated 2/14/23 23:32 (11:32 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/15/23 04:36 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/15/23 09:58 (AM), day shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/15/23 15:51 (3:51 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/16/23 04:45 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/16/23 15:09 (3:09 PM), day shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/16/23 15:41 (3:41 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/17/23 05:14 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/17/23 08:58 (AM), day shift. D. skin 1. WNL Dated 2/17/23 22:50 (10:50 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/18/23 01:05 (AM), night shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. Dated 2/18/23 12:55 (PM), day shift. D. skin 1. WNL Dated 2/18/23 23:16 (11:16 PM), evening shift. D. skin 6. Bruise. R. Summary did not indicate the location, measurement or description of the bruise. There were no PNs to describe the location, measurement or description of the bruise or any skin concerns. A review of the facility provided, Treatment Administration Record (TAR), dated 2/1/23 through 2/28/23, revealed that Resident #1 had a weekly skin check. Inspect from head to toe. Document in Progress Note. Every evening shift Friday. The weekly skin check was signed off as administered on 2/3/23, 2/10/23, 2/17/23, and 2/24/23. The TAR further revealed, sacral wound: cleans with NSS (normal saline solution), apply Medihoney (a gel wound dressing) to base, cover with dry dressing daily every evening shift for wound. The wound treatment was signed off as administered on 2/19/23, 2/20/23, and 2/21/23. The TAR further revealed, Santyl ointment (enzyme (protein) that breaks down collagen in damaged or dead skin) 250 unit/gm apply to sacrum topically every evening shift for wound and after cleansing with saline, cover with foam dressing. The wound treatment was signed off as administered on 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, and 2/28/23. A review of the facility provided, Wound Investigation, undated, for Resident #1, included but was not limited to Date Wound Noted: 2/19/23. Was the resident identified at risk for development of pressure ulcer? Yes. Was the wound acquired in the facility? Yes. skin breakdown maybe contributed by current change of medical condition due to on-going covid infection. Comments: current wound measurement 5 x 3 cm (centimeter) noted on 2/19/23. Seen by [name redacted] wound care services on 2/22/23. Brief Summary: included but was not limited to on 2/11/23, Resident #1 tested positive for COVID-19. On 2/19/23, Resident #1 was noted with open area to sacrum measuring 5 x 3 cm with slough (non-viable stringy and mucinous texture that may adhere to the base of the wound or wound bed). On 2/22/23, seen by wound care Nurse Practioner (NP) and wound measured 2 x 1 with 50% slough. There were no PNs to identify any skin concerns during the timeframe Resident #1 had COVID-19 at the facility. A review of the facility provided policy, Skin Care, revised 7/22, included but was not limited to Purpose: to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors. Prevention of Pressure Ulcer. Purpose: identify the risk factors as well as interventions to reduce or eliminate those considered modifiable. Risk Assessment. 1. Assess the resident on admission repeat the risk assessment weekly and upon any changes in condition. 4. Inspect the skin on a daily basis .a. identify any signs of developing pressure injuries, b. inspect pressure points. 5. Facility will schedule weekly skin inspection plotted in the TAR and document new, pertinent finding in the medical record. Monitoring. 1. Evaluate, report and document potential changes in the skin. NJAC 8:39-27.1(a)(e)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of twenty-five (25) residents reviewed, (Resident #76) for medication management and was evidenced by the following: On 4/17/22 at 11:20 AM, the surveyor observed Resident #76 in the room and seated in a wheelchair watching television. The surveyor reviewed Resident #76's medical records. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; hypertension (elevated blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to limbs) and nonrheumatic mitral (valve) insufficiency (mitral valve does not close properly, allowing blood to flow backward into the heart). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 2/21/23, reflected that the resident's cognitive skills for daily decision-making score was 9 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the Order Listing Report (physician's order sheet) dated 4/25/23 revealed a physician's order (PO) dated 12/24/22, for Metoprolol Succinate ER (extended-release) 25 mg (milligrams), give 3 tablets by mouth once daily for hypertension for a total of 75 mg. Hold for SBP (systolic blood pressure) less than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60. Do not crush. Take with or immediately following a meal. A review of the March 2023 and the April 2023 electronic medication administration record (eMAR) revealed an order dated 12/24/22, for Metoprolol Succinate ER 25 mg tablet, give 3 tablets by mouth one time a day for hypertension total of 75 mg. Hold for SBP less than 110, DBP less than 60, and HR less than 60. Do not crush. Take with or immediately following meals with a plotted time of 5 PM. The eMAR revealed that the Metoprolol Succinate was signed as administered when the SBP was less than 110 and the DBP was less than 60. A review of the March 2023 eMAR showed that the medication was administered (6) six times when the DBP was less than 60 on the following dates: 3/2/23, 3/4/23, 3/7/23, 3/17/23, 3/23/23 and 3/29/23 and one time when the SBP was less than 110 on 3/17/23. A review of the April 2023, eMAR showed that the medication was administered one time when the DBP was less than 60 (4/24/23) and one time when the SBP was less than 110 on 4/19/23. A review of the Consultant Pharmacist (CP)- Medication Regimen Review dated 4/4/23 revealed no CP recommendations. On 4/25/23 at 11:00 AM, the surveyor interviewed the CP who stated that his job requirement was to review the resident's medical records once a month which was usually done around the 4th of the month. The CP stated that part of his review was making sure that the facility nursing staff are following the medication parameters. At that same time, the surveyor, with the CP, reviewed the March 2023 eMAR for Resident # 76. The CP acknowledge the medication was signed as administered, (6) six times when the SBP was less than 110 and DBP was less than 60. The CP stated that he should have picked this up during his monthly medication review which was on 4/4/23. On 5/2/23 at 1:00 PM, the surveyor discussed the above observations and findings with the Director of Nursing (DON) and the Licensed Nursing Home Administrator. There was no additional information provided. A review of the facility's policy for Consultant Pharmacy dated 10/31/10, which was provided by the DON included the following: Under purpose: To provide the healthcare facility with a detailed, written report of the consultant pharmacist's findings after the monthly review. Under Pharmacist Responsibilities: Monthly reviews of drug regimen of each resident with reports of any irregularities. NJAC 8:39-29.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a). properly label, store, and dispose of medications in 1 (one) of 5 (five) medication carts and 1 (one) of 3 (three) medication room refrigerators inspected and b). failed to properly secure medications in 2 (two) of 4 (four) emergency crash carts inspected. This deficient practice was evidenced by the following: 1. On 4/26/23 at 9:35 AM, the surveyor inspected the [NAME] unit medication cart in the presence of a Registered Nurse (RN#1). The surveyor observed an opened and undated bottle of Pro-Stat solution (a protein supplement). The surveyor interviewed RN#1 who stated that an opened bottle of Pro-Stat solution once opened should have been dated because once opened it only had a 90-day expiration date. On 4/26/23 at 10:00 AM, the surveyor inspected the [NAME]/[NAME] medication room refrigerator in the presence of RN#1. The surveyor observed an opened and undated bottle of Lorazepam (anxiety medication) 2 mg (milligrams)/ml (millilters) solution. The surveyor interviewed RN#1 who stated that an opened bottle of Lorazepam solution should have been dated because once opened it only had a 90-day expiration date. A review of the Manufacturer's Specifications for the following medications revealed the following: - Pro-Stat solution once opened had an expiration date of 90-days. - Lorazepam 2 mg/ml solution once opened had an expiration date of 90-days. 2. On 4/28/23 at 11:30 AM, the surveyor inspected the [NAME] unit emergency crash cart in the presence of RN#2. The surveyor observed one bottle of 100-ml (milliliters) Sodium Chloride irrigation solution (a solution that cleans wounds) and 2-boxes of Sodium Chloride nebulizer solution (individual ampules) (medication to loosen mucus in the chest) that were stored in an unsecured (unlocked) draw of the emergency crash cart. The surveyor interviewed RN#2 who acknowledge that both the Sodium Chloride irrigation solution and nebulizer solution are medications and should have been stored in a secure storage area. On 4/28/23 at 12:00 PM, the surveyor inspected the [NAME]/[NAME] unit emergency crash cart in the presence of RN#3. The surveyor observed a 100-ml bottle of Sodium Chloride irrigation solution, a box of individual-use Bacitracin ointments (anti-biotic ointment to treat cuts or scraps), and 4 boxes of Sodium Chloride 0.9% nebulizer ampules that were in an unsecured section of the emergency crash cart. The surveyor interviewed RN#3 who stated Sodium Chloride irrigation solution, bacitracin ointment, and Sodium Chloride nebulizer solution are medications and should have been stored in a secure storage area. On 4/28/23 at 12:10 PM, the surveyor in the presence of the Director of Nursing (DON) inspected both the [NAME] and the [NAME] and [NAME] emergency crash carts. The DON acknowledge that both emergency carts contained medications and these medications should have been stored in a secure storage area. The DON was observed removing these medications from both emergency crash carts. On 5/2/23 at 1:00 PM, the surveyor discussed the above observations and findings with the DON and the Licensed Nursing Home Administrator. There was no additional information provided. A review of the facility's policy for Storage of Medications dated 7/31/22 and provided by the DON included that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) On 04/21/23 at 7:56 AM, Surveyor #3 observed medication administration with a Licensed Practical Nurse (LPN). The LPN had a multi-use wrist BP cuff and applied it directly to the skin of unsampled resident #1 (UR1) and obtained their BP reading. After removing the wrist BP cuff, the LPN placed the BP cuff on top of the medication cart. The LPN failed to disinfect the wrist BP cuff prior to or after use on UR1. On 04/21/23 at 8:00 AM, Surveyor #3 observed the same LPN use the same wrist BP cuff applied in direct contact with the skin of UR2. The LPN placed the wrist BP cuff on top of the medication cart. The LPN failed to disinfect the wrist BP cuff prior to or after use on UR2. On 04/21/23 at 8:24 AM, Surveyor #3 observed the same LPN use the same wrist BP cuff applied in direct contact with the skin of UR3. The LP placed the wrist BP cuff on top of the medication cart. The LPN failed to disinfect the wrist BP cuff prior to or after use on UR3. On 04/21/23 at 8:58 AM, during an interview with Surveyor #3, the LPN stated that multi-use resident equipment should be cleaned before and after use on the residents. When asked why the LPN used the wrist BP cuff on three residents without disinfecting the wrist BP cuff, the LPN responded, my bad. The LPN stated the reason the BP cuff had to be cleaned between residents was to prevent infections. On 04/21/23 at 9:37 AM, during an interview with Surveyor #3, the Registered Nurse Infection Preventionist (RN IP) stated multi-use equipment such as the BP cuff and pulse oximeter, must be disinfected between resident use to prevent cross contamination of infection. When asked what the process was, the RN IP stated there were disinfectant wipes to use with a contact time of 2 minutes. A review of the facility provided, Course Status Report, for the LPN included but was not limited to that on 2/14/22, the LPN had training in infection control. A review of the facility provided, Pharmacy: Medpass, dated 10/4/22, indicated the LPN had attended the Inservice. The Inservice included but was not limited to stethoscope, blood pressure machine, glucometer clean and operational. A review of the facility provided, Use of Thermometer, Pulse Oximeter, BP Apparatus, Stethoscope, revised 8/2022, included Policy to ensure appropriate technique in maintaining clean vital signs equipment. 3. Stethoscopes, pulse oximeter and BP apparatus will be disinfected with alcohol wipes before / after each use. NJAC 8:39-19.4; 27.1 Based on observation, interview, and record review it was determined that the facility failed to ensure a contracted staff donned (put on) the appropriate Personal Protective Equipment (PPE) prior to entering a transmissions-based precaution (TBP) room for contact precautions. This deficient practice was identified for 1 of 4 residents on TBP on 1 of 4 units, and b.) disinfect a multi-use wrist blood pressure (BP) cuff in between resident use. This deficient practice was identified for 3 of 6 unsampled residents during a medication administration observation. The evidence was as follows: On 4/20/23 at 6:20 AM, the surveyor observed room [ROOM NUMBER] with a yellow paper that had red Stop sign and PPE: Contact Precaution sign affixed to the outside of the a white PPE bin hung on the outside of the door. The sign revealed: Hand Hygiene, Wear Gloves, and Wear Gown. The yellow sign also indicated Visitors (underlined) Please check with nurse before entering room. At that time the surveyor observed, through the open door, a staff person enter the TBP room and was wearing only a surgical mask and gloves, and was not wearing a gown as the yellow sign indicated. The surveyor observed the staff person at the bedside speaking to the resident regarding taking blood, but the resident refused blood work at that time. The staff person then walked out of the room wearing the same gloves and removed the gloves outside of the room and did not perform hand hygiene. Upon the staff exiting the room, the surveyor interviewed the staff person. The staff identified herself as a contracted phlebotomist and stated, I went into the room to talk with the [resident] and asked about the blood and he/she said no.The surveyor asked what the TBP was for? She stated, I think it is for C. diff? (Infection of the large intestine (colon) caused by the bacteria Clostridium difficile). She further stated she could go into the room just to talk to the resident without a gown and a faceshield. At that same time, the surveyor reviewed the contact precaution sign posted on the door with the contracted phlebotomist and pointed to the part of the sign that indicated upon entry for the PPE. The contracted phlebotomist stated it was okay and that the resident was on the bedpan and asked are we done because I need to go and proceeded to walk away from the surveyor down the hallway. On that same day at 6:55 AM, the surveyor interviewed a Registered Nurse (RN) on the [NAME] unit who confirmed that the resident in room [ROOM NUMBER] was on contact isolation for C. Diff. The RN further stated, before you go in you must gown up. The surveyor inquired if a person can enter the room without gowning? The surveyor then informed the RN about the observation that occurred with the contracted phlebotomist. The RN stated, no, she should know better. I have issues with her. I saw her earlier in the hallway with a glove on. I will talk to my supervisor. That is why infection spreads. The RN also stated that the resident does not use a bedpan and has a colostomy that was changed this morning. The surveyor reviewed Resident # 336's medical record. Review of the admission Record (an admission summary) indicated the resident was admitted to the facility on [DATE], with diagnoses which included but not limited to entercoclitis due to Clostridium Difficile, recurrent. Review of the Order Summary Report (OSR) revealed a physician's order (PO) dated 04/19/23, to observe contact precautions for C-Diff every shift. Further review of the OSR revealed a PO dated 4/19/23 for Vancomycin HCI oral suspension [an antibiotic] 50 mg/ml [milligrams per milliliter] give 2 ml by mouth four times a day for C-Diff until 04/29/23 39 doses. Further review of the OSR revealed a PO dated 04/19/23 for Colostomy wafer change every day shift every 5 days(s) and Colostomy care every shift. On 04/20/23 at 7:44 AM, the surveyor interviewed the primary physician (MD) for Resident #336 while the MD was on the [NAME] unit. The MD stated that Resident #336 was on contact precautions do to having a history of Clostridium Difficile. On 04/20/34 at 7:55 AM, the facility Registered Nurse Infection Preventionist (RNIP) was observed outside of Resident #336's room, and was repositioning the yellow sign from the PPE bin to the side of the door on the wall. The surveyor asked the RNIP at that time why Resident #336 was on contact precautions, and the RNIP stated the resident came in last night, has C diff. in [his/her] stool and they observe contact precautions. The surveyor inquired to the RN IP if it was permitted to go into the room without donning PPE. The RNIP stated the PPE must be donned prior to entering the room to protect all staff since the resident may need to be touched. When asked what should be done when gloves were removed, the RNIP stated hand hygiene must be performed after removing all PPE, including gloves. The surveyor informed the RNIP of the surveyor's observations and the RNIP stated that the contracted phlebotomist was not allowed to enter the room without the proper PPE and she will contact the [name redacted] lab. Review of the facility's Transmission Based Precaution policy updated 4-2022 and provided by the Director of Nursing (DON) included transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Further review of the corresponding policy included that Transmission Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne . when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .the signage informs the staff of the type of CDC [Centers for Disease Control and Prevention] precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room .Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Staff and visitors will wear gloves (clean, non-sterile) when entering room Gloves will be removed and hand hygiene performed before leaving the room .Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/24/2023 at 12:25 PM, a review of Resident #55's Incident/Accident report dated 12/06/2022, revealed that on 12/06/2022 at 06:50 PM, the resident was noted to have a purplish discoloration below the left eye, on the eye bag area, medial side. No skin opening, surrounding skin intact; no swelling noted. The incident report indicated that Resident #55 was alert and oriented and able to verbalize needs, but not aware of how he/she sustained the bruise. The resident's medical doctor (MD) and family were notified of the incident. Further review of Resident #55's incident report indicated that the resident's condition before the incident was normal and that the exact location of the incident was the resident's room. The incident report included a diagram of the location of the bruise and a description and measurement of the bruise, which revealed a purple discoloration below the left eye bag corner measuring 1.5 cm [centimeters] x 1 cm. The incident report also included three (3) staff investigative statements as follows: 1. One statement from a Certified Nursing Assistant (CNA #1) on evening shift dated and signed on 12/06/2022, indicated that Resident #55 was on her assignment the day of the incident 12/6/2022, and the statement indicated the following: During the start of my evening shift at 03:00 PM I did my rounds and was taking vital signs of all my resident's including Resident #55, but at that time I didn't see any purple discoloration below his/her left eye yet, then around 06:50 PM the nurse informed me about the purple discoloration below the resident's left eye because someone reported to her and then I checked Resident #55 and I saw the purple discoloration below his/her left eye. 2. A second statement from (CNA #2) on night shift signed and dated 12/16/22 (10 days after the incident), did not indicate if Resident #55 was on (CNA#2's) assignment on the date of the incident of 12/6/2022. The night shift (CNA #2) statement revealed that the resident was in bed and (CNA#2) changed the resident. (CNA#2) documented, I do not record. 3. A third statement from (CNA#3) on day shift signed and dated 12/14/22 (8 days after the incident), indicated that Resident #55 was on his assignment the date of the incident 12/6/2022. The statement indicated the following: I saw the patient sleeping on bed. I helped the patient served and set-up the breakfast tray. I helped the patient do the AM care and get [him/her] dressed. I helped [him/her] to put in the bathroom. I didn't saw any bruises in [his/her] face. Further review of the Staff Investigative Statements of Resident #55's incident report, there was no documented statement from the nurse that notified (CNA#1) of the bruise observed under the left eye of the resident, or any documented statements from other direct care staff for Resident #55 on the date of the incident 12/6/22. In addition, there were no statements included in the investigation from Resident #55, other residents on the same unit as Resident #55, or any ancillary staff who may have had contact with the resident. A review of the Corrective Action section of Resident #55's incident report indicated that the resident might have bumped his/her eye somewhere while bending and touching hard objects, and that the resident tends to open cabinets and closets without staff assistance. This section also revealed that the resident's care plan was ongoing for skin fragility and there was no evidence of abuse. On 4/24/2023 at 12:36 PM, the surveyor reviewed the medical record for Resident #55. A review of the admission Record face sheet (an admission summary) reflected that the resident had a readmission date of 10/01/21 and had diagnoses which included, major depressive disorder, unspecified dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/31/23, reflected that the resident had a brief interview for mental status (BIMS) score of 07 out of 15, indicating severe cognitive impairment. Section G, for Functional Status, of the MDS revealed that the resident needed one personal physical assist for dressing, bathing, transfers, bed mobility, and toileting, and setup assistance only for eating. A review of the resident's individualized care plan with an initiated date of 1/25/2022, reflected a focus area that the resident had a potential for bruising due to aging, impaired cognition, medication use (aspirin), and skin fragility. The resident was able to self-propel in wheelchair and had episodes of being resistive with care. Interventions included to monitor the resident's overall mood and behavior which may put him/her at risk for bruising. A review of a Licensed Practical Nurse (LPN) nursing progress note dated 12/7/2022 at 01:33 PM, indicated that at 6:50 PM, Resident #55 was noted to a have purplish discoloration below his/her left eye. The resident was not aware of how he/she sustained the bruise, and the physician and Resident #55's son was notified of the injury. On 4/24/23 at 01:20 PM, the surveyor observed Resident #55 alert sitting in a wheelchair in the dining room at a table with three other residents shuffling a deck of playing cards. The resident looked at the surveyor when his/her name was called but did not respond to the surveyor questions. An activity staff person standing next to the table with the residents stated that Resident #55 was very hard of hearing and refused to wear his/her hearing aid. The surveyor attempted to interview the resident, but the resident would not respond to the surveyor inquiries. On 4/24/23 at 02:26 PM, the Director of Nursing (DON) stated that all resident's accident/incident reports are discussed at the facility's monthly fall committee meetings. The DON stated that there are no minutes kept from the fall committee meetings and explained that the process was that we bring the incident reports to the meeting to discuss, and then will add right on the incident sheet any added discussions or interventions. On 4/25/23 at 09:00 AM, the DON stated that the process for investigating an incident was that whoever discovered or was involved with an incident would report to the nurse in charge who would then initiate an incident report, interview the resident, and notify the family and the physician. CNAs (Certified Nursing Assistants) would tell the nurse and then the nurse would report findings to the DON and the Licensed Nursing Home Administrator (LNHA). If it was an injury of unknown origin, then the facility would investigate further. We would collect 24-hour statements, including the rehabilitation team, activities, Therapy Director, then would discuss the incident in the morning meetings and the LNHA would be notified. The DON added that she would make the summary of what was discussed and would give to the Medical Director to review. The DON revealed that if an injury of unknown origin, would extend statements for more than 24 hours. If there was a skin tear or bruise, would look at a resident's history, their medical record, and question family members regarding resident's past history. If a resident had a 1 cm bruise, will come up with a reason for the bruise. Or if a resident had a history of bruising or a black eye, will extend the investigation. The DON added that if an injury is suspicious for abuse, if there is a pattern of an injury, or if unknown bruise will initiate notification to the DOH (Department of Health) and the Ombudsman within 24 hours. The DON added that if the investigation is ongoing, will report in 48 hours. On 4/25/23 at 11:11 AM, the surveyor reviewed Resident #55's incident report in the presence of the DON. The surveyor asked the DON to clarify the date of the incident, and how did the facility rule out abuse regarding the resident's left eye bruise? The surveyor also asked if the injury was reported to NJDOH? The DON stated that the incident occurred on 12/6/22 and was not reportable because the size of the bruise was only 1.5 cm x 1 cm, showing the surveyor on a measuring tool, and because of the location of the bruise being below the left eye bag. The DON further stated that Resident #55 is very mobile and bends down a lot. She also added that the resident will go in his/her drawers and open his/her closets without the assistance of staff, was on a blood thinner, and had a history of seasonal allergies. The DON revealed that after discussion and investigation, it was decided that Resident #55's bruise was not related to abuse. On 05/03/23 at 12:37 PM, in the presence of the survey team, the DON stated, We discuss incidents every day at our morning meetings and then come up with an intervention. The DON further explained that the investigation would not be completed when discussing at the morning meetings in case there are updates or additional statements. It's an ongoing investigation. We don't ask residents for statements. It is not in the policy. We ask the resident what happened. It's a verbatim statement from the nurse. The DON provided additional information and stated that the Fall Committee concluded that Resident #55's bruise may have been sustained while bending, touching hard objects including room closet, and cabinet on his/her own. The DON added that the injury may have been sustained by rubbing his/her eyes with the mask on (had metal strip by nose bridge) since resident had seasonal allergies and is on an antihistamine. The DON explained that the presentation of the bruise was not consistent with forced-inflicted injury since discoloration is localized at 1.5 cm x 1 cm without any signs of swelling. The DON added that Resident #55's bruise presentation if force inflicted would be more pronounced since resident is on an anticoagulant. The DON revealed that the team concluded that the incident was without evidence of abuse and was deemed not reportable. The DON and LNHA could not speak to if any of the alert and oriented residents on the same unit and being cared for by the same staff as Resident #55 were interviewed, and if any other direct care staff or ancillary staff were interviewed. On 5/04/23 at 9:22 AM, the surveyor reviewed the facility's Investigating and Reporting Policy with a revised date of 5/2022, which included the following: 1. Reporting of incidents/accidents: a) Regardless of how minor an occurrence may appear, including injuries of unknown origin, it must be reported to the department supervisor as soon as such an occurrence is discovered or when information of an occurrence is learned. e) Refer to the Abuse or Neglect policy for procedure in the event of an actual or possible resident abuse or neglect situation. 1. Screening: Personal/Professional References, NJ DOH Online Public Registry check of current C.N.A. certification for new hires, with criminal background check completed .Outside service providers providing services on resident care units will provide the following proof of employment pre-screening requirements prior to proving [providing] services at the facility. License/certification numbers pertaining to their profession; expiration dates, and licence validation will be checked through New Jersey consumer affairs; Criminal background verification or employment application which indicates employees has never been convicted of a crime (such as c [NAME] of abuse/neglect, violence, dishonesty, financial or personal misconduct, etc. 4. Investigative action: a. The Nursing Supervisor and/or Department Head shall conduct an immediate investigation of the occurrence and take corrective action to prevent a re-occurrence if appropriate. 10. All injuries of Unknown Origin Incident Report will include statements from all direct caregivers during the past 24 hours. The surveyor reviewed the facility's Resident Abuse, Neglect and Exploitation of Resident & Property Policy with a revised date of January 2023, which included the following: D. Supervisor to complete supervisory Investigate report with interviews and written statement from all persons involved, including the resident, if possible, investigate three prior shifts. H. All written statements and documentation are to be completed within 48 hours and maintained under separate file cover in the DON's office. The facility's Abuse Policy did not include a reference or a procedure for how the facility would address an injury of unknown origin. The policy indicated to refer to the Facility's Accident/Incident policy. Human Resource Director Job Description, Date of Hire 10/01/2005 revealed Administrative Functions: Ensure that all employment related policies, procedures, and any additional requirements are followed in compliance with facility, legal and government requirements and reporting regulations. Director of Nursing Job Description Date Revised 10-2022 revealed: Personnel Functions, 4. Ensure that all nursing assistants are qualified to provide services, 19. Perform background checks on Nursing personnel accordance with established procedures, 20. Ensure that all CNAs credentials are verified through the State Nurse Aide Registry. On 5/04/23 at 10:59 AM, in the presence of the survey team, the surveyor asked the DON and LNHA what does it mean when the Accident/Incident policy indicated to refer to the Abuse policy in the event of a possible resident abuse? And where in the Abuse Policy was injury of unknown origin addressed? The LNHA stated that they follow the state form that lists types of abuse and refer to the Incident policy for investigating and when to report. The DON stated that we follow the reportable event form and answer the questions to determine if an injury of unknown origin could be abuse and continue with the investigation process to obtain statements from staff. The DON verified that the incident was not reported because it was concluded that the injury was not abuse. The LNHA added that we did not report because it did not fit the category of reporting. The DON and LNHA could not provide any additional documentation regarding Resident #55's incident report of 12/6/22. The DON and LNHA could not speak to where in the facility's Abuse Policy referenced how the facility would address an injury of unknown origin. NJAC 8.39-9.3(b)(c) Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the facility abuse policy was followed to ensure that all contracted uncertified Nurse Aides (NAs) received a.) the required criminal background check prior to working at the facility, and b.) information from licensing boards or other registries was reviewed including for alleged foreign credentialed staff. In addition, the facility failed to develop and implement a policy and procedure(s) for investigating injuries of unknown origin(s) in the facility's Abuse policy. The deficient practice was identified for 1 of 13 residents (Resident #55) reviewed for abuse, for 2 of 5 NAs reviewed (NA #2 worked at the facility from 09/04/22 through date of survey 05/04/23) and was evidenced by the following: On 04/17/23 at 11:40 AM, during the initial tour, a surveyor proceeded toward the end of one of the [NAME] unit hallway and observed an unmarked door that was located immediately past resident occupied rooms, and was held open with a magnet. Beyond the open, unsecured door, the surveyor observed room [ROOM NUMBER] without a name listed outside and a sign was affixed to the door that indicated 3 Occupants. The surveyor knocked on the door and an unidentified female answered the door. Upon interview, she stated she was a Certified Nurse Aide, and one of only two CNAs that were living at the facility. The CNA stated pointed to another female who was in the room in bed sleeping. She stated that her roommate was also a CNA and was sleeping because she worked a double shift. The CNA stated she had been living at the facility since November, 2022, and she just moved from a foreign country to the United States. The surveyor asked if she passed the CNA exam and she stated, technically passed. When asked what type of work she did while at the facility, she stated, I take care of patients. The surveyor asked if she had been fingerprinted and she stated in March [2023]. On 04/17/23 at 11:54 AM, a surveyor, accompanied by the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), proceeded through the door that was held open via a magnetic latch at the end of the [NAME] unit. The DON informed the surveyor that the rooms located past the door were resident rooms that have been converted into staff Aide rooms and the staff have a kitchen and bathroom in that area. The LNHA stated the area was not for nursing home use. The LNHA stated it was the employee overnight area, and it was an extension of the facility. The LNHA stated, it's hard to get staff and this was a wonderful opportunity. The surveyor asked the DON about the Aide staff and the DON stated, I have NAs, not TNAs (Temporary Nursing Assistants), that ended April 5, 2023. The DON stated the NAs were in school and confirmed the facility was not a nurse aide training program facility. At that time the surveyor requested a list of staff that resided on the facility premises. On 04/17/23 at 1:50 PM, the DON provided the surveyor with an untitled list that she identified as the list of staff that lived at the facility. The list included twenty-one names. All the names had a room number listed next to the name. Thirteen of the names were identified as CNAs, one was identified as a Unit Secretary and seven were identified as NA's. The CNA that was interviewed by the surveyor at 11:40 AM was identified as an NA (NA #3) on the list, as was her sleeping roommate (NA #2), not a CNA as she had identified herself to the surveyor. Eleven of the twenty-one staff listed had agency listed next to their names and the remaining were left blank. On 04/18/23 at 9:16 AM, the surveyor requested the DON to provide the prior three months of nursing assignment sheets for the entire facility, along with the employee files for the twenty-one staff listed. On 04/18/23 at 9:27 AM, the surveyor asked the DON who was responsible for confirming the staff was suitable for working at the facility. The DON stated the staffing agency completed the criminal background check and the facility was responsible for checking the licenses of the staff. On 04/18/23 12:34 PM, the surveyor interviewed the LNHA who stated the DON was responsible for ensuring that the NAs were up to date with licenses and stated, I don't directly communicate with the agency. The LNHA stated the normal process for confirming if CNAs were up to date would be through Human Resources and the DON, but not if the staff were agency staff. The surveyor asked the LNHA who was responsible to ensure there was a process in place, and the paperwork was completed for all of the NAs. The LNHA stated the agency should have the paperwork, an agency has a certain responsibility to ensure all the paperwork was in place. The LNHA then stated, ultimately I am responsible. On 04/19/23 at 12:41 PM, the surveyor, in the presence of the survey team, interviewed one of the staff identified on the list as an NA (NA #1) who was currently working. NA #1 was wearing a name tag that identified her as a CNA and then stated she had been working at the facility for three months and she lived at the staff house. The surveyor asked NA #1 what her job function was. NA #1 stated she did CNA work, and she took care of the elderly residents. She stated she transferred the residents into wheelchairs from the bed and stated that she used the mechanical lift sometimes if the resident could not stand. The surveyor asked if she used the mechanical lift alone, and she stated no, two people. NA #1 stated she provided showers to residents, and transported the residents to the shower room, and transferred them to the shower chair. NA #1 stated she changed diapers [incontinence briefs] for residents, fed residents, if they are a feeder, and emptied Foley catheter bags (a bag attached to the tubing from the urethra and used to collect urine). The surveyor asked what the NA #1's certification was. NA #1 stated, actually I am not certified for CNA, and stated she was a nursing graduate from [foreign country] and the staffing agency was helping her to be able to take the nursing exam in New Jersey to become a Registered Nurse (RN). NA #1 stated she passed the Nclex in New York (National Council Licensure Examination for Registered Nurses. The exam tests a nursing program graduate's competency and required by state boards of nursing to apply for a nursing license). The NA #1 stated that she gave the staffing agency (SA) her papers and they were in the process of getting her set up to take the RN exam. NA #1 stated maybe this December. The surveyor asked if NA #1 has attended any type of CNA (Certified Nurse Aide) school while in the United States. NA #1 stated no, nothing. The surveyor asked the NA #1 if the SA provided her with any documentation that the to show the SA was in the process of obtaining her eligibility for the RN exam. The NA #1 stated no, actually, no, not at all. The surveyor asked the NA #1 how she knew the SA had submitted documents for her to be eligible to take the nursing exam. The NA #1 stated she gave the SA a copy of her college transcript, diploma and copy of her passport. The following NA documents were provided by the facility: NA #1 On 04/18/23 at 1:15 PM the LNHA provided: -A facility Employee Health Exam Record dated 02/20/23. -A Tuberculosis (TB) Testing Record with Department: CNA listed, and dated 02/20/23, Date Read 02/22/23 and 03/01/23, Date Read 03/03/23 for two TB tests. -A consent for Hepatitis B. Immunization dated 02/09/23, Department, CNA. -A criminal search completed by the staffing agency, dated 02/27/23, no records found (Dated seven days after her start date which was provided by the DON and revealed Date Started: 02-20-23). -A copy of a transcript from the [name redacted] University, Year graduated: 12/18/04, Degree/Title: BS [Bachelor of Science] in Nursing. -A Nurse Aide Orientation Competency with an Evaluator signature 02/24/23 (pre-dated the background check by three days). NA #2 On 04/18/23 at 1:15 PM, the LNHA provided: - A medical form including medical history that was signed 09/23/22. - A letter dated 09/05/22 indicating that NA #2 was enrolled in the CNA class and starting on 09/12/23. - A criminal background search dated 09/30/23 (Seven days after NA #2 began working). -Nursing Scrub Sheets [Staffing Schedule] revealed NA #2 was assigned 34 resident care shifts from 09/04/22 through 09/30/22 (09/04/22 was 19 days before the DON indicated that CNA #2 began working). On 04/20/23 at 9:10 AM, the DON provided the surveyor with a typed-written document for NA #1 which revealed: Date Started: 02/20/23 Documents Attached: -Transcript of record attached showing evidence of Graduating BSN (Bachelors of Science in Nursing). Completed Fundamental of Nursing (healthcare 1 & Healthcare 2). -Criminal Background Report. -Facility Mandatory Orientation & Training. -Facility Nurse Aide Orientation Competency. -Employee Physicals. -PPD Screening. -Vaccine Card. Current Status- Working as NA, Facility utilizing waiver for student, graduate nurses, foreign licensed nurses and other who submit evidence of successful, timely completion of a course in fundamentals of nursing. Additionally, at the same time, a type written document for NA #2 revealed that NA #2 Date Started 09/23/22 which post-dated the dates provided on the Scrub Sheets. On 04/24/23 at 10:11 AM, the surveyor conducted an interview with the Human Resources Director (HRD), in the presence of the survey team. The HRD stated she has worked since 2003 and works for two other facilities and she is on the governing board of the facility. The surveyor asked what her responsibilities were. The HRD stated she doesn't do the actual hiring; each department is responsible for that. She stated she completed the criminal background checks and the social security check. When asked about who is responsible for licenses, the HRD stated that the DON was responsible for all nursing license verifications including for Registered Nurse, Licensed Practical Nurse, and Certified Nurse Aide. The surveyor asked if that was part of a policy, and the HRD stated, could be, I am not sure, and that is how we have done it for many years. The surveyor asked the HRD what her involvement with the agency staff was. The HRD stated, that goes through the DON, she verifies their licenses, and she keeps it up to date. At 10:19 AM, the HRD, again stated she is not involved with the agency staff. The HRD stated the department heads are responsible to do the reference check, and the end of the personnel file is her responsibility and she stated they have a checklist for that. On 04/24/23 at 10:22 AM, the surveyor requested the checklist. The surveyor asked the HRD was a reference check important. HRD stated that you have the potential to receive very important information about the employee. The surveyor asked about the agency staff and the HRD stated, I am not involved. I don't know if they do references on agency staff, they should be. If they are not on my payroll, they are not our employees. I really don't know the contracted staff rules. The surveyor asked who should know the contracted staff rules and the HRD stated that the staffing agency had to have the proper credentials, and a health file. HRD stated she was not involved and has no oversight over the agency staff. The HRD stated she would complete criminal background checks on in-house staff not the agency staffing, we rely on the agency to complete criminal background checks on the agency staff. The surveyor asked the HRD about the facility's screening policy and showed the HRD the screening process in the facility's abuse policy. The surveyor asked about the NAs and who would ensure that the proper screening was completed. The HRD stated that she had nothing to do with the staffing agency staff at all and that it was all the DON's responsibility. She further stated, that the DON would receive the criminal background checks from the staffing agency. The surveyor asked the HRD if that was important, and the HRD stated to ensure the safety of our residents. The HRD stated that currently the facility does not have any NAs, but when the facility employed NAs, she would use her checklist to keep track of the NAs and that the DON was responsible for ensure that the staff received certification and she followed up on the DON. On 04/24/23 at 10:50 AM, the surveyor interviewed the DON in the presence of the survey team. The DON stated she has been the DON for 14 years. The surveyor asked when you are hiring agency staff who is responsible for ensuring the agency staff was properly screened. The DON stated she was ultimately responsible for the agency staff. The DON stated she would get the information about the NAs from the agency from the staffing coordinator. The DON stated, I keep the file for the agency nursing staff. The surveyor asked how you are ensuring that the agency staff are legitimate to work. The DON stated, by history, we have worked with the staffing agency for a long time, I think 17 years and the ownership was involved with guidance for obtaining staff and she took direction from the LNHA. The DON stated that there was an arrangement between the staffing agency and the facility to have the staffing agency live at the facility. The DON stated, I usually ask for the license and criminal background check and I check the portal for license and that the CNAs are current. The DON stated the usual thing that she asked for was the license and criminal background check, the only exemption recently was the NA's. The surveyor asked what you do if you don't see license, regarding NA #1. The DON stated what she was given was the transcript and she did not know that the education had to be within one year, no, they never gave us anything on the foreign nurse. The surveyor asked when did you became aware that NA #1 did not have the proper credentials, when we had a discussion of the waiver. The surveyor asked was it during the current survey and the DON stated, yes. The surveyor asked the DON if she ever received proof of processing the foreign nursing graduate and the DON stated, no, nothing was provided by staffing agency. The surveyor asked what fell through the cracks with the five NAs. The DON stated the background check would come from the staffing agency and NA #2 was delayed for the classes, it didn't cross my mind. The surveyor asked the DON if she had been trained in the process to manage the NAs. The DON stated, no, the staffing agency provided the information. The surveyor asked if the HRD offered to educate her, and the DON stated, I don't recall, the HRD doesn't get involved with the agency flow. The DON stated the only thing she can recall regarding the NAs is the 120 days. The DON stated the staffing agency was responsible to make sure that they were monitoring the time frames for the NAs and the DON stated that she didn't interact with the CNA school, had information on the test results, and the fingerprinting the responsibility of the NAs. On 04/24/23 at 11:46 AM, the surveyor interviewed the LNHA and asked who was ultimately responsible for the NA's. The LNHA stated ultimately, he was responsible. The surveyor asked the LNHA what was the hiring process for staff in relation to the screening process of new employees. He stated, in general, it would have been the department head(s) and then stated Human Resources (HR). The LNHA stated HR completed the criminal background checks for the employees and that cannot deviate. On 04/24/23 at 11:53 AM, the surveyor reviewed the Abuse Policy in the presence of the LNHA. The LNHA stated the staffing agency and HR would be responsible for any outside agency information, and the criminal background check would be through HR. The surveyor informed the LNHA that the HRD informed the survey team that she was not involved with any contract staff and the LNHA stated that he was not aware that the HRD was not involved. On 04/24/23 at 1:07 PM, the surveyor interviewed the LNHA regarding what he had been educated on from the consultant LNHA. The LNHA stated to make sure that the NAs were enrolled in the CNA class and to make sure the background checks were completed. The LNHA stated that learning that the NAs went beyond the 120 days, and not notifying the Department of Health, was a mistake on the facility. On 04/26/23 at 10:00 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the Staffing Director (SD) at the staffing agency. The surveyor asked what the hiring process was for the NAs. The SD stated the NAs would fill out an application and we run a CBI [criminal background check], which was an automated service to check if an applicant had a criminal history and check references. The surveyor asked the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of medical records and other pertinent facility documents, it was determined that the facility failed to a.) ensure that there was consistent documentation of social service comprehensive assessments for 7 of 11 residents reviewed for social services (Resident's #4, #8, #10, #15, #35, #39, and #61) , and b.) clarify and accurately transcribe a physician's order for Ambien (a Sedative-Hypnotic) which resulted in a resident receiving the incorrect dose of the medication. This was identified for 1 of 25 residents (Resident #387) reviewed for medication management. The deficient practice was evidenced as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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. The evidence was as follows: 1. On 4/17/23 at 12:26 PM, the surveyor observed Resident # 4 in bed and eating lunch. The resident was willing to be interviewed and offered no concerns. Review of Resident #4's medical record: Review of the admission Record (an admission summary) reflected that the resident had diagnoses which included but were not limited to; hypertension, morbid obesity and difficulty walking. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an assessment reference date (ARD) for 8/8/22. Review of the Social Services Notes indicated that the last entry was dated 8/18/21 at 11:42 AM. 2. On 4/19/23 at 9:56 AM, the surveyor observed Resident #8 in a wheelchair being transported to Hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney are used to clean the blood.) The resident was alert, groomed and wearing a coat, hat and eyeglasses. The resident stated that he/she felt well. Review of Resident #8's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; chronic kidney disease - stage 4 (severe), dependence on dialysis, and unspecified dementia. Review of the Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 11 out of 15, which indicated that the resident had a moderate cognitive impairment. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an ARD for 12/16/22. Review of the Social Services Notes indicated that the last entry was dated 4/6/23 at 3:39 PM and before that on 10/20/21 at 4:19 PM. 3. On 4/19/23 at 10:38 AM, the surveyor observed Resident #10 in the resident council meeting. The resident was groomed and in a wheelchair. The resident was an active participant at the meeting. Review of Resident #10's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; heart failure, morbid obesity, generalized muscle weakness, and a right leg above knee amputation. Review of the Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an ARD for 11/3/22 and 11/8/21. Review of the Social Services Notes indicated that the last entry was dated 2/16/22 at 2:51 PM and before that on 8/18/21 at 11:47 AM. 4. On 4/17/23 at 11:43 AM, the surveyor observed Resident #15 in a wheelchair eating lunch in his/her room. The resident was groomed and offered no concerns. Review of Resident #15's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; heart failure, anxiety disorder and bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows.) Review of the Annual MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, which indicated that the resident was cognitively intact. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an ARD for 1/31/23 and 12/6/21. Review of the Social Services Notes indicated that the last entry was dated 2/9/22 at 1:39 PM and before that on 12/22/21 at 4:25 PM and before that on 9/15/21 at 12:04 PM. 5. On 4/17/23 at 12:01 PM, the surveyor observed Resident #35 in bed with the head of the bed elevated feeding him/herself lunch. The resident did not respond to the surveyor. Review of Resident #35's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; unspecified dementia, major depressive disorder, traumatic amputation of the right leg below the knee and generalized muscle weakness. Review of the Annual MDS dated [DATE], reflected that the resident had a BIMS score of 4 out of 15, which indicated that the resident had severe cognitive impairment. Review of the MDS schedule indicated that the resident was scheduled for a significant change comprehensive assessment with an ARD for 4/21/23 and 4/26/22. Review of the Social Services Notes indicated that the last entry was dated 4/26/23 at 9:09 AM. There were no other entries documented before that date. 6. On 4/27/23 at 10:00 AM, the surveyor observed Resident #39 in their room in a recliner chair. The resident's eyes were closed. Review of Resident #39's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; Alzheimer's disease, glaucoma and generalized muscle weakness. Review of the Quarterly MDS dated [DATE], reflected that the resident had short- and long-term memory problems. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an ARD for 11/8/22 and 11/10/21. Review of the Social Services Notes indicated that the last entry was dated 5/18/22 at 11:47 AM and before that on 8/18/21 at 10:37 AM. 7. On 4/19/23 at 10:38 AM, the surveyor observed Resident #61 in the resident council meeting. The resident was groomed and in a wheelchair. The resident was an active participant at the meeting. Review of Resident #61's medical record: Review of the admission Record reflected that the resident had diagnoses which included but were not limited to; right side hemiplegia and hemiparesis (weakness to possible paralysis) following a cerebral infarction (stroke) and generalized muscle weakness. Review of the Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. Review of the MDS schedule indicated that the resident was scheduled for an Annual comprehensive assessment with an ARD for 5/9/22. Review of the Social Services Notes indicated that the last entry was dated 11/16/22 at 10:30 AM and before that on 8/18/21 at 11:24 AM. On 4/19/23 at 10:12 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for the [NAME] and [NAME] units. She stated that the social workers progress notes should be in the electronic medical record (EMR). On 5/1/23 at 11:02 AM, the surveyor interviewed the social worker (SW) in the presence of a second surveyor. She stated that she worked part time and was assisting in the transition between the previous Social Services Director and the newly hired. She stated that her responsibilities included all new admission comprehensive assessments and obtaining the residents social history. In addition, she scheduled Interdisciplinary Care Plan (IDCP) meetings with residents and families (new admission, quarterly and annually reviews and if there was a significant change in the resident's condition) and participated in discharge planning and arranged for services the resident needed after discharge. She further stated that she completed sections D (related to mood) and Q (related to the resident's plan for discharge or long-term placement) of the MDS and handled any grievances. She stated that the new admission social worker resident assessment would be found in the paper chart on a blue form in the care plan section. She further stated that subsequent comprehensive assessments and progress notes should be in the EMR in the social service section. She also stated that IDCP documentation would be in the social service section and could have been written by the nurse unit managers. On 5/1/23 at 1:25 PM, the surveyor interviewed the SW in the presence of a second surveyor. She stated that the majority of her responsibilities was related to the subacute population and not the long-term care population. She further stated that subacute tasks were her main focus unless otherwise delegated by the previous Social Service Director who was responsible for the long-term care population. The surveyor requested copies of the social service notes for resident's #4, #8, #10, #15, #35, #39 and #61. On 5/2/23 at 12:06 PM, the surveyor interviewed the SW in the presence of a second surveyor. She stated that a social services comprehensive resident assessment should include review of the care plan, advanced directives, any changes within the last three months including any hospitalization's, changes in medication and overall condition. She also stated, it's my understanding that the Director of Social Work documented in the social service notes in the EMR for quarterly, annual and significant change assessments, and it's my understanding that she stopped because her role changed, and she relied on the IDCP meeting notes a few years ago. She further stated that since then the quarterly, annual and significant change documentation changed and the social worker attended the IDCP meetings, reviewed the nurse generated IDCP progress note and signed that she attended the meeting and no longer documented herself. During this same interview, the SW acknowledged that the nurse generated IDCP meeting note would not have encompassed all that a social service comprehensive assessment would have. She also acknowledged that the content of the IDCP meeting note could not be used as a look back reference to support and complete an MDS, as the meeting takes place after the MDS was completed. In addition, she could not speak to whether or not the previous Social Service Director decided to change her documentation process on her own or if that was approved by administration. She further acknowledged that a social service note written for Resident #8 on 4/6/23, was not considered a comprehensive assessment and that a comprehensive assessment should have been completed for Resident #35 for a significant change MDS after being discharged from hospice services on 4/14/23. On 5/3/23 at 10:07 AM, the surveyor interviewed the SW in the presence of the survey team. She stated that the SW reviewed the IDCP meeting note and if any social service concerns were reviewed, she would have documented that in the social service section in the EMR and initiated a paper grievance. She also stated, It's my understanding that anyone from the team can document the content of the team meeting and it was primarily completed by nursing. The SW again acknowledged this was not the same as a comprehensive social service assessment. She further stated that she did not document the information she ascertained and assessed from the resident related to the MDS sections she completed. She also stated that the Director of Nursing (DON) was unable to provide her with any policies related to social service assessments or documentation other than the RAI and Care Planning Process policy. On 5/3/23 at 12:36 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The DON stated that anyone form the team could document on a resident's quarterly assessment, and if any social service-related issues were discovered during the IDCP meeting then the SW should have generated a paper grievance. She stated that an annual comprehensive assessment had to have been documented in the social services section of the EMR. She further stated that both a significant change and annual assessment should have been comprehensive and documented in the social services section of the EMR; it's the standard of practice. On 5/4/23 at 11:04 AM, the survey team met with the LNHA and the DON. The LNHA stated that it was his responsibility to oversee the social workers' work. No additional information was provided. Review of the facility policy Social Services with a revised date of 4/2023, included the responsibilities of the SW, Maintains a written record of the frequency and nature of the social service consultation and services provided or obtained; .Performs an evaluation of each resident's social needs. The plan for providing care shall be formulated and recorded in the residents; medical record and periodically re-evaluated in conjunction with the resident's total plan of care. Review of the facility policy Quality of Care with a revised date of 2/2023, included, It is the policy of the facility to ensure that each resident receive, and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance to State and Federal Regulations. In addition, it included, Quality of Care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 8. On 4/19/23 at 9:49 AM, the surveyor observed Resident #387 wearing a back brace and being assisted to ambulate by the therapy department. On 4/20/23 at 7:52 AM, the surveyor observed Resident #387 sitting up in bed being assisted by staff with the breakfast tray. On 4/25/23 at 9:16 AM, the surveyor observed Resident #387 sitting in a chair in the hall eating. On 4/20/23 at 7:22 AM, the surveyor reviewed the Narcotic/controlled medication counts in the medication cart with the medication nurse. The surveyor observed two Bingo cards (cards which hold resident medications), one for Ambien 10 milligrams (mg) and a second for Ambien 5 mg. At that same time, the surveyor interviewed the 11 PM to 7 AM Registered Nurse (RN) #1 who stated the Ambien order needed to be clarified. She stated Resident #387 was administered Ambien 10 mg on the 4/19/23, by the 3 PM - 11 PM shift Licensed Practical Nurse (LPN) #1. RN #1 further stated that the resident should have received Ambien 5 mg and another Ambien 5 mg an hour later if not effective, but LPN #1 on the 4/19/23, 3 PM - 11 PM shift had administered Resident #387 Ambien 10 mg. RN #1 stated that LPN #1 had informed her that she incorrectly administered Ambien 10 mg instead of Ambien 5 mg. RN #1 showed the surveyor the Bingo card with Ambien 10 mg pills with 3 pills missing. RN #1 showed the surveyor the Bingo card with Ambien 5 mg pills and no pills were missing. The surveyor in the presence of RN #1 reviewed the Patient Controlled Substance Administration Record (PCSAR) for the Ambien 5 mg which indicated all 30 pills were present as observed. A review of the PCSAR for the Ambien 10 mg indicated three pills had been signed out including 4/19 at 8:48 PM, as observed. On 4/20/23 at 8:14 AM, the surveyor interviewed the RN/UM who stated she was responsible to transcribe orders into the Medication Administration Record (MAR). She stated the nurse on the 11 PM to 7 AM shift would be responsible to double check the orders. The surveyor inquired about the process for when a medication was discontinued. The RN/UM stated the discontinued controlled substance medication should be removed from the medication cart by the nurse receiving the order. The RN/UM stated that the nurses perform a controlled substance medication count between shifts and that if not done already, the on coming nurse should have removed the discontinued medication. The surveyor inquired what could happen to a resident who received twice the ordered dose of Ambien. The RN/UM stated it should be reported to the Director of Nursing (DON) and the physician and the resident would need to be monitored. On that same date and time, the surveyor in the presence of the RN/UM reviewed the Electronic Medical Record (eMR) transcribed order for Ambien Oral Tablet Give 1 tablet by mouth at bedtime for restlessness, sleeplessness. If first 5 mg tablet ineffective, see PRN (as needed) and give 1 tablet by mouth as needed for insomnia and may give additional second 5 mg (=10 mg) at bedtime if unable to sleep within the hour first tablet administered. The RN/UM stated that the order should have been clarified. A review of the hybrid medical record revealed that Resident #387 had recently been readmitted on [DATE] and had diagnoses which included but were not limited to; post laminectomy syndrome (persistent lower back or leg pain after surgery), chronic kidney disease stage 4 severe, mild cognitive impairment, insomnia, and unspecified abnormalities of gait and mobility. A review of the Daily Skilled Note, dated 4/15/23, included cognition as alert, oriented to person, and confused. Neuro/muscular included gait unsteady, balance problem, and tremors. Summary included new admission, period of confusion. A review of the comprehensive Care Plan included but was not limited to a focus area dated 4/16/23, at risk for adverse effects related to the use of hypnotic. Interventions included but were not limited to evaluate effectiveness and side effects of medications and provide education to risks and benefits of medications as needed. A review of the Order Summary Report included but was not limited to a physician's order dated 4/15/23, observe potential side effects of sedatives/hypnotics. A review of a physician's order dated 4/15/23, Ambien 10 milligrams (mg) give 1 tablet by mouth at bedtime for restlessness, sleeplessness. A review of the facility provided, admission Medication Regiment Review (aMRR) dated 16-Apr [April]-23, included the pharmacy consultants recommendations 1. the maximum recommended initial dosage of Ambien in women is 5 mg. If the present dose is required, evaluate the risk vs. benefit for use. A handwritten note on the bottom of the unsigned recommendation form, indicated faxed to [name redacted] 4/17 at 1:30p. A review of a Clarification Required paper dated 4/18/23, revealed the Ambien original order (10 mg) will be changed. There was a prescription with the clarification which was dated 4/19/23, Ambien 5 mg T (one) tab (tablet) qHS (at hour of sleep) and T or if unable to sleep with 1 tab in an hour. A review of a telephone order dated 4/19/23 at 8:39 (am), was transcribed as Ambien Oral Tablet 10 mg. Give 1 tablet by mouth at bedtime for restlessness, sleeplessness. If first 5 mg tablet ineffective, see PRN (as needed) and give 1 tablet by mouth as needed for insomnia and may give additional second 5 mg (=10 mg) at bedtime if unable to sleep within the hour first tablet administered. A review of the Medication Administration Record (MAR) date range 4/1/23 - 4/30/23 and provided on 4/27/23, included but was not limited to a routine order for Ambien Oral Tablet 10 mg. Give 1 tablet by mouth at bedtime for restlessness, sleeplessness. If first 5 mg tablet ineffective, see PRN and give 1 tablet by mouth as needed for insomnia and may give additional second 5 mg (=10 mg) at bedtime if unable to sleep within the hour first tablet administered. The time of administration was plotted for 2100 (9:00 PM). Start date 4/19/23, D/C (discontinuation) date 4/21/23. The MAR was signed as being administered on 4/19/23 and 4/20/23. It was unclear as to what milligram had been administered to the resident. The MAR further included the same order for Ambien Oral Tablet 10 mg. Give 1 tablet by mouth at bedtime for restlessness, sleeplessness. If first 5 mg tablet ineffective, see PRN and give 1 tablet by mouth as needed for insomnia and may give additional second 5 mg (=10 mg) at bedtime if unable to sleep within the hour first tablet administered. Start date 4/19/23, D/C (discontinuation) date 4/21/23, with the time of administration as PRN. There were no staff initials to indicate that the Ambien PRN had been administered. A review of the Progress Notes (PN) included but were not limited to date 4/15/23 Note Text this order is outside of the recommended dose or frequency. Ambien Oral Tablet 10 mg *Controlled Drug* give 1 tablet by mouth at bedtime for restlessness, sleeplessness -the daily dose of 1 tablet exceeds the usual dose of 0.5 tablet. - the single dose of 1 tablet exceeds the maximum single dose of 0.5 tablet. The usual daily dose is 0.5 tablet. A PN dated 4/19/23 at 8:40 AM, Note Text this order is outside of the recommended dose or frequency. Ambien Oral Tablet 10 mg *Controlled Drug* give 1 tablet by mouth at bedtime for restlessness, sleeplessness if first 5 mg tablet ineffective, see PRN and give 1 tablet by mouth as needed for insomnia may give additional second 5 mg (=10 mg) at bedtime if unable to seep within the hour first tablet administered. -the daily dose of 1 tablet exceeds the usual dose of 0.5 tablet. -the single dose of 1 tablet exceeds the maximum single dose of 0.5 tablet. The usual daily dose is 0.5 tablet. A PN dated 4/21/23 at 10:43 (am) spoke to resident about Ambien dose and he/she wants 10 mg daily at HS. This order was not clarified, or the resident spoken to until 4/21/23 after the surveyors brought it to the attention of the facility. On 5/3/23 at 1:10 PM, the DON provided a late entry PN dated 4/20/23 at 8:37 (am), that Resident #387's Ambien order was changed to Ambien 10 mg and to discontinue the 5 mg. However, the order was not entered into the eMR for the medication nurses to follow. On 04/21/23 at 10:26 AM, the surveyor interviewed the Consultant Pharmacist (CP) and reviewed the 4/19/23, Ambien order. The CP stated, that's too much Ambien.The CP stated that the order needed to be clarified and he would have to talked to the Administrator or DON. On 04/21/23 at 11:21 AM, during an interview with four surveyors, the DON in stated she was told that the Ambien was ordered for 10 mg but that the Nurse Practitioner (NP) wrote an order for Ambien 5 mg to be given routinely and PRN. The DON stated the order should have indicated that Ambien 5 mg had to be administered routinely and Ambien 5 mg after 1 hour PRN. She stated that if the order read Ambien 10 mg give 1 tablet, it means give a table of Ambien 10 mg. The DON further stated the original order should have been discontinued and re written. When asked if she had spoken to LPN #1 who administered Ambien 10 mg instead of Ambien 5 mg, the DON stated no. The DON acknowledged that the Ambien order had been changed and should have been clarified on the MAR so the nurse's knew what mg to administer. The DON acknowledged she was not aware that the order had still not been changed on the MAR. On 04/26/23 at 12:23 PM, the surveyor conducted a telephone interview with LPN #1 who stated she recalled the Ambien order from 4/19/23. She stated she had been the residents nurse the entire time and it (Ambien) was always 10 mg and no parameters were ever given for Ambien before. She further stated, I gave her the 10 mg as usual because the order read Ambien 10 mg. LPN #1 stated, I realized after I administered it (Ambien 10 mg) that it was (Ambien) 5 mg and it was transcribed wrong. It should have dawned on me because it is not a medication that had regular parameters. I never would have checked for parameters. I spoke to the 11 PM nurse to ask the UM to clarify the order. If you are the one to give the Ambien, you would never look further to see parameters. The order should have read (Ambien) 5 mg with a PRN order for the other hour and the additional (Ambien) 5 mg. A review of the facility provided policy, Physician Order Transcription, revised 4/23, included but was not limited to Purpose -to establish uniform guidelines in the receiving and recording of physician orders. Recording Orders 1. Medication Orders - when recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. 2. PRN Medication Orders - when recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. A review of the facility provided policy, Discontinued Medication, revised 3/19, included but was not limited to Policy Statement: staff shall destroy discontinued medications or shall return them to the dispensing pharmacy. Interpretation and Implementation: 2. The nurse receiving the order to discontinue a medication is responsible for recording the information 3. discontinued medications must be destroyed or returned to the issuing pharmacy. A review of the facility provided policy, Administration of Medication, revised 11/22, included but was not limited to Procedure: G. Prior to Medication Administration: 1. Verify each medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right resident. 2. Verify that the MAR reflects the most recent medication order. A review of the facility provided policy, Charting, revised 4/22, included but was not limited to Policy Statement: The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Interpretation and Implementation: 2. The following information is to be documented in the resident medical record: b. medications administered. E. events, incidents or accidents involving the resident. NJAC 8:39-27.1 (a); 39.3(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow Physician Orders (PO) with regards to blood pressure medications with parameters for 1 of 25 residents (Resident #76) reviewed for medication management. This deficient practice was evidenced by the following: On 4/17/22 at 11:20 AM, the surveyor observed Resident #76 in the room and seated in a wheelchair watching television. The surveyor reviewed Resident #76's medical records. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to limbs) and nonrheumatic mitral (valve) insufficiency (mitral valve does not close properly, allowing blood to flow backward into the heart). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 2/21/23, reflected that the resident's cognitive skills for daily decision-making score was 9 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the Order Listing Report (OLR) dated 4/25/23, revealed a PO dated 4/1/23, for Furosemide 20 mg (milligrams), give 1 tablet by mouth in the morning for edema (excess fluid trapped in the body tissue) hold if SBP (systolic blood pressure) is less than 110 or the HR (heart rate) is less than 60. Further review of the OLR dated 4/25/23, revealed a PO dated 12/24/22, for Metoprolol Succinate ER (extended release) 25 mg, give 3 tablets by mouth once daily for hypertension for a total of 75 mg. Hold for SBP less than 110 or DBP (diastolic blood pressure) less than 60 or HR less than 60. Do not crush. Take with or immediately following a meal. A review of the April 2023 electronic Medication Administration Record (eMAR) revealed an order dated 4/1/23, for Furosemide 20 mg tablet, give 1 tablet by mouth in the morning for edema hold if SBP was less than 110 or HR less than 60 with a plotted time of 9 AM. The e-MAR revealed that the Furosemide was signed as given when the resident's SBP was less than 110. A review of the April 2023 eMAR showed that the medication was administered (7) seven times on the following dates: 4/5/23, 4/6/23, 4/11/23, 4/15/23, 4/19/23, 4/20/23 and 4/26/23. A review of the March 2023 and the April 2023 eMAR revealed an order dated 12/24/22, for Metoprolol Succinate ER 25 mg tablet, give 3 tablets by mouth one time a day for hypertension total of 75 mg. Hold for SBP less than 110, DBP less than 60, and HR less than 60. Do not crush. Take with or immediately following meals with a plotted time of 5 PM. The eMAR revealed that the Metoprolol Succinate was signed as being given when the SBP was less than 110 and the DBP was less than 60. A review of the March 2023 eMAR showed that the medication was administered (6) six times when the DBP was less than 60 on the following dates: 3/2/23, 3/4/23, 3/7/23, 3/17/23, 3/23/23 and 3/29/23, and one time when the SBP was less than 110 on 3/17/23. A review of April 2023, eMAR showed that the medication was administered one time when the DBP was less than 60 on 4/24/23 and one time when the SBP was less than 110 on 4/19/23. On 4/25/23 at 11:45 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she was familiar with Resident #76 and had administered medications to the resident. The RN acknowledged that Resident #76 had two orders that had medication parameters for Furosemide and Metoprolol. At that time, the surveyor in the presence of the RN, reviewed the eMAR. The RN confirmed that she administered both the furosemide 20 mg tablet and Metoprolol succinate ER when the directions indicated that the medications should have been held. She further stated that she was confused with the SBP parameter because she usually sees an order holding the medication when the SBP is less than 100, but also stated that it was her responsibility to review the direction(s) before administering the medications. On 4/26/23 at 9:15 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who stated that she floats throughout the facility, but that she was familiar with Resident #76 and had administered medications to the resident. The LPN acknowledged that the resident had two orders that had medication parameters for Furosemide and Metoprolol. At that same time, the surveyor in the presence of the LPN, reviewed the eMAR. The LPN confirmed that she administered the Furosemide 20 mg when she should have held the medication. The LPN could not speak to why she didn't hold the medication, but stated that it was her job to review the physician's order before administering the medication(s) and that would also include reviewing the medication parameters. On 5/2/23 at 1:10 PM, the surveyor discussed the above observations and findings with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Administration of Medication dated 12/31/10, which was provided by the DON included the following: If required, obtain vital signs before medication administration. a. Review parameter indicated in the order prior to pouring medication; b. Enter the parameter indicated in the order. Withhold/ administer the medication as order. NJAC 8:39-11.2 (b), 29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to ensure a process was in place and followed to ensure untrained staff without sufficient competencies to meet the health and/or safety needs of one or more residents. [Non-permanent Nurse Aides (NAs)] were competent to provide resident care by failing to ensure: a.) NAs were full-time employees who were enrolled in a State- approved training and competency program, and b.) a system was in place to ensure all NAs received the appropriate training and deemed eligible to provide resident care, which included, but was not limited to; assisting with two person transfers, bathing and feeding dependent residents. This deficient practice was identified for 5 of 7 NAs reviewed that provided care on 4 of 4 resident units from 09/04/22 through 04/20/23, and was evidenced by the following: The evidence was as follows: On 04/17/23 at 11:40 AM, during initial tour, a surveyor proceeded toward the end of one of the [NAME] unit hallways and observed an unmarked door located past resident rooms which was held open with a magnet. The surveyor observed room [ROOM NUMBER] with no name and a sign on the door that indicated 3 Occupants. The surveyor knocked on the door and an unidentified female answered the door. Upon interview, she stated she was a Certified Nurse Aide (CNA), one of only two CNAs that were living at the facility. The CNA stated I don't want to get in trouble and pointed to another female in the room who was in bed sleeping. She stated that her roommate was also a CNA and was sleeping because she worked a double shift. The CNA stated she had been living at the facility since November 2022 and she just moved from a foreign country to the United States. The surveyor asked if she passed the CNA exam and stated, she technically passed. When asked what type of work she does at the facility, she stated, I take care of patients. The surveyor asked if she had been fingerprinted, as required to be a CNA, and she stated in March [2023]. On 04/17/23 at 11:54 AM, a surveyor, accompanied by the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), proceeded through the door that was held open via a magnetic latch at the end of the [NAME] unit. The DON informed the surveyor that the rooms located past the door were resident rooms that had been converted into staff Aide rooms and the staff have a kitchen and bathroom in that area. The LNHA stated the area was not for nursing home use. The surveyor asked the DON about the Aide staff and the DON stated I have NAs, not TNAs (Temporary Nursing Assistants), that ended April 5, 2023. The DON stated the NAs were in school and the facility was not a nurse aide training facility. At that time the surveyor requested a list of staff that resided on the facility premises. On 04/17/23 at 1:50 PM, the DON provided the surveyor with an untitled list that she identified as the list of staff who lived at the facility. The list included twenty-one names. All the names had a room number listed next to the name. Thirteen of the names were identified as CNAs, one was identified as a Unit Secretary and seven were identified as NAs. The CNA that was interviewed by the surveyor at 11:40 AM was identified as an NA on the list, as was her sleeping roommate, not as a CNA as she had identified herself as. Eleven of the twenty-one staff listed had agency listed next to their names and the remaining were blank. On 04/18/23 at 9:16 AM, the surveyor requested the DON to provide the prior three months of nursing assignment sheets for the entire facility, along with the employee files for the twenty-one staff listed. 04/18/23 at 9:27 AM, the surveyor asked the DON who was responsible for confirming the staff were suitable for work. The DON stated the staffing agency completed the criminal background check and the facility was responsible for checking the licenses of the staff. On 04/18/23 at 9:29 AM, the surveyor asked the DON who the remaining staff had been employed by, since the list was blank for nine of the staff. The DON stated one staff member was employed as a CNA with the facility and the remaining staff were employed through the agency. On the same day at 9:30 AM, the DON provided a new staff listing for the staff that lived at the facility, with all twenty-one staff now listed as agency, including the one staff identified as being employed by the facility. On 04/18/23 at 9:44 AM, the surveyor asked the DON what type of program the staffing agency had regarding the nurse aid training. The DON stated she was not aware of a program for nurse aides. On 04/18/23 at 10:04 AM, the surveyor requested from the DON, all employee files from the staffing agency, including education. On 04/18/23 12:34 PM, the surveyor interviewed the LNHA who stated the DON was responsible for ensuring that the NAs were up to date with certifications and stated, I don't directly communicate with the agency. The LNHA stated the normal process for confirming if CNAs were up to date would be through Human Resources and the DON, but not if the staff were agency staff. The surveyor asked the LNHA who was responsible to ensure there was a process in place, and the paperwork was completed for all the NAs. The LNHA stated the agency should have the paperwork, an agency has a certain responsibility to ensure all the paperwork is in place. The LNHA then stated, ultimately I am responsible. The following NA documents were provided by the facility: NA #1 On 04/18/23 at 1:15 PM the LNHA provided: -A facility Employee Health Exam Record dated 02/20/23. -A Tuberculosis (TB) Testing Record with Department: CNA listed, and dated 02/20/23, Date Read 02/22/23 and 03/01/23, Date Read 03/03/23 for two TB tests. -A consent for Hepatitis B. Immunization dated 02/09/23, Department, CNA. -A criminal search completed by the staffing agency, dated 02/27/23, no records found (Dated seven days after NA #1's start date provided by the DON: 02-20-23, -A copy of a transcript from the Philippine Women's University, Year graduated: 12/18/04, Degree/Title: BS [Bachelor of Science] in Nursing. -A Nurse Aide Orientation Competency with an Evaluator signature 02/24/23 (pre-dated the background check by three days). On 04/19/23 at 10:00 AM, the LNHA provided: -Hand checked off multiple choice questions for Behavioral Competencies, Technical Competencies and Resident-Based Competencies which were dated March 2023 (no specific date). -There was an attached Scorecard for All Competencies with NA #1's name handwritten on top and the your % was left blank for all three competencies. The Total section was blank for all three sections. -A general Mandatory Orientation Checklist, dated 02/22/23 (pre-dated the criminal background check by five days). On 04/20/23 at 9:10 AM, the DON provided a typed-written sheet that indicated NA #1 started working on 02/20/23, and her current status was as an NA (Not a C.N.A. as was identified on NA #1's name badge). NA #2 On 04/18/23 at 1:15 PM, the LNHA provided: -A letter dated 04/07/23, that NA #2 was enrolled in a Nurse aide training course to start on 04/03/23 (Letter was dated three days after the course was scheduled to begin). -A health form with medical history that was signed and dated 12/08/22. -Employee Health Exam Record signed and dated 12/23/22. -A TB Testing record Date Given: 12/08/22 and 12/16/22, Date Read: 12/10/22 and 12/19/22. A Nurse Aide Competency signed by an evaluator on 12/16/22. On 04/19/23 at 12:30 PM, the DON provided the surveyor with facility staffing sheets from 01/01/23 through 04/19/23, which revealed that NA #1 and NA #2 worked on 4 of 4 units. On 04/20/23 at 9:30 AM, the DON provided a typed-written document that indicated NA #2 started working 12/08/22. -A Behavioral, Technical and Resident-Based competency multiple choice test document with the NA #2's handwritten name and dated, March 2023, was filled out with answers hand-written in. The Scorecard: All Competencies, Behavioral, Technical and Resident-Based was completely blank. (This training document was dated three months after NA #2 began working). NA #3 On 04/18/23 the DON provided: -A health form with medical history signed and dated 04/10/23. On 04/18/23 at 12:44 PM, the surveyor interviewed the DON regarding NA #3's file that did not contain a letter confirming that they were enrolled in a Nurse Aide Training Program. The DON stated that she spoke with the staffing agency on 04/18/23, regarding when NA #3 attending Nurse Aide Training Program. The surveyor asked the DON if the NAs were permitted to work prior to submitting to the Department of Health and proof of enrollment in a Nurse Aide Training Program. The DON stated the NAs were told toward the end of the CNA class that the NAs needed to schedule an appointment with the Department of Health. The DON stated that the staffing agency was responsible to ensure that process occurred. The surveyor asked the DON how she would know if the aides were deemed competent to provide care, and the DON stated, it is coordinated, the schedule [CNA class schedule] was used as proof. The DON provided a letter dated 04/18/23 (this was the same day that the DON stated she spoke to the staffing agency), that indicated that NA #3 was beginning the CNA program on 04/18/23 and provided a copy of the LTC-April 2023 with NA #3's name hand-written on it with Course Week 31, Dated 04/19/23 (not 04/18/23 as documented in the letter). On 04/18/23 at 1:15 PM, the LNHA provided documents for NA #3 which revealed: -A health form with medical history signed and dated 04/10/23. On 04/19/23 at 8:41 AM, the DON informed the surveyor that the staffing agency would not release employee files. The surveyor asked the DON if the staffing agency was responsible for providing education and the DON stated the facility was responsible for educating the NAs. The DON stated that she only asked the staffing agency for credentials and medical clearance. At that time, the DON stated that she was unable to obtain and provide all of the surveyor requested NA files from the staffing agency. On 04/20/23 at 9:10 AM, the DON provided a typed-written document that revealed NA #3 started work on 04/11/23, seven days prior to receiving proof that NA #3 was enrolled in a Nurse Aide Training Program. NA #4 On 04/18/23 at 1:15 PM, the LNHA provided: - a certificate that NA #4 completed 16 hours of the certified nurse aide program on September 28th, 2022. The document was dated 09/02/22 (more than three weeks prior). - Behavioral, Technical and Resident-based competencies had handwritten multiple choice questions. The Scorecard: All competencies with NA #4's name handwritten on top was completely blank. -The NA Orientation Competency was signed by an Evaluator on 10/13/22. - An untitled type-written document provided by the DON on 04/20/22 at 9:10 AM, which revealed NA #4 started working on 09/27/22, and was currently an NA. -Behavioral, Technical and Resident Based Competencies for NA #4, revealed multiple choice questions and the Scorecard for All Competencies were left blank. NA #5 On 04/18/23 at 1:15 PM, the LNHA provided: - A medical form including medical history that was signed 09/23/22 - A letter dated 09/05/22 indicating that NA #5 was enrolled in the CNA class starting on 09/12/23. - A criminal background search dated 09/30/23 (Seven days after NA #5 began working.) -Nursing Scrub Sheets [Staffing Schedule] revealed NA #5 was assigned 34 resident care shifts from 09/04/22 through 09/30/22. 04/19/23 12:41 PM, the surveyor, in the presence of the survey team, interviewed one of the staff identified on the list as an NA (NA #1) who was currently working. NA #1 was wearing a name tag that identified her as a CNA and then stated she had been working at the facility for three months and she lived at the staff house. The surveyor asked NA #1 what her job function was. NA #1 stated she did CNA work, and she took care of the elderly residents. She stated she transferred the residents into wheelchairs from the bed and stated that she used the mechanical lift sometimes if the resident could not stand. The surveyor asked if she used the mechanical lift alone, and she stated no, two people. NA #1 stated she provided showers to residents, and transported the residents to the shower room, and then transferred the residents to the shower chair. NA #1 stated she changed diapers [incontinence briefs] for residents, fed residents, if they are a feeder, and emptied catheter bags (a bag attached to the tubing from the urethra and used to collect urine). The surveyor asked what NA #1's certification was. NA #1 stated, actually, I am not certified for CNA and stated she was a nursing graduate from [foreign country] and the staffing agency was helping her to be able to take the nursing exam in New Jersey to be a Registered Nurse (RN). The NA #1 stated that she provided the staffing agency (SA) with her papers, and they were in the process of getting her set-up to take the RN exam. NA #1 stated maybe this December. The surveyor asked if NA #1 has attended any type of CNA school while in the United States. NA #1 stated no, nothing. The surveyor asked the NA #1 if the SA provided her with any documentation to show that the SA was in the process of obtaining her eligibility for the RN exam. The NA #1 stated, no, actually, no, not at all. The surveyor asked the NA #1 how she knew the SA had submitted documents for her to be eligible to take the nursing exam. The NA #1 stated she gave the SA a copy of her college transcript, diploma and copy of her passport. On 04/20/23 at 9:10 AM, the DON provided the surveyor with a typed- written document for NA #1 which revealed: Date Started: 02/20/23 Documents Attached: -Transcript of record attached showing evidence of Graduating BSN. Completed Fundamental of Nursing (healthcare 1 & Healthcare 2). -Criminal Background Report. -Facility Mandatory Orientation & Training. -Facility Nurse Aide Orientation Competency. -Employee Physicals. -PPD Screening. -Vaccine Card. Current Status- Working as NA, Facility utilizing waiver for student, graduate nurses, foreign licensed nurses and other who submit evidence of successful, timely completion of a course in fundamentals of nursing. On 04/20/23 at 9:10 AM, the DON provided a document that revealed 09/27/22 was the date that NA #4 started and was currently working as an NA. The assignment sheets for 09/21/22, revealed that NA #4 was on orientation on the [NAME] and [NAME] unit for the 7-3 & 3-11 shift (this is prior to NA #4s start date). On 04/20/23 at 9:10 AM, the DON provided the surveyor with a typed-written document of NA #3's Date Started: 04/11/23 (seven days prior to when the DON confirmed that NA #3 was enrolled in a CNA program as required) and NA #3 was on orientation. On 04/20/23 at 9:10 AM, the DON provided the surveyor with a typed-written document for NA #5 which revealed:NA #2 revealed that NA #5 Date Started 09/23/22 which post-dated the dates provided on the Scrub Sheets. On 04/20/23 at 9:30 AM, the DON provided the surveyor with a typed-written document that revealed NA #2 start date date was on 12/08/22, NA #2 was in CNA school, and the facility was using a waiver extension that ends on May 11, 2023. The facility failed to clarify why NA #2 was not enrolled in the CNA school in a timely manner, or why the information for NA #2 was not provided to the Department of Health as required. There were two documents, one revealed a Temporary Rule, Waiver/Modification .Requirements for Nurse Aide Certification, adopted by the Department of Health, effective April 29, 2020. B. Students, graduate nurse, foreign licensed nurses and others who submit evidence of the successful, timely completion of a course in the fundamentals of nursing .adding new subsection (b), to permit students, graduate nurses, or foreign licensed nurses, pending licensure, who submit to a facility evidence of the successful completion of a course in the fundamentals of nursing within the preceding 12 months, to be temporarily employed as certified nurse aides without completing the requirements to pass the Departments written/oral examination . (d)1.Nursing homes, assisted living facilities, assisted living programs and comprehensive personal care homes may temporarily employee individuals who qualify under N.J.A.C. 8:39-43.19 (b)and (c). Facilities that hire one or more nurse aides under the modified requirements created by this waiver/modification must: 1. Retain records detailing which, if any, of the above actions were implemented, including a list of the names, Social Security numbers and birth dates of the individuals temporarily hired pursuant to this waiver/modification, and the duration of the implementation; and 3. Within one week of the hiring, of one or more nurse aides, provide the Department with the names, Social Security numbers and birth dates of the individuals temporarily hired pursuant to this waiver/modification . Facilities that hire one or more nurse aides under the modified requirements created by this waiver/modification must retain records detailing which if any, of the above actions were implemented. The records must also include: (a) a list of the names, social security numbers and birth dates of the individuals temporarily hired pursuant to this waiver/modification .8:39-43.1- Nurse Aide competency, (c) during the existence of the Public Health Emergency and for forty-five days thereafter, an individual has been employed for less than 210 days and is currently enrolled in an approved nurse aide in long term care facilities training course and scheduled to completed the competency evaluation program (skills and written/oral examination) within 210 days of employment; or 2. The individual has been employed for no more than 210 days, has completed the required training specified in (a) 2 above, and has been granted a conditional certificate by the Department of Health while awaiting clearance from the criminal background investigation conducted in accordance with N.J.A.C. 8:43 (1). The second document was dated 02/27/23, from Centers for Medicare and Medicaid that detailed the federal Public Health Emergency for COVID-19 was to expire at the end of the day on May 11, 2023. On 04/24/23 at 10:11 AM, the surveyor conducted an interview with the Human Resources Director (HRD), in the presence of the survey team. The HRD stated she has worked for the facility since 2003 and works for two other facilities and she is on the governing board of the facility. The surveyor asked what her responsibilities were. The HRD stated she doesn't do the actual hiring; each department was responsible for that. She stated she completed the criminal background checks and the social security check. When asked about who was responsible for licenses, the HRD stated that the DON was responsible for all nursing license verifications including for Registered Nurse, Licensed Practical Nurse, and Certified Nurse Aide. The surveyor asked if that was part of a policy, and the HRD stated, could be, I am not sure. That is how we have done it for many years. The surveyor asked the HRD what her involvement with the agency staff was. The HRD stated, that goes through the DON, she verifies their licenses, and she keeps it up to date. At 10:19 AM, the HRD, again stated she was not involved with the agency staff. The HRD stated the department heads are responsible to do the reference check, and the end of the personnel file was her responsibility and she stated they have a checklist for that. On that same day at 10:22 AM, the surveyor requested the checklist. The surveyor also asked the HRD was a reference check important. The HRD stated, you have the potential to receive very important information about the employee. The surveyor asked about the agency staff and HRD stated, I am not involved. I don't know if they do references on agency staff, they should be. If they are not on my payroll, they are not our employees. I really don't know the contracted staff rules. The surveyor asked who should know the contracted staff rules and the HRD stated that the staffing agency had to have the proper credentials, and a health file. The HRD stated she was not involved and has no oversight over the agency staff. The surveyor asked the HRD regarding the screening policy and showed HRD the screening process in the abuse policy. The surveyor asked about the NAs and who would ensure that the proper screening was completed. The HRD stated she had nothing to do with the staffing agency staff at all and that it was all the DON's responsibility, and the DON would receive the criminal background checks from the agency. The surveyor asked the HRD if that was important, and the HRD stated, yes, to ensure the safety of our residents. The HRD further stated that currently the facility does not have any NAs, but when the facility did, she would use her checklist to keep track of the NAs and that the DON was responsible to ensure that the staff received certification and she followed up on the DON. The HRD stated she would keep the file for the NAs to make sure that they had the certification, and the NAs would be tracked. The HRD stated, they would not be able to stay if they did not pass certification past four months. The surveyor asked the HRD if that was a strict rule and she stated, yes. The surveyor requested the HRD's job description and hiring policy. On 04/24/23 at 10:50 AM, the surveyor interviewed the DON in the presence of the survey team. The DON stated she has been DON at the facility for 14 years. The surveyor asked when you are hiring agency who is responsible for the agency staff. She stated yes, I am responsible. The DON stated she would get the information about the NAs from the staffing agency staffing coordinator. The DON stated she thought that since the waiver came out in 2020, that it covered the NAs. The DON stated, I keep the file for the agency nursing staff. The surveyor asked how you are ensuring that the agency staff are legitimate to work. The DON stated, we have worked with them a long time. I think 17 years and the ownership was involved with guidance for obtaining staff along with the LNHA. The DON stated the usual thing that she asked for was the license and criminal background check, the only exemption recently was the NAs. The surveyor asked what you do if you don't see a license, regarding NA #1. The DON stated she was given the transcript and she did not know that the education had to be within one year, no they [staffing agency] never gave us anything on the foreign nurse. The surveyor asked when did you become aware and the DON stated when we had a discussion of the waiver. The surveyor asked was it during the survey and the DON stated, yes, that she did not meet the criteria and confirmed that she became aware during the survey. The surveyor asked the DON if she ever received proof of processing the foreign nursing graduate. The DON stated, no, no nothing was provided by the staffing agency. The DON stated, just the waiver that was printed out. The surveyor asked what fell through the cracks with the five NAs. The DON stated the background check would come from the staffing agency and NA #2 was delayed for the classes, it didn't cross my mind. The surveyor asked what information she was provided to know a NA was enrolled in school. The DON stated that the staffing agency would verbally inform her that an NA was starting school. The DON stated when the NAs started that they would buddy with a CNA. When asked if the NAs were trained in how to shadow, the DON stated, we usually just do verbal. The surveyor asked the DON if she had been trained in the process to manage the NAs. The DON stated, no, the staffing agency provided the information. The surveyor asked if the HRD offered to educate her, and the DON stated, I don't recall, HR doesn't get involved with the agency flow. The DON stated the only thing she could recall regarding the NAs is the 120 days. The DON stated the staffing agency was responsible to make sure that they were monitoring the time frames for the NAs and the DON stated that she didn't interact with the CNA school, have information on the test results, and the fingerprinting was the responsibility of the NAs. On 04/24/23 at 11:20 AM, the surveyor inquired who the governing body was. The DON stated that was the ownership and they would tell the facility what staffing agency to use. The DON stated NA #2 had a delayed CNA class and it was not in the system she had. The DON stated she completed an in-house orientation prior to NA #2 attending CNA class because there was a need for staff at the facility. The surveyor asked the DON why the staffing agency sent NAs that were not enrolled in CNA school to the facility. The DON stated, she thought they were in school, and during the survey she found out that was not the system in place. The surveyor asked the DON if she had kept track of the NAs milestones. The DON stated no unless the NA needed a day off for an exam or something. On 04/24/23 at 11:46 AM, the surveyor interviewed the LNHA and asked who was ultimately responsible for the NA's. The LNHA stated ultimately, he was responsible. The surveyor asked the LNHA what was the hiring process for staff in relation to the screening process of new employees. The LNHA stated, in general, it would have been the department head and then stated HR. The LNHA stated HR completed the criminal background checks for the employees and that cannot deviate. On 04/24/23 at 11:53 AM, the surveyor reviewed the Abuse Policy in the presence of the LNHA. The LNHA stated the staffing agency and HR would be responsible for any outside agency information, and the criminal background check would be done through HR. The surveyor informed the LNHA that HR informed the survey team that she was not involved with any contract staff and the LNHA stated that he was not aware that HR was not involved. On 04/24/23 at 1:07 PM, the surveyor interviewed the LNHA regarding what he had been educated on from the consultant LNHA. The LNHA stated to make sure that the NAs were enrolled in the CNA class and to make sure the background checks were completed. The LNHA stated that learning that the NAs went beyond the 120 days, and not notifying the Department of Health, was a mistake on the facility. On 04/24/23 at 1:08 PM, the HRD provided a copy of the checklist that she used to ensure that the CNA/NA files were completed appropriately. The checklist document revealed the following: Application, Reference Checked, Certificate Verification, W-4 Form, I-9 Form, I.D. #1, I.D. # 2, Criminal History Report. On 04/26/23 10:00 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the Staffing Director (SD) at the staffing agency. The surveyor asked what the process was for the NAs. The SD stated, the NAs don't necessarily have to be enrolled in CNA school. The SD stated the NAs would fill out an application, they would complete a criminal background check and references. The surveyor asked the SD if the NA did not have work history references that they would use character references. The surveyor asked if there were any references for NA #1 when she worked as a nurse in a [foreign country] and who was awaiting confirmation to take the nursing exam. The SD stated NA #1 was not a nurse in [name redacted] and that she was an administrative worker. The surveyor asked the SD if she could provide a copy of NA #1's nursing certificate. The SD stated, well, her transfer of records and her diploma, and that is what we got from her. The surveyor asked the SD if NA #1 ever showed her a nursing certificate. The SD stated, what we saw was her diploma and transcripts of records. The SD further stated that NA #1 wanted to be a nursing assistant, so we told the facility that she had nursing background and she worked in [name redacted] in an administrative capacity. The surveyor asked the SD if NA #1 ever worked as a nurse. The SD confirmed that she never provided a nursing certificate in any aspect and confirmed NA #1 was sent as an uncertified nurse aide to the facility. The SD stated NA#1 did not submit anything to the staffing agency so that the agency would assist her with her obtaining a nursing license. The SD further stated what we had at the time was an opportunity for the NA license and we did not know if the facility was taking her as an NA, or in another capacity. The surveyor asked how they inform the facility what the status is of the person that they recommend. The SD stated, we know that the NAs need to be enrolled in a CNA class and that the NAs can work if they are uncertified and must finish 16 hours of the class before they are able to start working. The surveyor asked who was monitoring that process. The SD stated that she and another person monitored the NAs and if they referred an NA, they were unaware of what capacity they were working in at the facility. The SD stated she was unaware of waivers, since they were located in New York. The understanding was for 120 days the NA can be uncertified, and the NA had to be enrolled in the CNA course and have the 16 hours completed before they were able to work as a CNA. The surveyor asked the SD what happened regarding NAs not being enrolled in the CNA program timely. The SD stated, we just assumed, that if the facility put them on the schedule, they are okay because of the waivers, we try our best to get them into the school. Review of the undated Nurse Aide Qualifications and Training Requirements Policy, revealed a facility Policy Statement; Nurse aides must undergo a state-approved training program; 1. Policy Interpretation and Implementation, Nurse Aide is defined as any individual providing nursing or nursing-related services to resident in our facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay; 4. Our facility will not use any individual as a nurse aide for more than four months full-time, temporary, per diem, or other basis, unless: b. That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent as provided in 483.150 (a) and (b) of the Requirements of Participation; 5. Our facility will not use any individual as a nurse aide who has worked less than four months unless the individual: a. Is a full-time employee and participating in a state-approved training and competency program .6. Applicants who meet the qualifications for a nurse aide and are in training will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents .8. Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. Review of the undated Certified Nursing Assistant Job Description, included the following essential duties: Assist residents with dressing, bathing, oral hygiene and other personal care; serves food, feeds residents and collects trays, maintai[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to a.) ensure policies and procedures were implemented and followed to ensure all agency employed Nurse Aides (NAs) were competent and eligible to provide direct resident care for 5 of 7 NAs who worked on 4 of 4 units and provided facility wide direct resident care from 09/04/22 through 04/20/23 and b.) follow the facility's abuse policy to ensure that all contracted NAs received criminal background check(s) prior to working at the facility and review information from licensing boards or other registries including for alleged foreign credentialed staff. The LNHA failed to to have a system in place to ensure that all staff were appropriately screened to ensure they have never been convicted of a crime or other disqualifying offences. The deficient practice was evidenced by the following: Refer to F728F and 607E On 04/17/23 at 11:40 AM, during initial tour, a surveyor proceeded toward the end of one of the [NAME] unit hallways and observed an unmarked door located past resident rooms which was held open with a magnet. The surveyor observed room [ROOM NUMBER] with no name and a sign on the door that indicated 3 Occupants. The surveyor knocked on the door and an unidentified female answered the door. Upon interview, she stated she was a Certified Nurse Aide (CNA), One of only two CNAs that were living at the facility. The CNA stated I don't want to get in trouble and pointed to another female in the room who was in bed sleeping. She stated that her roommate was also a CNA and was sleeping because she worked a double shift. The CNA stated she had been living at the facility since November 2022 and she just moved from a foreign country to the United States. The surveyor asked if she passed the CNA exam and stated, she technically passed. When asked what type of work she does at the facility, she stated, I take care of patients. The surveyor asked if she had been fingerprinted and she stated in March [2023]. On 04/17/23 at 11:54 AM, a surveyor, accompanied by the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) proceeded through a door that was held open via a magnetic latch at the end of the [NAME] unit. The DON informed the surveyor that the rooms located past the door were resident rooms that have been converted into staff Aide rooms and the staff have a kitchen and bathroom in that area. The LNHA stated the area was not for nursing home use and that it was a residential area that nurse staff resided in. The LNHA then contradicted his statement, and admitted that immediately past the open door was a shower area that was being used to shower residents. The DON also confirmed that the shower in the staff Aide rooms was used for resident showers. The surveyor asked the DON about the Aide staff and the DON stated I have NAs, not TNAs (Temporary Nursing Assistants), that ended April 5, 2023. The DON stated the NAs were in school and the facility was not a nurse aide training facility. The DON confirmed that the staff paid $150.00 per month in rent to live at the facility. At that same time, the surveyor requested a list of staff that resided on the facility premises. On 04/17/23 at 1:50 PM, the DON provided the surveyor with an untitled list that she identified as the list of staff who lived at the facility. The list included twenty-one names. All the names had a room number listed next to the name. Thirteen of the names were identified as CNAs, one was identified as a Unit Secretary and seven were identified as NA's. The CNA that was interviewed by the surveyor at 11:40 AM was identified as an NA on the list, as was her sleeping roommate, not a CNA as she had identified herself as. Eleven of the twenty-one staff listed had agency listed next to their names and the remaining were blank. On 04/18/23 at 9:16 AM, the surveyor requested the DON to provide the prior three months of nursing assignment sheets for the entire facility, along with the employee files for the twenty-one staff listed. 04/18/23 at 9:27 AM, the surveyor asked the DON who was responsible for confirming the staff were suitable for work. The DON stated the staffing agency completed the criminal background checks and the facility was responsible for checking the licenses of the staff. On 04/18/23 at 9:29 AM, the surveyor asked the DON who the remaining staff had been employed by, since the list was blank for nine of the staff. The DON stated one staff member was employed as a CNA with the facility and the remaining staff were employed through an agency. On that same day at 9:30 AM, the DON provided a new staff listing for the staff that lived at the facility, with all twenty-one staff now listed as agency staff, including the one staff who was identified as being employed for the facility. On 4/18/23 at 9:44 AM, the surveyor asked the DON what type of program the staffing agency had regarding the nurse aides training. The DON stated she was not aware of a program for nurse aides. On 4/18/23 at 10:04 AM, the surveyor requested all employee files from the [name redacted] staffing agency including education from the DON. On 4/18/23 at 12:34 PM, the surveyor interviewed the LNHA who stated, the DON was responsible for ensuring that the NAs were up to date and stated, I don't directly communicate with the agency. The LNHA further stated the normal process for confirming if CNAs are up to date would be through Human Resources and the DON, but not if the staff are agency staff. The surveyor asked the LNHA who is responsible to ensure there is a process, and the paperwork is in place. The LNHA stated, the agency should have the paperwork, an agency has a certain responsibility to ensure all the paperwork is in place. The LNHA further stated, ultimately, I am responsible. 04/19/23 12:41 PM, the surveyor, in the presence of the survey team, interviewed one of the staff identified on the list as an NA (NA #1) who was currently working. NA #1 was wearing a name tag that identified her as a CNA and then stated she had been working at the facility for three months and she lived at the staff house. The surveyor asked NA #1 what her job function was. NA #1 stated she did CNA work, and she took care of the elderly residents. She stated she transferred the residents into wheelchairs from the bed and stated that she used the mechanical lift sometimes if the resident could not stand. The surveyor asked if she used the mechanical lift alone, and she stated, no, two people. NA #1 stated she provided showers to residents, and transported the residents to the shower room, and transferred them to the shower chair. NA #1 stated she changed diapers [incontinence briefs] for residents, fed residents, if they are a feeder, and emptied Foley catheter bags. The surveyor asked what the NA #1's training had been. NA #1 stated actually, I am not certified for CNA and further stated she was a nursing graduate from a [foreign country] and the staffing agency was helping her to be able to take the nursing exam in New Jersey to be a Registered Nurse (RN). The NA #1 stated that she gave the staffing agency (SA) her papers and they were in the process of getting her set up to take the RN exam. NA #1 stated maybe this December. The surveyor asked if NA #1 had attended any type of CNA school while in the United States. NA #1 stated no, nothing. The surveyor asked NA #1 if the SA provided her with any documentation to show the SA was in the process of obtaining her eligibility for the RN exam. The NA #1 stated no, actually, no, not at all. The surveyor asked the NA #1 how she knew the SA had submitted documents for her to be eligible to take the nursing exam. The NA #1 stated she gave the SA a copy of her college transcript, diploma and copy of her passport. On 4/24/23 at 11:39 AM, the surveyor interviewed the LNHA in the presence of the survey team. He stated he has been the LNHA at the facility since 2005. He spoke to the process of hiring new employees and that each department would advertise there need, they would interview the applicant conduct reference checks, criminal background checks and then a start date is decided on and they start. He stated that agency staff are normally nurses or CNAs. He could not give a date when the facility began utilizing NAs. He stated, more prevalent during the pandemic and used NAs very little over the years. He stated, ultimately, the administrator is responsible overseeing NAs. I think, we had NAs that were beyond the 120 days and we thought because of the waiver it was ok. On 4/24/23 at 11:53 PM, the surveyor reviewed the Abuse Policy in the presence of the LNHA who stated the staffing agency and HR would be responsible for any outside agency information, and the criminal background check would be through HR. The surveyor read the facility Abuse screening section to the LNHA. The LNHA stated, we may not have followed the screening process that was identified in the Abuse policy. The surveyor handed the LNHA the facility's Abuse policy and the LNHA stated, personal references would be the department head or myself, registry for new hires criminal background check(s) would be the DON or HR. The 90-day probation period depended on each department head, outside service providers, nursing agency information is between the DON and HR; licenses and expiration dates would be the DON and HR and the criminal background check would be the responsibility of HR. The surveyor informed the LNHA that the HRD informed the survey team that she was not involved with any contract staff and the LNHA stated that he was not aware that the HRD was not involved. On 5/2/23 at 11:32 AM, the surveyor interviewed the LNHA and DON regarding QAPI. The LNHA stated that NAs are sporadically utilized on and off and confirmed that he was aware that they have been utilized more after COVID. The LNHA acknowledged that the facility was under the assumption that there was a wavier and thought certain things did not have to be in place. The LNHA acknowledged that NAs should be enrolled in a state approved NATCEP school/program and have received 16 hours of education and a criminal background check completed prior to working at the facility. The DON and LNHA confirmed they became aware that the NAs were not eligible to work at the facility during survey. On 4/20/23, the surveyor reviewed the Facility Administrator job description updated 10/2022, which indicated the following: This position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state and local regulations. Also, to develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Review of the Essential Requirements, Duties, and Responsibilities include the following: 1. Develop, maintain and implement operational policies and procedures to meet residents' need compliance with federal, state and local requirements; 2. Determine the personnel requirements of the facility in collaboration with Department Managers and the Human Resource Department and hire or arrange for sufficient staff to provide for sound resident care and implement the facility policies and procedures; 3. Establish systems to enforce the facility policies and procedures; 4. Maintain close supervision in the development of all personnel policies and job descriptions to assure compliance with federal, state and local requirements; 5. Supervise the recruitment, employment, performance, evaluation, promotion and discharge of all staff in collaboration with the Human Resource Department; 6. Participate in the scheduling, planning and procuring of material and information for staff meetings and in-service education programs; 7. Inform appropriate agencies of changes in facility personnel as required; 8. Interpret all federal, state and local regulations for the facility staff; 9. Establish systems to ensure compliance with all federal, state, and local regulations; 10. Observe all facility policies and procedures. N.J.A.C. 8:39-5.1(a) N.J.A.C. 8:39-9.2(a) N.J.A.C. 8:39-9.3(a)1-4,(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to attempt to verify information on a newly hired Certified Nursing Aide (CNA) with Reciprocity qualification status in the multi-state registry. This deficient practice was identified for 1 of 5 newly hired staff in the last four months (CNA #1). On [DATE] at 9 AM, the surveyor reviewed five randomly selected newly hired employees in the last four months. The following was revealed: A review of the employee file for CNA #1 revealed a hire date of [DATE]. A review of the New Jersey Department of Health (NJDOH) Online Public Registry verification revealed that CNA #1 had an active certification in New Jersey but had received it based on a qualifying basis of Reciprocity. The Original Issue Date was [DATE]. A criminal background check performed on [DATE] revealed no findings. There was no documented evidence within the personnel file of CNA #1 of an attempt to seek information on the status through the multi-state registry verification systems. At 10:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when they hire new Certified Nursing Aides they only check the NJDOH online public registry to make sure it says active under their certification status, and if it says reciprocity they don't do anything further. She could not speak to what other state the CNA had a certification in, in the past. She stated that the facility does criminal background checks and would check the NJDOH registry but not any other states for the CNA verification in other states. On [DATE] at 10:45 AM, the surveyor interviewed the DON a second time who stated that she has been looking into the Reciprocity of CNA #1 and stated that the CNA originally lived in California more than 20 years ago, but when checking the Online Public Registry for CNA #1, nothing comes up. At 10:55 AM, the DON stated that she checked all the states the CNA #1 had previously lived according to the their background check as well, and there was no record of the CNA #1 having had certification in that state. She stated that most of the states don't keep certificate files status' before 2003 listed on their website. On [DATE] at 12:30 PM, the DON stated that they had no other newly hired employees in the last four months with Reciprocity designation. On [DATE] at 8:50 AM, the surveyor interviewed the DON who stated that she is still awaiting a response from the Department of Health in California, but thus far there have been no records found on CNA #1. On [DATE] at 10:30 AM, the facility provided the surveyor a copy of an email from California Department of Health which included that CNA #1 had a certificate in good standing with no disciplinary actions that had expired on [DATE]. The DON stated that he had worked in multiple facilities in New Jersey since Reciprocity was issued in 2003, and he had only worked as a CNA in New Jersey. The DON confirmed that she had not attempted to seek Reciprocity information, prior to surveyor inquiry. A review of the Resident Abuse, Neglect and Exploitations of Resident & Property Policy revised 1/2020 included that newly hired staff would be screened which would include NJ DOH Online Public Registry check of current CNA certification for new hires, with criminal background check completed .License/Certification numbers pertaining to their profession, expiration dates and license validations will be checked through New Jersey Consumer Affairs . (The policy did not address checking other states for certification, other than New Jersey, if qualifying status was listed as Reciprocity.) NJAC 8:39-43.4