Based on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment by administering medications to a resident who was in the dining room for the breakfast meal. This deficient practice was identified for 1 resident (Resident #83) during the meal observation and was evidenced by the following: On 12/06/2024 at 8:25 AM, the surveyor observed a Registered Nurse (RN) #1 approach Resident #83 sitting alone at a table in the main dining area preparing to eat breakfast which was on the table. RN #1 administered Resident #83 medications and exited the area. The surveyor observed there were multiple other residents throughout the main dining area as well. On 12/06/2024 at 8:30 AM, the surveyor inquired about administering medications in the dining area in front of other residents during breakfast. RN #1 stated Resident #83 was already in the dining room and that the resident needed to take the medications. The RN further stated the purpose of not administering medications in the dining area was because the resident could not always be supervised. RN #1 acknowledged Resident #83 was not care planned to have medications administered in the dining room and that, it was my fault, sorry. On 12/06/2024 at 8:45 AM, the surveyor approached the RN as she was walking toward the medication cart. The Director of Nursing (DON) was in the hallway at the time of the observation and the surveyor informed the DON of the observation, who stated, Oh, that's not right. On 12/06/2024 at 8:47 AM, RN #1 stated that she administered calcium, magnesium, and vitamin D to Resident #83 and that those supplements were to be given with meals. A review of the medical record revealed that Resident #83 had been admitted to the facility with diagnoses which included but were not limited to; psychotic disturbance, mood disturbance, and anxiety. A review of the most recent admission Minimal Data Set (MDS) an assessment tool used to facilitate resident care, dated 12/22/2024, included but was not limited to; a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe cognitive impairment. A review of the Order Summary Report dated active orders as of 12/11/2024, included but were not limited to; dated 12/04/2024, calcium 600 + D tablet 600-5 mg (milligram)-mcg (microgram) give 1 tablet by mouth one time a day for supplement; and dated 09/16/2024, magnesium oxide 400 mg give 1 tablet by mouth one time a day for supplement. The medications were not ordered to be given with meals. A review of the facility provided policy, Medication Administration undated, included but was not limited to; B. Medication administration may begin sixty minutes before the scheduled time but may not exceed sixty minutes after the scheduled time. 4. Medications ordered before meals approximately thirty minutes before meals. Medications ordered after meals are no later than thirty minutes after a meal has ended. The policy did not address administering medications in the dining room. On 12/12/2024 at 12:44 PM, the surveyor informed the facility administrative staff. The facility had no additional information to provide. NJAC 8:39-4.1(a)(12); 27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to residents who were unable to carry out activities of daily living (ADLs). This deficient practice occurred for 2 of 2 residents (Resident #19 and #33) reviewed for nail care and was evidenced by the following: 1. On 12/3/24 at 10:19 AM, during an initial tour, the surveyor observed Resident #19 sitting in their bed. The surveyor observed the resident's fingernails to be long, jagged with a brown colored substance underneath the nails. On 12/4/24 at 9:14 AM, the surveyor observed the Resident #19 lying in their bed. Resident #19 had long, jagged nails with brown colored substance underneath the fingernails. When asked by the surveyor, the resident stated staff did not cut their nails. The surveyor reviewed the medical records of Resident #19 which revealed: A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; glaucoma (an eye disease that damages the optic nerve, which sends signals from your eyes to your brain so you can see), Cerebrovascular disease [CVA] ( is a condition in which the blood supply to the brain is interrupted or severely reduced, resulting in the death of brain tissue due to lack of oxygen and nutrients), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side (the half of the body in which a person is stronger), and Contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) right elbow. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 9/1/24, revealed the Resident #19 had a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating the resident's cognition was severely impaired. Section GG documented that Resident #33 had impairment on one side of upper extremity and required maximal assistance with personal hygiene. A review of the Care Plan included a Focus area for an ADL self-care deficit related to Right hemiparesis, CVA, . Goals included will receive assistance necessary to meet ADL needs through next review. Interventions included but were not limited to .Assist with daily hygiene, grooming and oral care as needed; Grooming- Assist X 1. On 12/12/24 at 8:20 AM, the surveyor observed the Resident #19 having breakfast in their bed. Resident #19 was holding a glass of juice in their left hand and the surveyor observed long, jagged nails with brown colored substance underneath the nails. Resident #19 stated the staff did not clean their nails during care. 2. On 12/05/24 at 9:42 AM, the surveyor observed Resident #33 sitting in their wheelchair, the nails were long and jagged with a brown colored substance underneath the fingernails. Resident #33 stated I have to ask them to cut my nails. The resident looked at their hand nails and further stated they look terrible and filthy. I scratch myself in my sleep. I have weakness in my hands, and I am not able to cut my nails on my own. The surveyor reviewed the medical records of Resident #33 which revealed: A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), general weakness, and lack of coordination (means they have difficulty performing physical movements smoothly, accurately, and efficiently). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Section GG documented that Resident #33 required maximal assistance with personal hygiene. A review of the individualized Care Plan included a Focus area for ADL (activities of daily living) deficit related to Spinal stenosis. Goals included will be clean, dressed and well groomed daily to promote dignity and psychosocial well-bring through next review and will receive assistance necessary to meet ADL needs through next review. Interventions included but were not limited to .Assist with daily hygiene, grooming and oral care as needed. On 12/11/24 at 11:07 AM, during an interview with the surveyor, Certified Nurse Aide (CNA) #3 stated nail care was provided twice weekly. The process was that they must ask the nurse first if it was okay to provide nail care. On 12/11/24 at 11:09 AM, during an interview with the surveyor, CNA #4 stated the process was to check resident's hands prior to meals and during their care. The CNA further stated the staff must ask the nurse if the nails needed to be cut and nails would be cleaned as needed. Nail care was explained during training and orientation. On 12/11/24 at 11:32 AM, during an interview with the surveyor, the assigned CNA #1 stated nail care was provided during morning care. The CNA #1 further stated if the nails needed to be trimmed, I would check with the nurse prior to providing the nail care. The CNA #1 stated the nail care would be documented in the book but she could not provide the book. On 12/12/24 at 8:30 AM, the surveyor observed Resident #33 eating breakfast in the dining room, and observed the nails were long, jagged and had brown colored substance underneath the fingernails. The resident shook their head sideways indicating that their nails were not trimmed yet. On 12/12/24 at 8:33 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 stated If I noticed the resident with long nails, I would ask the resident's CNA to trim resident's nails or shave a resident if they have long facial hair. The LPN further stated that grooming, trimming nails and shaving were all part of the morning care and would be done as needed. The LPN stated it was important to provide nail care for patient safety so they would not hurt themselves by scratching. On 12/12/24 at 8:57 AM, during an interview with the surveyor, the LPN/Unit Manager (UM) stated if the resident had long nails, it was expected the staff would provide nail care and if the resident was diabetic then they staff could file resident's nails. The LPN/UM further stated the nail care was important because it was a part of hygiene, dignity, and resident might scratch themselves. The LPN/UM observed Resident #19 and 33's nails in presence of the surveyor and acknowledged that the staff should have cut their nails. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. A review of the facility provided, Certified Nurse Aide Job Description dated 2/2024, included but was not limited to; 3.) Provides personal care to residents/ guests (bathing, cleaning fingernails, shaving and perineal care, etc.) and assures that resident/guest dresses appropriately. The surveyor reviewed the facility policy titled Activities of Daily Living (ADL's) Policy dated 12/23 included Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Under Policy Interpretation and Implementation: 2.) Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, assistance with: a. hygiene (bathing, dressing, grooming, and oral care). On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was stored and dated in accordance with professional standards when not in use for 1 of 1 resident (Resident #36) reviewed for respiratory care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/3/24 at 9:17 AM, during an initial tour, the surveyor observed Oxygen in use signage posted on the door. The surveyor observed Resident #36 resting in their bed with oxygen at 4 Liters (L) per minute via Nasal Cannula [NC] (a tube delivering oxygen into the nose), which was connected to an oxygen concentrator (a medical device used for delivering oxygen). The NC was not dated. On 12/4/24 at 9:30, the surveyor observed Resident #36 was not in their room. The surveyor observed Resident #36's NC was placed on top of the oxygen concentrator. The surveyor observed the NC was not stored properly in a plastic bag when not in use. On 12/4/24 at 10:02 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 stated O2 equipment including NC were changed weekly by night shift staff as per facility policy. The LPN further stated the NC would be stored in a special plastic bag and the bag would be labeled with resident's name and the date when it was changed. The LPN stated the residents were sick and that's why it was important to change the NC and store it in a bag for infection control and sanitation. On 12/4/24 at 10:20 AM, during an interview with the surveyor, the LPN / Unit Manager (UM) stated the NC was changed and dated weekly for cleanliness purposes and for infection control. The LPN/UM further stated NC would be placed in a plastic bag which would be labeled with resident's name and date. The LPN/UM stated if she observed a NC placed on top of the concentrator, she would replace the NC and place it in the plastic bag. At 10:26 AM, the surveyor informed the LPN/UM about the above findings. The LPN/UM accompanied the surveyor to Resident #36's room and disposed of the undated NC. The surveyor reviewed the medical record for Resident #36. According to the admission Record, Resident #36 was admitted to the facility with diagnoses which included but was not limited to: Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), Anemia (low red blood cells), depression and Anxiety. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/7/24, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that Resident #36 was cognitively intact. Further review of the MDS revealed the resident had used oxygen while a resident. A review of the resident's Care Plan (CP) included a focus area that indicated the resident is at risk for breathing patterns and/or respiratory distress related to: Diagnosis / History: COPD, Shortness of Breath; Currently on O2 4 LPM via NC continuously initiated on 10/11/24. A further review of the CP revealed that there was no plan or intervention on labeling the NC after changing it weekly and how to store the NC properly when O2 was not in use. A review of Resident #36's Order Summary Report reflected a physician orders (PO) as follows: dated 6/27/24, O2 continuously 4 LPM via NC every shift, and Change and Date oxygen tubing (NC) and humidifier bottle weekly every night shift every Sunday dated 11/1/24. The above POs were transcribed to the December 2024 electronic medication administration record (eMAR) signed by a nurse y (yes) on Sunday 12/1/24 at night shift. On 12/6/24 at 10:10 AM, during an interview with the surveyor, the Assistant Director of Nursing / Infection Preventionist (ADON/IP) stated NC should be dated, placed in a bag when not in use and the tubing should not be touching the floor. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. The surveyor reviewed the facility's undated policy titled Oxygen Administration. The policy did not address the following: 1.) Labeling of O2 equipment and 2.) Proper storage of equipment when not in use. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information, and did not refute the findings. NJAC 8:39-11.2(b) 27.1(a)

Based on observation and interview, it was determined that the facility failed to ensure a) meals were consistently provided in a dignified and homelike manner, and b) provide resident meal assistance in a dignified manner. The deficient practice was observed in the main dining room, for 2 of 2 residents (Resident #33 & #48) and on 2 of 2 units (East and West). The deficient practice was evidenced by the following: a) On 12/03/24 at 12:10 PM, Surveyor #1 observed the meal service in the main dining room. A staff member brought a tray over to Resident #33, who had just returned from the smoking area. The staff did not offer Resident #33 hand hygiene upon re-entering from the smoking area. The staff then proceeded to set up the resident's meal, without removing the food items from tray, then she dropped a peanut butter and jelly sandwich on the floor. The staff then proceeded to pick the sandwich up from the floor and placed the soiled sandwich in the tray lid that was face up, along with the other trash, which was directly in front of the resident meal tray. Surveyor #1 continued to observe the meal service and multiple staff continued to set the meal trays in front of six other residents, and placed the tray lid upright which was used as a garbage receptacle next to the resident's meal. The meal tray was also left on the table with the meal items on it. On 12/04/24 at 12:30 PM, Surveyor #1 observed the meal service in main dining room. The surveyor observed that staff were again, delivering meal trays and leaving the trays on the table in front of the residents, staff opened items and placed the garbage in front of the residents inside of the face up tray lid. On 12/11/24 at 10:16 AM, Surveyor #1, in the presence of the survey team, interviewed the Registered Dietitian (RD) and the Food Service Director (FSD) regarding the meal service. Surveyor #1 asked if leaving the garbage at the table with the residents meal tray was dignified. The FSD and RD confirmed that it was not dignified and the FSD stated there were carts in the dining room that should be used for the dirty items. b) 1. On 12/12/2024 at 8:11 AM, Surveyor #2 observed Resident #48 lying in bed and CNA #2 sitting in a chair next to the resident using her cell phone. Surveyor #2 observed the partially eaten breakfast meal on the overbed table. When Surveyor #2 entered the room, CNA #2 closed her cell phone cover and continued to assist feeding Resident #48. Surveyor #2 observed the breakfast meal garbage of a drinking lid and plastic in the plate lid on the overbed table. A review of the medical record revealed that Resident #48 had been admitted to the facility with diagnoses which included but were not limited to; muscle disorder, dementia, and severe protein-calorie malnutrition. A review of the quarterly MDS included but was not limited to; the staff was unable to establish a BIMS for Resident #48; and that Resident #48 was dependent on staff for eating. A review of the resident-centered on-going Care Plan included but was not limited to; focus areas of the potential to lose weight related to dementia and malnutrition and altered cognition related to dementia with interventions which include to assist with meals and to engage the resident in conversation to offer opportunity for reminiscing. On 12/12/2024 at 8:17 AM, CNA #2 stated that she should not have been using her cell phone, I apologize and further stated that she should have used hand hygiene after using her cell phone for infection control reasons. On 12/12/2024 at 12:44 PM, the above observation was discussed with the facility. The DON acknowledged that was not allowed. 2. On 12/12/24 at 8:14 AM, Surveyor #1 observed Resident #15 in bed, and a staff was observed feeding the resident while standing to the side of the resident. On 12/12/24 at 8:27 AM, Surveyor #1 interviewed CNA #1 regarding if staff could assist a resident with the meal, while the staff was standing. CNA #1 stated that the staff had to be seated while assisting the residents for safety concerns. The facility admission Agreement revealed: Every resident has a legal right to the following: Physical and Personal Environment: To live in a safe, clean, comfortable and home -like environment. To be treated with courtesy, dignity and respect. NJAC 8:39-4.1(a); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor #3: On 12/05/24 at 9:42 AM, the surveyor observed the Certified Nursing Assistant (CNA #2 ) obtain a cigarette lighter from Resident #33's personal bag in presence of the surveyor. The surveyor observed a pack of cigarettes in the bag and Resident #33 stated that it was their lighter and had taken it from the CNA to go out to smoke. Resident #33 stated I keep my cigarettes with me all the time. The resident further stated, all the residents have their cigarettes with them, and they take the lighter when they go out to smoke. The surveyor reviewed the medical records of Resident #33 and revealed: A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), general weakness, and lack of coordination (means they have difficulty performing physical movements smoothly, accurately, and efficiently). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Section J Health conditions indicated that Resident #33 was a current tobacco user. A review of the Individualized Care Plan included a Focus area admitted to facility with a history of smoking, with a Goal that resident will smoke safely. Interventions included that smoking supplies will be supplied during appropriate smoking times. Smoking Rules & Agreement signed on 8/15/23. On 12/12/24 at 8:33 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 explained that the residents smoked under supervision. The staff was responsible to hold the lighter when the resident went out to smoke in the designated area. The LPN further stated smoking schedules were listed at the nursing stations. The LPN was not able to provide the surveyor information about where the cigarettes and lighters were securely kept when not in use. On 12/12/24 at 10:18 AM, during an interview with the surveyor, in the presence of the survey team, CNA #2 stated that no one had ever told him about smoking facility and he state, I don't know how it works. The CNA acknowledged Resident #33 always held their lighter and cigarettes with them in the personal bag. The surveyor asked what residents had to wear the smoking aprons and CNA #2 stated, I don't know about that. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON and presented the above findings. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-27.1(a) Based on observation, interview, and document review, it was determined that the facility failed to a) ensure a cognitively impaired resident was provided with adequate supervision to prevent falls with injury and reassess, reevaluate, and implement appropriate fall interventions to the Care Plan (CP) for a resident who was at high risk for falls, and sustained multiple falls. This deficient practice occurred for 1 of 2 residents reviewed for falls (Resident #39), and b) ensure the facility, developed and implemented a consistent smoking process to prevent potential injury or fire. The deficient practice was identified for 5 of 5 residents (#11, #33, #54, #63 and #388) reviewed for smoking and was evidenced by the following: a) On 12/04/24 at 9:30 AM, Surveyor #1 observed Resident #39 seated at a table by themselves in the main dining room, was drinking a beverage, and was observed wearing slippers on their feet and no leg rests were observed on the wheelchair. On 12/04/24 at 11:14 AM, Surveyor #1 interviewed the Rehabilitation Director/ Speech Therapist (RDST). The RDST stated the facility conducted fall committee meeting twice monthly to review falls and interventions to prevent falls and see what can be done differently to prevent falls. Th RDST stated that the Department Heads including the Director of Nursing and therapy attended. The RDST also provided Resident #39's therapy treatment notes. A 09/14/23 Occupational Therapy (OT) Evaluation revealed: referred to OT due to new onset of decrease in strength, decrease in transfers, reduced functional activity tolerance, reduced static and dynamic balance, decreased judgement, increased need for assistance from others and reduced ADL participation placing patient at risk for compromised general health, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers and muscle atrophy. Precautions: Falls. On 12/04/24 at 4:18 PM, the surveyor reviewed the medical record for Resident #39 which revealed: The admission Record (admission summary) revealed diagnoses, which included but were not limited to; unspecified fracture of left patella (knee), and cognitive communication deficit. The Fall Risk Assessment, Full Assessment was completed on 09/20/23 which indicated that the resident was a High Fall Risk with a score of 38. An annual Minimum Data Set (an assessment tool) dated 08/28/24, which revealed the Brief Interview for Mental Status score was 05 out of 15 which indicated Resident #39 had a severe cognitive impairment. Section GG, functional abilities revealed the resident required touching assistance to roll left and right and to go from sitting to standing, and the resident required substantial/maximum assistance to transfer from the wheelchair to the bed. Resident #39 was coded yes for having two or more falls that resulted in injury (Injury= skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain). A Care Plan (CP) Focus: At risk for falls due to history of falls, which included resolved and current interventions had a Goal: Minimize the risk for falls through next review, Date Initiated: 09/01/23 revealed the date of falls: 09/10/23, 09/20/23, 10/05/23, 1/13/24, 1/17/24, 2/12/24, 3/24/24, 4/25/24, 5/25/24, 6/19/24, and 07/28/24. The Progress notes revealed the following: Effective Date, 10/05/23 18:54 (6:54 PM) revealed Resident #39 in dayroom eating dinner when yelling was heard. Staff attended. Skin tear to right and left elbow noted. Purple mark to forehead noted and resident send to hospital for evaluation. A Late Entry Progress Note by the Nurse Practitioner (NP), Effective Date 10/06/23, 10:08 AM and signed by the NP on 10/07/23 at 10:08 AM. The Chief Complaint: Status post emergency room visit after fall, head trauma. Nursing reported resident fell forward in dining room from wheelchair. A Late Entry Physician (MD) Progress note, Encounter Date; 10/26/23, Effective 10/26/23 at 14:09 (2:09 PM) revealed Given the history of falls and fractures, continue with fall risk prevention strategies including regular physiotherapy sessions to improve strength and balance, use of non-slip footwear, ensuring that living area is well-lit and free of trip hazards, and use of assistive devices as needed for mobility. A Progress Note dated 01/14/24 at 8:29 AM and signed by an LPN revealed. Roommate called nurse attention to resident being on floor. Resident was observed on floor close to the lamp and stand table. Resident stated trying to get up to dress. Small skin tear below the Left knee observed. A Progress Note Effective 01/1724 at 13:22 (1:22 PM) and signed by unidentified staff, revealed, Resident tried to reach the bingo coin from the floor and fell to the floor. Assisted off floor with two persons to wheelchair and first aid provided. A Progress Note Effective 02/12/24 at 10:22 AM and signed by unidentified staff, revealed resident observed sitting on floor at bedside. Resident noted with two skin tear right arm . Assisted off floor with two persons to bed, first aid provided. A Progress Note Effective 03/24/24 at 22:41 (10:41 PM) and signed by unidentified staff revealed Resident observed sitting on floor by the door. Resident noted with skin tear to back of upper right arm. Stated I was trying to get out of bed. A Progress Note Effective 04/25/24 at 16:24 (4:24 PM) signed by an LPN revealed Resident was found sitting on the floor of room close to wheelchair. Skin tears noted to Left inner forearm and wrist. A Progress Note Effective 07/28/24 at 22:58 (10:58 PM), signed by an LPN revealed responded to the sound from nurse's station, resident noted sitting on the floor . resident noted bruise and minimal swelling on forehead and nose bridge. A Progress Note Effective 06/19/24 at 23:57 (11:57 PM) and signed by an LPN revealed at 11:10 PM staff reported resident is on the floor, upon arrival resident noted sitting on the floor by the door, bed was low, call bell within reach, but not used, skin tear to left elbow noted. On 12/05/24 at 8:00 AM, the surveyor requested all fall investigations from the [NAME] President of Clinical Services Registered Nurse (VPRN) for Resident #39. On 12/05/24 at 9:06 AM, the VPRN provided the surveyor with the following fall incident reports and confirmed that what was provided was everything. The incident reports revealed: Fall #1 - Date: 09/10/23- Nursing Description: notified by staff that resident fell from [wheelchair] bedside and Resident unable to give description. Injuries observed at time of incident: Bruise-face, Laceration-face, Hematoma-right elbow. Under Notes: The team met to discuss residents fall, found on floor in room. Sent to emergency room for evaluation and admitted with acute urinary tract infection /sepsis [infection] and head injury. A review of the CP revealed the following interventions initiated on 09/01/23: Administer medications per physician order; Encourage to transfer and change positions slowly; Provide assistance to transfer and ambulate as needed; and Report development of pain, bruises, change in mental status/ ADL function, appetite, or neurological status per facility guidance. Under focus: Readmit 09/13/23 CP updated and the Interventions listed did not include any interventions added or revised post fall with injury that occurred on 09/19/23. Fall #2- 09/20/23-Nursing Description: Rounds after dinner found on floor near bed. Intervention added to CP on 09/20/23, staff will offer resident the opportunity to go to bed after dinner. Fall #3- 10/05/23- Nursing Description: Resident in dayroom eating dinner when yelling was heard. Skin tear to right hand and left elbow noted, purple mark to forehead and physician ordered to be sent to Emergency Room. Under Notes: The [NAME] met to review the fall on 10/06/23 and staff observed the resident on the floor. The intervention added to the CP on 10/05/23 was Staff to ensure leg rests in place. There were no interventions to address who was supervising the resident during meals when the resident was found on the floor yelling. Fall #4- 01/13/24- Resident attempted to get out of bed at 1:30 AM and get dressed and the CP intervention added 01/13/24, was to provide a digital clock. Fall #5 - 01/17/24- Nursing Description: Resident attempted to reach to bingo coin on floor and fell with an abrasion to back of right hand. The intervention added to the CP on 01/17/24 was resident educated to ask for staff assistance and not to bend over when objects fall on the floor. There were no interventions/revised interventions related to supervision at activities and were leg rests in place and if not effective revised. Fall #6- 02/12/24- Nursing Description: Resident observed sitting on floor at bedside, noted with two skin tears on right arm. Intervention added 02/12/24- Resident to ask for staff assistance prior to attempting to self-transfer when wants to get out of bed. Fall #7- 03/24/24- Nursing Description: Resident observed sitting on floor by the door. Noted with skin tear to back of upper right arm. Resident stated: I was trying to get out of the bed. On 03/24/24 an intervention for non-skid socks was added to the CP. The CP did not address the previous intervention added on 02/12/24 when the resident was also found with skin tears on the floor in the room trying to get out of bed. Fall #8- 04/25/24- Nursing Description: Resident found sitting on floor in room close to wheelchair and stated wanted to transfer to bed. Skin tears noted on left inner forearm and wrist. On 04/26/24 the team met to discuss the fall when resident was attempting to self-transfer to bed when noted on floor by staff. The intervention added to the CP on 04/25/24 was to provide a fall mat. The interventions that were added for the prior two falls were not modified/ addressed in the CP. Fall #9- -5/25/24- Nursing Description: Resident was found lying on the floor in room next to bed and stated, I was trying to get into bed. I was tired. On 05/25/24- the team met to discuss the fall after a failed attempt to get in bed. The intervention added to the CP was to offer a nap in the afternoon. The previous interventions that were added to prevent falls in the room were not addressed or revised. Fall #10- 06/19/24- Nursing Description: Resident found on floor by door and resident stated, going to see mom and sustained skin tear to left elbow. The CP intervention added 06/20/24 was to provide a low bed. Fall #11- 07/28/24- Nursing Description: Staff responded to a sound at the nurse's station and found resident on the floor. Resident stated was taking off sock, lost balance and fell. On 07/29/24 the team met and determined that the resident wanted to go the room before dinner, staff intercepted and placed in front of nursing station, and resident tried to remove socks and fell. The CP intervention was to encourage resident to participate in activities added 07/28/24. The previous interventions were not addressed or revised. On 12/05/24 at 12:55 PM, the surveyor interviewed the VPRN regarding the provided incident reports. The incident report for the first fall that occurred on 09/10/24 did not have attached statement and asked the VPRM if there should have been statements with the incident report. The VPRN stated, yes, when asked how the fall happened, the VPRN stated, I cannot tell you. The surveyor asked the VPRN if the facility knew the causal factor of the fall and she stated, this one they don't, and the surveyor asked the VPRN if a laceration was an injury and she stated, yes. The surveyor asked the VPRN if there was a root cause analysis and she stated, no. The surveyor asked if the 10/05/23 incident was a complete investigation to determine how the resident was found in the dining room and the VPRN stated, no. The surveyor then reviewed the 02/12/24 incident with the VPRN. There was one statement from a nurse regarding finding resident on the floor and the surveyor asked the VPRN if the investigation was complete, and she stated, no. The surveyor then reviewed the 03/24/24 incident with the VPRN and the surveyor asked what the intervention was that was added to the CP and the VPRN stated nonskid socks. The surveyor asked was that an intervention based off of the root cause of the fall and the VPRN stated, no, it is basic. The surveyor then reviewed the 04/25/24 fall, that again occurred in the resident's room. The surveyor asked the VPRN what the intervention was and she stated, the fall mat. The surveyor asked was the root cause of the fall identified and a specific intervention added and the VPRN stated, no. The VPRN stated we recognized that the old management team was not effective. On 2/12/24 at 8:27 AM, the Certified Nurse Aide (CNA #1) who was assigned to Resident #39 was interviewed after the CNA provided morning care to the resident and transported the resident to the dining room. The surveyor asked if the resident had falls and the CNA stated, yes the resident had falls and tried to transfer themselves to bed, and also did not like to stay in bed. The CNA then stated, we are supposed to keep an eye on [him/her]. The Falls and Fall Risk Management Policy (undated) revealed: Policy Statement: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Procedure: 1. The interdisciplinary team, with the input of the Attending Physician as appropriate, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall risk: 1. The staff will monitor and periodically document each resident's response to interventions intended to reduce falls or the risks of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors that continue to present a risk for falling or injury due to falls. b. On 12/03/24 at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility had residents who smoked, and the survey team requested a list of residents who smoked, smoking times and the smoking policy. On 12/03/24 at 9:34 AM, the LNHA, in the presence of another surveyor provided the Smoking Hours, the Smoker's List list with 14 resident names and the Smoking Rules and Agreement. The surveyor asked for the smoking policy and the LNHA stated the Smoking Rules and Agreement was what the facility used and there was no different policy. The LNHA stated the document was filled out for every resident who smoked and a copy was in the Electronic Medical Record (EMR). The Smoking Rules and Agreement revealed 1. Prior to being permitted to smoke, a safe smoking evaluation will be conducted by the nurse or designated member of the healthcare team. a. This evaluation will determine your ability to smoke independently, how much supervision you will need, and whether any protective devices (such as a smoking apron) may be used in order for you to be granted smoking privileges. B. Your ability to smoke and level of independence will be re-evaluated regularly and will be part of our plan of care. We will review your plan of care with you regularly and document the review in the medical record. 2. If it is determined you can safely smoke independently, you may only smoke in the designated smoking area. You may never smoke in your room or any other non designated smoking area. 3. You may never give cigarettes, lighters, matches to other residents or otherwise assist other patient or resident of the center to smoke. 4. For the safety of all staff and residents you may not retain your own lighter, matches or other course of ignition. If you have been evaluated as an independent smoker, you will be given your lighting materials before going out to smoke, and you must return them to the nurse when you return from smoking. On 12/04/24 at 9:39 AM, Surveyor #1 observed resident #388 smoking a cigarette in the courtyard. On 12/04/24 at 9:40 AM, Surveyor #1 interviewed Licensed Practical Nurse (LPN #1) regarding the cigarettes for Resident #388. She stated that she did not have any cigarettes for any of the residents who smoked that were on her assignment, and that maybe the Charge Nurse (CN) held the cigarettes and lighters. On 12/04/24 at 9:44 AM, Surveyor #1 interviewed the CN who stated that the nurses held the cigarettes and she did not hold them. Surveyor #1 asked where the lighters were kept and she stated, it depends and she confirmed that she did not have any lighters either. On 12/04/24 at 9:50 AM, Surveyor #1 interviewed CNA #3 about the smoking process and she stated, I don't know the process and stated the cigarettes are with the nurse. On 12/04/24 at 10:00 AM, Surveyor #1 interviewed Resident #11 who stated they just started smoking again. On 12/04/24 at 10:20 AM, Surveyor #1 reviewed the electronic medical record for Resident #11, which revealed the admission Agreement, Exhibit 6, Smoking Policy. The signed and undated document revealed Resident agrees to comply with the Facility's Smoking Policy . On 12/04/24 at 10:30 AM, Aurveyor #1 reviewed the electronic medical record for Resident #388. The current 11-page Care Plan did not include a care plan for smoking, and there was no smoking assessment. The admission Agreement, last page #19 revealed: Exhibit 6- Resident agrees to comply with the Facility smoking policy. The resident affirms that he/she has been provided a copy of the Smoking Policy, has had the opportunity to read its contents, understand the Smoking Policy and agrees to abide by the terms. The paper was signed and undated. On 12/04/24 at 12:11 PM, Surveyor #1 observed Resident #11 smoking a cigarette in the courtyard. On 12/04/24 at 12:18 PM, Surveyor #1 interviewed Resident #54 who stated they smoked and the facility held the cigarettes, but not the lighter. On 12/06/24 at 1:52 PM, Surveyor #1 while in the main dining room and observing smoking area, asked the facility Infection Preventionist (IP) and CNA #4 what the smoking process was. The IP stated that there were three residents who required a smoking apron for safety (Resident #63, #33 and an unsampled resident (UR #1) and that the CNAs would have an assignment for smoking. Surveyor #1 asked if there was a list so that the staff would know if a resident needed an a smoking apron and the IP stated it was posted on the [NAME] Wing. Surveyor #1 asked to see the list of residents who needed to wear an apron and brought the surveyor to the [NAME] Wing. The IP stated the list was not there, only a list of times to smoke and went to the Charge Nurse (CN) to see the list and the CN was unable to provide a list. Surveyor #1 interviewed CNA #4 about the presence of a list for residents who were required to wear a smoking apron and she stated there was no list. Surveyor #2: On 12/04/24 at 9:26 AM, Surveyor #3 observed Resident #63 sitting in a wheelchair being propelled by staff, at that time, Resident #63 had a cigarette in their mouth. On 12/04/24 at 11:00 AM, Surveyor #3 reviewed the electronic medical record (EMR) for Resident #63 and reviewed the Care Plan. The Care Plan had a Focus for smoking that was initiated on 09/19/22. The Goal was for Resident #63 to smoke safely through next review and be free from any injury through next review. Target Date: 12/19/24. An Intervention: Smoking supplies will be supplied. Initiated 09/19/22. On 12/11/24 at 8:39 AM, Surveyor #3 observed Resident #63 in bed with one package of cigarettes observed on the table next to the bed. Resident #63 stated, they have smoked for the past 20 years. On 12/12/24 at 8:50 AM, Surveyor #3 observed Resident #63 sitting in the dining room eating breakfast. Resident #63 stated that after breakfast they will go their room to get their cigarettes.

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment of the needs of the population of residents who smoked and included policy, services, and staff competencies for those residents, and b.) for the Asian American populations which identified ethnic, cultural, religious preferences and staff competencies. The deficient practice affected residents who resided on both the East and [NAME] wing of the facility and was evidenced by the following: Refer to F679 and F689 On 12/03/2024 at 8:50 AM, two surveyors were present in the conference room and requested the surveyor information from the Licensed Nursing Home Administrator (LNHA) regarding residents who smoked, the smoking policy, and smoking times. On 12/03/2024 at 9:34 AM, in the presence of the two surveyors, the LNHA provided smoking hours, a list of 14 residents who smoke, and a document Smoking Rules and Agreement. When asked about the smoking policy, the LNHA explained that the Smoking Rules and Agreement was the facility policy. On 12/03/2024 at 9:55 AM, entrance conference was conducted with the LNHA. At that time, additional survey documents were provided which included but were not limited to; the Facility Assessment Tool. 1. On 12/04/2024 at 9:40 AM, the Licensed Practical Nurse (LPN) was asked the process for resident's who smoke and that she did not hold any resident cigarettes. The LPN stated she did not care for any residents who smoked and that maybe the Charge Nurse (CN) kept the resident cigarettes and lighters. On 12/04/2024 at 9:44 AM, the CN stated that the nurses were responsible to hold the resident's cigarettes and lighters. On 12/04/2024 at 9:50 AM, during an interview regarding the smoking process with a Certified Nursing Assistant (CNA), the CNA stated, I don't know the process and believed the cigarettes were kept with the nurses. On 12/05/2024 at 9:42 AM, CNA #2 was observed obtaining a lighter out of a resident's personal bag in their room, which also contained a pack of cigarettes. At that time, the surveyor followed as the lighter was given to Resident #33. Resident #33 informed the surveyor, I keep my cigarettes with me all the time. The resident further stated, all the residents have their cigarettes with them, and they take the lighter when they go out to smoke. On 12/06/2024 at 1:52 PM, the surveyor was observing the smoking area which was visible from the main dining area. The LPN Infection Preventionist (LPN/IP) was present and stated there was a list of three residents who required smoking aprons and that the CNAs had an assignment for smoking observation. The LPN/IP stated the list was posted on the [NAME] unit. The LPN/IP and surveyor went to the [NAME] unit but were unable to find the list. The surveyor asked CNA #4 about the list and was informed there was no list. 2. On 12/03/2024 at 9:58 AM, the surveyor observed Resident #25 lying in bed with a family member present. The family member expressed concern that the resident was supposed to be receiving a daily newspaper in their language of Korean, but that was not happening. On 12/04/2024 at 12:28 PM, the surveyor was in the main dining room and observed residents of Asian American culture. The surveyor also observed a menu and activities calendar in Chinese. On 12/5/2024 at 9:35 AM, the surveyor observed Resident #25 lying in bed with no newspaper present. On 12/5/2024 at 9:49 AM, the Activities Director (AD) stated that she was familiar with the resident and that the resident was supposed to get the special newspaper, but she was not sure who was supposed to provide the newspaper. A review of the facility provided, Facility Assessment Tool dated 8/2024, included but was not limited to; Resident Profile which indicated the facility was licensed for 112 residents. 1.4 The admission of a resident or continuation of care with certain conditions, diagnoses or needs . to ensure the facility has the appropriate equipment, training/education and staff to provide care to ensure residents shall receive necessary care and service to attain or maintain highest practicable, physical, mental, and psycho-social well-being. On 12/12/2024 at 12:58 PM, the LNHA and administrative team were made aware that the Facility Assessment did not address the cultural needs of the Asian American population, the smoking needs of the residents, and the lack of staff knowledge with no smoking policy to follow. On 12/12/2024 at 3:01 PM, the survey team met with the facility administrative team. The facility had no additional information to provide regarding the facility assessment. NJAC 8:39-7.3(a)(g); 27.1(a)(b)

Based on observation and interview on 12/4/2024 in the presence of the Maintenance Director (MD), it was determined that the facility failed to ensure corner guards were free from sharp edges and failed to provide protective endcaps to corner guards. This deficient practice had the potential to affect all residents on the east wing and was evidenced by the following: An observation at 2:27 PM with the MD, revealed two metal corner guards by the handrails in the main dining room had a sharp edge and no protective endcaps installed to prevent an injury. In an interview at the time, the MD confirmed the findings. The facility's Administrator was notified of the deficient practice at Life Safety Code survey exit conference on 12/5/2024 at 2:45 PM. NJAC 8:39-31.4(a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) carry out activities per a resident's care plan for 1 of 5 residents reviewed (Resident #25), and b.) conduct on-going activity assessments to determine resident's interests, hobbies, and cultural preferences to acquire a meaningful life for 5 of 5 residents (Resident #3, #21, #25, #83, #84) reviewed for activities. This deficient practice was evidenced by the following: 1. On 12/3/2024 at 9:58 AM, the surveyor observed Resident #25 lying in bed. Resident #25's family member was present and stated that the resident was supposed to be getting a daily newspaper in their preferred language. On 12/5/2024 at 8:27 AM, the surveyor observed Resident #25 lying in bed and no newspaper was available. On 12/5/2024 at 9:35 AM, the surveyor observed Resident #25 lying in bed and no newspaper available. On 12/5/2024 at 9:49 AM, the Activities Director (AD) was interviewed. The AD stated that she had been AD for only a few weeks. The AD stated that when a resident was admitted , the activities department would conduct an assessment. She stated the assessment would go into the electronic medical record (EMR) to track residents participation in activities. The AD stated she was familiar with Resident #25 and that the resident was supposed to get a newspaper daily, but she was not sure who was supposed to provide the newspaper. The AD stated that there should be an activities assessment done quarterly for all residents. On 12/5/2024 at 9:50 AM, the Minimum Data Set (MDS) Coordinator approached the surveyor and the AD. The MDS coordinator stated that the newspaper had been a discussion in morning meeting very far back but not sure of the date and that the surveyor should ask the admissions staff about the newspaper. On 12/5/2024 at 9:57 AM, the Admissions staff who stated she was not sure why the resident did not get a newspaper and that she would investigate. A review of the admission Record (AR) revealed Resident #25 had been admitted with diagnoses which included but were not limited to; Parkinson's disease (a neurodegenerative disease of the central nervous system). A review of the resident-centered on-going care plan included but was not limited to; resident prefers to stay in room . goal: will respond positively to 1:1 visits by staff or volunteers accepting 5 visits per week and interventions including encourage volunteer visits, invite, and encourage to social programs of interest, visit 1:1 five times a week for increased social interaction. A review of the most recent facility provided, Activity Participation Review was dated 06/30/2022, and included but was not limited to; B. Attendance and Participation Summary . relaxing in room reading the newspaper and conversation with staff. On 12/05/2024 at 10:12 AM, the AD stated that she had no idea who went to Resident #25's room for 1:1 visits and was not aware of any documentation of Resident #25's participation in activities. On 12/05/2024 at 11:13 AM, the in presence of the survey team, the AD and the Social Worker (SW) were interviewed. The AD stated an activities staff member who worked at a different facility was helping with the facility's activities program. The SW stated there was no documentation that the residents had participated in any activities that were identified as their individual interests. The SW further stated the previous AD left the facility in the summer. 2. On 12/05/2024 at 1:38 PM, the surveyor requested the activity assessments and participation documentation for Resident #3, #21, #25, #83, and #84. On 12/05/2024 at 2:50 PM, the Assistant Director of Nursing (ADON) informed the survey team that there was no updated activity assessments for the residents. A review of the EMR's revealed the following: Resident #3, admitted in 2013, and the last documented activity assessment was dated 2022, and there were no activity participation logs to confirm that resident participated in activities. Resident #21, admitted in 2022, and there were no activity assessments or documentation to confirm activity participation. Resident #25, admitted 2018, and the last activity assessment completed was dated 2022, and there was no documentation to confirm activity participation. Resident #83, admitted 2024. On 12/05/2024, the surveyor was told there was no activity assessment completed and documented. On 12/11/2024 at 1:54 PM, the facility provided a handwritten form of three pages that had not been entered into the EMR. Page one had the resident's name and was filled out, pages 2 and 3 had no resident name, admission date, room number, or date of birth and page 3 was blank. Resident #84, admitted 2024, and there were no activity assessments completed and no documentation to confirm activity participation. The facility was unable to provide any documentation to confirm resident's participation activities for the residents who resided in the facility. The surveyor requested a policy for activities and received the facility provided job description for Recreation Director. The description included but was not limited to; summary: establish, coordinate, and direct a comprehensive recreation program . develops a program to relate to the physical, psychological, social, intellectual, cultural, and spiritual needs of each resident. Establish, coordinates, and documents all assessments, review plans and progress notes pertaining to activities. Facilitate activity and recreation pursuits of residents. Part I: Standards: 1. Coordinate, monitor, and document all assessments timely and appropriately. 3. Review progress notes . for tardiness and accuracy of treatment outcomes. 4. Design and implement a comprehensive therapeutic program of activities accommodating resident needs, abilities, and interests. 5. Adheres to objectives, standards of practice, policies and procedures . for the therapeutic recreation department and ensures personal are being supervised. Part II: 13. Evaluates and recommends appropriate activities programs for the residents. On 12/12/2024 at 12:44 PM, the above concerns were discussed with the facility administration. The facility had no additional information to offer. NJAC 8:39-4.1 (a)(24); 7.1(a); 7.2; 7.3(a)(1-7)(g); 8.1

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility activities program was directed by a qualified therapeutic recreation specialist or activity professional. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: On 12/03/2024 at 9:58 AM, Surveyor #1 observed a family member in resident #25's room. The family member stated they were upset because Resident #25 was supposed to be getting a daily newspaper in their language, but no newspapers were being delivered. On 12/04/24 at 9:19 AM, Surveyor #2 observed a staff assisting residents at mealtime in the main dining room. The staff identified herself as the Staffing Coordinator/ Lead Certified Nursing Aide (SC/LCNA). On 12/05/2024 at 9:49 AM, Surveyor #1 observed activities taking place in the main dining area. Surveyor #1 interviewed a staff member who introduced herself as the Activities Director (AD). The AD stated she had been the AD for two weeks and prior to that, she had been with the facility as a unit clerk for 30 years. When asked what the process was for residents, the AD stated upon admission there would be an activities admission assessment completed and that would go into the electronic medical record (EMR). The AD stated after that, each resident would have quarterly activity assessments. Surveyor #1 inquired about Resident #25's daily newspaper and the AD replied she was familiar with the resident but was not sure who was responsible to deliver the newspaper. At 10:12 AM, Surveyor #1 asked the process of documentation to determine which residents were at which activities or offered any activities or room visits. The AD replied she had no idea who conducted resident room visits or documentation of resident activity participation. On 12/05/24 at 11:17 AM, the SC/LCNA (who introduced herself to Surveyor #1 as the AD) and Social Worker addressed the survey team regarding the Activity Director and stated another facility Activity Director would help at times, but that there was no trained Activity Director currently at the facility since the summertime when the last AD left the position. The SC/LCNA stated she will now be the Activity Director. The SC/LCNA stated that there has not been a consistent activity Director since July, other people for a week or so. The surveyor asked if the SC/LCNA had a Bachelor's degree and she stated the facility told her she would take an online course. The surveyor asked if she has ever been to a Quality Assurance meeting or a resident care plan meeting and she stated, I have not been to one yet. On 12/5/2024 at 9:08 AM, Surveyor #1 requested the activity policy and the AD job description. On 12/5/2024 at 10:34 AM, Surveyor #1 was provided only the signed AD job description. A review of the facility provided, Recreation Director job description date of hire 11/17/2024, included but was not limited to; Qualifications: Bachelor's degree from an accredited college with a major area in Recreations, Creative Arts, Therapy, Therapeutic Recreation, Art Education, Psychology, or Music Therapy. A Master's degree preferred. 2-3 years of experience in recreation and/or management experience. NJAC 8:39-8.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, b.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days, and c.) documented an admission History and Physical (H&P) within 72 hours of a resident's admission to the facility. This deficient practice was observed for 4 of 18 residents and 1 closed record (Resident #13, #33, #81, #83 and #85) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 12/05/24 at 09:42 AM, the surveyor observed Resident #33 sitting in the wheelchair, in their room. The resident informed the surveyor that he/she did not see a doctor regularly. The resident stated I saw a doctor about 2 weeks ago and I did not know who he was, and he stated, I am your doctor. Resident #33 further stated I saw him for the 1st time in 4 years. The surveyor reviewed the medical record (MR) for Resident #33. A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), and Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. A review of the Electronic Medical Record (EMR) revealed a Physician Annual history and physical (H&P) note from the resident's attending physician with an effective date of 1/26/24 and had a created date of 8/8/24. The note was marked as a Late Entry. 2. On 12/03/24 at 10:03 AM, during an initial tour, the surveyor observed Resident #81 watching TV in their bed. The surveyor reviewed the MR for Resident #81. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a chemical imbalance in the blood which can cause difficulty thinking clearly), Type 2 diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar), and Cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS of 9 out of 15, indicating the resident was moderately cognitively impaired. A review of the EMR revealed an attending physician H&P note dated 2/16/24. A review of the Physician progress notes (PN) revealed the attending physician documented a visit for the resident on 8/1/24. Further review of the EMR revealed the Nurse Practitioner (NP) also documented visits for the resident on 5/23/24, 5/30/24, 6/24/24, 7/5/24, 9/26/24, 11/12/24. A review of the EMR did not reveal a PN from the attending physician or the attending NP for March 2024, April 2024, and October 2024 or that the physician and NP were consistently alternating monthly visits. 3. On 12/5/24 at 12:00 PM, the surveyor observed Resident #13 sitting in their wheelchair, in the dining room. The resident was waiting for lunch calmly. The surveyor reviewed the MR for Resident #13. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Hypertension (high blood pressure), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges.), Cerebral infarction (blood vessel blockage in the brain) and anxiety disorder. A review of the Comprehensive MDS dated [DATE], revealed the Resident #13 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating the resident was moderately cognitively impaired. A review of the EMR revealed an attending physician H&P note dated 10/15/24. It did not reveal any additional physician progress notes. A further review of the EMR revealed the resident was admitted to the facility in October 2024. On 12/11/24 at 11:31 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN #1) stated physicians make rounds every month for monthly visits and they document in EMR while at the facility. The LPN was unsure how soon the H&P would be completed for a new admission. On 12/11/24 at 11:43 AM, during an interview with the surveyor, the LPN Unit Manager (LPN/UM) stated H&P for a new admission should be done within 48 hours to 72 hours. The LPN/UM further stated the physician has to see their residents every 60 days. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. 5. On 12/06/2024 at 8:25 AM, a surveyor observed Resident #83 in the main dining area. A review of the AR revealed that Resident #83 was admitted [DATE] to the facility. A review of the EMR Progress Notes (PN) documented a Late Entry 09/17/2024, type: Physician H&P. The PN documented a chief complaint: very forgetful, unable to live alone. The remainder of the H&P contained areas such as HPI, ROS (review of systems), Family History, Mod History/Diagnosis on file, Social History, physical exam, diagnostics/labs, assessment, and Plan of Care (draft) were all blank. A review of the Late Entry Draft assessment revealed the effective date as 9/17/24 but the created date as 10/6/24. The assessment also contained the chief complaint, but all other assessment areas were blank. On 12/11/2024 at 11:36 AM, the Registered Nurse (RN) on the [NAME] Unit stated that upon admission, the staff would call the doctor. The expectation would be that the doctor would be in to see the resident for an H&P within 24 to 48 hours. 6. On 12/03/24 at 4:07 PM, a surveyor conducted a closed medical record review of Resident #85's electronic medical record (EMR). The EMR revealed a nursing progress note that on 10/12/24 Resident #85 was discharged home with a visiting nurse referral made. On 10/15/2024 at 12:33 the Physician completed a History and Phyisical (H & P) which revealed the following physician note: Effective Date: 10/15/2024 12:33 (completed 3 days after the resident was discharged ) Type: Physician H&P Cheif Complaint: HPI: Patient evaluated at side, spoke to [spouse], has history of dementia, had viral gastroenteritis and became weak. All questions and concerns answer with [spouse]. is reportedly doing a lot better per [spouse]. Spoke to nurse and reviewed chart no concerns at this time Time spent, including counseling and coordination of care: 50 minutes Rendering Provider, [Physician Name] Author: [Physician Name] - Physician [e-SIGNED] On 12/11/2024 at 11:43 AM, a physician who has residents at the facility was on the telephone with the survey team. The physician stated that he had been one of the physician's at the facility for 2 to 3 years and that upon a resident's admission, the resident should be seen within 48 hours. On 12/12/2024 at 2:10 PM, the survey team conducted a telephone interview with the Medical Director (MD). The MD was asked about his expectations regarding physician's at the facility entering late entry notes months after the supposed visit with the resident. The MD specified that the notes should be entered into the EMR immediately. The survey team asked the MD if it was appropriate for a physician to document an actual visit progress note after a resident was discharged and the MD stated, no, because the resident was not there. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. At 3:01 PM, during exit conference, the facility had no additional information to provide. The surveyor reviewed the facility's policy titled Physician Visits with last revised date of 4/2008 included under Policy Statement: The Attending Physician must make visits in accordance with applicable sate and federal regulations. Under Policy Interpretation and Implementation: 1.) The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. 2. After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A Physician assistant or nurse practitioner may make alternate visits after the initial 90 days following admission, unless restricted by law or regulation. The facility policy failed to address the physician visit upon admission. The surveyor reviewed the facility provided undated Guidelines for Charting and Documentation included under Physician Orders 1. a.) Each resident must be under the care of a licensed physician authorized to practice medicine and must be seen by the physician at least every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter. NJAC 8:39-11.2(c); 23.2(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review it was determined that the facility failed to ensure that residents were explicitly informed of and understanding was assessed prior to having the residents enter into a arbitration agreement which was identified as a mandatory part of the admission Agreement for 9 of 9 Residents who attended a resident council meeting (Resident #6, #11, #20, #21, #24, #27, #40, #71, #78) and was evidenced by the following: On 12/03/24 at 10:07 AM, during the facility entrance conference held with the Liscensed Nursing Home Administrator (LNHA) and the [NAME] President of Clinical Services Registered Nurse (VPRN). The surveyor asked if the facility utilized arbitration agreements. The LNHA stated absolutely, we offer arbitration and it is in their admission agreement. The LNHA then stated, but it is a separate area, and it is overseen by legal. The surveyor requested a list of all the residents that had signed the arbitration agreements. The VPRN stated there is no one in an active arbitration agreement, and stated the admission Director was responsible for the arbitration agreements. On 12/03/24 at 10:30 AM, the surveyor reviewed the survey binder provided by the administration which revealed under the arbitration agreement section, a typed document revealed:[facility name] does have any current resident that have entered into a binding arbitration agreement. The survey binder included a copy of the 19 page admission agreement which revealed the following: k. Arbitration: All claims arising out of this Agreement must be handled pursuant to the terms of the annexed Mandatory Arbitration Sub-Agreement. By signing this Agreement Resident/Sponsor expressly confirms having reviewed the Agreement and Mandatory Arbitration sub-agreement and agree to all the terms in their entirety including the terms of the annexed Mandatory Arbitration sub-agreement. Resident expressly agrees to having had the opportunity and time to read the Argeement and Mandatory Arbitation Sub-Agreement in their entirety and to having the option of having both reviewed by an attorney of Resident's choice prior to signing. Page 8 of the admission Agreement revealed Resident/Sponsor confirms that these exhibits were provided to resident prior to signing of the admission Agreeement and that such exhibits are part of the admission Agreement. Index of Exhibits: Resident/Sponser Initials: Exhibit 1- Mandatory Binding Arbitration Agreement. Exhibit 1 (Page 9) revealed: Mandatory Binding Arbitration Sub-Agreement. Arbitration Explained: Arbitration is a specific process of dispute resolution instead of utilizing the traditional state or federal court system. Instead of a judge and/or jury determining the outcome of a dispute . Mandatory arbitration has been selected with the goal of reducing the time, formalities and cost of utilizing the court system . Page 11 of the AA revealed I agree to the terms Mandatory Arbitration Sub Agreement in it's entirety (Subsections A-K). I acknowledge and confirm that I was given ample opportunity to read the Mandatory Arbitration Sub-Agreement in its entirety, that I have in fact read and understood the Mandatory Arbitarion Sub-Agreement and had the opportunity to have it reviewed by an attorney of my choosing prior to signing. Print Resident Name, Signature Line and Faciltiy admission Director signature and date. There was no option to refuse the agreement contained within the admission Agreement. On 12/03/24 at 11:22 AM, the facility General [NAME] (GC), in the presence of the LNHA, addressed the survey team regarding the requested entrance documents and the list of residents who entered into an arbitration agreement. The GC stated there was an arbitration agreement and there is an admission agreement and obviously everyone signs the admission agreement. The GC stated, we don't track who signed the arbitration agreements and we have no way to track them. The LNHA stated we can go manually and track them and the GC stated, we would have to track them manually and it would be a slow process. On 12/04/24 at 11:06 AM, a resident council meeting was conducted with nine residents (Resident #6, #11, #20, #21, #24, #27, #40, #71, #78 ). The surveyor asked the residents if they had been aware of what an arbitration agreement was and 9 of 9 responded, no. The surveyor asked if anyone had explained it to them and 9 of 9 residents responded, no. The surveyor then asked if the residents had signed an arbitration agreement during the admission process and 9 of 9 residents responded yes. On 12/04/24 at 1:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #11. The EMR revealed the admission Agreement was signed on 09/16/24 by the Resident and the AD, and Exhibit 1 was signed by the resident and undated and was not signed by the admission Director. On 12/04/24 at 1:52 PM, the Surveyor interviewed the admission Director (AD), in the presence of the survey team and LNHA.The surveyor asked what the admission process was and the AD stated they worked with all departments to confirm the admission and then met with the family to explain resident rights, smoking and they sign the admission Agreement(AA). On 12/04/24 at 1:55 PM, the surveyor showed the AD the AA and asked her what the Mandatory Binding Arbitration Agreement (AA) was. The AD stated if the resident had a complaint, we discuss it at the facility. The surveyor asked if the AD director read over and explained the AA as part of the admission process. The AD stated, they can read it and ask questions if they have questions. The surveyor asked the AD what the Mandatory part of the AA was and the AD stated, it must be signed. The surveyor asked if the AD had a list of residents who either signed the agreement or refused to sign it and she stated she did not. NJAC 8:39-4.1(b)

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to a.) ensure a process was in place to identify residents who were on Enhanced Barrier Precautions (EBP) (an infection control intervention used to reduce the transmission of resistant organisms in accordance with the Centers for Disease Control and Prevention), by posting clear signage outside of resident rooms indicating the type of Protective Personal Equipment (PPE) to be worn and defining the high risk resident care activities associated with EBP for 8 of 8 EBP rooms, b.) provide residents with hand hygiene (hh) and ensure staff performed hh in between serving and setting up residents with meals, c.) remove contaminated gloves prior to walking around in a non-clinical area, the dining room and making contact with multiple residents, d.) ensure the ice containers on 2 of 2 units were dated and had self-draining holders, and e.) use hh after touching a cell phone and prior to assisting to feed a resident who was dependent on staff for eating for 1 resident (Resident #48). This deficient practice was evidenced by the following: 1. On 12/04/24 at 12:28 PM, the surveyor observed a resident room on the East unit with an orange dot sticker next to a Resident #21's name. The surveyor asked the Certified Nursing Assistant (CNA) #1 what the orange sticker meant. CNA #1 replied that it meant the resident was on a special diet like thick liquids. CNA #1 stated he had worked at the facility full-time for about 1 year. There was no other signage on the resident's door and no PPE available by the room entrance. A review of the admission Record (AR) revealed Resident #21 was admitted with diagnoses which included but were not limited to; osteomyelitis right ankle and foot (infection of the bone), sepsis, and diabetic food ulcer. A review of the Care Plan included a focus area that Resident #21 was on EBP due to diabetic wound with interventions that included ensure PPE is accessible and ensure PPE is worn during direct care. On 12/05/2024 at 8:35 AM, Surveyor #1 observed a resident room on the [NAME] unit with signage for enteric contact isolation, stop and see the nurse, how to don (put on) and doff (remove) PPE, and the steps to take for care, housekeeping, transporting, workflow, and visitor instructions. There was a bin with PPE available outside the resident's door. During observations on both units, Surveyor #1 observed the East and [NAME] unit had a total of 8 resident rooms with an orange dot sticker next to a resident name. Surveyor #1 observed that PPE bins were not readily available outside those resident doors. On 12/05/2024 at 10:09 AM, Surveyor #1 requested all Transmission Based Precaution (TBP) categories, the signage and the precautions required with each TBP used in the facility. The [NAME] President of Clinical Services (VPC) #1 provided Surveyor #1 with only the EBP policy at that time. Surveyor #1 questioned the other TBP categories and the signage for EBP. VPC #1 stated that the EBP rooms only needed an orange dot and no signage. Surveyor #1 asked about how staff and visitors would know what to wear or what precautions to take. Surveyor #1 inquired what if a visitor was to assist a resident to the bathroom or with dressing? VPC #1 replied the facility does not encourage visitors to assist residents. On 12/06/2024 at 10:10 AM, the Licensed Practical Nurse Infection Preventionist (LPN/IP) in the presence of three surveyors stated that EBP was an extra precaution and not isolation. She stated that the PPE was located at the nurses station and that if visitors did not stop at the nurses station to ask, they would not know that the orange dot indicated EBP. She stated that the staff was all aware that PPE was required for direct care. Surveyor #1 inquired if tasks such as changing linens and dressing required PPE. The LPN/IP stated the staff were aware. The surveyor made the LPN/IP aware of the interview with CNA #1 who was not aware of the meaning of the orange dot and it's precautions. Surveyor #2 asked if the facility followed the Centers for Disease Control and Prevention (CDC) guidelines. The LPN/IP stated yes. Surveyor #1 requested the facility staff education regarding EBP with the education material that was used. A review of the facility provided staff sign in sheets revealed that on 03/28/2024, CNA #1 signed in as having watched a video about EBP. There was no educational material provided. The facility provided EBP precautionary signage, but the signage was not posted on any EBP doors. The signage specified Stop. Enhanced Barrier Precautions everyone must: clean their hands before entering and when leaving; providers and staff must wear gloves and gown for following dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use and wound care. The facility provided a link to an Internet [name redacted] video on EBP. A review of the facility provided policy, Enhanced Barrier Precautions (EBP) effective 4/1/24, included but was not limited to; Statement . implementing effective measures to prevent the transmission of multi-drug resistant organisms within our facility. Procedures: EBP is employed when performing high-contact activities: dressing, bathing/showering, transferring, hygiene, changing linens, changing briefs, or assisting with toileting, device care, and wound care. 3. Training and Education: all HCP (health care providers) will receive training on identification, management, and prevention . including use of contact precautions and EBP *identified as orange dot on resident door name. regular education and updates will be provided to ensure compliance. A review of the CDC Long-term Care Facilities (LTCFs) Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes dated 06/28/2024, included but was not limited to; 28. Does posting signs specifying the type of precautions and recommended PPE outside the resident room violate . resident dignity? No. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the residents. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. Signs should not include information about the resident's diagnosis or the reason for the precaution (e.g. presence of resistant pathogen); inclusion of that information would violate HIPAA (Health Insurance Portability and Accountability Act) and resident dignity. A review of the facility provided policy, Infection Control undated, included but was not limited to; 5. The Administrator or Governing Board . had adopted the infection control policies and practices as outlined to reflect the facility's needs for preventing transmission of infections . as set for in CDC guidelines and recommendations. Nursing: 7. Places a sign on the resident's door including please see nurse before entering. All staff: 8. Contact nurse before entering the room for what PPE is needed to perform the task. 9. Without violating HIPAA, notify staff member what precautions are needed. 11. Educates resident and family regarding proper infection control techniques to prevent the spread of infection. 2. On 12/03/2024 from 11:45 AM through 12:23 PM. Surveyor #1 and Surveyor #2 observed the lunch meal in the main dining room. The surveyors observed the following: At 12:05 PM, a resident entered into the dining room from the door to the smoking area. The resident opened the smoking area door, touched their chair and cell phone. Two additional residents from the smoking area entered the dining room. The staff delivered the three resident's their meal trays but did not offer any hh and there was no form of hh available on the trays. At 12:13 PM, a staff identified as LPN #2 delivered a tray to a resident and walked over into the [NAME] unit. LPN #2 passed 3 alcohol-based hand rub (ABHR) dispensers and did not perform hh. LPN #2 obtained another tray and handed the tray to another staff member. Next LPN #2 obtained another tray, walked into the dining room and handed that tray to a different staff member. LPN #2 next assisted to move a resident in their wheelchair. LPN #2 did not perform hh between handling the food trays or before or after assisting the resident. At 12:17 PM, LPN #2 failed to perform hh, picked up a tray and handed the tray to a staff member. LPN #2 next took a tray and delivered the tray to one resident at a table of four residents. LPN #2 began opening up items for one of the other residents at the table without performing hh. At 12:23 PM, LPN #2 stated that the process was to use hh for the residents and staff, to set up trays and if passing a tray to another resident, I must clean my hands to prevent germs. A review of the facility provided policy, Handwashing/Hand Hygiene undated, included but was not limited to; statement . hand hygiene the primary means to prevent the spread of infection. 5. Employees must wash their hands for at least 20 seconds . under the following conditions: g. before and after assisting a resident with meals; 6. In most situations, the preferred method of hh is with ABHR . for the following situations: a. before and after direct contact with residents. On 12/12/2024 at 12:44 PM, the above concerns were addressed with the facility administrative team. Surveyor #1 requested the policy for resident meal service. The surveyor was provided the dietary department policy. The surveyor clarified which policy was requested. The facility did not provide the policy nor any additional information. 3. On 12/03/2024 at 11:52 AM, staff identified as the Occupational Therapist (OT) walked with a resident using a walker, from the therapy gym, through one small dining area, into the main dining room and to a table. The OT was wearing PPE gloves the entire time. The OT next placed her gloved hand on another resident's right shoulder. The OT went to a third resident and held that resident's hand with her gloved hand. The OT removed her gloves after having contact with all three residents and their surroundings. At 11:58 AM, the OT stated that she was wearing gloves because sometimes the resident she was assisting, can be soiled. The OT stated she had forgotten to remove the gloves before interacting with the other two residents. She stated it was important to remove the gloves because it could cause the spread of infection. A review of the CDC The National Institute for Occupational Safety and Health (NIOSH), Donning and Doffing PPE: Proper Wearing, Removal, and Disposal last reviewed 10/3/2022, included but was not limited to; remove PPE before entering any non-clinical areas. 4. On 12/04/2024 at 9:03 AM, Surveyor #2 observed an uncovered cup next to a small ice chest on the [NAME] unit. The ice bin was filled and there was a sticker dated 12/3/24. During an interview at that time, the Registered Nurse (RN) stated, they forgot to change the sticker and pulled off the dated sticker. On 12/04/2024 at 9:30 AM, Surveyor #2 observed an uncovered pink drink pitcher next to a container of ice on the East unit. The ice scoop was not self-draining. A review of the facility provided policy, Ice Machines and Ice Storage Chests revised 04/2012, included but was not limited to; statement: ice machines and storage/distribution containers will be used and maintained to assure safe and sanitary supply of ice. Methods of contamination: d. improper storage or handling of ice. Preventing contamination: g. uses a smooth-surface ice scoop to obtain and dispense the ice; h. keeps the ice scoop and bin in a covered container when not in use; k. if another receptacle such as a small chest or bin is used . do not distribute ice directly from an open container. On 12/12/2024 at 12:44 PM, the above concern was presented to the facility. The facility did not provide any additional information. 5. On 12/12/2024 at 8:11 AM, Surveyor #1 observed CNA #2 sitting in a chair next to the Resident #48 lying in bed. On the overbed table, Surveyor #1 observed the partially eaten breakfast meal. Surveyor #1 further observed that CNA #2 was actively texting on her cell phone. As the surveyor entered the room, CNA #2 closed the cell phone case and began assisting to feed Resident #48 the rest of their breakfast without performing hh. On 12/12/2024 at 8:17 AM, CNA #2 stated that she should not have been on her cell phone. She stated she should have used hh after using her cell phone and prior to resuming feeding the resident for infection control reasons. A review of the facility provided In-Service: Handwashing dated 11/28/2024, included but was not limited to; CNA #2's signature that she had attended the education which included but was not limited to; protect yourself and patients from deadly germs by cleaning your hands. clean your hands: when moving from soiled to clean . on the same patient . A review of the facility provided policy, Handwashing/Hand Hygiene undated, included but was not limited to; statement . hand hygiene the primary means to prevent the spread of infection. 6. ABHR is the preferred method for the following situations: a. before and after direct contact with residents; i. after contact with objects in the vicinity of the resident. NJAC 8:39-19.4(a)(m)(n); 19.6(d); 27.1(a); 27.5(c)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for six (6) of ten (10) newly hired staff reviewed, (Staff #1, #2, #6, #7 #8, and #9). This deficient practice was evidenced by the following: On 9/28/23 at 8:30 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 10/24/21, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. Staff #2, a Physical Therapy Assistant (PTA), hired 12/20/21, had a New Jersey Division Consumer Affairs license verification printout (used to verify the status of a licensed professional other than a CNA) which had accurate as of December 22, 2021 2:48 PM. The date was two days after the date of hire. Staff #6, a Licensed Practical Nurse (LPN), hired 7/12/21, had a New Jersey Division Consumer Affairs license verification printout which had accurate as of November 18, 2021 4:55 PM. The date was four months after the date of hire. Staff #7, a Registered Nurse (RN), hired 01/26/23, had a New Jersey Division Consumer Affairs license verification printout which had accurate as of September 26, 2023 11:35 AM. The date was eight months after the date of hire. Staff #8, a Certified Nursing Assistant (CNA), hired 7/26/22, had a NJDOH online Public Registry license verification printout that was dated 9/24/23 12:32 PM. The date was more than 1 year after the date of hire. Staff #9, a Certified Nursing Assistant (CNA), hired 3/26/23, did not have a NJDOH online Public Registry license verification printout. There was no documented evidence that Staff #9's license was verified. On 9/28/23 at 9:44 AM, the surveyor interviewed the Human Resource Director (HRD) regarding the process for license verification of newly hired employees. The HRD stated that after the employee was interviewed, she would do the license verification. The surveyor asked when the date of hire was. The HRD stated that the hire date was once they clear everything. She added all should be done prior to the hire date and that date was when the employee started on the floor even if they were only shadowing another employee. On that same date and time, the surveyor asked when the HRD started at the facility. The HRD stated that she had started on 8/21/23. The surveyor asked the HRD if the employee files that were provided to the surveyor were the complete files. The HRD stated that she could not speak for someone else's work and that if the prior person went through her process that the files should be complete. On 9/28/23 at 10:27 AM, in presence of another surveyor, the HRD confirmed that six of the nine employees did not have the license verification prior to date of hire. On 9/28/23 at 11:47 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that the employees did not have a license verification prior to date of hire. On 9/28/23 at 11:58 AM, in the presence of the survey team and LNHA, the DON stated that the employees should have license verification before date of hire. A review of the undated facility provided policy, titled New Hire and Onboarding Process included the following: Prior to a start date: Valid NJ State License (RN, LPN, C.N.A., etc.) A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 3/18/23, included the following: Employee and Volunteer Screening 2. Inquiry of State Nurse Aide Registry for CNA applicants 3. Inquiry of licensing authorities for all licensed/certified positions . N.J.A.C. 8:39-43.15(a)

Based on interviews, and review of the facility provided documents, it was determined that the facility failed to revise a care plan to address the discharge plan for one (1) of three (3) residents reviewed for closed record, (Resident #90) reviewed for a comprehensive person-centered care plan. This deficient practice was evidenced by the following: The surveyor reviewed Resident #90's medical records. The admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to diffuse traumatic brain injury without loss of consciousness (following trauma, secondary diffuse brain injury), major depressive disorder, recurrent severe without psychotic features, chronic obstructive pulmonary disease unspecified (COPD; a group of lung diseases that block airflow and make it difficult to breathe), other seizures (caused by rapid and uncoordinated electrical firing in the brain), and anxiety (feeling of fear, dread, and uneasiness). The admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 7/26/23 showed Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident's cognitive status was intact. The aMDS Section Q Participation in Assessment and Goal Setting revealed that the resident participated in the assessment and the resident's overall goal established during the assessment process that the resident expects to remain in the facility. A review of the Progress Note (PN) dated 8/17/23 in the electronic medical record by Social Worker#1 (SW#1) revealed that the resident was cognitively intact and was able to make his/her needs known. In addition, the 8/17/23 PN included that the resident was a long-term care (LTC) resident and had plans to be discharged (d/c) to the community. Further review of the 8/24/23 PN included that the resident came to SW#1 and communicated that the resident would like to be d/c next week. The SW also documented that SW to follow up and begin the d/c process. The baseline care plan dated 7/20/23 in the electronic medical record showed that the initial admission/discharge goals were blank. A review of the baseline care plan dated 8/16/23 revealed that the initial admission/discharge goal was to remain in the facility and that the discharge plans were not initiated. Further review of the electronic medical record showed that the comprehensive personalized care plan did not include revision of the d/c care plan when the resident communicated to the SW on 8/17/23 and 8/24/23 that the previous plan for being a LTC resident was changed to be d/c to the community. On 9/26/23 at 01:29 PM, the surveyor interviewed SW#2 who informed the surveyor that she replaced SW#1 and SW#2 started on September 21, 2023. SW#2 stated that discharge planning starts on admission and is documented in the baseline care plan within 48 to 72 hours upon admission and care plan revision as needed. She further stated that if there will be a change in the d/c plan, there should be an interdisciplinary (IDCP) meeting to make sure that the d/c plan is safe and care plan will be updated. On 9/27/23 at 8:44 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of another surveyor. The surveyor notified the DON of the above findings. The surveyor then asked the DON why the resident's care plan was not revised on two opportunities that the resident communicated on 8/17/23 and 8/24/23 his/her plan to be d/c to the community. The DON did not respond. On 9/27/23 at 01:22 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and notified them of the above findings. A review of the facility's Discharge Planning Policy that was provided by the DON with a revised date of 3/29/23 included that Goal: the resident's needs pertaining to post-discharge care will be assessed upon admission. The IDCP team members will perform the assessment. A plan to meet these needs will be developed and interventions to meet specific discharge planning goals will be designed. The plan will be monitored and revised as necessary throughout the nursing home stay. Process: at the time of admission the following tasks will be accomplished by the following disciplines indicated if necessary. 1. Admissions will notify all departments of a resident's admission status, i.e. short -term or long-term. 2. IDCP team will meet within 72 hours after the admission of a short term resident to discuss placement status. Care plans will be written for each of the identified residents which shall include the problem, goals, and interventions.7. The discharge planning process will begin with the pre-admission screen review and the Therapy Discharge Planning Schedule which are communicated to the whole IDCP team. A review of the facility's undated Interdisciplinary Care Planning Policy and Procedures that was provided by the LNHA included that it is the policy of this facility to establish an individualized interdisciplinary plan of care for each resident within seven days of completion of the MDS assessment. In addition, the IDCP must evaluate resident progress a minimum of quarterly or as required by changes in the resident's condition. Procedure: An interim plan of care that addresses the immediate care needs of the resident will be initiated by nursing on the day of admission. An interdisciplinary note will be completed at the conclusion of the care conference that provides the rationale for care plan decisions and will be signed by all in attendance. The IDCP team will assess each resident at a minimum of once every three months to determine if any changes are needed to the care plan of care. Since the care plan is a dynamic document, in the interim between quarterly reviews, the IDC team must revise problems, goals, and interventions in response to changes in the needs of residents. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference and the facility did not refute findings. The facility management did not provide additional information. NJAC 8:39-11.2 (e, 1)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility staff failed to follow a physician's order for one (1) of nineteen (19) residents reviewed (Resident #5). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, 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 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 stated, 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 9/20/23 at 11:20 AM, the surveyor observed Resident #5 seated in a wheelchair in the resident's room. The surveyor reviewed Resident #5's medical record. The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), acquired absence of left leg below knee (below knee amputation) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 8/10/23, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact. Further review of the qMDS indicated the resident received antipsychotic medication (also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders). A review of Resident #5's September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) included the following orders: 1. BEHAVIOR & INTERVENTION MONITORING See Key every shift for Monitoring BEHAVIOR(S) EXHIBITED: 0. NONE 1. Agitated 2. Anxious 3. Biting 4. Pacing 5. Crying 6. Screaming/Yelling 7. Hallucinations/Paranoia/Delusions 8. Insomnia 9. Striking out/hitting 10. Withdrawn-Order Date 11/04/2021 0021 Each shift for each day were signed by the nurse with a check mark which was not a symbol that was indicated in the key under the physician's order. The surveyor was unable to determine if the resident had any behaviors since the numbers that were indicated to use under the key were not used. 2. BEHAVIOR & INTERVENTION MONITORING See Key every shift Record Potential Side Effects: 0. None 1. Stiff Neck 2. Tremors 3. Confusion 4. Tardive Dyskinesia 5. Hypotension/Dizziness 6. Dehydration 7. Insomnia 8. Anxiety/ Agitation 9. Sedation 10. Appetite Changes-Order Date 11/04/2021 0021 Each shift for each day were signed by the nurse with a check mark which was not a symbol that was indicated in the key under the physician's order. The surveyor was unable to determine if the resident had any side effects to the medication they received since the numbers that were indicated to use under the key were not used. The surveyor then reviewed Resident #5's June 2023, July 2023 and August 2023 MAR/TAR which indicated that the two orders for Behavior and Intervention Monitoring had a check mark for each shift of each day and not a number that was indicated in the key under the order. On 9/20/23 at 11:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding a physician's order for behavior monitoring. The LPN stated that in the MAR/TAR there would be an order for the behavior monitoring and that there is a number for either no behavior or a behavior like agitation. The surveyor asked the LPN if there would be a check mark that the nurse puts on the MAR/TAR. The LPN stated that it would have a number and not a check mark. On 9/20/23 at 01:25 PM, the surveyor interviewed the Director of Nursing (DON) regarding a physician's order for behavior monitoring. The DON stated that there is an order in the MAR/TAR and that the order had numbers equivalent to a behavior or none to indicate there was no behavior. The surveyor then asked the DON to view Resident #5's printed September 2023 MAR/TAR. The surveyor asked the DON if the check marks on the two orders were the correct way to document the behavior monitoring and side effect monitoring. The DON stated that she would get back to the surveyor and that it might be a glitch. On 9/21/23 at 9:17 AM, the DON stated that there must have been a glitch in the computer system and that the system did not generate the number key for the two orders. The surveyor asked the DON who would view the MAR/TAR to do the monthly summary recap of behaviors. The DON stated that the Unit Manager (UM) would do the summary but that she was on vacation. The surveyor asked the DON what the process was for doing the monthly recap of behaviors. The DON stated that the UM would look at the resident's progress notes, talk to staff and look at the MAR/TAR. The surveyor asked the DON if the UM should have seen that the physician order was not followed prior to surveyor inquiry. The DON stated that the UM could have picked it up if she had looked at the MAR/TAR. The surveyor asked what the expectation was to see how many episodes a resident had a behavior. The DON stated that the expectation would be to look at the monthly MAR/TAR to count how many episodes of a behavior the resident had. On 9/22/23 at 10:39 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator and the DON the concern that Resident #5's physician's order for behavior monitoring and side effect monitoring was not followed as ordered. On 9/27/23 at 01:43 PM, in the presence of the survey team and LNHA, the DON stated that Resident #5's physician's order was fixed in the computer system and that the error should have been picked up earlier. A review of the facility provided policy titled Physician Medication Orders with a revised date of December 2020, did not include information regarding physician orders for behavior monitoring. A review of the undated facility provided policy titled Behavior Assessment and Monitoring did not include information regarding following a physician's order for behavior monitoring on the MAR/TAR. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-11.2 (b)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that: a) a physician order for discharge (d/c) was obtained for two (2) of two (2) residents (Resident #84 and #142) and b) d/c summary was completed by the physician for one (1) of two (2) residents who were transferred to another facility (Resident #142) reviewed for d/c. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident #84. The admission Record (or AR; face sheet; an admission summary) reflected that the resident was admitted to the facility and had diagnoses that were not limited to malignant neoplasm of the pancreatic duct (most common malignant tumor of the pancreas), type two diabetes mellitus without complications (a chronic disease affecting blood glucose regulation), unspecified lack of coordination, and muscle weakness. A review of the admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/13/23 Section C Cognitive Patterns and with a Brief Interview for Mental Status (BIMS) score of 10 out of 15, reflected that the resident's cognitive status was moderately impaired. Further review of the most recent discharge return not anticipated MDS (DRNA/MDS) showed that Section A Identification Information included that the resident was d/c to another nursing home. There was no physician order for the resident's transfer to another facility in the hybrid medical record (both electronic medical record (eMR) and the paper chart). On 9/21/23 at 01:39 PM, the surveyor in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the concern that there was no physician order for transfer that was obtained for Resident #84. The DON verified and confirmed that there was no written and transcribed order for d/c to another facility on the hybrid medical records. The DON stated that there should be an order from the physician. On 9/22/23 at 10:07 AM, the survey team met with the LNHA and the DON, and the surveyor notified the facility management of the above findings. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA stated that Resident # 84 was still within 30 days for the physician to do a d/c summary but should have an order for transfer to another facility. 2. The surveyor reviewed the medical records of Resident #142. The AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to chronic multifocal osteomyelitis (a disease that causes pain and damage in bones due to inflammation) right femur (right thigh bone), muscle weakness, anemia unspecified (when blood produces a lower-than-normal amount of healthy red blood cells), other abnormalities of gait and mobility. The aMDS with an ARD of 8/02/23 showed a BIMS score of 15 out of 15 which indicated that the resident's cognitive status was intact. Further review of the DRNA/MDS showed that Section A included that the resident was d/c to another nursing home. There was no physician order for the resident's transfer to another facility in the hybrid medical records. On 9/21/23 at 12:54 PM, the surveyor met with the DON and the LNHA in the presence of the survey team. The surveyor asked the facility management about the facility's process of discharging residents to another facility. The DON stated, that the nurse will call the doctor to get an order for the transfer to another facility, which should be transcribed to eMR the order for d/c. The DON further stated that the d/c summary was done by a physician, then a nurse will write when the resident was d/c on the date of d/c. The DON informed the surveyor that it was the physician's responsibility to write the summary of the resident's stay in the facility including the diagnosis and what was done to the resident at the facility. On that same date and time, the DON stated that the physician should write the discharge summary at the time of discharge and shortly after. The DON further stated that the physician can write the order for d/c in either paper or electronic order. At that same time, the DON checked and verified the hybrid medical records for the physician's d/c order and d/c summary. The DON confirmed that there was no order for transfer to another facility and no physician's discharge summary. Both the LNHA and the DON acknowledged that it should have been done. A review of the facility's Discharge Planning Policy that was provided by the DON with a revised date of 3/29/23 included that Goal: the resident's needs pertaining to post-discharge care will be assessed upon admission. The IDCP team members will perform the assessment. A plan to meet these needs will be developed and interventions to meet specific d/c planning goals will be designed. The plan will be monitored and revised as necessary throughout the nursing home stay. Process: at the time of admission the following tasks will be accomplished by the following disciplines indicated if necessary. 1. Admissions will notify all departments of a resident's admission status, i.e. short -term or long-term. 2. IDCP team will meet within 72 hours after the admission of a short term resident to discuss placement status. Care plans will be written for each of the identified residents which shall include the problem, goals, and interventions.7. The discharge planning process will begin with the pre-admission screen review and the Therapy Discharge Planning Schedule which are communicated to the whole IDCP team. 9. The Physician Discharge Summary will be completed within thirty days are the resident has been permanently discharged from the facility. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. NJAC 8:9-36.1(b), (c)

Based on observation, interview, and record review, it was determined that the facility failed to provide a communication device for a resident identified as having language barrier. This deficient practice was identified for one (1) of one (1) resident (Resident #39) reviewed for language and communication deficits and was evidenced by the following: On 9/18/23 at 10:54 AM, the surveyor observed the resident lying in bed, who waived to the surveyor. The surveyor observed the menu in the Resident's room was written in both English and Chinese. The English Activities Communication Calendar in Resident #39's room was dated September 2023, and the Chinese Activities Communication Calendar was dated June 2023. On 9/18/23 at 12:08 PM, the surveyor called the family for interview and did not receive a response. On 9/19/23 at 10:40 AM, the resident was observed lying in bed, waived to the surveyor and pulled the blanket over his/her shoulders. The surveyor reviewed the medical records for Resident #39. The resident's admission Record (an admission summary) reflected that Resident #39 was admitted to the facility with diagnoses that included but were not limited to chronic kidney disease, hypertension (high blood pressure), gastroesophageal reflux disease without esophagitis (acid reflux), atrial fibrillation (abnormal heart rhythm). According to the quarterly Minimum Data Set, (qMDS), an assessment tool used to facilitate the management of care dated 7/27/23, with a Brief Interview for Mental Status score of 4 out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section A. 1100 revealed the resident needed or wanted an interpreter to communicate with doctor or health care staff. A review of the Care Plan (CP) included a focus that indicated the resident had a diagnosis of dementia initiated and revised on 12/10/23. The interventions included use brief/simple words, cues and/or statement when speaking with resident. Repeat as needed. Further review of the CP reflected a focus that Resident #39 participated in daily activities provided, initiated on 6/07/21, and revised on 5/12/22. The interventions included, provide a monthly activity schedule initiated on 6/07/21, and revised on 5/12/22. A review of the Form CMS-672 (a standard form from Centers for Medicare and Medicaid Services) submitted by the facility revealed under section F142 that there were Zero residents in the facility that utilized non-oral communication devices. On 9/20/23 at 10:51 AM, the surveyor interviewed the Recreation Director (RD) who stated she had worked in the facility for five weeks but had over 20 years of experience. The RD explained that the activities for the English and Chinese speaking residents occurred simultaneously in the Dining area. Both programs followed the same calendar. At that time, the RD informed the surveyor that the Activities Communication Calendars were posted every first of the month by her and her staff. The calendars were available in English and Chinese which were both placed in the Chinese speaking resident's rooms. At that time, the RD stated the Recreation Aid who spoke Chinese would enter each of the Chinese speaking resident's room and remind the Resident of the day's activities schedule. My team and I would ask the resident if they will be attending. On 9/20/23 at 11:43 AM, during a follow up interview with the surveyor, the RD stated she posted the calendars in each of the resident's room. At that time, the surveyor and the RD entered Resident #39's room to review the calendars posted on the walls. The surveyor asked the RD to step outside the resident's room to discuss. At that time, the RD confirmed the Activities Communication Calendar in English was dated September 2023, while the Chinese was dated June 2023. At that time, the RD stated she missed it along with everyone else (recreation aid and nurses) who had the opportunity to observe it and missed it since June 2023. The RD stated that the accurate date [month] on the Activities Communication Calendar was important for the resident's reality orientation. It will take time to train. On 9/22/23 at 10:09 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the two different dates for the Activities Communication Calendar for Resident #39, with the Chinese translated Activities calendar that was not updated since June 2003, and its possible effects on the residents time orientation and emotions. On 9/25/23 at 10:36 AM, during a meeting with the survey team, and the DON, the LNHA stated an audit for the calendars were conducted, the calendar was replaced and a Quality Assurance and Performance for Improvement (QAPI; a data driven and proactive approach to quality improvement that included QA and Performance Improvement to ensure services are meeting quality standard and assuring care reached a certain level) was initiated after surveyor's inquiry. A review of the facility provided policy Activity Program revised August 2006 included under Policy Statement, Activity programs designed to meet the needs of each resident are available on daily basis. The Policy and Interpretation and Implementation included under section 6. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to the residents who cannot access the bulletin board (e.g. Bed bound or visually impaired residents). A review of the Recreation Director job description dated 9/21/23 included under Job Responsibilities and Standards section 8. Prepares and posts are written monthly activity schedule for their area, and section 13. Oversees the over-all performance of the recreation staff for this area. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews, review of the facility closed record, and the review of facility provided documents, it was determined that the facility failed to: a) follow the physicians' orders for consultation for two (2) of 22 residents (Residents# 12 and #89) and b) ensure that the physician documented a recapitulation (a summary) of resident's stay at the facility and visit progress notes in accordance with the resident's care and professional standards of clinical practice for two (2) of 22 residents, (Residents#12 and #89) reviewed for quality of care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the N.J. Admin. Code § 8:85-2.3, Current through Register Vol. 54, No. 42, [DATE], Section 8:85-2.3 - Physician services included: 2. The attending physician shall also be responsible for initial and ongoing medical evaluation, as follows: i. The medical assessment of the Medicaid beneficiary shall begin at the time of admission to a NF and shall be the foundation for the planning, implementation, and evaluation of medical services directed toward the care needs of the resident. ii. The medical assessment shall consist of the complete, documented, and identifiable appraisal (from the time of admission to discharge) of the Medicaid beneficiary's current physical and psychosocial health status. The medical assessment shall be utilized to determine the existing and potential requirements of care. The evaluation of the data obtained from the medical assessment shall lead to the development of the medical services portion of the interdisciplinary care plan. The assessment data shall be available to all staff involved in the care of the resident. iii. The tools utilized in the assessment process shall include a complete history and physical examination, eliciting medically defined conditions and prior medical history, admission form(s), transfer form(s), HSDP, and data from other members of the interdisciplinary team. 3. Physician progress notes shall: i. Be maintained in accordance with accepted professional standards and practices as necessitated by the Medicaid beneficiary's medical condition; ii. Be a legible, individualized summary of the Medicaid beneficiary's medical status and reflect current medical condition, including clinical signs and symptoms; significant change in physical or mental conditions; response to medications, treatments, and special therapies; indications of injury including the date, time and action taken; medical necessity for extent of change in the medical treatment plan; and iii. Be written, signed, and dated at each visit. 1. The surveyor reviewed the medical records of Resident #12 as follows: According to the admission Record (AR; or face sheet; an admission summary), Resident #12 was admitted to the facility with a diagnosis that was not limited to pneumonia (an infection that affects the lungs), chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and encounter for attention to gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach). The most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an ARD (assessment reference date) of [DATE] on Section C Cognitive Patterns showed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which reflected that the resident's cognitive status was severely impaired. Further review of the MDS showed that the last MDS that was done for the resident on Section A Identification Information included that Resident #12 had an unplanned discharge to an acute hospital. A review of the Physician's Orders (PO) dated [DATE] handwritten orders of the Medical Doctor (MD) showed an order for a GI (gastrointestinal) consult (in internal medicine who specializes in problems concerning your digestive tract) for anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) to rule out (r/o) GI bleed and hematology consult for anemia. There was a Report of Consultation dated [DATE] in the paper medical record that was signed by Nurse Practitioner#1 (NP#1) with the following information: Report requested regarding: GI f/u (follow-up) Signature of Attending Physician: blank Findings: + (positive) abd (abdominal) bloating (a buildup of gas in the stomach and intestines) Diagnosis: blank Recommendations: bolus tube feed (type of feeding method using a syringe to deliver formula through a feeding tube) QID (four times a day), QID, if worsening pain, inform the clinic and will consider CT (computed tomography; combines a series of X-ray images taken from different angles around the body and uses a computer) abd. Further review of the above [DATE] GI consult showed that the order on [DATE] of the MD for a GI consult for anemia to r/o GI bleed was not followed. In addition, the attending physician (or MD) did not sign the report of consultation and there was no diagnosis included. Furthermore, there was no documentation that the [DATE] order for hematology consult was followed. There was no documentation as to why the order for a hematology consult was not followed. Review of the hybrid medical records (a combination of paper, scanned, and computer-generated records) revealed that the MD's paper visit notes were filed in the closed record that was provided by the Licensed Nursing Home Administrator (LNHA), and the last notes was dated [DATE]. The MD's visit notes in the electronic medical record (eMR) were on [DATE]. There were no other visit notes from the MD after [DATE] and the next visit notes were on [DATE], [DATE], and [DATE]. MD had no visit notes or Progress Notes (PN) both in paper and eMR from [DATE] through [DATE]. The [DATE] MD's PN in the eMR did not include the required progress notes that shall be consistently maintained in accordance with accepted professional standards and practices that indicate the resident's medical condition; individualized summary of the resident's medical status and reflect current medical condition, including clinical signs and symptoms; a significant change in physical or mental conditions; response to medications, treatments, and special therapies; indications of injury including the date, time and action taken; medical necessity for the extent of change in the medical treatment plan. Further review of the eMR revealed that NP#2 initial PN was on [DATE]. The succeeding PN in the eMR of NP#2 were on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 01:22 PM, the survey team met with the LNHA and the Director of Nursing (DON). The DON verified and checked that the hybrid medical records of the resident did not include the MD's visit and progress notes from [DATE] through [DATE]. The DON acknowledged that the MD's eMR notes were not in compliance with the facility's practice and regulations about documentation. On that same date and time, the surveyor notified the above findings and concerns regarding the [DATE] MD's PO regarding GI and hematology consults. On [DATE] at 11:29 AM, the survey team met with the LNHA and the DON. The DON stated that she called the Licensed Practical Nurse/Unit Manager (LPN/UM) and the LPN/UM stated that she did not recall the orders on [DATE] about the GI and hematology consults and that was why it was not done. 2. According to the AR, Resident #89 was admitted to the facility with a diagnosis that was not limited to encephalopathy unspecified (damage or disease that affects the brain), retention of urine unspecified, benign neoplasm of cerebral meninges (tumors that develop from the membrane (meninges) that covers the brain and spinal cord. They are the most common primary brain tumor in adults), major depressive disorder, and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The most recent qMDS with an ARD of [DATE] on Section C showed that the resident had a BIMS score of 05 out of 15 which reflected that the resident's cognitive status was severely impaired. Further review of the MDS showed that the last MDS that was done for the resident on Section A Identification Information included that Resident #89's discharge status was deceased . A review of the resident's medical records revealed that there was no physician's recapitulation of the resident's stay after the resident expired at the facility. The last PPNN in the eMR was dated [DATE] created and signed electronically by NP#2 which was a few weeks before the resident expired. There were no other documented notes from the MD and NP#2 after the [DATE] notes. Further review of the medical records showed that the last monthly paper visit notes of the MD were on [DATE]. The eMR revealed that NP#2 started to document visit notes from [DATE] through [DATE]. Both the [DATE] MD visit notes and the [DATE] through [DATE] visit notes of the NP met the progress notes requirements according to the regulations and standard of practice. There were succeeding PNs from the MD from [DATE] through [DATE] which did not consistently include requirements according to the regulations that the progress notes shall be maintained in accordance with accepted professional standards and practices as legible, individualized summary of the status and reflect current medical condition, including clinical signs and symptoms; a significant change in physical or mental conditions; response to medications, treatments, and special therapies; indications of injury including the date, time and action taken; medical necessity for the extent of change in the medical treatment plan; and be written, signed, and dated at each visit. The PO dated [DATE] that was handwritten and signed by the MD included an order for a cardiology consult (responsible for providing a variety of cardiac health care treatment plans) for DVT (deep vein thrombosis; when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs) and neurology consult (in the diagnosis and treatment of disorders of the brain, spinal cord, nerves, and muscles) for stroke (damage to the brain from interruption of its blood supply). The PO was part of the paper medical record that was provided to the surveyor for review by the LNHA. Further review of the paper medical record revealed a PO dated [DATE] for a neurology consult for stroke that was handwritten and signed by MD. A review of the eMR showed that there was an order from the MD on [DATE] for a cardiology consult for DVT and a neurology consult for stroke that was transcribed by Licensed Practical Nurse#1 (LPN#1). A review of the PN in the eMR revealed the following: 1. [DATE] PN by the MD with a note text: leg pain, urgent venous doppler, urgent arterial doppler, blood test, cardiology consult, vascular consult, and neurology consult. 2. Late Entry for an effective date of [DATE] and created on [DATE] PN by the MD with a note text: saw the patient, vitals stable, order blood test, and continue current tx. 3. [DATE] PN by LPN#2 with a note text: MD in to see pt (patient) Neuro appt (appointment) requested. Further review of the hybrid medical records showed that there was no documentation as to why the physician's order for cardiology and neurology consults was not followed. On [DATE] at 01:40 PM, the surveyor notified the LNHA and the DON of the above findings. On [DATE] at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA stated that the MD should have documented within 30 days the recapitulation of the resident's stay in the facility and this should have been followed for all residents who were discharged (d/c) from the facility including Resident #89 who expired at the facility. On [DATE] at 12:15 PM, the DON stated that the resident had to go out for the cardiologist and neurologist consults because. The DON confirmed after checking the medical records that there were no other cardiology and neurology consult notes except for [DATE] for cardiology and [DATE] for neurologist. On that same date and time, the DON further stated that she did not know why the physician's order on [DATE] for cardiology and neurology consults and the [DATE] order for neurology consult was not followed. On [DATE] at 9:26 AM, the surveyor interviewed the LNHA and the DON in the presence of the survey team. The LNHA acknowledged that the MD utilized hybrid medical records for visits and PN. The LNHA informed the surveyor that it was the facility practice and procedure that the physicians including the resident's MD to document visit notes in the eMR. Both the LNHA and the DON acknowledged that the eMR visit notes of the PMD should comply with the required documentation according to the regulation. At that same time, both the DON and the LNHA acknowledged that the provided printed MD's visit notes from [DATE] through [DATE] after the surveyor's inquiry were not all reflective of what the PMD wrote in the eMR progress notes and there were discrepancies. In addition, the DON stated that she followed up with the MD on his documentation when the resident expired. According to the DON, the MD informed her (DON) that he did not write a recapitulation summary for the resident who expired because the death certificate was his d/c summary. The DON further stated that she educated the MD about the recapitulation summary and that it should have been done for Resident #89. A review of the provided QAPI (Quality Assurance Performance Improvement) that was provided by the [NAME] President of Clinical Services (VPoCS) dated [DATE] showed that the goal was that the attending MD will complete the resident's History and Physical in a timely manner as per regulations, NP will follow the resident plan of care at least monthly and/or as needed depending resident clinical status. Further review of the above QAPI showed that the facility did not identify the surveyor's findings and concerns. A review of the facility's Consultants Policy that was provided by the DON with a revised date of [DATE] included the goal that the facility uses outside resources to furnish specific services provided by the facility. Process: the facility may use needed outside resources to furnish specific services to residents and to the facility such personnel are employed on a consultant basis; consultant services may be utilized in the areas of physicians with specialties and radiologists and diagnostic; consultants provide the facility with written, dated and signed reports of each consultation visit such reports contain the consultant's recommendations, plan for implementation of his/her recommendations, findings, and plan for continued assessment. On [DATE] at 01:30 PM, the survey team met with the LNHA, DON, and VPoCS. The facility management did not provide additional information and did not refute findings. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of one (1) resident reviewed for falls (Resident #2). This deficient practice was evidenced by the following: On 9/18/23 at 11:09 AM, the surveyor observed Resident #2 seated in a wheelchair in the dayroom. Resident #2 did not speak English. The surveyor interviewed the resident via an interpreter that was an employee of the facility and the resident stated that he/she was very good. The surveyor reviewed Resident #2's medical record. The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; cerebrovascular disease (a term for conditions that affect blood flow to your brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and dysphagia (difficulty or discomfort in swallowing). Resident #2's significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/29/23, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which reflected that the resident's cognition was severely impaired. Resident #2's Discharge Return Anticipated MDS, dated [DATE] indicated the resident had one fall with major injury. A review of Resident #2's individualized comprehensive care plan (CP) reflected a focused area with an initiated date of 12/18/20, at risk for falls due to Impaired balance/poor coordination, Unsteady gait; Fall on 11/10/2022; Fall on 11/11/2022; s/p fall 7/26 returned 7/26. The following interventions were included: Encourage to transfer and change positions slowly Date Initiated: 12/18/2020 Have commonly used articles within easy reach Date Initiated: 12/18/2020 Keep rolling walker within reach Date Initiated: 02/14/2023 Low bed Date Initiated: 07/26/2023 Provide assistance to transfer and ambulate (walk) as needed Date Initiated: 12/18/2020 Refer to the Therapy Plan of Treatment in the medical record for more detail Date Initiated: 02/14/2023 Reinforce the need to call/ring for assistance Date Initiated: 12/18/2020 Therapy evaluation and treatment as ordered Date Initiated: 12/18/2020 Toileting schedule ac (before meals), hs (at bedtime) and prn (as needed)-assist to toilet Date Initiated: 07/26/2023 Resolved interventions included: RESOLVED: 7/11-close monitoring when in room Date Initiated: 07/19/2022 Resolved Date: 05/05/2023 RESOLVED: Bed placed against wall for safety Date Initiated: 05/08/2023 Resolved Date: 08/04/2023 RESOLVED: Reinforce wheelchair safety as needed such as locking brakes Date Initiated: 12/18/2020 Resolved Date: 02/14/2023 Further review of the CP showed that there were no new interventions implemented on or around the fall of 11/10/22 and 11/11/22. On 9/19/23 at 11:49 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for incidents or investigations that occurred for Resident #2 during the last year. On 9/20/23 at 10:06 AM, the surveyor interviewed Resident #2's assigned Licensed Practical Nurse (LPN) regarding the process after a resident had a fall. The LPN stated that after the resident was assessed for any injury and family and physician was notified, an incident report is done. She added that an investigation is done if the fall was unwitnessed and if it was witnessed ask the person what caused the fall. On that same date and time, the surveyor asked if a new intervention would be put in place on the CP and who would do that. The LPN stated that a new intervention would be put in place after a fall but that she did not know who placed it on the CP. The LPN then stated that she knew that an intervention should be put in place as soon as possible. The surveyor then asked the LPN if Resident #2 had any falls. The LPN stated that she knew that the resident had recently fell and was sent to the hospital and had a right hip fracture. At the same time, the LPN further stated that the resident was on the other wing before and that she was not aware if the resident had any falls prior to that. The surveyor asked the LPN to look at Resident #2's CP. The LPN confirmed that Resident #2's CP did not have any new interventions placed after the two falls in November 2022. On 9/20/23 at 10:19 AM, the Director of Nursing (DON) provided the surveyor with three incident/investigation reports that occurred in the last year. A review of the reports included the following: 7/19/23 Incident Description: 6:10 p (PM) The interpreter informed nurse that resident was found sitting on floor .resident was sitting on his/her buttocks with his/her pants down-also there was urine on the floor. Notes: 7/20/23 Team met to discuss fall. Resident#2 was attempting to self-toilet in a room which resident thought was a bathroom . xray was performed .found to have a non-displaced fracture to his/her right hip. Resident#2 was sent to hospital for evaluation. 11/11/22 Incident Description: Was called to day room by another staff that resident is on the. Notes: IDC (Interdisciplinary) team met to review incident, Patient is alert and oriented with periods of confusion. During the day patient in the dayroom with activities for close monitoring. PT (Physical Therapy) screen order. 11/10/22 Incident Description: While passing out medications, nurse heard a noise in pt's (patient's) bathroom, went in there, found pt. lying on floor. Notes: IDC team Met to review incident, PTS (patient) is AAOx3 (Awake, Alert, Oriented), reeducated pts (patient) on the importance of using his/her walking and call for help, PT (Physical Therapy) screen order. On 9/20/23 at 01:28 PM, the surveyor interviewed the DON regarding the process of implementing a new intervention after a resident has a fall. The DON stated that there should be an intervention put in place if something changed unless there was an isolated incident. The surveyor asked the DON if there should be a new intervention placed on the CP after a fall. The DON stated that there should be an intervention close to the date [of the fall]. The surveyor asked the DON what was the reason that a new intervention be implemented. The DON stated that a new intervention would be put in place to prevent a fall in the future. On 9/20/23 at 01:31 PM, the surveyor interviewed the Assistant DON (ADON) regarding updating the CP after a resident has a fall. The ADON stated that the Unit Manager (UM) would have a meeting and that the UM usually updated the CP. She added that the CP could also be updated by the ADON or DON. The surveyor asked the ADON if she recalled Resident #2's falls that occurred in November 2022. The ADON stated that she did not remember. On 9/20/23 at 01:37 PM, the surveyor interviewed the DON regarding Resident #2's CP. The DON confirmed that there were no new interventions added after the 11/10/22 and 11/11/22 falls. The surveyor asked the DON what the expectation would be. The DON stated that the expectation was that there should have been an intervention after each fall. On 9/22/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the LNHA and DON the concern that Resident #2 did not have any new interventions put in place on the CP after the resident fell two times in November 2022. On 9/22/23 at 10:41 AM, the surveyor asked the DON for a policy for falls. The DON stated that falls was included in the accidents and investigations policy that was previously provided to the survey team. On 9/27/23 at 01:37 PM, in the presence of the survey team and LNHA, the DON stated that the interventions were listed on the incident report but they were not placed on the resident's CP. The DON stated that the interventions should have been placed on the CP. A review of the facility provided policy titled, Accidents and Incidents-Investigating and Reporting with a revised date of 5/18/2022 included the following: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of accidents or incidents as appropriate. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: . k. Any corrective action taken; l. Follow-up information as applicable; . n. Other pertinent data as necessary or required; . 3 .This individual will submit completed documents to the DON/designee and discuss the incident at the morning management meeting. 4. An investigation of incidents as appropriate will be completed. The policy did not include any information specific to falls. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to: a) monitor residents returning from the dialysis center for hemodialysis access site and vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and b) complete the Hemodialysis Communication Record (HCR), post dialysis treatment according to standard of practice, policy, and facility practice. The deficient practice was observed for one (1) of two (2) residents (Resident #7) reviewed for hemodialysis. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, 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 casefinding; 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 9/19/23 at 10:24 AM, the surveyor observed Resident #7 sitting on edge of the bed, completely dressed. The resident was interviewable. The resident stated that their dialysis (also known as hemodialysis; the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) days were on Tuesdays, Thursdays, and Saturdays at around 5:30 AM. On 9/19/23 at 9:05 AM, the surveyor reviewed the hybrid medical records (combination of electronic medical record and physical chart) of Resident #7. The admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), kidney transplant failure (your new kidney may stop working over time because your body's immune system is constantly fighting it), dependence on renal dialysis, type 2 diabetes mellitus (DM) (a disease that occurs when your blood glucose, also called blood sugar, is too high). A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care with assessment with a reference date (ARD) 6/25/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated that resident's cognitive status was intact. A review of the care plan, last review dated 6/29/23, revealed resident #7 will have the consequences of ESRD controlled at the highest level possible with the prescribed dialysis regimen, date initiated 6/24/22 and revised on 7/04/23. On 9/25/23 at 02:20 PM, the surveyor reviewed the Dialysis Communication Log (a binder on the unit which contains a resident's HCR forms) of Resident #7. The HCR (a facility form used to communicate the resident's status on hemodialysis treatment days between the facility and the dialysis center) contained three separate areas to be filled out; the top section was to be completed by the facility nurse prior to the resident leaving the facility for the dialysis treatment, the bottom section was to be completed by the Dialysis center staff after treatment and in the top section, was post dialysis vitals to be completed by the facility nurse upon the residents return to the facility. The surveyor reviewed the HCR's from 9/16/23 to 9/23/23 which revealed that five (5) of five (5) dates had incomplete HCRs for Resident #7. The following dates were: 9/16/23, 9/19/23, 9/21/23, 9/22/23 and 9/23/23, five (5) of the five (5) days Resident #7 attended hemodialysis. The facility return section for VS (vital signs) was not completed. The resident's weights were not filled out prior or post dialysis five (5) of five (5) forms. Vascular access section was left blank. The Dialysis unit section was completely blank on 9/23/23 upon the residents return. On 9/27/23 at 02:09 PM, the Director of Nursing (DON) confirmed that the form should be completed upon the residents return to the facility. The DON added that it was a two-part form in case the resident did not return from Dialysis with the form. The Licensed Nursing Home Administrator (LNHA) provided the surveyor with the facility policy titled: Dialysis Policy. Initial or revision dates were not documented within the policy. The policy revealed: 9.) A communication book will be sent with the residents to dialysis. Upon return from dialysis, the charge nurse will review and take note of any recommendations. 10.) Upon return from dialysis the resident will be checked for the following: a) check dressing for bleeding, b) check for warmth and redness. 14) document treatment and the resident's response in nursing summary and evaluation. The Dialysis Communication Book Policy was attached to the dialysis policy provided by the LNHA. During review, it was revealed: ~~It is the policy of the facility to have open and ongoing communication with dialysis centers treating our residents to help promote quality and continuity of care. 4) Pertinent information can include but is not limited to changes in medication, diet, complaints of pain, redness, swelling at the shunt, changes in bruit, weight, change in vital signs. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-2.7(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. As per the Nurse Staffing Report completed by the facility for the week of staffing from 9/03/23 to 9/16/23 for the standard survey, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on one (1) of 14 overnight shifts as follows: The facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -09/03/23 had 6 CNAs for 92 residents on the day shift, required at least 11 CNAs. -09/03/23 had 6 total staff for 92 residents on the overnight shift, required at least 7 total staff. -09/04/23 had 10 CNAs for 91 residents on the day shift, required at least 11 CNAs. -09/05/23 had 7 CNAs for 89 residents on the day shift, required at least 11 CNAs. -09/06/23 had 6 CNAs for 89 residents on the day shift, required at least 11 CNAs. -09/07/23 had 7 CNAs for 89 residents on the day shift, required at least 11 CNAs. -09/08/23 had 7 CNAs for 89 residents on the day shift, required at least 11 CNAs. -09/09/23 had 10 CNAs for 88 residents on the day shift, required at least 11 CNAs. -09/10/23 had 9 CNAs for 87 residents on the day shift, required at least 11 CNAs. -09/11/23 had 8 CNAs for 87 residents on the day shift, required at least 11 CNAs. -09/12/23 had 8 CNAs for 86 residents on the day shift, required at least 11 CNAs. -09/13/23 had 8 CNAs for 86 residents on the day shift, required at least 11 CNAs. -09/14/23 had 9 CNAs for 86 residents on the day shift, required at least 11 CNAs. -09/15/23 had 9 CNAs for 86 residents on the day shift, required at least 11 CNAs. -09/16/23 had 7 CNAs for 89 residents on the day shift, required at least 11 CNAs. On 9/19/23 at 10:32 AM, during an interview with the surveyor, CNA#5 stated the following: The census for the East wing was 45. There were two (2) nurses on duty with three (3) CNAs including herself. CNA stated she knew the ratio was supposed to be one (1) CNA for every eight (8) residents on the 7AM to 3PM shift. The CNA explained that there were four (4) CNAs scheduled that day, but one (1) CNA had called out from work which was the reason for the (3) CNA on that shift. At that time, LPN#3 stated she too was aware of the mandated ratio of one (1) CNA to eight (8) residents on the 7 AM to 3 PM shift. The management was aware of the CNA who called out from their morning shift at work, but it was too short of a notice to get another person to cover their shift. At that time, CNA#5 stated it was hard to complete her assignments, but we get the work done. The surveyor reviewed the staff assignment sheet dated 9/19/23 that reflected three (3) CNAs and two (2) nurses were assigned to 45 residents. On 9/25/23 at 7:30 AM, during the meeting with the surveyors, the LNHA and the DON stated that they were aware of very short staffing on weekends. The LNHA stated he was giving $75-$100 staffing bonuses. The surveyor also notified the facility management of the PBJ (payroll based journal; allows staffing information to be collected on a regular and more frequent basis than previously collected) report for low weekend staffing. On 9/25/23 at 10:10 AM, the Human Resource Director (HRD) informed the surveyors that the payroll time clock (an electronic based system that recorded when a staff clocked in for their shift and clocked out from their shift) was not working and was unable to provide the payroll staff report. The same report used for the PBJ required to be submitted to the Centers for Medicare and Medicaid Services (CMS). The HRD informed the surveyors that the payroll time clock was broken since 9/14/23. She had been manually entering the information into the payroll time clock. On 9/25/23 at 10:36 AM, during a meeting with the surveyors, the LNHA and the DON, the surveyor discussed the staffing concerns. At that time, during the meeting with the surveyors, and the DON, the LNHA showed the surveyors the recruiting binders he utilized as effort to staff the facility. We are trying our best. At that time, the LNHA stated he had just learned that morning that the payroll time clock was not working. The LNHA clarified that the employees including himself were able to clock in and out of the payroll time clock, and the issue was in the transmission of data. On 9/26/23 at 9:38 AM, in the presence of the surveyors, and the LNHA, the surveyor interviewed the corporate Payroll Administrator (cPA) telephonically. The cPA informed the surveyors that she was made aware of the issue with the time clock on 9/22/23 The cPA explained that their vendor captured the data from the time clock and sent the data for PBJ reporting to CMS. The cPA confirmed she learned that the HRD was manually entering the staffs pay roll data, and the cPA told the HRD not to do that. The cPA stated that entering the payroll time clock data manually was manipulating the time clock, could be misconstrued as falsifying time submitted. At that time, The cPA stated she was working with the time clock software vendor to address the issue. A review of the facility provided policy; Staffing revised on 3/29/23, included: Goal: [Facility name redacted] will provide adequate staffing to meet needed care and services for our resident population. Process 1. [Facility name redacted] will maintain adequate staffing on each shift to ensure that our residents 's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan. 4. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies as required. Such work week is selected by the state survey agency. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-27.1(a) Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents' highest practical wellbeing by failing to: a.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey (NJ) and b.) ensure that 7 AM-3 PM, 3-11 PM, and 11-7 shifts were staffed to provide the ADLs (activities of daily living) for three (3) of 16 residents, (Residents#2, #35, and #67) according to facility practice, required minimum direct care staff-to-shift ratios as mandated by the state of NJ, and facility assessment. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. On 9/25/23 at 6:38 AM, the surveyor in the presence of another surveyor interviewed the 11-7 shift Licensed Practical Nurse#1 (LPN#1) from East Wing who informed the surveyors that she had been working in the facility for seven years, a regular shift 3-11 shift nurse and also works other shifts according to her availability. On that same date and time, LPN#1 informed the surveyor that there were two CNAs last night for the 11-7 shift with one call-out. The LPN stated that there should be three aides in the unit. She further stated that there was no nursing supervisor in the 11-7 shift and there had been no supervisor, for how long no supervisor, the LPN cannot remember. The surveyor asked for a copy of the 11-7 shift assignments including Saturday (9/23/23) and Sunday (9/24/2) and she stated that she would get back to the surveyor. On 9/25/23 at 6:42 AM, the surveyor interviewed the 11-7 shift nurse from the [NAME] Wing. LPN#2 informed the surveyor that she was an agency nurse and this was her first day to work at the facility. The LPN stated that the [NAME] Wing census (total count of residents) was 45, two CNAs, and one LPN (herself), and that there was no nursing supervisor. On that same date and time, the surveyor asked LPN#2 where were the two aides in the unit, and LPN#2 responded that one aide was in the dining area and she was not sure where the other aide was. The LPN further stated that the morning care and personal care of all residents in the unit were done. At this time, the surveyor observed CNA#1 in the dining area with her bag and sweater on walking around. Also, the surveyor observed Resident #67 in the dining area seated in their wheelchair, well-dressed and clean. Resident #67 was from [NAME] Wing. On 9/25/23 at 6:44 AM, the surveyor observed Resident # 2 in their room lying on the bed with eyes closed. The resident was covered with a blanket, the resident was clean, and no smell of urine inside the room. On 9/25/23 at 6:46 AM, the surveyor interviewed the 11-7 CNA from the [NAME] wing in the hallway going to the dining area. CNA#1 informed the surveyor that she had been the CNA at the facility for a year. CNA#1 was unable to state the [NAME] Wing census and how many residents she took care of for the 11-7 shift. She further stated that she took care of all residents on her assignment and that there was one nurse in the unit. At that same time, CNA#1 was not aware of the nurse staffing ratio. She indicated that in the [NAME] wing, usually there a three aides assigned but last night two CNAs worked. She further stated that she was not sure if there was a call-out. CNA#1 informed the surveyor that she did not have a regular assignment and that she works all shifts and different wings depending on the availability, and she claimed that she was a per diem CNA. In addition, CNA#1 was unable to state the name and whereabouts of the other aide in the [NAME] Wing unit. The surveyor was unable to see the other aide in the unit. On 9/25/23 at 6:53 AM, the surveyor went to [NAME] Wing room [ROOM NUMBER] and observed Resident # 35 lying on the bed. The surveyor asked the resident if he/she was cleaned by the aide today and she stated Yes. The resident did not have a complaint about care. The surveyor observed the resident clean and no smell of urine inside the resident's room A review of the provided [NAME] wing assignments for the 11-7 shift (9/24/23) showed that LPN#2 was the nurse, CNA#2 had a total of 23 residents, and CNA#1 had a total of 24 residents. A review of the provided East wing assignments for the 11-7 shift (9/24/23) LPN#1 was the assigned nurse, CNA#3 had a total of 25 residents, and CNA#4 had a total of 20 residents. Further review of the provided Master Copy for staff assignment for 9/24/23 (Sunday) that was provided by the Director of Nursing (DON) included the following: West Wing: 7-3 Shift assignment 1 CNA:15 residents, assignment 2 CNA:14 residents, and assignment 3 CNA:18 residents. 3-11 Shift assignment 1 CNA:23 residents and assignment 2 CNA:24 residents. East Wing: 7-3 Shift assignment 1 CNA:24 residents and assignment 2 CNA:23 residents. 3-11 Shift assignment 1 CNA:23 residents and assignment 2 CNA:23 residents. On 9/25/23 at 7:30 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and DON in the presence of another surveyor. The surveyor notified the facility management about the findings above. The DON stated that it was an expectation that all staff should be at the unit until 7 AM. The DON further stated that there was no supervisor for the 11-7 shift and that was been the staffing for the 11-7 shift. The DON indicated that one nurse in each unit and three aides in each unit for staffing for 11-7. On that same date and time, the DON stated that weekend staffing varies and they (facility management) were aware of the weekend short staffing. She further stated that she would get back to the surveyor as to why CNA#2 was not in the [NAME] wing before the 7 AM shift ended. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The DON stated that CNA#2 left at 6 AM. The surveyor asked the facility management why the nurse and the aide in the [NAME] unit were not aware that CNA#2 left at 6 AM, and who covered for CNA#2's assignment. The DON stated that she will get back to the surveyor. On 9/25/23 at 12:15 PM, the DON provided a copy of an updated [NAME] and East wing census of residents as follows: West wing 11-7 shift of 9/24/23 census=45 East wing 11-7 shift of 9/24/23 census=44 At the same time, the DON stated that the two-bed hold was added to the census which was why the census was 91 instead of 89 and there was a discrepancy on previously submitted assignments from the [NAME] and East wing. The DON acknowledged that they were aware of the mandated staffing law and based on the provided assignments on 9/24/23 for weekend staffing and observed by the surveyor on 9/25/23 for the 11-7 shift, the facility was not in compliance with the staffing.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted Resident Care Staffing Report (24-hour staffing report) was up to date and provided accurate information. This deficient practice was evidenced by the following: On 9/18/23 at 9:18 AM, the surveyors entered the facility and observed the posted 24-hour staffing report which was dated 9/15/23. The census listed was 90. The staffing report was not up to date and it was three days late. On 9/23/23 at 11:26 AM, the surveyors observed the posted 24-hour staffing report which was dated 9/19/23. The census listed was 91. The staffing report was not up to date and it was four days late. On 9/25/23 at 8:35 AM, the surveyor observed the posted 24- hour staffing report which was dated 9/22/23. The census listed was 90. The staffing report was not up to date and it was three days late. On 9/25/23 at 10:36 AM, the Licensed Nursing Home Administrator (LNHA) provided copies of the facility daily census report from 9/15/23 to 9/25/23 and reflected as follows: Date 9/15/23; Census: 89 (not reflected, the posted census was 90) Date 9/16/23; Census: 91 Date 9/17/23; Census: 91 Date 9/18/23; Census: 91 Date 9/19/23; Census: 91 Date 9/20/23; Census: 91 Date 9/21/23; Census: 91 Date 9/22/23; Census: 90 Date 9/23/23; Census: 90 Date 9/24/23; Census: 90 Date 9/25/23; Census: 90 (not reflected, the posted census was 91) The surveyor compared daily census report to the 24-hour staffing report that was posted on 9/18/23, and 9/25/23. On both of the outdated 24-hour staffing report posted, the census listed was inaccurate. Further review of the 24-hour staffing report reflected the following: Date 9/22/23; No Registered Nurse (RN) was scheduled. Date 9/24/23; No Registered Nurse (RN) was scheduled. Date 9/25/23; No Registered Nurse (RN) was scheduled. On 9/25/23 at 9:50 AM, during an interview with the surveyor, the Human Resource Director (HRD) stated her responsibilities included on-boarding, orientation, in-services, and staffing. The HRD stated she was still under orientation by the outgoing Staffing Co-Ordinator. At that time the HRD informed the surveyors that she reviewed the census and the scheduled staff per shift. The HRD was unsure if an RN was required to be on the schedule. The HRD informed the surveyors that she was aware of the following: 7-3 shift required 1 CNA (Certified Nursing Aid) for every 8 residents. 3-11 shift required 1 CNA for every 10 residents. 11 to 7 shift required 1 CNA for every 14 residents and the Licensed Practical Nurse (LPN) could help out the CNA in the evening. At that time, the surveyor asked why there were no RN scheduled for the 9/22/23 9/24/23, and 9/25/23, the HRD did not respond to the question. On 9/25/23 at 9:59 AM, during an interview with the surveyors, the CNA/Unit Clerk (UC)/ outgoing Staffing Co-Ordinator (SC) stated she scheduled CNAs, nurses and was training the HRD, but was not in-charge of posting the census and the staffing in the lobby that was the sole responsibility of the HRD. At that time, the CNA/UC/ outgoing SC stated an RN should be scheduled but was only able to schedule employees who were available to work. Sometimes, she had to post the schedule without an RN, but I always informed the Director of Nursing. The DON and I worked with three (3) agencies, although I am unable to authorize incentives without the authorization of the administrator or the owner. I was able to receive authorization, for example, in the last two weeks, I received approval for incentives. On 9/25/23 at 10:10 AM, the surveyor and the HRD reviewed the 9/22/23, 9/24/23 and 9/25/23 together. The HRD stated she was unsure as to why there was no RN scheduled. The HRD explained that the census posted was obtained from the morning meeting. The HRD also stated that she took the daily staffing sheet and calculated the number of employees scheduled and entered the data onto the 24- hour staffing report. At that time, the HRD confirmed there were no RNs listed on the 24-hour staffing report. The HRD compared the scheduled staff against the 24- hour staffing report and acknowledge she had made an error on the posting. The HRD stated she had categorized one (1) of the RN as a CNA. At that time, the surveyor asked the HRD what the significance was of an RN not scheduled on the 24-hour staffing report. The HRD stated I don't know the significance, why that is important. She further stated that the DON and the Minimum Data Set Coordinator were both an RN and works Monday through Friday. She indicated that the DON also comes in on weekends at times. At that time the surveyor requested for the license verification for the LPN and the payroll time clock report. On 9/25/23 at 10:19 AM, the HRD provided the surveyor a copy of the license verification for the RN who was mislabeled as a License Practical Nurse. At that time, the HRD informed the surveyors that the payroll time clock (an electronic based system that recorded when a staff clocked in for their shift and clocked out from their shift) was not working and was unable to provide the payroll staff report. The same report used for the Payroll Based Journal (PBJ) required to be submitted to the Centers for Medicare and Medicaid Services (CMS). The HRD informed the surveyors that the payroll time clock was broken since 9/14/23. She had been entering the information into the payroll time clock. On 9/25/23 at 10:36 AM, during a meeting with the surveyors, the LNHA and the Director of Nursing (DON), the surveyor discussed the staffing concerns, the outdated 24- hour staffing report that was posted on 9/18/23, 9/23/23 and 9/25/23, the inaccurate census listed on 9/15/23 and 9/25/23, and the 24-hour staffing reports which did not include an RN on the schedule for 9/22/23, 9/24/23 and 9/25/23. At that time, the LNHA showed the surveyors the recruiting binders he utilized as effort to staff the facility. We are trying our best. At that time, the LNHA and the DON stated they were not aware that bed holds should not have been included as part of the census in the facility. At that time, the LNHA stated he had just learned that morning that the payroll time clock was not working. The LNHA clarified that the employees including himself were able to clock in and out of the payroll time clock, and the issue was in the transmission of data. On 9/26/23 at 9:38 AM, in the presence of the surveyors, and the LNHA, the surveyor interviewed the corporate Payroll Administrator (cPA) telephonically. The cPA informed the surveyors that she was made aware of the issue with the time clock on 9/22/23. The cPA explained that their vendor captured the data from the time clock and sent the data for PBJ reporting to CMS. The cPA confirmed she learned that the HRD was manually entering the staffs pay roll data , and the cPA told the HRD not to do that. The cPA stated that entering the payroll time clock data manually is manipulating the time clock, could be misconstrued as falsifying time submitted. At that time, the cPA stated she was working with the time clock software vendor to address the issue. No further data was submitted. A review of the facility provided policy; Staffing revised on 3/29/23, included: Goal: [Facility name redacted] will provide adequate staffing to meet needed care and services for our resident population. Process 1. [Facility name redacted] will maintain adequate staffing on each shift to ensure that our residents 's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan. 4. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies as required. Such work week is selected by the state survey agency. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-41.2 (a)(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented including the approprite hours of sleep snacks (HS snacks) for one (1) of 19 residents, (Resident #7) reviewed. This deficient practice was evidenced as follows: On 9/19/23 at 10:24 AM, the surveyor observed Resident #7 seated on the edge of their bed with breakfast tray on the bedside table. There were no visible menus in the room for the resident to review. The residents breakfast meal was on his/her bedside table, the ticket only read, scrambled eggs, double portion. The preference and the dislike columns were blank. On 9/19/23 at 10:24 AM, during the interview the surveyor asked the resident about how he/she like their breakfast tray? The resident stated, not really, I don't get to choose my meals. I get to talk to the dietician but no I do not fill out a menu for what I want. I have told her what I like but I do not get it. The surveyor asked if the resident receives a bedtime snack? The resident responded, no, I do not get a snack at bedtime. On 9/22/23 at 9:20 AM, the surveyor interviewed the Registered Dietician (RD) who stated, all of our residents are given the menu in their room, preset with alternates, the kitchen is on a (3) three-week cycle. Resident #7 is on a Renal/ No added Salt/ Carbohydrate controlled Diet (Renal/NAS/CCD). The resident has not discussed with me about not liking his options or food. Everyone in the building gets an Hour of Sleep (HS) snack. On that same date and time, the RD informed the surveyor that Nursing is responsible to put in the order per the doctor or my communication recommendation sheets. She further stated that the floor staff and nurses hand the snacks out to the residents. The RD stated that the snacks are either cart blanche or prebagged for the diabetics or special requests. She further stated that My [NAME] is that they should receive any item they want but a smaller portion if they are a diabetic. The facility is very liberal. On 9/22/23 at 9:38 AM, the surveyor interviewed the Food Service Director (FSD). The FSD informed the surveyor that the current prebagged snack list we have for the offered HS snack in the system does not include Resident #7. Meaning he/she does not have a special request or a prebagged diabetic snack listed in the kitchen. At that same time, the FSD explained that the kitchen computer system and the facility documentation system do not talk to each other. The FSD further stated that the list I showed you is created by verbal communication, or a correspondence form provided by the RD with the resident's preferences. The surveyor asked the FSD if there is a par level list for the HS snack cart that goes to the floors? The FSD stated, no, we put all snack items available in the kitchen or items that should be used based on expiration date, so food does go to waste. On 9/22/23 at 10:42 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that an HS snack is an order that gets entered into the electronic ordering system for every resident by either a doctor's order or the communication form from the RD. She further stated that once that order is placed it generates a nurse sign off in the medication administration record for the nurse to sign off. The FSD stated that the HS snack is sent up on a cart from the kitchen for all the residents. Furthermore, the FSD stated that the residents that have a special request or diabetic snack ordered come up in a labeled prepackaged bag. On 9/27/23 at 11:45 AM, the surveyor interviewed the FSD, are there smaller portion sizes like a ½ slice of pie or 1 cookie instead of 3 in a bag provided on that cart? The FSD responded, no, we do put a slice of pie, pudding, cookies on there but it is a normal portion. The surveyor asked, are there other therapeutic menu provided to the residents to pick their own food for the day or week? The FSD replied, no, we only provide our 3-week cycle menu that has an alternate choice at the bottom, a Chinese food menu, and an always available menu. We do not have special therapeutic diet menus such as renal or diabetic. The therapeutic diet residents are controlled with a menu extension that the residents are not given. It is for the line staff to be able to adjust our 3-week cycle menu for what is in range for the specialized diet. The menu extension shows that a renal resident can not have Orange Juice and we change it out for apple juice. The surveyor asked, do the residents see that they are getting apple juice on the menus provided to them? The FSD replied, no. On 9/27/23 at 12:07 PM, during the interview of the surveyor with the resident , the resident stated, The eggs never got rectified after I spoke to the dietician after your last visit, and they keep sending me scrambled eggs. I told the dietician that I like the round preformed eggs better then these scrambled eggs. The surveyor observed at that time, the resident had a menu stapled to his bulletin board. When the surveyor inquired about it the resident stated, I did not know it was there. The surveyor asked the resident if he/she would the see it? The resident stated. yes. After the resident reviewed it, the resident stated, I have never been shown this menu or that it had an alternate on the bottom. At that same time, the resident informed the surveyor that he/she did not know that there was an always available menu to choose from. The surveyor observed that the lunch ticket that was served at this time to the resident had preferences and dislikes written on it. The surveyor asked the resident if what was written was accurate. The resident stated, It says here that I don't like ice cream, I do like ice-cream it is just melted by the time it gets to me. During an interview on 9/28/23 at 10:21 AM of the surveyor with the DON and LNHA, both the LNHA and DON acknowledged that there is a communication issue between the RD, Nursing and FSD for prescribed HS snacks for residents on a therapeutic diet. On 9/19/23 at 09:05 AM, the surveyor reviewed the electronic medical record and physical chart of Resident #7. The admission Record, (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), kidney transplant failure (your new kidney may stop working over time because your body's immune system is constantly fighting it), dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions), type 2 diabetes mellitus (DM) (a disease that occurs when your blood glucose, also called blood sugar, is too high). A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 6/25/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated that resident's cognitive status was intact. Further review of CMDS Section F0400-Preferences for customary routine and activities. It revealed that letter D.) how important is it to you to have snacks available between meals? Was coded as (1) one (Very important). A review of section I, Active diagnosis, it revealed under I2900 that the resident has diabetes mellitus (DM). A review of section K0510 revealed the resident has been on a therapeutic diet since in the facility. A review of Resident #7's Care Plan (CP), revealed, a focus of the potential for hypo/hyperglycemia related to (R/T) a diagnosis of DM. Under goal, resident will be free of adverse effects of hypo/hyperglycemia daily through the next review. Under interventions, Provide ordered diet and encourage compliance if needed. Assist as needed. Date initiated 6/24/22. The care plan did not reflect the residents' preferences for his/her therapeutic diet or snacks. A continued review of Resident #7's Care Plan (CP), revealed, a focus of resident has a desire to gain weight he/she receives therapeutic diet for ESRD/DM. Under goal, will consume appropriate amounts of food to maintain target body weight. Date initiated 6/26/22 revision on 7/31/23. Interventions reflected Diabetic HS snack, dated 9/22/23 post surveyor inquiry. The Interdisciplinary Care Team Conference (IDCP) reports with an effective date of 3/28/23 and 6/26/23 do not list any preferences in section E.) dietary note by the RD for the resident. A review of the physician order list (POL)date range of 10/1/22 -9/30/23 revealed: Offer HS snack, for bedtime supplement; Active 9/20/23. Offer HS snack, for bedtime supplement; discontinued 10/1/22-10/6/22. Offer HS snack, for bedtime supplement; discontinued 10/13/22. Offer HS snack, for bedtime supplement; discontinued 11/14/22-12/31/22. The HS snack was entered in the POL system after surveyor inquiry on 9/20/23, nine (9) months since the previous order was discontinued on 12/31/22. It did not reflect the resident's meal preferences or choices. It did not reflect a prebagged diabetic HS snack order. A review of the physician order set (POS) for diet revealed an active order with a start date 01/17/23 for Renal/ CCD/ NAS diet, regular texture, thin consistency. It did not reflect the resident's meal preferences or choices. It did not reflect a prebagged diabetic HS snack order. A review of the Treatment Administration Record (TAR) from 6/01/23- 9/30/23 revealed, offer HS snack order date on 9/20/23 with nursing sign off started on 9/20/23. A review of policy and procedure Therapeutic Diets, dated 9/20/20, read as; When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a resident to achieve outcomes /goals of care. Under the procedure section # 2) A list of approved /standard diets will be available for nursing staff, who will notify physicians of the diets available at the facility. Theses diets correspond with the therapeutic diets on the facility menu extension. A review of Interdisciplinary Care Planning Policy and Procedure, dated 3/29/23, read as: #11) Since the care plan is a dynamic document, in the interim between quarterly reviews, the IDC team MUST revise problems, goals, and interventions in response to changes in the needs of residents. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. NJAC 8:39-17.4 (c), (e)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain complete and accurate records for a resident. This deficient practice was identified for one (1) of 1 resident reviewed for Hospice and End of Life services (Resident #51) and was evidenced by the following: On 9/18/23 at 10:48 AM, the surveyor observed Resident #51 sleeping on their right-hand side and was covered with a thin blanket. The surveyor reviewed Resident #51's medical record. Resident # 51 was admitted to the facility with diagnoses that included unspecified dementia without behavioral disturbance (decline in memory), lack of coordination, hypothyroidism, hypertensive heart disease with heart failure, malnutrition, muscle weakness, dysphasia (difficulty swallowing food or liquids), difficulty walking, schizoaffective disorder, bipolar type, Alzheimer's disease ((A type of brain disorder that causes problems with memory, thinking, and behavior. This is a gradually progressive condition) and urinary tract infection. According to the quarterly Minimum Data Set, (qMDS), an assessment tool used to facilitate the management of care dated 7/21/23 with a Brief Interview for Mental Status score of 00 out of 15, indicating that the resident had a severely impaired cognition. A review of the Physician's Order included Hospice Care ordered on 4/18/23. A review of the Care Plan included a focus that included Resident #51's wishes for the Hospice services to complement the care at the facility which was initiated on 4/20.23, and the need due to Terminal/End stage disease, initiated on 4/20/23. A review of the interventions included the following: -Monitor for daily comfort/pain, call Physician as needed or recommended by Hospice for treatment with medications or alternative therapy, initiated on 4/20/23. -Facilitate hospice visits, initiated on 4/20/23. A review of the Progress Notes (PN) revealed a late entry dated 8/30/23, Licensed Practical Nurse#1 (LPN #1) documented, the Certified Nursing Assistant (CNA) was attending to the resident called the nurse's attention to a skin tear observed to the resident Left lower arm MD and family member made aware. A review of the [Company name redacted] Hospice communication dated 7/31/23, record included the following: - Resident's Name and Resident Number - Facility Name - Request for Recommendations made by - Resident's diagnosis - Current Treatment Regimen - Name of Symptoms - Recommendations - Recommendations made by - Date and time - Signature - Recommendation received by with the nurse's signature. On 9/22/23 at 11:17 AM, during an interview with the surveyor, LPN #2 assigned to Resident #51, stated the hospice nurse visited every week and assessed the resident once a week. The hospice nurse would speak with the nurses on duty and used the [company name redacted] hospice communication record paper (HCR). The HCR was placed within the Resident's paper medical record. At that time, the surveyor and LPN #2 reviewed the paper medical record for Resident #51. The surveyor asked LPN #2 why there were no HCR on the paper medical record for August and September 2023. The LPN stated she did not know. At that time, during an interview with the surveyor, the LPN/ Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) informed the surveyor that the expectation was that hospice would take over services for the resident and ensure the resident was comfortable. The facility assisted in the care for the resident. The nurses from hospice came once a week and communicated with us [the nurses] and documented the resident's needs. At that time, the LPN/ADON/IP informed the surveyor that the Unit Manager who was on vacation, was in-charge of ensuring that the hospice nurse left a documentation for the nurses. The LPN/ADON/IP acknowledged that without the HCR she could not be certain that the hospice nurse had visited to assess the resident's needs. On 9/25/23 at 10:36 AM, during a meeting with the surveyors, the surveyor informed the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) regarding the concern of the missing communication records from Hospice for August and September 2023. At that time, the DON informed the surveyors that the expectation was that the hospice nurse would see the resident once or twice a weeks, speak with the nurses, assess the resident and document within their software and provide the facility a copy. The Nurses were expected to document in the PN, the interaction with the hospice nurse, and what was communicated to them by the hospice nurse. At that time, the DON informed the surveyors that the Unit Manager responsible for ensuring that the HCR was sent to the facility for Resident #51. It should have been in the chart. On 9/27/23 at 01:45 PM during a meeting with the surveyor and LNHA, the DON confirmed no additional documents were available for review. A review of the facility provided document Hospice Services revised 3/29/23, included under Procedure section 4. During their time on Hospice Services, the Director of Social Services acts as the liaison between the resident, their representative, the facility and the Hospice agency and ensures Care Coordination. A review of the facility provided Hospice Services Agreement dated 10/01/2007, included under section IV. Records subsection 4.1 Preparation and Contents Nursing Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice Patient receiving services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. NJAC: 8:39-35.2(d)(5)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify a resident and offer a subsequent pneumococcal vaccine and b) revise the facility pneumococcal vaccine policy to reflect the current Pneumococcal vaccination guidelines in accordance with the CDC's (Centers for Disease Control and Prevention) guidelines for one (1) of five (5) residents, (Resident #14) reviewed for immunization. This deficient and was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: For adults who only received the Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23) regardless of risk and condition, should received one (1) dose of Pneumococcal conjugate vaccine (PCV 15 or PCV20) at least one year after the most recent PPSV23. On 9/21/23 at 9:53 AM, the surveyor observed Resident #14 in the patio, light his/her cigarette and began smoking. The surveyor reviewed the medical records for Resident #14. The resident's admission Record (an admission summary) reflected that Resident #14 was admitted to the facility with diagnoses that included but were not limited to type 1 diabetes mellitus without complications (high blood sugar) , multiple sclerosis (a progressive neurological disease involving damage to nerve cells of the brain and spinal cord), chronic obstructive disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). According to the most recent annual Minimum Data Set, (aMDS), an assessment tool used to facilitate the management of care dated 8/10/23, with a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident was cognitively intact. Further review of the aMDS section O. 0300 Pneumococcal Vaccine revealed 1 the resident's Pneumococcal Vaccination was up to date. A review of the resident's Pneumococcal Vaccination record indicated the resident received a Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23) six years ago when the resident was less than [AGE] years of age. The immunization record did not show a subsequent immunization for Pneumococcal was offered. On 9/22/23 at 11:44 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN)/ Assistant Director of Nursing/ Infection Preventionist stated she tracked the resident's immunization. On 9/22/23 at 12:34 PM, during a follow up interview with the surveyor, the LPN/ADON/IP stated she could not locate the Pneumococcal tracking form she had. If it is not documented within the electronic medical record, under immunization, it was missed. On 9/25/23 at 10:36 AM, during a meeting with the surveyors, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the surveillance of Resident #14's Pneumococcal vaccination, the resident's missed subsequent Pneumococcal vaccination that should have been administered one year after the first PPSV23, (received 6 years ago) and the concern regarding the facility policy. At that time, the DON stated, We follow CDC guideline, and the Resident should have had another dose. On 9/25/23 at 11:43 AM, during a meeting with the surveyors, the LPN/ADON/IP stated the resident should have received another vaccination. Moving forward we would follow the guideline in a timely manner. The LPN/ ADON/ IP acknowledged that the immunization surveillance was inaccurate. A review of an undated facility provided policy Pneumococcal Vaccination included: Purpose, all residents are provided the opportunity and encouraged to receive Pneumococcal vaccinations. Under General Information: Pneumococcal vaccine is given only one time. A review of another undated facility provided policy Pneumococcal Vaccination included: Policy, it is the policy of this facility to document evidence of annual vaccination against Pneumococcal disease for all residents who are [AGE] years of age or older in accordance with the recommendations of the advisory committee on immunization practices of the Center for Disease Control most recent to the time of vaccination unless such vaccination is medically contraindicated, or the resident has refused offer of the vaccine . On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. NJAC 8:39-19.4 (a) (i)

Based on interviews and review of other facility documentation, it was determined that the facility failed to ensure the facility staff had the mandatory behavioral health training for two (2) of the five (5) Certified Nursing Assistants (CNA #3 and CNA #5) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files within a year according to their date of hire. A review of the facility form, Continuing Education Record for 2022 to 2023 revealed the log did not include the mandated behavioral health education training for CNA#3 and #5. On 9/27/23 at 12:06 PM, during an interview with the surveyor, the Licensed Practical Nurse / Assistant Director of Nursing (ADON) Infection Preventionist /Education Co-Ordinator (EC) stated she received an informal training from the previous ADON. At that time, the surveyor and the EC reviewed the Continuing Education Record for the five (5) random CNAs. The EC opened a binder an showed the surveyor an In-Service (continuing education) attendance sign-in sheet for Caring for Combative and Confused Residents, October 2022. At that time, the EC confirmed with the surveyor that the signatures for CNA #3 and CNA #5 were missing. At that time, the EC stated they were using an electronic education module on-line but had since switched to paper. The EC stated she distributed the invites to the staff and the employee was able to log into the classroom under an indiscernible name or email. For those who attended the in-service who were not using their real name or last name, we had difficulty correlating which staff attended and received the in-service. It made it difficult to track. It was not effective. At that time the EC confirmed to the surveyor that she was unable to provide documentation that CNA #3 and CNA #5 received the in-service. On 9/27/23 at 01:4 PM, during a meeting with the surveyors, the Licensed Home Nursing Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the missing in-services for the CNAs. On 9/28/23 at 11:32 AM, during a meeting with the surveyors and the DON, the LNHA stated moving forward we added the behavioral health training and Quality Assurance and Performance Improvement (QAPI) program. No additional information was provided. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. NJAC 8:39-9.3(2), Appendix B XI-5

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to treat all residents in a dignified manner. This deficient practice occurred for two (2) of four (4) residents reviewed for dignity (Resident #14 and #67) and was evidenced by the following: On 9/20/23 at 10:25 AM, the surveyor met with Residents #8, #14, #27, and #67 for the Resident Council meeting (RCm) in a closed-door meeting. During the RCm, the surveyor followed the probes (the process of asking questions and examining facts in a situation) in the survey process, in question #18 for if resident rights were being respected in a dignified manner, Residents #14 and #67 both claimed they were not. On that same date and time, both residents informed the surveyor that staff at times do not knock before entering their room. Resident #14 stated that he/she was unable to remember the name of the staff and that it happened a few times on both morning and afternoon shifts. At that time, a staff wearing a green scrub (the sanitary clothing worn by physicians, nurses, and other workers involved in patient care) entered the door, walked straight through the room without notifying the residents and the surveyor of the staff purpose. The surveyor greeted the staff, the staff did not respond, and later on the staff left after going to another room that was inside the room where the RCm was being conducted. Then, Resident #14 stated that the staff who entered the room was a nurse and the same staff the resident was talking about who entered the resident's room without knocking. Resident #14 further stated I remembered her (the nurse), but was unable to remember the name. Furthermore, at that same time, during the RCm, another staff entered the room without first knocking and did not explain the purpose of why she entered the room. The Recreation Aide (RA) stated that she works in the activity department and wanted to get an activity supply after the surveyor's inquiry, and then the RA left. On 9/20/23 at 11:07 AM, after the RCm ended, at the door was the Activity Director (AD). The surveyor notified the AD of the above concerns regarding the RA who did not knock prior to entering a closed room meeting, and the AD provided the RA's name. On that same date and time, the Director of Nursing (DON) joined the AD. The surveyor notified the DON of the same concern and the surveyor asked the DON the name of the nurse who did not knock prior to entering the closed-door meeting room. The DON stated that she will get back to the surveyor. On 9/20/23 at 11:22 AM, the surveyor went to the East wing unit and found the nurse who entered the room during the RCm. The Licensed Practical Nurse (LPN) acknowledged that she was the nurse who did not knock before entering the closed-door meeting room. The LPN stated that when she saw there was a meeting ongoing in the room she thought that it was just a regular meeting within the facility of residents and staff and she did not realize that it was the surveyor who was inside the room not until she was inside the room already. At that time, the LPN informed the surveyor that she went inside the room to talk to the therapist (Rehabilitation staff) regarding her one resident. The LPN further stated I'm sorry, and that she realized afterward what she did, and that she should have knocked first before entering the room. A review of Resident #14's most recent annual Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/10/23, showed in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that resident's cognitive status was intact. A review of Resident #67's aMDS with an ARD of 9/07/23 in Section C a BIMS score of 15 which reflected that the resident's cognition was intact. On 9/22/23 at 10:07 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON, and the surveyor notified the facility management of the above findings. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA stated that the staff should have knocked first and waited to be accepted to enter, and explain what they were supposed to do, and that's our standard practice. A review of the facility's Resident Rights Policy that was provided by the LNHA, with a revised dated August 2009 included that employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: #3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. NJAC 8:39-4.1 (a)(12)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint# NJ00166296 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in a) one (1) of three (3) residents, (Resident #142) reviewed for environment concerns, b) the dining, and c) the laundry area observed and reviewed for a clean, comfortable, and homelike environment of residents. This deficient practice was evidenced by the following: 1. The surveyor reviewed Resident #142's medical records. The admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to chronic multifocal osteomyelitis (a disease that causes pain and damage in bones due to inflammation) right femur (right thigh bone), muscle weakness, anemia unspecified (when blood produces a lower-than-normal amount of healthy red blood cells), other abnormalities of gait and mobility. The admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/02/23 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of the 8/07/23 at 10:39 AM phone interview of another surveyor with the resident's Responsible Party (RP) revealed that according to the RP (also known as the caller), the resident's room was dusty, dirty, looked like not been cleaned in weeks, the air conditioner blows dust, and sheets not changed. The RP further stated that on 8/06/23 found clothes with feces in the corner of the bathroom and per RP according to Resident #142, they were there for two days. According to the Census information in the electronic medical records, the resident was in the following rooms during resident's stay in the facility: West Wing 1st Floor 24-2 Semi-Private West Wing 1st Floor 2-2 Semi-Private West Wing 1st Floor 6-1 Semi-Private A review of the provided folder of Pest Control Log (PCL) by the Licensed Nursing Home Administrator (LNHA) included invoice#430427 for a work date of 9/15/23; service description: pest-weekly service; general comments/instructions: Inspected areas on the first floor; treated rooms included room [ROOM NUMBER] as a continued preventative all baseboard heater vents in hallways were treated for roach activity. Recommend continued sanitation practices in the facility. On 9/19/23 at 10:46 AM, the surveyor and the Director of Nursing (DON) toured the [NAME] wing unit and entered room [ROOM NUMBER], there were no residents in the room at that time and the DON stated that the residents were in the activity. Upon entry, both the surveyor and the DON observed the blackish substances in the flooring edges around the door, bed one (a bed near the door) and bed two (a bed near the window) cork boards and overhead lights checked by the DON with use of her bare hands and observed an accumulation of dust. The DON stated that it should have been cleaned. Then both the surveyor and the DON went inside the shared toilet room and observed that the tissue holder was broken and no tissue paper. The DON further stated that she would have it fixed. According to the above information, this was the previous room of Resident #142. On 9/19/23 at 10:51 AM, the surveyor and the DON went to room two (2) and the two current residents were not in the room. Both the surveyor and the DON observed there was high dusting in both beds in their cork boards where the activity calendars were posted and the overbed lights. The DON confirmed the high dusting by DON touching the surfaces with her hands and noted dust accumulation. room [ROOM NUMBER] was the previous room of Resident#142. The DON stated that it should have been cleaned. On 9/19/23 at 10:53 AM, the surveyor and the DON went to room six (6) and both observed that the room was closed. The DON informed the surveyor that there were no residents in room [ROOM NUMBER] which was why it was closed, then the surveyor and the DON entered room [ROOM NUMBER] and there were two made beds (bed one and bed two), and there was an extra bed with no mattress. The surveyor asked the DON if that was appropriate to store an extra bed inside a clean room. The DON stated that it was okay to store an extra bed inside the room and that it would be removed once admission came in. On that same date and time, both the surveyor and the DON observed the adjoined toilet room between rooms 5 (five) and 6 (six). There was a broken bedpan with a minimal amount of water that was on the floor with no identification to whom the used bedpan was. The DON picked up the bedpan from the floor and the DON stated that it should not be there. There was also a urinal hung on the handrail, the used urinal had a yellow colored substance on the bottom part of the urinal and the DON stated that she did not know who was using the urinal and that it should not be there. The toilet holder was broken, the DON attempted to put the toilet paper but it would not hold. 2. On 9/19/23 at 10:38 AM, the surveyor toured the dining area. There were 16 residents and five (5) facility staff assisting the residents with activity. The surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN). The MDSC/RN informed the surveyor that the area was called the Recreation and Dining Area. Both the surveyor and the MDSC/RN observed the back wall of the dining area with scattered multiple black and brownish substances from the lower part to the top of the ceiling wall. There was a wall painting of a tree and a piano near the back of the wall. Next to the piano area were two vending machines (one machine for food/snacks and the other vending machine for drinks soda/water) at the back and bottom part were scattered papers, an empty carton of Ensure milk with a straw inside, round shape reddish candy, a coin, socket screwdriver, scattered accumulation of dust. Next to the two vending machines was the suction machine covered with plastic. The plastic covering of the suction machine had scattered holes and with accumulation of dust. The center area above the ceiling of the dining area was three (3) exhaust fans with dust accumulation. The three exhaust fans were in used. At that same time, the MDSC/RN confirmed the above findings and stated that it should have been cleaned. On 9/19/23 at 10:43 AM, the surveyor and the DON observed the Soiled Utility room in the [NAME] wing, the entrance flooring with blackish substances around the area edges and the DON confirmed that it should have been cleaned. On 9/21/23 at 8:47 AM, the LNHA stated that he was aware of the surveyor's concerns regarding facility cleanliness and environmental issues. Further review of the PCL, included invoice#426634 for a work date of 8/02/23; service description: pest-weekly service; general comments/instructions: Followed up on rooms completed in [NAME] wing rooms 24 to 33 for roach activity. Recommend cleaning each room thoroughly. Treated day room behind the piano for roaches. Treated bathrooms on the East and [NAME] side. 3. On 9/22/23 at 8:21 AM, the surveyor toured the Laundry area and observed Housekeeper#1 (HK#1), HK#2, HK#3, and Laundry Staff (LS). HK#1 stated that she will call the Housekeeping Director (HD) to assist the surveyor with the Laundry tour. HK#1 further stated that since the breakfast trays were in the units, housekeepers were in the laundry area to help in folding. Upon entry to the Laundry area there was a metal rack of donated clothes not covered, a table with folded blankets, a box of gloves, a plastic bottle of soda with below half liquid content, paper, and rolled plastic bags, across the table was another table with multiple socks on top which HK#3 putting them together and above the table where multiple socks was a hanging electric fan in use with surrounded accumulation of dust in the metal parts of the fan. There were 3 dryers not in use at that time. On 9/22/23 at 8:24 AM, the HD entered the laundry area and informed the surveyor in the presence of three housekeepers and LS that she started working in the facility for four weeks. The surveyor and the HD both observed the hanging electric fan in use with accumulation of dust and below was a folding table with multiple different clean socks. The surveyor asked the HD about the electric fan in use what was around the metal parts of the fan and how long she thinks it was not cleaned, the HD stated that it was dust and probably, a week it was not clean. The HD further stated that she would ask the [NAME] who was responsible for cleaning the fan to clean it. The HD stated that those socks were considered clean and being folded and that the donation clothes in the metal racks were considered clean as well. On that same date and time, the surveyor and the HD then went to the three metal racks near the table of folded blankets wherein on top of the metal rack was a plastic food container, a personal phone next to clean folded towels, in the middle of two metal racks was a feather duster touching the clean folded blankets. On the last metal rack on top were two plastic divider curtain which were dirty accumulation of dust and black and brown substances that was tucked between clean folded privacy curtain. The HD stated that the personal phone should not be placed in the clean folded towels, the feather duster used for cleaning should not be near the clean folded blankets and any other clean supplies, and the plastic divider curtain which will be replaced soon awaiting for replacement should not be tucked in a clean privacy curtain for residents due to contamination and infection control. At the same time, the surveyor also asked the HD to check the metal racks for cleanliness and the HD swiped her fingers on top of the metal rack for cleaned folded blankets and fitted sheets and informed the surveyor that there was high dusting that should have been cleaned. The HD also stated that she would ask the LS to rewashed the contaminated supplies and she educated the housekeepers and the LS regarding personal phones and personal soda not being placed on the tables used for folding clean linens, towels, socks, blankets, and fitted sheets as well as cleaning equipment and supplies away from cleaned supplies. Furthermore, the HD explained to the surveyor that the 1st room was considered a clean area where the three dryers were located, and the next room in between the plastic divider curtain was considered the dirty room where the two washers were located. The HD confirmed that the plastic curtain divider had multiple scattered black and brown substances and accumulation of dust should have been cleaned. On 9/22/23 at 8:42 AM, the surveyor observed the shared toilet room of rooms five (5) and six (6), and the toilet paper dispenser was not fixed, the metal part was apart. On 9/22/23 at 8:47 AM, the surveyor observed the shared toilet room of rooms [ROOM NUMBERS], the toilet paper dispenser was not fixed and missing a middle part that would hold the tissue paper. At that time, tissue paper was placed on top of the handrail of the toilet seat. On 9/22/23 at 8:49 AM, the surveyor, DON, and the Maintenance Director both went to the shared toilet of rooms [ROOM NUMBERS], there were no residents in the rooms at that time. Both the surveyor and the facility management observed that there was a missing part on the toilet dispenser. The surveyor also notified the facility management that it was the same in the shared toilet room of rooms [ROOM NUMBERS] and the Maintenance Director stated that he would be back to get the missing part replacement and will fix the one in rooms [ROOM NUMBERS]. On 9/22/23 at 10:07 AM, the survey team met with the LNHA and the DON and were made aware of the above findings. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA informed the surveyor that rooms in the [NAME] wing (rooms 2, 3, 5, 6, and 24) were immediately cleaned after the surveyor's inquiry. The LNHA acknowledged the high dusting and stated that the tissue holders were replaced immediately. He further stated that he acknowledged the concerns about environmental issues that were brought out by the surveyor during the environmental tour in the dining area, resident rooms, and laundry area. A review of the undated Housekeeping Policy that was provided by the LNHA included that it is the policy of this facility to provide and maintain a safe, clean, and homelike environment for residents. All equipment and environmental surfaces shall be clean to sight and touch. All toilets and bathrooms shall be kept clean to sight and touch, in good repair, and free of odors. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services. The facility management did not provide additional information and did not refute findings. NJAC 8:39-31.2 (e), 31.4(a)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/19/2023 at 1:07 PM, in the presence of the survey team, the surveyor asked the LNHA to confirm that the requested reportable to the State Agency (SA) was submitted to the team its entirety. At that time, LNHA stated he would have to confirm with nursing. The LNHA stated that the investigation and reportable were in one sheet and section three (3) was the conclusion. Once a reportable event occurred, we (the LNHA, nursing and social worker) investigated, and interviewed all parties. The LNHA stated that the SA form AAS-45 was used to document the information gathered from the investigation, interviews, and conclusion. The witnesses, when applicable would write their statement on a piece of paper. The surveyor reviewed the Reportable Event Record/Report form AAS-45 (a facility reported event/incident; FRE/FRI) for Resident #143 which included the following: Today's Date: 8/14/23 Date of Event 8/12/23 Time of Event 11:30 PM Was this a significant event? No Was significant event called in? Yes, 8/14/23 at 2:20 PM Location of Incident: Facility enclosed patio Type of Incident: Staff to Resident Abuse 1) On 8/14/23, Resident #143 reported that on 8/12/23 at approximately 11:30 PM, [he/she] was talked to rudely by staff. 2) Prior to the event, was a plan of care developed that addressed this issue, and were planned interventions in place when the event occurred? Not Applicable 3) What interventions were implemented after the incident/event? . The employee was removed off the schedule. the physician and psych were notified of the event. administration reviewed the policy with Resident#143 about going outdoors after hours. during our investigation, it was noted that Resident #143 was observed sitting on the ground on the enclosed patio with legs crossed looking for used cigarette butts. the staff asked [the resident] to stop and return indoors because it was late. [The resident] began to yell and curse at him/her. After a short while, he/she was eventually able to coax [the resident] to their room, despite objections. Abuse in this case was found to be unsubstantiated . The surveyor reviewed the facility provided Grievance log for August 2023, which did not include the FRE for Resident #143. The surveyor reviewed the medical records for Resident #143. A review of the resident's AR reflected that Resident #143 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of supraglottis (cancer above the true vocal cords, emphysema (a lung condition that causes shortness of breath) , undifferentiated schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), dysphagia (swallowing disorder) According to the admission MDS dated [DATE], Resident #143 was documented with a BIMS score of 15 out of 15, indicated that resident was cognitively intact. Further review of the MDS section E Behavior revealed the resident was not delusional and section N revealed the resident received antipsychotic, and antianxiety medications. On 9/21/23 at 11:31 AM, during a meeting with the surveyors, and the DON the LNHA stated he was the abuse coordinator since 7/31/23, when he started with the facility. The LNHA explained the process for allegation of abuse. At that time, the LNHA stated that allegations were documented into the grievance log or risk management report. The LNHA further clarified that grievance forms, complaints, and missing items were documented into the grievance log. The Social Worker (SW) kept the grievance forms and the grievance log. The grievance log was checked by the LNHA every morning and discussed during the morning and afternoon meeting to bring awareness to everyone. At that time, the DON stated the Social Worker would conduct interviews and write a statement that is not on the electronic file. After the whole investigation the SA and the Ombudsman are notified. After the conclusion whether substantiated or not we do not assign the same Certified Nursing Assistant CNA/or staff to the same resident to prevent further issues. At that time, the LNHA stated for reported events/incident (FRE/FRI), the SA form AAS-45 is utilized. He further stated that the unreported events and if we obtain a statement, it would be on the grievance form which the SW kept. The LNHA informed the surveyor that She is the end person of the reporting process. The LNHA further stated that all staff can initiate the reporting process. On 9/21/23 at 12:46 PM, during a follow up interview with the surveyors, the LNHA and the DON stated the resident concern form was used to track all concerns with residents, family and other types. The record was important to track for trend issues and concerns. The trends were tracked by the department heads who also reported during our morning and afternoon meetings. At that time, the surveyor asked the LNHA how grievances were identified and tracked for trend since Resident #143's grievance was not documented on the grievance log. The LNHA stated we do not have a way to track the trend of grievances. On 9/22/23 at 10:09 AM, during a meeting with the survey team, LNHA and DON, the surveyor discussed the concerns regarding the facilities process failure of receiving and tracking the trend for grievances. On 9/25/23 at 10:56 AM, during a meeting with the survey team, and the DON, the LNHA stated after the surveyor inquiry, they added Resident #143' a information to the grievance log. The LNHA stated their process was that when a concern was brought to the attention of a facility representative, we then would log the information into the grievance log. At that time, the LNHA acknowledged the Resident #143's grievance regarding a staff to resident abuse should have been record into the grievance log for trend tracking. No further information was provided. A review of the facility provided policy Resident Grievance/Complaint Policy included: Policy Statement; Any resident his/her representatives (sponsor), interested family member or advocate may file a grievance/complaint concerning his/her treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of reprisal in any forms. Procedure: 1. Obtain a complaint form from the nurse's station or social services office. A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 3/18/23, included the following: Prevention 3. Encourage residents, families and staff to report concerns, incidents and grievances without the fear of retribution and provide feedback regarding the concerns that have been expressed. Reporting 1. Any witnessed, alleged, or suspected violations involving mistreatment, neglect or abuse, .MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE'S SUPERVISOR. 2. The supervisor must immediately notify the Administrator and/or the Director of Nursing. 3. Abuse allegations .will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or the Director of Nursing including but not limited to local law enforcement agencies, NJDOH, and NJ Ombudsman in compliance with regulatory requirements. 4. Reports must be submitted in writing, which may include incident report, employee statement, grievance/concern form, or other written documentation . 7. Upon receiving reports of abuse .the Charge Nurse and/or Nursing Supervisor shall immediately examine and interview the resident. 8. The information and examination will be recorded in the resident's medical record . 18. Appropriate agencies will be contacted by telephone to report instances of abuse immediately, including but not limited to NJDOH, the local police, and the Office of the Ombudsman. 19. A written report will follow as required by the reporting agency. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services. The facility management did not provide additional information and did not refute findings. NJAC 8:39-4.1(a)(35);13.2(c) Complaints: #NJ00164042, # NJ00166566, #NJ00165848, #NJ00166567 Based on observation, interview, and review of pertinent documents, the facility failed to ensure that the method for filing a grievance was consistent with the facility's practice and policy. This deficient practice was identified for five (5) of five (5) residents, (Residents #10, #13, #56, #82, and #143) reviewed. This deficient practice was evidenced by the following: 1. On 8/19/23 at 11:00 AM, the surveyor asked the Licensed Nursing home administrator (LNHA) for a copy of Resident #10's grievance reports for the last five (5) months, and the LNHA stated that he will get back to the surveyor. The provided Grievance/Complaint Report (G/CR) logs showed that the months of April 2023, May 2023, and August 2023 did not reflect a grievance logged for Resident #10. A review of Complaint #NJ00164042 reflected an alleged event date on 4/28/23 showed that the resident complained about a staff member yelled and attempted to give the resident with a wrong medication. A review of Complaint #NJ00166566 reflected an alleged event on 8/15/23 showed that Resident #10 reported Resident #13 inappropriately touched Resident #82. Further review of the above G/CR logs and complaint and reported concern of Resident #10 revealed that there was no grievance documentation that was initiated on 4/28/23 and 8/15/23. The surveyor reviewed the medical records of Resident #10. The resident's admission Record (AR; or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; dementia in other diseases classified elsewhere(a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with assessment reference date (ARD) of 7/18/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated that the resident's cognitive status was intact. The surveyor reviewed the medical records of Resident #13. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic kidney disease (involves a gradual loss of kidney function), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). The cMDS with an ARD of 8/03/23 showed that the resident's BIMS score was 4 out of 15, which indicated that the resident's cognitive status was severely impaired. The surveyor reviewed the medical records of Resident #82. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; unspecified intellectual abilities (diagnosis given when an individual is over the age of five and standardized testing is unable to be completed due to physical, motor, behavioral, or mental health factors) and Type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). The quarterly MDS (qMDS) with an ARD of 9/10/23 showed that the resident's BIMS score was 4 out of 15 which reflected that the resident's cognition was severely impaired. On 9/21/23 at 11:31 AM, the survey team met with the LNHA and the Director of Nursing (DON). The surveyor asked the facility management about the process of handling grievances. The DON stated that the staff would initiate the resident complaint form and it would be given to the Unit Manager, the DON or the LNHA. On that same date and time, the LNHA stated that once the grievance was reported to New Jersey Department of Health (NJDOH), it will be followed up, and investigated. The LNHA further stated that he should be aware, and the grievance would be logged and filed for document keeping in the grievance binder. The LNHA informed the surveyors that he manages the grievance binder. 2. On 9/20/23 at 02:45 PM, the surveyor reviewed the reportable event record/report AAS-45 (FRE; Facility Reported Event) dated 7/10/23 that was provided by the facility which included the following: Today's Date: 7/10/2023 Date of Event: 7/06/2023 Time of Event: unk [unknown] Was This a Significant Event? Yes Was Significant Event Called in? Yes Date: 7/10/2023 Time: 5:15 PM Type of Incident: Staff-to-Resident Abuse Narrative: 1) Describe the event . Resident #56 allegedly told Responsible Party (RP) that while changing his/her diaper the individual described as [redacted] slapped resident's forearm. He/she said that since the alleged incident, he/she has not seeing [seen] the person again . 3) What interventions were implemented after the incident/event? . Skin assessment reveals with no redness or bruising noted and Resident #56 was assessed and does not report any pain or discomfort. Resident #56 alleged incident happened in the evening to RP but upon his/her interviewed told the nurse it happened in the day shift and stated the person did not hit him/her but was rough. After reviewing all statements and visual assessment, no bruising or discoloration noted on the patient's body, in addition to his/her discrepancies of the time of the incident and coupled with the description of the alleged perpetrators, we conclude that the allegation of abuse is unsubstantiated Review of the additional documentation attached to the report included the following: Copy of an email from Assistant Director of Nursing (ADON) to the former LNHA and the former Social Worker dated Fri. (Friday) Jul (July) 7, 2023 at 3:58 PM .Resident #56's RP will be in on Monday 7/10/2023 to discuss concerns with her/his [parent]. The surveyor reviewed the medical record for Resident #56. The AR reflected that the resident had been admitted with diagnoses which included but were not limited to wedge compression fracture of first lumbar vertebra, type 2 diabetes mellitus and cerebral infarction. The significant change in status MDS dated [DATE], reflected that the resident had a BIMS score of 10 out of 15, which indicated that the resident's cognitive status was moderately impaired. On 9/21/23 at 9:41 AM, the surveyor, in the presence of the LNHA asked the DON about Resident #56's FRE. The DON stated that she was not here at the time and that she was on vacation. She then asked the ADON to come to the office. On 9/21/23 at 9:42 AM, the surveyor interviewed the ADON in the presence of the DON regarding Resident #56's FRE. The ADON stated that Resident #56's RP was told about the alleged incident by another RP the next morning. ADON stated that the alleged event happened on 7/06/23. The surveyor asked the ADON why the allegation of abuse was not reported right away and was reported on 7/10/23. The ADON stated that she did not that information. On 9/21/23 at 11:31 AM, in the presence of the survey team, the surveyor asked the LNHA and DON what the process was for an allegation of abuse. The LNHA stated that the alleged threat is removed from the situation and that it is called in to the state and Ombudsman and then investigated [the allegation]. The surveyor then asked if there was a form that was used. The DON stated that it depended on the type of allegation but that they might fill out the AAS-45. She added that if someone alleged that they were hit by a staff member then that person would be taken off the schedule, we would talk to the resident and to staff and that the resident would have a body assessment done. The surveyor then asked if there should be documentation in the medical record and where it would be located if a family member made an allegation of abuse. The LNHA stated that it would be documented in the grievance [log]. The DON stated that if would not be in the progress notes. On 9/21/23 at 12:46 PM, in the presence of the survey team and DON, the surveyor asked the LNHA if the grievance form was used for everyone. The LNHA stated yes. He then added that the monthly log was just to track but that each incident would have a form that was filled out. The surveyor then asked why was it important to maintain a record of complaints. The LNHA stated that it was to track and see if there were any trends. A review of Resident #56's Progress Notes from 7/01/23 to 7/13/23 did not include a note that a RP alleged abuse by a staff member. A review of the facility provided Grievance Log for July 2023 did not include an allegation of abuse in regards to Resident #56. On 9/22/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the LNHA and DON the concern that Resident #56's allegation of abuse by the resident's RP was not listed as a grievance in the facility's grievance log. The LNHA stated that it seemed that the facility did not put allegations of abuse on the grievance form if it was reported to the state. On 9/27/23 at 01:38 PM, in the presence of the survey team and the DON the LNHA stated that there was no additional information but that moving forward the facility would put reportable's on the grievance form/log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaints: #NJ00164042, # NJ00166566, NJ#165848 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident abuse in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for four (4) of six (6) investigations of reportable incidents reviewed (Residents #10, #13, #56 and #82). This deficient practice was evidenced by the following: 1. On 8/19/23 at 11:00 AM, the surveyor asked the Licensed Nursing home administrator (LNHA) for a copy of Resident #10, #13 and #82 Incident/Accident and Reportable (I/A&R) reports for the last five (5) months, and the LNHA stated that he will get back to the surveyor. A review of the provided I/A&R reflected that Complaint #NJ00164042 and # NJ00166566 were both reported beyond the required timeframe as follows: The Staff to Resident allegation of abuse of Resident #10 with a Complaint # NJ00164042 reflected an alleged event date on 4/28/23 at 5:35 PM and intake receive date of 5/05/23 at 3:30 PM. The Resident to resident allegation of abuse of Resident #10 that included Resident #13 and #82, with a Complaint # NJ00166566 reflected an alleged event date on 8/15/23 at approximately 8:00 AM and intake receive date of 8/17/23 at 01:33 PM. The surveyor reviewed the medical records of Resident #10. The resident's admission Record (AR; or face sheet; admission summary) reflected that Resident #10 was admitted to the facility with diagnoses that included but not limited to; dementia in other diseases classified elsewhere (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 7/18/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated that resident's cognitive status was intact. The surveyor reviewed the medical records of Resident #13. Resident #13's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic kidney disease (involves a gradual loss of kidney function), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). The cMDS with an ARD of 8/03/23 showed that the resident's BIMS score was 4 which indicated that resident's cognitive status was severely impaired. The surveyor reviewed the medical records of Resident #82. Resident #82's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; unspecified intellectual abilities (diagnosis given when an individual is over the age of five and standardized testing is unable to be completed due to physical, motor, behavioral, or mental health factors) and type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). The quarterly MDS (qMDS) with an ARD of 9/10/23 showed that the resident's BIMS score was 4 which indicated that the resident's cognitive status was severely impaired. 2. On 9/20/23 at 02:45 PM, the surveyor reviewed the reportable event record/report AAS-45 (FRE; Facility Reported Event) dated 7/10/23 that was provided by the facility which included the following: Today's Date: 7/10/2023 Date of Event: 7/06/2023 Time of Event: unk [unknown] Was This a Significant Event? Yes Was Significant Event Called in? Yes; Date: 7/10/2023; Time: 5:15 PM; Type of Incident: Staff-to-Resident Abuse Review of the additional documentation attached to the report included the following: Body Check V 3.1 Effective date: 7/07/2023 01:41 PM. Other, specify: No visible discoloration, skin tear or scar opening or injuries. Signed date: 7/07/2023. Copy of an email from Assistant Director of Nursing (ADON) to the former LNHA and the former Social Worker dated Fri. (Friday) Jul (July) 7, 2023 at 3:58 PM .Resident #56's Responsible Party#1 (RP#1) will be in on Monday 7/10/2023 to discuss concerns with her/his [parent]. The surveyor reviewed the medical record for Resident #56. The AR reflected that the resident had been admitted with diagnoses which included but were not limited to wedge compression fracture of first lumbar vertebra (the front of the vertebral body collapses but the back does not, meaning that the bone assumes a wedge shape), type 2 Diabetes Mellitus and cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The significant change in status MDS dated [DATE], reflected that the resident had a BIMS score of 10 out of 15, which indicated the resident had mildly impaired cognition. On 9/21/23 at 9:41 AM, the surveyor, in the presence of the LNHA asked the DON about Resident #56's FRE. The DON stated that she was not here at the time and that she was on vacation. She then asked the ADON to come to the office. On 9/21/23 at 9:42 AM, the surveyor interviewed the ADON in the presence of the DON regarding Resident #56's FRE. The ADON stated that Resident #56's RP#1 was told about the alleged incident by RP#2 the next morning. ADON stated that the alleged event happened on 7/06/23. The surveyor asked the ADON why the allegation of abuse was not reported right away and was reported on 7/10/23. The ADON stated that she did not have the information. On 9/21/23 at 11:31 AM, in the presence of the survey team, the surveyor asked the LNHA and DON what the process was for an allegation of abuse. The LNHA stated that the alleged threat is removed from the situation and that it is called in to the state and Ombudsman and then the allegation was investigated. The surveyor asked if there was a timeframe that the allegation of abuse was to be reported to the NJDOH. The LNHA stated that the timeframe was right away if it was abuse, within one hour. At that same time, the surveyor then asked if there was a form that was used. The DON stated that it depended on the type of allegation but that they might fill out the AAS-45 (FRE form from NJDOH). She added that if someone alleged that they were hit by a staff member then that person would be taken off the schedule, we would talk to the resident and to staff and that the resident would have a body assessment done. The surveyor then asked if there should be documentation in the medical record and where it would be located if a family member made an allegation of abuse. The LNHA stated that it would be documented in the grievance [log]. The DON stated that it would not be in the progress notes. On 9/21/23 01:28 PM, the LNHA stated that he spoke with the former LNHA and that the former LNHA stated that he was notified on July 10, 2023 when he met with Resident #56's family and that was when the former LNHA reported the allegation to NJDOH. The LNHA stated that the ADON emailed the former LNHA and former Social Services Director on 7/07/23 that Resident #56's family would be in on 7/10/23 to discuss concerns regarding Resident #56. The surveyor then asked the LNHA if the facility was notified of the allegation of abuse on 7/10/23 then would not the skin assessment be dated 7/10/23 and not 7/07/23. The LNHA stated yes. On 9/21/23 at 3:38 PM, the surveyor reviewed the assessment tab in the electronic medical record of Resident #56 and there was only one body check dated 7/07/23 from the time period of June 2022 to present. A review of the July 2023 Medication and Treatment Administration Record did not indicate there was a weekly order for a skin observation that could have been done on 7/07/23. On 9/22/23 at 7:37 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) that signed Resident #56's skin assessment dated [DATE] regarding what situations would a skin assessment might be done. The LPN stated that if a resident had a fall and if a staff member saw something different on a resident then a skin assessment would be done. The surveyor asked if a skin assessment would be done if someone complained about someone hitting them. The LPN stated yes and that usually he would document the reason why the skin assessment was done in a note. The surveyor then asked the LPN about the reason Resident #56's skin assessment was done on 7/07/23. The LPN did not recall why the skin assessment was done that day. A review of Resident #56's Progress Notes from 7/01/23 to 7/13/23 did not include a note that indicated the reason why the skin assessment was done on 7/07/23 and did not include a note that a family member alleged abuse by a staff member. On 9/22/23 at 9:20 AM, in the presence of the LNHA and DON, the surveyor asked the ADON what time the meeting was on 7/10/23 between Resident #56's daughter and the former LNHA. The ADON stated that the meeting was at 10 am. On 9/22/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the LNHA and DON the concern that Resident #56's allegation of abuse was not reported immediately or within two hours to the NJDOH. On 9/27/23 at 01:38 PM, in the presence of the survey team and the DON, the LNHA stated that there was no additional information. The LNHA stated that from the emails the former LNHA met with the family on that Monday (7/10/23) and called it in on Monday (7/10/23). The surveyor asked if the meeting was at 10 AM then why was it not called in until 5:15 PM that evening. The LNHA did not provide any further information. A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 3/18/23, included the following: Prevention 3. Encourage residents, families and staff to report concerns, incidents and grievances without the fear of retribution and provide feedback regarding the concerns that have been expressed. Reporting 1. Any witnessed, alleged, or suspected violations involving mistreatment, neglect or abuse, .MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE'S SUPERVISOR. 2. The supervisor must immediately notify the Administrator and/or the Director of Nursing. 3. Abuse allegations .will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or the Director of Nursing including but not limited to local law enforcement agencies, NJDOH, and NJ Ombudsman in compliance with regulatory requirements. 4. Reports must be submitted in writing, which may include incident report, employee statement, grievance/concern form, or other written documentation . 7. Upon receiving reports of abuse .the Charge Nurse and/or Nursing Supervisor shall immediately examine and interview the resident. 8. The information and examination will be recorded in the resident's medical record . 18. Appropriate agencies will be contacted by telephone to report instances of abuse immediately, including but not limited to NJDOH, the local police, and the Office of the Ombudsman. 19. A written report will follow as required by the reporting agency. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services for an Exit Conference. The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-5.1(a), 13.4(c)(2)(v)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files within a year according to their date of hire. A review of the facility form, Continuing Education Record for 2022 to 2023 revealed the log did not include the mandated QAPI education training for CNA#1, #2, #3, #4, and #5. On 9/27/23 at 12:06 PM, during an interview with the surveyor, the Licensed Practical Nurse / Assistant Director of Nursing (ADON) Infection Preventionist /Education Co-Ordinator (EC) stated she received an informal training from the previous ADON. At that time, the EC stated the QAPI education training was for the director and managers. We have not done it for the CNAs, nurses or other staff. On 9/27/23 at 01:4 PM, during a meeting with the surveyors, the Licensed Home Nursing Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the missing in-services for the CNAs. On 9/28/23 at 11:32 AM, during a meeting with the surveyors and the DON, the LNHA stated moving forward we added the behavioral health training and Quality Assurance and Performance Improvement (QAPI) program. No additional information was provided. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. N.J.A.C. 8:39-9.3(2),33.1

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to store foods, maintain sanitation in a safe, and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/18/23 at 10:15 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1. In the freezer the surveyor found one opened box of breaded eggplant without an open and use by date. The interior bag holding the eggplant strips were opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 2. In the freezer the surveyor found one opened box of pancakes. The exterior of the box was labeled with 8/31 (no year was indicated). The FSD could not explain if 8/31 was a received on, used by, or open date. The interior bag holding 24 pancakes was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 3. In the freezer the surveyor found one opened box of strawberries. The exterior of the box was labeled with 4/6 delivery date (no year was indicated). The interior bag was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 4. In the freezer the surveyor found one opened box of blueberries without an open and use by date. The interior bag holding was opened and unlabeled. The interior bag was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 5. During rounds with FSD, the surveyor observed four (4) six in food pans stacked together with water droplets on the interior of each one. The FSD stated, these pans should have been dried thoroughly prior to putting them away to prevent infection and cross contamination while cooking. A review of Rose Mountain Care Center Food Storage Procedure provided by the FSD, indicated; #5) All food stored in refrigerator or freezer shall be labeled and dated and #8) Uncooked and raw animal products and fish shall be stored separately and below fruits, vegetables and other ready to eat foods. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00162232 Based on interviews and a review of the medical records (MRs) and other facility documentation on 5/3/23, it was determined that the facility staff failed to immediately report an injury of unknown origin to the facility Administration as required and according to the facility's policy for 1 of 3 sampled residents (Resident #2) reviewed for abuse. This deficient practice is evidenced by the following: 1. According to the admission Record, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: Dementia and Hypercholesterolemia. A Minimum Data Set (MDS), an assessment tool, dated 2/10/23, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition, and the resident required assistance with activities of daily living (ADLs). A review of a care plan (CP) revised on 4/25/22 included that Resident #2 was at risk for pressure ulcers. Interventions included but were not limited to: Cushion to wheelchair, monitor skin daily during care and report changes to the nurse, and weekly nursing skin assessment. The Order Summary Report (OSR) included a Physician Order (PO) for weekly skin checks. A review of the medication administration record (MAR) revealed a PO for a weekly skin check, but it was generated as unscheduled. It was clarified during a telephone interview with the Director of Nursing (DON) on 5/4/23 at 11:30 AM and 5/16/23 at 10:00 AM that nurses complete the shower weekly skin assessment form instead of documenting it in the MAR. The weekly shower skin assessment, document dated 4/17/23, signed by the Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1, revealed that Resident #2 had no skin redness, discoloration, or open areas. According to the shower schedule, the resident was scheduled for a shower twice a week. However, the facility was unable to provide additional documentation of the weekly shower assessments for April and May 2023. On 5/3/23 at 10:40 AM, the surveyor, in the presence of another surveyor and LPN #1, observed Resident #2 in bed. The surveyor observed a yellow discoloration to the left forehead, approximately 3cmx3cm. LPN #1 stated that the discoloration had always been there. The surveyor was unable to interview Resident #2 due to impaired cognition. The surveyor observed and discussed Resident #2's discoloration to the forehead with the DON and Administrator on 5/3/23 at 4:34 PM. They confirmed that they were not aware of the discoloration. On 5/4/23 at 10:59 AM post survey, the surveyor received an investigation summary document from the Administrator. The document was dated 5/3/23 completed by the Administrator which revealed a conclusion and resolution that the discoloration noted on Resident #2's left forehead was due to the resident routinely resting the forehead on the dining table. A review of a document attached to the investigation summary, titled body check, a skin assessment form dated 5/3/23, included an ecchymotic area to face. A review of a CP attached to the investigation summary, initiated on 5/3/23, included that Resident #2 had an alteration in skin integrity related to placing her forehead on the dining room table. Interventions included but were not limited to: Place cushion between forehead and table. Assess for signs/symptoms of infection and notify the physician for redness, warmth, changes in vital signs, or resident's status. During an interview with the surveyor on 5/3/23 at 1:32 PM and a telephone interview on 5/4/23 at 1:35 PM, LPN #1 explained that the skin discoloration on Resident #2's forehead had always been there, and he was unable to remember when he first noticed it. LPN #1 further explained that he would report any injury of unknown origin to the supervisor, DON, Assistant DON (ADON), or Administration. However, LPN #1 confirmed he never reported Resident #2's skin discoloration to the administration staff because the resident was always combative and rested his/her head on the dining table; therefore, it was not an injury of unknown origin. During a telephone interview with the surveyor on 5/4/23 at 11:30 AM, the ADON stated that CNAs and nurses should report any skin alteration, such as ecchymosis, so that the administration staff could investigate further. During an interview with the surveyor on 5/3/23 at 4:34 PM and a telephone interview on 5/4/23 at 11:30 AM, and 5/16/23 at 10:00 AM, the DON stated that CNAs and nurses are expected to report any skin alteration, such as bruises, noted during skin checks to the administration staff. She further stated that nurses are required to conduct skin assessments during shower days and complete the weekly shower skin assessment. She acknowledged that the weekly shower skin assessment forms should have been completed as scheduled. Additionally, LPN #1 should have reported the skin discoloration to the administration staff to be investigated further. A review of the facility's policy titled Prohibition of Resident Abuse & Neglect dated 6/18/22, included but was not limited to: 1. Any witnessed, alleged, or suspected violations involving mistreatment .including injuries of unknown source .MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE SUPERVISOR. 2. The supervisor must immediately notify the Administrator and/or the DON. 3. Abuse Allegations (abuse .includes injuries of unknown source) will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or Director of Nursing. NJAC 8:39-9.4(f)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to: a.) report an allegation of abuse to the New Jersey Department of Health (NJDOH) and b.) failed to follow the facility policy and procedure for reporting abuse allegations. This deficient practice was identified for one of two residents (Resident #19) reviewed for abuse. The evidence was as follows: 1. On 06/11/21 at 11:25 AM, the surveyor interviewed an alert and oriented resident who wished to remain anonymous. The resident told the surveyor to speak with the resident representative of Resident #19 because the resident told him/her that he/she was hit by a Certified Nursing Aide (CNA) working at the facility. On 06/11/21 at 12:02 PM, the surveyor observed Resident #19 seated in his/her wheelchair in the main dining. The surveyor interviewed the resident and the resident yelled out, I want to go home. When the surveyor attempted to further interview the resident, the resident stared blankly at the surveyor and did not speak. The surveyor reviewed the medical record for Resident #19. Review of the resident's admission Record, dated 06/21/21, indicated that Resident #19 was admitted with diagnoses that included unspecified dementia without behavioral disturbances, paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's Minimum Data Set (MDS), an assessment tool, dated 03/15/21, indicated that Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A further review of the resident's MDS, Section E -Behavior indicated that the resident had delusions (misconceptions or beliefs that are firmly held contrary to reality) and verbal behaviors directed at others almost daily. Review of the undated, Statement and Summary, written by the Director of Nursing (DON) for Resident #19, indicated that on 05/20/21 at approximately 6:00 PM, the DON was informed by the resident's representative that the resident stated the CNA's were hitting and yelling at him/her. The Statement and Summary indicated that the resident had a history of falsely accusing staff of hurting him/her and was care planned to always have two care givers. The Statement and Summary further indicated that statements were obtained by all nursing staff, a full body assessment was performed on the resident which showed no evidence of abuse, and it was concluded that the abuse did not occur. Review of the resident's Care Plan (CP) revised on 01/9/21, indicated a focus area that the resident had a history of false accusations against staff such as stealing personal belongings and abuse. The CP further indicated that the resident was at risk for behavioral disturbances. The interventions of the residents CP indicated to report development of pain, bruises, change in mental status, activity of daily living function, appetite, or neurological status per facility guidelines. On 06/15/21 at 3:06 PM, the surveyor interviewed the DON who stated that Resident #19 was alert with periods of confusion and had a history of abuse which occurred in another nursing facility. The DON stated that she had overheard the resident say to the resident representative when she walked by, They hit me. The DON further stated that she immediately investigated and found the abuse to be unsubstantiated. The DON stated that Resident #19 representative told her that the resident made accusations of abuse frequently, was care planned for the behavior of false accusations, had care performed in pairs, so she was able to unsubstantiated the abuse quickly. The DON stated that allegations of abuse needed to be reported to the NJDOH within one hour. On 06/15/21 at 3:34 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated allegations of abuse would be reported to the NJDOH within an hour. On 06/16/21 at 9:16 AM, the surveyor conducted a telephone interview with Resident 19's resident representative who stated that he/she visited the resident often and the resident was happy at the facility. The resident representative further stated that Resident #19 had behaviors as a result of, issues that the resident had at another facility and would, go back to when he/she was previously mistreated and, will act out and say that they pushed me and this that and the other. On 06/16/21 at 10:26 AM, the surveyor interviewed the resident's regular CNA who stated the resident was alert and oriented at times and at other times the resident's cognition varied. The CNA further stated that care was always performed by two caregivers who were the same gender. On 06/16 21 at 10:31 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that if a resident told her that they were abused she would immediately report it to the DON, or nurse in charge, and the Social Worker (SW) and they would conduct an investigation. On 06/16/21 at 10:37 AM, the surveyor interviewed the facility's SW who stated that if a resident made an allegation of abuse it would be thoroughly investigated to determine the validity. The SW further stated that all allegations of abuse would be reported to the NJDOH. On 06/22/21 at 1:28 PM, the surveyor interviewed the Administrator who stated that all allegations of abuse would be reported to the NJDOH. On 06/23/21 at 10:38 AM, the surveyor conducted a follow up interview with the Administrator in the presence of the DON and survey team. The Administrator stated that if a resident had a behavior of saying that staff was hitting the resident, then it wasn't necessary to investigate or report the abuse allegation because it was a behavior that the resident had. Review of the facility's, Prohibition of Resident Abuse & Neglect Policy and Procedure dated 3/18/20 indicated in regard to reporting, Abuse Allegations (abuse, neglect, exploitation or mistreatment, includes injuries of unknown source or misappropriation of resident's property) will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or Director of Nursing including but not limited to, local law enforcement agencies, NJDOH, and NJ Ombudsman in compliance with regulatory requirements. Reports must be submitted in writing, which may include incident report, employee statement, grievance/concern form, or other written documentation. NJAC 8:39-9.4(f)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to verify or dispose of two pre-filled insulin syringes which were not labeled according to professional standards of practice. This deficient practice was identified for 1 of 2 nurses reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a 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 06/15/21 at 4:37 PM during medication administration observation, the Licensed Practical Nurse (LPN) was in the East unit hall at her medication cart. The LPN reviewed a resident's order for two insulin injections, obtained the syringes, obtained the insulin vials, cleaned the top of the insulin vial, and drew up the first insulin amount. The LPN partially engaged the safety slide of the first syringe and held it while she drew up the second insulin amount in the second syringe. The LPN partially engaged the safety slide of the second syringe. The LPN gathered supplies such as gloves and alcohol swabs and walked to the resident's room, but the resident was in the bathroom. On 06/15/21 at 4:38 PM, the LPN walked back to her medication cart in the East unit hall, opened the top drawer and placed the unlabeled syringes in the drawer. The LPN was observed gathering glucometer supplies and going to a separate resident's room to obtain a blood glucose reading. On 06/15/21 at 4:45 PM, the LPN returned to her medication cart, opened the top drawer, retrieved the two unlabeled insulin syringes, and proceeded to the resident's room. On 06/15/21 at 4:46 PM, the LPN administered the insulin one syringe at a time. When asked, the LPN stated she was able to identify the different insulins by the amount of insulin that was in the syringe. On 06/15/21 at 4:49 PM, the LPN acknowledged the syringes were not labeled and should have been. On 06/15/21 at 5:46 PM, the Director of Nursing (DON) stated the LPN should have discarded the two insulins because they were not labeled and for infection control practices. Review of the facility pharmacy, Medication Pass Observation for the LPN, dated 03/22/21 revealed the LPN was deemed competent. The Medication Pass Observation included tasks that included but were not limited to 2. medication is not pre-poured by a nurse. Review of the facility provided, Administering Medications, policy dated reviewed 11/20/20, included but was not limited to 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. NJAC 8:39-27.1(a)

Based on observation, interview, record review and other facility documents, it was determined that the facility failed to: a.) evaluate a resident who had contractures to the right hand for the appropriate interventions to prevent further decline, and b.) implement care plan (CP) interventions to address a resident's right hand contractures. This deficient practice occurred for 1 of 1 residents reviewed for range of motion (Resident #12). On 6/15/21 at 11:46 AM, the surveyor interviewed Resident #12 while the resident was lying in bed. The resident appeared to have a contracted right hand, and the surveyor observed pieces of something that was white in color and was sticking outside of the resident's right hand. The resident stated he/she could not open his/her right hand and it was due to a stoke. The resident then used his/her left hand and proceeded to pull out a frayed roll of white gauze out of his/her right hand, and showed the gauze to the surveyor. At that time, the surveyor observed that the nails were trimmed and clean on the partially opened right hand. The resident stated that he/she asked for a new piece of gauze every few days so his/her nails would not hurt his/her right palm. On 06/15/21 at 12:21 PM, the surveyor interviewed Resident #12's primary CNA. The CNA stated Resident #12 was alert and oriented. The CNA stated that the gauze roll was put in daily after cleaning the resident's hand. The surveyor reviewed the medical record for Resident #12 which revealed the following: The admission Record revealed Resident #12 had diagnoses which included major depressive disorder and hemiplegia and hemiparesis (paralyses) following cerebral infarction (stroke) affecting right dominant side. The annual minimum data set (MDS), an assessment tool, dated 03/10/21 revealed a Brief Interview for Mental Status revealed a score of 15, which indicated the resident was cognitively intact. The functional status section of the MDS revealed the resident was not ambulatory and required extensive assistance for bed mobility, personal hygiene and had an impaired range of motion on one side for the upper and lower extremity. The MDS section Prior Device Use, was blank under Orthotics/Prosthetics. The Care Plan (CP) for Resident #12 revealed a Focus initiated 12/09/20 of resident had decreased range of motion and flexibility related to generalized debility that may benefit from a restorative nursing program with a Goal initiated 12/09/20 that the resident will maintain range of motion and flexibility through the next review with a Target Date of 08/26/21. The care plan did not include the right hand contracture and the use of the gauze for the right hand contracture. The Medication Administration Record and Treatment Administration Record for May 2021 did not reveal a physician order for an orthotic device or for use of the gauze in the resident's right hand. On 06/15/21 at 2:36 PM, the surveyor interviewed the assistant director of nursing (ADON), who also administered medications to Resident #12 on the same day. The surveyor inquired about use of the gauze roll and ADON stated the CNA informed her today that Resident #12 had a piece of gauze in the right hand and although she had seen the resident a few times that day, she was filling in and was unaware of the gauze in the resident's right hand. The ADON stated after she was made aware of the gauze in the resident's hand she requested therapy to see the resident. The ADON stated that the gauze was not provided to Resident #12 by therapy and could not provide further details to why the resident had the gauze in the right hand. At 2:42 PM, the director of rehabilitation (DOR) joined the interview and stated to the surveyor that therapy was going to evaluate the resident for the right hand. The DOR stated she observed that the resident's right hand was contracted. The surveyor inquired to the ADON regarding if Resident #12 had a CP for the right hand contracture. At that time the ADON reviewed Resident #12's CP with the surveyor and stated there was no CP for the right hand contracture. The surveyor inquired to the DOR if gauze was a typical intervention for a contracted hand and the DOR stated we don't use gauze. The ADON stated if Resident #12 was given gauze to use, there should have been a physician order and it should have been included in the resident's CP. The ADON provided the surveyor with two rehabilitation screening forms for Resident #12, dated 09/09/20, and 12/02/20 and the ADON indicated they were from the former rehabilitation company. Both forms revealed Resident #12 had a right upper extremity/lower extremity contracture and the resident refused to wear splints. The DOR and ADON could not offer the surveyor information regarding the refusal of the splints or if any alternate interventions were considered, or if the resident had a follow-up rehabilitation screen since 12/02/20 . On 06/22/21 at 10:45 AM, the surveyor reviewed a Multidisciplinary Therapy Screen (MTS) for Resident #12, dated 06/15/21. The MTS revealed Resident #12 was evaluated by the Occupational Therapist (OT) for right hand contractures to promote proper hand positioning. Resident #12 was issued a therapy carrot to promote proper hand positioning and hand hygiene, and it was recommended for Resident #12 to wear at all times except for hygiene and bathing. At that time the surveyor conducted a telephone interview with the OT who completed the MTS for Resident #12 on 06/15/21. The OT stated he was asked to screen Resident #12 because the resident had a contracture to the right hand. He stated the hand was very contracted. The OT stated he recommended a carrot for the resident to wear, which was an orthotic device. He stated the carrot was chosen because it promoted hygiene and it was graduated. The OT stated a gauze roll was not a good choice for hand hygiene purposes and if there were concerns with the resident's nails and the potential for skin breakdown. The OT stated the carrot may help prevent further contracture of Resident #12's hand. The OT stated gauze was not considered an orthotic device. The Care Plans - Comprehensive Policy, revised December 2010 revealed a Policy Statement, individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed. Each comprehensive care plan is designed to, a. incorporate identified problem areas, f. aid in preventing or reducing declines in the resident's functional status and/or functional levels . The undated Therapy Evaluation and Referral Policy revealed the Purpose was to ensure a collaborative, interdisciplinary approach to the coordination of patient care and planning to meet care goals and achieve optimal outcomes . NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to provide consistent suprapubic catheter (s/p) (permits direct urinary drainage from the bladder through the lower abdominal wall from a surgically fashioned opening located just above the pubic symphysis) site care to aide in the prevention of infection for 1 of 1 residents reviewed for a catheter (Resident #25). The deficient practice was evidenced by the following: The admission Record for Resident #25 revealed the resident had diagnoses that included, but were not limited to, sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood) and neuromuscular dysfunction of the bladder (bladder dysfunction caused by neurologic damage). The quarterly Minimum Data Set, an assessment tool, dated 03/16/21, indicated Resident #25 had a moderately impaired cognition, required total care with all aspects of activities of daily living and had an indwelling urinary catheter. On 06/14/21 at 11:46 AM the surveyor observed Resident #25 in bed with a urinary drainage tube and drainage bag (collects urine) inside of a black privacy bag and was hanging on the bottom of the bed frame below the level of the Resident's bladder. The resident was unable to be interviewed due to having a decreased cognition. Review of the Treatment Administration Record (TAR) indicated that Resident #25 had a s/p catheter, however there was no evidence that s/p catheter site care was being performed. On 06/15/21 at 9:21 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that Resident #25 had a s/p catheter. The LPN stated that she cleaned Resident #25's s/p catheter site with normal saline solution (NSS) when she provided care to the resident but stated there was not a physician's order to perform the treatment to the s/p catheter. She further stated that she did not know what the policy was for s/p catheter care but she knew that the s/p tube was changed monthly by the urologist. On 06/15/21 at 9:35 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she was not aware of a specific policy for s/p catheter care. She further stated as a nursing judgement the s/p tube site should be cleansed daily with NSS to prevent the site from becoming infected. She further stated that it was the responsibility of the nursing staff to obtain a physician's order for s/p catheter site care and that it should be documented in the TAR. On 06/15/21 at 10:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated that s/p catheter site care was a standard of practice and did not require a physician's order. She added that the usual practice was for nurses to cleanse the s/p catheter site with NSS every shift. When the surveyor inquired to the DON how the staff would know they had to perform this treatment to a s/p catheter site every shift, she responded that they would just know. She also stated that performing this treatment to the s/p tube site would protect the skin and it would help the nurses to assess the s/p tube site for signs and symptoms of infection, such as drainage. She added that if the nurses were performing catheter care every shift they would be able to assure that the s/p was not leaking. On 06/15/21 at 11:47 AM, in the presence of two surveyors, the LPN uncovered Resident #25's s/p tube and the site appeared clean and dry. The surveyor reviewed the Physician Order Sheet (POS) dated 12/2020, 01/2021, 02/2021, 03/2021, 04/2021, 05/2021 and 06/2021 which revealed that there were no physician orders (PO) to perform any treatments to Resident #25's s/p catheter site. A typed timeline that was provided by the DON and signed and dated 06/21/21 at 9:00 AM, indicated that Resident #25 had a diagnosis of neurogenic bladder with frequent urinary tract infections and was followed by the infectious disease (ID) medical doctor. The surveyor reviewed the lab results dated 05/03/21, which reflected that Resident #25 had a recent urinary tract infection and urine contained the bacteria Klebsiella Pneumonie Extended Spectrum Beta Lactamase (ESBL). According to the Medication Administration Record (MAR) dated 05/3/21, the resident received the antibiotic Macrobid 100 milligram (mg) one capsule every 12 hours for the treatment of a urinary tract infection (UTI) for 5 days. The Care Plan (CP) dated 12/16/2020, reflected an intervention that staff were to provide catheter care, however the intervention did not specify what type of treatment was to be performed to the s/p catheter site, how often the s/p catheter site care was to be provided or who was responsible to provide the s/p catheter site care. The DON provided the surveyor with a facility policy for s/p tubes dated 11/20/20, and according the policy, the facility was to provide for safe aseptic, removal and change of a s/p catheter to prevent infection and to maintain catheter patency. There was no indication on the policy as to what type of treatment was to be performed to the s/p catheter site, how often the s/p catheter site care was to be provided or who was responsible to provide the s/p catheter site care. The facility policy titled, Care and Management of indwelling Catheters dated 01/4/21, reflected that it was the policy of the facility that every effort will be made to maintain and prevent infection to all residents assessed and requiring an indwelling catheter. N.J.A.C. 8:39-19.4(a)5

Based on interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to provide an urgent psychiatry consult for a resident who expressed suicidal ideation. This deficient practice was identified for Resident #55, 1 of 3 residents reviewed for mood/behavior and was evidenced by the following: Review of the admission Record for Resident #55 revealed the resident had diagnoses which included, but were not limited to, cerebral infarct (necrotic tissue in the brain which resulted from a blockage or narrowing), dementia, age related osteoporosis (condition when bone strength weakens and is susceptible to fractures), right patellar fracture, and a lacerated liver. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/06/21, revealed under Section D Mood, that Resident #55 had expressed the following symptoms in half or more of 7-11 days: little interest or pleasure in doing things; feeling down, depressed, or hopeless; and trouble falling asleep. The MDS further revealed under Section A Language, that Resident #55 needed or wanted an interpreter to communicate with a doctor or health care staff and that his/her primary language was Chinese. Review of a physician's order dated 04/29/21, revealed urgent psychiatric consult for suicidal ideation, CBC (complete blood count), CMP (comprehensive metabolic panel), and UA (urinalysis) and urine culture. On 06/16/21 at 10:46 AM, the Assistant Director of Nursing (ADON) observed a physician order from 04/29/21, in the presence of the surveyor. The ADON confirmed an urgent consult for suicidal ideation was ordered for Resident #55. The ADON further stated she was not sure which practioner came into see the resident for the urgent consult and that there should have absolutely been documentation regarding the consult in Resident #55's medical record. The ADON was unable to provide the surveyor with the urgent psychiatric consult from 04/29/21. The ADON stated the prior Director of Nursing (DON) took the order and would have been the one to call the physician to obtain the urgent psychiatric consult. The ADON stated that a suicidal ideation would be important for the staff to know and the procedure would have been to keep the consult order documentd on the 24-hour report until the order was carried out. The ADON stated she had been moved to the EAST unit about 05/22/21 and at that time she reviewed all the residents to ensure all orders were correct and carried out. The ADON stated it was at that time she became aware of the emergency psychiatric consultation order that was not carried out, and immediately contacted the psychiatric practioner for Resident #55 who evaluateded the resident the same day. On 06/16/21 at 11:23 AM, in the presence of three surveyors, the facility interpreter stated Resident #55 did not get along with his/her roommate and that the physician had called the facility and said the resident was suicidal. The interpreter stated it was at that time she was called to go see the resident with the previous DON. The interpreter stated the resident told her that he/she wasn't happy with their roommate and stated, I wanted to die but did not want to go to the hospital. On 06/16/21 at 11:59 AM, the DON stated if a resident expressed suicidal ideation, the facility would immediately place the resident on observation and the physician would be made aware. The DON stated the resident would immediately have a psychiatrist evaluation or be transferred to the emergency room for a psychiatric evaluation. The DON stated this information would be documented in the medical record and that it would be important to take a suicidal ideation seriously because the resident could act on it. The DON stated the facility would require a psychiatrist or a Licensed Clinical Social Worker (LCSW) to assess the resident to determine if the resident were suicidal. On 06/16/21 at 12:37 PM, the Licensed Practical Nurse (LPN #1) stated she was the current nurse caring for the resident, the resident had moved to room they were currently in last month. LPN #1 stated Resident #55 had moved rooms because the resident stated his/her roommate was unkind and slammed the door on the resident. LPN #1 further stated Resident #55 was alert and oriented and could make his/her needs known. LPN #1 stated she remembered there was a time staff was monitoring the resident every 30 minutes because he/she wanted to hurt himself/herself and she was not taking care of the resident when the incident happened. On 06/16/21 at 1:26 PM, during a telephone interview with the survey team, the ordering physician stated Resident #55 was seen by him on the morning of 04/29/21 and stated that he/she did not want to live. The ordering physician gave an order for an urgent psychiatric consult for suicidal ideation. The ordering physician stated the resident was seen by the psychiatric practioner and that the previous DON had called him back. The ordering physician stated he did not receive a written report from the psychiatric practioner and he did not provide any details or a date. The ordering physician then stated it was verbal and that I wanted the psychiatric consult first. On 06/16/21 at 1:31 PM, during a telephone interview with the survey team, the facility's psychiatric practioner stated the facility first consulted him on 05/22/21 regarding Resident #55 having suicidal ideations. The psychiatric practioner further stated that at the time of the consult, he spoke with the resident and the (facility) team was informed that Resident #55 was having issues with his/her roommate. The psychiatric practioner stated when he saw the resident, he/she had no suicidal ideations, that the (facility) team had moved Resident #55's room, and that the resident was fine. The psychiatric practioner stated again, and confirmed, that he wasn't consulted on 04/29/21 but was notified on 05/22/21. The psychiatric practitioner stated he should have been notified immediately about the consultation for Resident #55's suicidal ideations for the resident's safety and was available at all times. On 06/17/21 at 8:57 AM, the ADON stated the process for consultations was to write the phone order, put the order on the 24-hour report for the physicians who regularly come to the facility. The ADON further stated the psychiatric practioner would come to the facility any time he was called. The ADON reviewed Resident #55's progress notes (PN) and was unable to confirm that the emergency psychiatric consultation had been completed on 04/29/21 per the physician's order. She continued to state she could not locate a note from the psychiatric practioner to confirm that Resident #55 was seen. She then, on 05/22/2021, called the psychiatric practioner and informed him of the order for consultation that was ordered on 04/29/21 for suicidal ideations. The ADON stated the nurses or the ADON were responsible for obtaining consultations. Review of the East unit Daily Census & Report Sheet (24-hour report), dated 04/29/21, 04/30/21, 05/01/2, and 05/02/21 revealed Resident #55 had been placed on report and that all three shifts had been monitoring every 30 minutes for suicidal ideations. There was no documentation of the urgent psychiatric consultation ordered for Resident #55 on 04/29/21. Review of the Psychiatric Follow-Up Form dated 05/22/21, provided by the facility, revealed met with (resident) today per request for consultation 2nd (secondary) to possible suicidal ideations, denies any distress. On 06/23/21 at 10:19 AM, the DON informed the surveyors that the facility was unable to locate any documentation that Resident #55 had an emergent psychiatric consult on 04/29/21 by a psychiatric practioner or a LCSW. The facility was unable to provide any policy and procedure for suicidal ideation emergencies but provided staff education, Mental Health Emergency, undated, which revealed if there was evidence that a person was experiencing a mental health emergency, what to do included: stay with resident-if safe to stay, alert another staff member via call bell or take resident with you to alert primary nurse, primary nurse to alert administration and PMD, PMD will direct next process. Review of the facility provided, Charting and Documentation, policy dated 11/20, revealed all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy further included but was not limited to 2. Entries may be recorded in the resident's clinical record by licensed personnel (e.g. physicians, therapists, etc.). 3. All incidents, accidents, or changes in the resident's condition must be recorded. NJAC 8:39-27.1(a)

Based on observation, interview, record review and document review it was determined that the facility failed to treat all residents in a dignified manner. This deficient practice occurred for 3 of 24 residents reviewed for dignity (Resident #281, #12 & #180) and was evidenced by the following: 1. On 06/15/21 from 4:13 PM to 4:20 PM, the surveyor observed the 3:00 PM - 11:00 PM Registered Nurse (RN) gather medications for Resident #281 while at the medication cart which was in front of the nurse's station and then entered Resident #281's room. When the surveyor and the RN arrived inside the resident's room, the surveyor observed that the resident's eyes were closed, and the head of the resident's bed was in a low position. The surveyor observed the RN touch the side of the resident's right arm and gently shake the resident to wake him/her up. The surveyor overheard the RN tell the resident to wake up because it was time to take his/her medications. The RN then stated the resident's name and asked to see the resident's name bracelet. At that time, the resident's eyes remained closed. The surveyor further observed the RN pull down the resident's sleeve to check the resident's name bracelet. As the RN pulled down the resident's sleeve to check the name bracelet, the surveyor then observed the resident's eyes open. The surveyor further observed that the resident then swatted away the RN with the resident's right hand and then the resident bean speaking in his/her primary language. The RN did not speak back to the resident in his/her primary language and then stated to the resident, in English, that it was time for the resident to take his/her medications. The RN then raised the head of the resident's bed as the resident sleepily shut his/her eyes and then the RN repeated to the resident, in English, to take his/her medications. The resident opened his/her eyes again, and used his/her hand to swat away the RN, and then started to speak loudly back to the RN in his/her primary language. The RN then looked at the surveyor and stated that the resident was refusing the medications. The RN and the surveyor exited the resident's room and the RN signed the June 2021 Electronic Medication Administration Record (eMAR) that the resident had refused the medications. On 06/15/21 at 4:36 PM, the surveyor interviewed the RN who stated that Resident #281 slept in bed most of the time during her shift. The surveyor asked the RN if she noticed the resident was ever awake at a specific time during her shift. The RN stated that the resident was normally awake during dinner time and would normally not refuse his/her medications. The RN further stated that she could have administered the medications to the resident later in the evening when she was awake. On 06/16/21 at 10:15 AM, the surveyor interviewed the resident's 7:00 AM - 3:00 PM Certified Nursing Aide (CNA) who stated that the resident was alert and oriented at times, required total assistance with care, got up out of bed every morning, and did not speak English. The CNA further stated that the resident did not refuse care for her. On 06/16/21 at 10:16 AM, the surveyor interviewed the resident's 7:00 AM - 3:00 PM Licensed Practical Nurse (LPN) who stated that the resident was alert and could make his/her needs known by saying yes or no in English, but primarily spoke a different language. The LPN stated that the resident never refused care for her and she provided care for the resident based off the resident's mood. The LPN gave the example that if the resident was not responding to her, she would get a translator so the resident would feel more comfortable. The LPN stated that she would never wake a resident up to the administer medications and would first check on the resident to see if he/she was sleeping before she prepared the medications for the resident. On 06/21/21 at 10:46 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated that if the resident was sleeping and the resident needed medications, it would be appropriate to gently wake them up. The DON further stated that if a resident refused medications due to sleeping, the nurse should have attempted to give the medications to the resident at another time. 2. On 06/15/21 at 11:36 AM, the surveyor conducted an interview with Resident #12 while the resident was lying in his/her bed. At that time a male staff knocked on Resident #12's door and proceeded to enter the resident's room without explaining the purpose of the visit or obtaining consent from the resident to enter the room. The male staff immediately proceeded to a wall by the right side of the resident's bed. Then, without first explaining to the resident what he was doing, he proceeded to remove a large calendar that was affixed to the resident's wall with a tack. The calendar was observed to have large printing and was within the resident's line of sight. The staff then placed the calendar on the chair in the resident's room. At that time, the surveyor requested the male staff to identify himself, and he identified himself as the social worker (SW). The surveyor inquired to the SW as to why he abruptly removed the calendar from the resident's wall. The SW stated he needed to remove the tacks out of the wall and he was removing them because it was a safety hazard. The surveyor inquired as to why it was a safety hazard and the SW stated I really don't know, I am doing as I have been told. He then told the resident he would be stapling the calendar to the wall and attempted to use a small stapler to staple the calendar to the wall. The calendar would not stay affixed with the staple and the SW left the calendar lying on the chair. At that time Resident #12 stated to the SW I want my calendar back, it has been the same for a long time. The surveyor observed that the resident appeared visibly upset and the Resident #12 stated I know it upset me to the surveyor. At that time, in the presence of the surveyor, Resident #12 stated to the SW that he/she didn't understand why this was happening and it was only because the state was there. Resident #12 then stated to the surveyor I have my wits about me and I am not going to hurt myself and then stated to the SW that when you remove the staples from the wall, they will fall to the floor and someone could get hurt from them. The SW stated to the resident that he would use tape to affix the calendar to the wall and then exited the room. On 06/17/21 at 11:00 AM during and interview with Resident #12 in the resident's room, the surveyor observed the calendar was not hung on the wall and was on the same chair as the prior observation on 06/15/21. The surveyor interviewed the resident regarding the calendar, while the resident was lying in bed. The Resident stated that the calendar had not been hung up. The surveyor reviewed the medical record for Resident #12 which revealed the following information. The annual minimum data set (MDS), an assessment tool, dated 03/10/21 revealed a Brief Interview for Mental Status revealed a score of 15, which indicated the resident was cognitively intact. The functional status section of the MDS revealed the resident was not ambulatory and required extensive assistance for bed mobility and personal hygiene. On 06/22/21 at 1:58 PM, in the presence of the survey team and the Director of Nursing (DON), the administrator stated that the SW should not have removed the tacks and it didn't make sense. On 06/23/21 at 10:13 AM, in the presence of the survey team and DON the administrator stated he told the SW to remove the tacks from the walls. 3. On 06/14/21 at 11:54 AM the surveyor observed the following while in the hallway between the day room and the [NAME] wing: A staff member pulled Resident #180 backwards while the resident was facing forward and awake in a recliner chair. The staff then proceeded to pull the resident backwards past five resident rooms and then entered then entered the resident's room. At that time the surveyor interviewed the staff member who pulled Resident #180 backwards, and the staff identified herself as a physical therapy assistant (PTA). The PTA stated the chair was easier to pull backwards and that was how she was taught to transport residents in the recliner chairs. On 06/22/21 at 10:08 AM the surveyor interviewed the Director of Rehabilitation (DOR). The surveyor interviewed the DOR regarding what was the proper method to transport a resident in a recliner chair. The DOR stated residents should be pushed forward, not backwards and it was not okay to pull a resident backwards in a recliner chair. The DOR stated it was not okay because the resident should be able to see where they were going. On 06/22/21 at 1:52 PM, in the presence of the survey team and administrator. The surveyor inquired if it was appropriate to pull a resident backwards in a recliner. The DON stated no, residents should not be pulled backwards as it was a dignity issue. The Resident Rights policy, dated August 2009, revealed a Policy Statement that employees shall treat all residents with kindness, respect and dignity. The Policy Interpretation and Implementation revealed residents are entitled to exercise his/her rights to assure that the resident is always treated with respect, kindness and dignity. NJAC 8:39-4.1

4.) On 06/15/21, Surveyor #3 made the following handwashing observations during medication administration on the East unit: a.) At 3:52 PM, LPN #2 was in a resident bathroom. LPN #2 turned on the sink faucet with her bare hands, wet and applied soap to her hands, then lathered her hands for 17 seconds, then rinsed her hands under running water, then dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. b.) At 3:57 PM, LPN #2 was in another resident bathroom. LPN #2 turned on the sink faucet with her bare hands, wet and applied soap to her hands, lathered her hands for 18 seconds, then rinsed her hands under running water, dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. c.) At 4:06 PM, LPN #2 was in the East unit restroom. LPN #2 turned on the sink faucet with her bare hands, wet and applied soap to her hands, lathered her hands for 16 seconds, then rinsed her hands under running water, dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. d.) At 4:21 PM, LPN #2 was at the East Unit nurse's station sink. LPN #2 turned on the sink faucet with her bare hands, wet her hands and applied soap to her hands, lathered for 11 seconds, rinsed her hands under running water, dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. e.) At 4:29 PM, LPN #2 was at the East unit nurse's station sink. LPN #2 turned on the sink faucet with her bare hands, wet her hands and applied soap to her hands, lathered for 11 seconds, rinsed her hands under running water, dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. LPN #2 went into a room and obtained a cigarette for a resident. f.) At 4:43 PM, LPN #2 was in the East unit restroom. LPN #2 turned on the sink faucet with her bare hands, wet and applied soap to her hands, lathered her hands for 16 seconds, rinsed her hands under running water, dried her hands with a paper towel and used the same paper towel to turn off the sink faucet. 5.) On 06/15/21, Surveyor #2 made the following observations during the medication administration on the East unit: a.) On 06/15/21 at 4:25 PM, LPN #2 donned gloves, picked up the glucometer with the test strip from the top of the medication cart, obtained a lancet and alcohol pad and walked to a resident's room. LPN #2 then used the glucometer to knock on the resident's door and LPN #2 then entered the room and placed the glucometer on the resident's dresser top by a coffee cup. LPN #2 ripped the alcohol pad half open exposing part of the pad and laid it down where the alcohol pad was in direct contact with the top of the dresser. The LPN #2 next used the exposed pad that was in direct contact with the dresser, to clean the resident's finger and finished obtaining the resident's blood glucose reading. LPN #2 then returned to her medication cart where she placed the glucometer directly on the top of the med cart. The surveyor then interviewed LPN #2 who stated the glucometer should have been after each use to prevent contamination. LPN #2 further stated the process for hand washing was to first open the faucet with a paper towel to prevent contamination, wet hands, apply soap and lather for at least 20 seconds, dry hands and turn off the faucet. When asked, LPN #2 stated a new paper towel was not needed to turn off the faucet. On 06/15/21 at 5:46 PM, the DON stated the process for handwashing was to turn the water on with bare hands, apply soap and lather for 20 seconds, rinse, dry with a paper towel, and use a new paper towel to turn off the faucet because the faucet was turned on with dirty hands. The DON stated the glucometer should be wiped with an appropriate disinfectant and allowed to dry before it was used on a resident and after the glucometer was used, the staff must repeat the process. The DON stated the purpose of cleaning between uses was for infection control, not contaminating others with body fluid or blood. The DON stated the process was to bring the lancet, glucometer, and alcohol pad into the resident's room; apply gloves; wipe the resident's finger with alcohol and allow to dry; use the lancet and then place used lancet into sharps; doff gloves; and wash hands. The DON stated the disinfected glucometer should be placed on a clean paper towel or a barrier and the alcohol pad should not be opened prior to use because of infection control. The DON acknowledged that the glucometer should not have been used to knock on the door and reiterated that the glucometer should have been cleaned prior to use. Review of a Hand Washing Competency Validation, dated 03/22/21 revealed that LPN #2 had been deemed competent in the task. Steps of the task included turn faucets on and adjust temperature and flow of water, wet hands and wrists under running water, apply soap and thoroughly distribute over hands, vigorously rub hands together for 20 seconds covering all surfaces of the skin, keep hands away from sides and bottom of sink, rinse hands thoroughly under running water, before turning off water, dry hands with a paper towel and discard, and use a dry paper towel to turn off faucet and discard. Review of a Glucometer Competency Checklist, dated 04/24/19 revealed LPN #2 demonstrated competency in all steps which included, but were not limited to, cleaned and understood proper maintenance of glucometer per manufacturer. Review of the following documents revealed: Handwashing/Hand Hygiene policy and procedure dated 01/22/21, revealed that hand hygiene was considered the primary means to prevent the spread of infection. 5) Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water. The procedure revealed vigorously lather hands with soap and rub them together, creating friction to all surfaces for at least 20 seconds under a moderate stream of running water, rinse hands thoroughly under running water, dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Obtaining a Fingerstick Glucose Level policy and procedure dated 11/27/20, revealed the following equipment and supplies will be necessary when performing this procedure: 3. Disinfected blood glucose meter (glucometer). Steps in the procedure included 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses and 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the facility's, undated Transmission-Based Precautions Teaching Tool revealed more then one TBP category could be used as a precautionary measure. The teaching tool indicated that with contact precautions, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon entry and discarding before exiting the patient room is done to contain pathogens. The teaching tool further indicated regarding droplet precautions, Droplet precautions are intended to prevent transmission of pathogen spread through close respiratory or mucous membrane contact with respiratory secretions. The New Jersey Department of Health Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised date 10/22/2020 included residents that were new or re-admissions from the community or other healthcare facilities should be placed in an observation area cohort for fourteen days to monitor for symptoms that might be compatible with COVID-19. The plan also included that these residents be placed on TBP with PPE which included N95 mask, eye protection, gloves, and gown. The U.S. Centers for Disease Control and Prevention (CDC) guidelines, Using Personal Protective Equipment (PPE), updated 8/19/20, included the following steps 1. Identify and gather the proper PPE; 2. Perform hand hygiene; 3. Put on isolation gown; 4. Put on N95; 5. Put on face shield or goggles; 6. Put on gloves; 7. HCP may now enter patient room. NJAC 8:39-19.4(a)(n) 2.) Surveyor #2 made the following observations during a medication administration observation on the [NAME] unit. On 06/15/21 from 4:13 PM to 4:20 PM, the Registered Nurse (RN) gathered medications, a liquid nutritional supplement, eye drops 1.5% for dry eyes, and cranberry tab 450 mg, 1 tab as a supplement. After the nurse gathered the medications, Surveyor #2 observed the RN don gloves at the medication cart which was positioned directly in front of the nurses station. The RN then used her gloved hands and touched the handle of the sink to fill up a plastic cup with water, then walked down the hallway wearing the same gloves and entered the residents room. The RN then touched the resident, touched the residents overbed table, touched the resident's bed controls to raise the residents bed, and then attempted to administer the eye drops to the resident, who then refused. The RN failed to remove her gloves and perform hand hygiene after she touched: the handle of the sink, the resident, resident's bed, over bed table, bed controls and then attempted to administer the eye drops to the resident. Review of the facility's undated, Infection Control Policy and Procedure indicated that it was the policy of the facility to adhere to basic infection control guidelines to limit and prevent the spread of infection. The purpose of the facility's, Infection Control Policy and Procedure was to comply with the Department of Health Guidelines and prevent the spread of infection and to maintain a safe, sanitary, comfortable environment. The policy and procedure indicated in regard to awareness of policies, All personnel will be trained on our infection control policies and practices upon hire and periodically and thereafter, including where to find and use pertinent procedures and equipment related to infection control. The depth of the employees training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of the RN's Hand Washing Competency Validations dated 03/22/21 and 06/15/21 indicated that the RN successfully passed both hand washing competencies. Review of the facility's, Handwashing/Hand Hygiene Policy and Procedure dated 01/22/21 indicated that employees must wash hands for at least 20 seconds using antimicrobial or non-microbial soap and water or an alcohol-based hand rub before and after contact with the resident. 3.) On 06/15/21 from 4:24 PM to 4:30 PM, Surveyor #2 observed the RN, wearing only a surgical mask then walked into a resident's room who was on TBP without first performing hand hygiene and donning appropriate PPE. Surveyor #2 then observed that there was a plastic PPE bin located directly outside of the resident's door which was stocked with PPE, such as gowns, surgical masks, N95 masks, KN95 masks, face shields, and gloves. The surveyor further observed an alcohol-based hand rub located directly on top of the plastic PPE bin. The surveyor observed signage posted on the resident's door which indicated, STOP, Droplet Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. Additional signage posted on the resident's door indicated, STOP, Contact Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. The surveyor then further observed signs posted on the resident's door which provided instructions on how to appropriately don and doff (remove) PPE. The surveyor stood outside of the resident's room and observed the RN placed a glucometer (a device used to measure blood sugar level), lancet (device used to prick the skin to draw blood), and a testing strip on the resident's over bed table. The RN then touched the resident's over bed table and proceeded to take the residents blood sugar using the glucometer. The RN then walked out of the residents room wearing the same gloves, and failed to remove the gloves and then perform hand hygiene. On 06/15/21 at 4:30 PM, the surveyor interviewed the RN prior to her having contact with another resident. The RN stated, I did not know [gender redacted] was on isolation precaution. The RN further stated that the purpose of TBP was to protect people when they cough. The RN was unable to explain the purpose, or importance of wearing PPE and for why PPE was donned prior to entering the resident's room who was on contact and droplet precautions. On 06/15/21 at 4:33 PM, the surveyor interviewed the Nursing Supervisor who stated that the appropriate PPE that was required to be donned prior to entry to a resident's room for a resident who was on contact and droplet precautions consisted of: an N95 mask, a surgical mask on top of the N95 mask, eye protection, gown, and gloves. The Nursing Supervisor further stated that the resident was on TBP due to the resident being a new admit to the facility and the resident was quarantined for 14 days due to the incubation period related to unknown exposure of the COVID-19 virus. The Nursing Supervisor was unaware of the resident's vaccination status. On 06/15/21 at 4:46 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident was not vaccinated, was still on his/her 14-day quarantine period, and had tested negative twice for COVID-19. The DON stated the RN should have donned PPE and performed hand hygiene prior to entry of the resident's room who was on TBP. Based on observation, interview, record review, and review of pertinent facility documentation it was identified the facility failed to: a.) adhere to infection control practices for hand hygiene according facility policy and the Centers for Disease Control (CDC) guidelines, b.) disinfect multi-use point of care testing equipment, and c.) properly don (put on) Personal Protective Equipment (PPE) prior to entry to a resident's room who was on Transmission-Based Precautions (TBP), according to facility policy and CDC guidelines. The deficient practice was identified during 1 of 1 resident wound care observations (Resident #63) and for 2 of 2 nurses who administered medication during the medication pass observation. This deficient practice was evidenced by the following: 1.) Surveyor #1 made the following observations during a wound care observation for Resident #63. On 06/17/21 at 11:00 AM, a Licensed Practical Nurse (LPN #1) was observed preparing a clean field and then disinfected the overbed table with disinfecting wipes. The surveyor then observed LPN #1 perform hand hygiene under running water three times at the bathroom sink. The LPN #1 first applied soap and lathered her hands for 7.76 seconds and then placed her hands under the running water. At 11:03 AM, LPN #1 performed hand hygiene for the second time. She applied soap, then lathered her hands for 4 seconds, and then placed her hands under running water. After redressing Resident #63's wound, LPN#1 went into the bathroom and washed her hands a third time. She applied soap, then lathered her hands for 4.23 seconds and then placed her hands under running water. On 06/17/21 at 11:20 AM, the surveyor interviewed LPN #1 who stated that she learned the process for hand hygiene while in school and was taught the hand hygiene procedure during the facility orientation but was not familiar with the facility's hand hygiene policy. The LPN #1 could not speak to the amount of time required to lather hands prior to placing hands under running water.