**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) discontinue a treatment order for a healed wound and b.) follow a physician's treatment order. The deficient practice was identified for 1 of 18 residents (Resident # 50) reviewed for physician orders and is evidenced by the following. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 10/22/24 at 1:30 PM, the surveyor observed Resident # 50 lying in bed alert and awake and able to make their needs known. On 10/23/24 at 1:30 PM, the surveyor reviewed the following medical records. The admission Record revealed the following diagnoses, which included but were not limited to, atherosclerotic heart disease, acute and chronic systolic congestive heart failure and essential hypertension. The Minimum Data Set assessment tool (MDS) dated [DATE] revealed the brief interview for mental status (BIMS) score was 15 of a possible 15 indicating no cognitive deficits. The October 2024 Order Summary Report included two physician's orders as follows. Clean toe web spaces well with soap and water and place gauze in each web space to wick moisture daily every day shift for moisture. Cleanse right buttock deep tissue injury (DTI) with normal saline solution (NSS) and apply foam cover daily every day shift for DTI. The October 2024 Treatment Administration Record (TAR) indicated the nurse continued to sign the treatment order daily for the right buttock up to and including on 10/23/24. The 9/21/24 Wound Assessment Report noted that the right buttock wound had resolved. On 10/23/24 at 12:10 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor. The surveyor and the RN Supervisor reviewed the resident's treatment orders which included the order for the right buttock DTI and the order for gauze placement in between toes. The RN Supervisor confirmed that nursing continued to sign the TAR daily up to and including on 10/23/24 even though the buttock wound was documented to have healed on 9/21/24. Additionally the treatment for gauze placement was signed as performed on 10/23/24. At that same time, the surveyor and the RN Supervisor went to the resident's room. The resident was interviewed and stated they were not receiving any wound treatments. The RN Supervisor inspected the resident's right buttock area and the resident's feet. The RN Supervisor confirmed there was no dressing on the right buttock or gauze placed in between the toes. On 10/23/24 at 1:20 PM, the surveyor discussed with the Director of Nursing the concerns regarding physician treatment orders. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 resident, (Resident #1) reviewed for respiratory care and services. This deficient practice was evidenced by the following: On 10/23/24 at 1:20 PM, the surveyor observed Resident #1 in his/her room seated in a geriatric chair. The resident did not respond to the surveyor. The surveyor observed an oxygen concentrator in the Resident's room, not in use. The surveyor observed a sign above the resident's bed which instructed to ensure oxygen was in use. At that time, the surveyor observed the Registered Nurse (RN) assigned to Resident #1's care entered the room and stated that the oxygen should have been on since the resident was supposed to be on continuous oxygen. The RN moved the concentrator closer to the resident's bed, plugged the concentrator into the outlet, turned it on, applied the nanal cannula tubing, set the gauge at 2.5 Liters Per Minute (lpm) and exited the resident's room. A review of Resident #1's admission Record revealed Resident #1 was admitted to the facility with diagnoses which included but were not limited to acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (a lung disease that causes permanent lung damage) and dementia. A review of Resident #1's most recent Minimum Data Set (MDS), an assessment tool, dated 9/20/24 revealed Resident #1 had a short-term and long-term memory problem and had a severe cognitive impairment. A review of the resident's individual care plan (ICP) initiated on 6/23/24 included a focus: resident may require supplemental oxygen r/t acute respiratory failure with interventions that included but were not limited to: oxygen at 2 liters via nasal cannula as needed for shortness of breath. A review of the October 2024 Order Summary Report (OSR) revealed an active physician order (PO) with an order date of 8/31//24 for Oxygen 2 lpm via NC continuously. On 10/23/24 at 1:45 PM, the surveyor observed Resident #1 in their room, seated in a geri chair with the oxygen concentrator in use and the oxygen gauge set at 2.5 lpm via nasal cannula. At that time, the surveyor asked the RN to accompany her to the resident's room. The surveyor and the RN entered Resident #1's room, and both observed the resident was wearing a nasal cannula and the oxygen concentrator was on with the gauge set at 2.5 lpm. On that same day at the same time, the surveyor and the RN reviewed the electronic medical record (EMR) for the resident's order for oxygen. The RN confirmed that the resident's PO was for 2LPM, not 2.5 LPM and acknowledged she should have followed the PO. On 10/24/24 at 1:40 PM, the surveyor observed Resident #1 in their room seated in a geriatric chair. The oxygen concentrator was off. On that same day, at that same time, the RN entered the resident's room and stated, oh no, I did it again. The RN proceeded to turn on the concentrator, applied the nasal cannula and set the gauge at 2 lpm. A review of the facility's policy entitled, Oxygen Administration revised 10/2010 revealed .the purpose of this procedure is to provide guidelines for safe oxygen administration .verify that there is a physician order .review the physician order or facility policy for oxygen administration . On 10/24/24 at 1:54 PM, the survey team met with the administration to discuss the above observations and concerns. NJAC 8:39-27.1(a)

Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify psychoactive medication irregularity, twice in four months, during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for one (1) of five (5) residents reviewed for unnecessary medication, Resident #30. This deficient practice was evidenced by the following: On 10/23/24 at 11:20 AM, the surveyor observed the Resident's door of the room was closed. The surveyor knocked on the door and was opened by the Licensed Practical Nurse/Supervisor (LPN/S). The LPN/S offered his assistance, to the surveyor, and the surveyor politely declined. The LPN/S exited the room, while the surveyor entered the room. At that time, the surveyor observed Resident #30 was asleep, and was not roused by the surveyor's voice. Resident #30 had a short sleeved top and had no bruising on both arms but the upper arm to the shoulder was not visible since it was covered by the resident's sleeves. On 10/24/24 at 10:55 AM, the surveyor observed Resident #30 asleep, not roused by the surveyor's voice and could not be interviewed. On 10/24/24 at 11:12 AM, during an interview with the surveyor, LPN/S #2 stated that the resident was blind, needed assistance with eating, and was monitored for constantly touching their own arms. LPN/S also stated, She does sleep a lot and was not sure of the behavior/side effect of drowsiness and sleepiness was reported to the physician. The surveyor reviewed Resident #30's hybrid (paper and electronic) medical record. According to the admission Record (admission summary) Resident # 30 was admitted to the facility with diagnoses that included unspecified dementia without behavioral disturbances (loss of memory, language, problem-solving and other thinking abilities), obsessive compulsive disorder (long lasting confusion of recurring thoughts engaging in repetitive behavior), anxiety, and major depressive disorder (persistent feelings of sadness and loss of interest). A review of the most recent quarterly MDS (qMDS; an assessment) dated 7/22/24, reflected a Brief Interview for Mental Status score of four (4) out of 15 which indicated the resident had severe cognitive impairment, with no indication of hallucination or delusions. The resident showed behaviors associated with rejection of care and had active diagnoses of anxiety, depression, and psychotic disorder (severe mental condition that causes abnormal thinking and perception, not schizophrenia). Section N, of the qMDS reflected that the resident received an antipsychotic medication (used to treat psychosis) and an antidepressant. A review of the Order Summary Report, dated 10/29/24 included the following physician's orders: -Escitalopram 10 milligram (Lexapro; mg), 1 tablet by mouth at bedtime, for depression. The physician order was started on 4/16/24. -Mirtazapine 30 mg (Remeron), 1 tablet by mouth at bedtime, for depression. The physician order was started on 4/16/24. -Quetiapine 100 mg (Seroquel), 1 tablet by mouth two times a day, for psychosis. The physician order was started on 4/16/24. -Seroquel 300 mg, 1 tablet by mouth at bedtime, for psychosis. The physician order was started on 4/16/24 and discontinued on 4/16/26. -Seroquel 300 mg, 1 tablet by mouth in the evening, for psychosis. The physician order was started on 4/18/24. A review of the monthly Psychoactive (a medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) Medication Monthly review from 8/13/24 to 10/1/24, included potential side effects and documented as: dizziness, drowsiness, tiredness, lack of energy, increase appetite, upset stomach, vomiting and nausea. The sleep pattern was documented as: sleeps well, no complaint, and no issues for Resident #30 who was assessed with severe cognitive impairment. A review of the Psychiatric Progress Notes (PPS) dated 5/18/24, reflected that the Advanced Practical Nurse/ Board Certified Psychiatric Nurse Practitioner (APN-C) made recommendations that included to decrease Lexapro to 5 mg once a day for depression, a gradual dose reduction (GDR) attempt. A review of the Physician's Progress Note from 5/2024 to 10/6/24 did not reflect knowledge of the GDR made by APN-C and did not reflect a rationale for not following the APN-C's recommendation, no evidence that the optimal dose was achieved without trialing a gradual dose reduction for Lexapro, and did not have a documented discussion with the family regarding risk versus benefit of the Lexapro dose reduction, prior to surveyor inquiry. A review of the CP recommendations from 5/1/24 to 9/30/24, did not show that the CP identified the irregularity, between the APN-C's GDR recommendation regarding Lexapro, and physician's progress note that did not indicate a rationale for not following the APN-C's recommendation for the GDR. The CP recommendations included the following: -on 5/20/24, no recommendation -on 6/16/24, recommendation to consolidate vitamins -on 7/18/24, no recommendation -on 8/25/24, no recommendation -on 9/17/24, recommendation to consolidate vitamins Further review of the PPS dated 7/24/24, reflected that the Advanced Practical Nurse/ Board Certified Psychiatric Nurse Practitioner (APN-C) made recommendations that included to decrease Seroquel to 50 mg once a in the morning [a GDR attempt], to continue the 100 mg at 4:00 PM and 300 mg at bedtime for psychosis. A review of the Physician's Progress Note from 5/2024 to 10/6/24 did not reflect knowledge of the GDR made by APN-C and did not reflect a rationale for not following the APN-C's recommendation, no evidence that the optimal dose was achieved without trialing a gradual dose reduction for Seroquel, and did not have a documented discussion with the family regarding risk versus benefit of the Seroquel dose reduction, prior to surveyor inquiry. A review of the CP recommendations from 5/1/24 to 9/30/24, did not show that the CP identified the irregularity, between the APN-C's GDR recommendation regarding Seroquel, and the physician's progress note that did not indicate a rationale for not following the APN-C's recommendation for the GDR. On 10/28/24 at 10:42 AM, in the presence of the survey team, the Director of Nursing, the Licensed Nursing Home Administrator (LNHA), the Regional Director of Clinical Operations (RDCO) and the Regional Director of Clinical Services (RDCS), the surveyor discussed the concerns regarding the failure of the consultant pharmacist (CP) to identify the irregularity twice, after the APN-C's recommendation on 5/18/24 and on 7/24/24. Additionally, the surveyor discussed the concern with the physician, who did not have a documented rationale for not following the APN-C's recommendation of the GDR of Lexapro and of Seroquel while Resident #30 was observed to be drowsy, and often sleeping. On 10/28/24 at 1:20 PM, in the presence of the survey team, the DON stated that the physician was made aware of the prior GDRs and that the family member had declined the GDR. The DON confirmed that the Physician Progress Note did not reflect that a discussion with the niece had occurred, which was the reason the GDR did not occur. The DON stated that the documentation was being entered into Resident #30's medical record as she spoke with the survey team. On 10/29/24 at 10:58 AM, in the presence of the survey team, the LNHA, the RDCO and the RDCS the DON confirmed and acknowledged that when a GDR was recommended, the nurse should have followed- up with the physician, the physician would then determine the outcome of the interventions recommended. The physician should have documented in the medical record, the discussions with the family. At that time, the DON confirmed and acknowledged that the CP should have spoken with the nursing staff, reviewed the resident's chart, documented recommendations, and sent the recommendation to the physician. A review of the undated/unsigned Consultant Pharmacist Provider Agreement provided by the facility, included the following: 1.1.3 Consultant shall assist Facility in determining that resident's medication therapy is necessary and appropriate. 1.1.5 Consultant shall identify any irregularities as defined in the State Operations Manual. A review of the undated, facility provided policy, Pharmacy Services, Role of the Consultant Pharmacist included under section 5, b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services including medication irregularities and pertinent resident-specific documentation in the medical record . No further information was provided. NJAC 8:39- 29.1(b), 29.3 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 6 of 37 residents reviewed for accommodation of needs (Resident #70, #15, #1, #48, #13, and #86), and was evidenced by the following: a. On 10/22/24 at 10:43 AM, the surveyor observed Resident #70 in bed, with his/her eyes closed. Resident #70 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was not within the Resident's reach. On 10/23/24 at 12:59 PM, the surveyor observed Resident #70 in bed with his/her eyes closed. Resident #70 did not respond to the surveyor. The surveyor observed the resident's call bell was not within the Resident's reach. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus and chronic obstructive pulmonary disease (a lung disease which causes permanent lung damage and breathing difficulties). A review of Resident #70's annual Minimum Data Set (MDS) an assessment tool dated 4/8/24 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #70 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance and or supervision for activities of daily living (ADLs). A review of Resident 70's individualized care plan (ICP) initiated on 4/2/23 included a focus area: resident is at risk for falls with interventions which included but were not limited to: be sure call light is within reach and provide reminders to use call bell for assistance as needed. On 10/24/24 at 1:30 PM, the surveyor observed Resident #70 in bed with his/her eyes closed. The surveyor observed Resident #70's call bell on the floor behind the resident's bed. On 10/24/24 at 1:35 PM, the surveyor accompanied by the Certified Nursing Assistant (CNA #1) assigned to care for Resident #70, entered the resident room. The surveyor and the CNA observed Resident #70's call bell on the floor under the resident's bed. The CNA confirmed that she should have checked to ensure that the call bell was within the resident's reach. b. On 10/23/24 at 1:15 PM, the surveyor observed Resident #15 in bed. The surveyor observed the call bell was under the resident's bed not within the resident's reach. On 10/24/24 at 8:00 AM, the surveyor in the presence of the Registered Nurse (RN #1), observed Resident #15's call bell under the resident's bed not within the resident's reach. The RN stated, it's stuck and further stated that it should have been clipped to the bed and kept within the resident's reach. The surveyor reviewed the medical record for Resident #15. A review of Resident #15's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus and repeated falls. A review of Resident #15's admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 3 out of 15 which indicated Resident #15 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance and or supervision for activities of daily living. A review of Resident 15's ICP initiated on 5/10/24 included a focus area: resident is at risk for falls with interventions which included but were not limited to: be sure call light is within reach and provide reminders to use call bell for assistance as needed. c. On 10/23/24 at 1:20 PM, the surveyor observed Resident #1 was out of bed seated in a geriatric chair in his/her room. The surveyor observed the call bell was positioned in the middle of the resident's bed, not within the resident's reach. On that same day, at that same time, the surveyor observed RN #2 entered Resident #1's room. The surveyor showed RN #2 the call bell and asked RN #2 if the call bell should have been positioned so that the resident could reach it. RN #2 did not respond verbally to the surveyor's inquiry and positioned the call bell within Resident #1's reach. The surveyor reviewed the medical record for Resident #1. A review of Resident #1's admission Record revealed Resident #1 was admitted to the facility with diagnoses which included but were not limited to acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease and dementia. A review of Resident #1's most recent Minimum Data Set (MDS), an assessment tool, dated 9/20/24 revealed Resident #1 had short-term and long-term memory problems and had a severe cognitive impairment. A review of the resident's ICP initiated on 5/25/24 included a focus area: Resident is at risk for falls with interventions which included but were not limited to: Be sure call light is within reach and provide reminders to use call bell for assistance as needed. d. On 10/24/24 at 7:50 AM, the surveyor and RN #1 entered Resident #48's room and observed Resident #48 in bed with their call bell on the floor under the bed, not within the resident's reach. RN #1 confirmed that the call bell should be kept within the resident's reach. A review of Resident #48's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited dementia, depression and an overactive bladder. A review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 7 out of 15 which indicated Resident #48 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision and or assistance for ADLs. A review of Resident 48's ICP initiated on 11/13/23, included a focus area: Resident has an ADL Self Care Performance Deficit with interventions which included but were not limited to: Encourage me to use call bell for assistance. e. On 10/24/24 at 7:53 AM, the surveyor accompanied by RN #1 observed Resident #13 in bed. The surveyor and RN #1 observed Resident #13's call bell was behind the headboard, hanging down towards the floor. RN #1 stated that the call bell was stuck behind the bed and should have been within the resident's reach. A review of Resident #13's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hypertension and chronic obstructive pulmonary disease. A review of Resident #13's most recent MDS revealed Resident #13 had a BIMS score of 2 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision/ assistance for ADLs. A review of Resident 13's ICP initiated on 11/8/23, included a focus area: Resident has an ADL Self Performance Deficit with interventions which included but were not limited to: Encourage me to use call bell for assistance. f. On 10/24/24 at 8:00 AM, the surveyor accompanied by RN #1 observed Resident #86 in bed. The surveyor and RN #1 observed Resident #86's call bell was behind the headboard not within the resident's reach. A review of Resident #86's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia and cognitive communication deficit. A review of Resident #86's admission MDS revealed Resident #86 had a BIMS score of 4 out of 15 which indicated the resident had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for ADLs. A review of Resident 86's ICP initiated on 7/3/24, included a focus area: I have an ADL Self Care Performance Deficit with interventions which included but were not limited to: Encourage me to use the call bell for assistance. On 10/24/24 at 8:10 AM, the surveyor interviewed RN #1 who stated that the nurses and CNAs should ensure that the call bells are always kept within the resident's reach. The surveyor attempted phone interviews with the assigned 11 PM-7 AM, CNAs for Residents #15, #48, #13, and #86. The surveyor left messages for both CNAs with no return calls. On 10/24/24 at 1:54 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that call bells should be kept within the resident's reach. A review of the facility policy entitled, Answering the Call Light undated, reflected .The purpose of this procedure is to ensure timely responses to the resident's requests and needs . NJAC 8:39-31.8 (c)(9) .

Based on observation, interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or the Notice of Medicare Non-coverage (NOMNC) for 3 of 3 residents (#82, #349, #348) reviewed for facility change notifications regarding insurance termination. The evidence is as follows. On 10/28/24 at 11:28 a.m., the facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and were required to have received Beneficiary Notices. The surveyor reviewed 3 of the residents listed (Resident #82, #349, #348) who were discharged from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident #82's last documented day of coverage for Medicare Part A service was 4/28/24. The resident elected to stay in the facility. The facility was required to provide both a SNF ABN form and a NOMNC form to the resident/responsible party. The facility provided a NOMNC, however, they did not present the resident with the required SNF ABN form to notify them of the termination of insurance. Resident #349's last documented day of coverage for Medicare Part A service was 6/27/24. The resident elected to stay in the facility. The facility was required to provide both a SNF ABN form and a NOMNC form to the resident/responsible party. The facility provided a NOMNC, however, they did not present the resident with the required SNF ABN form to notify them of the termination of insurance. Resident #348's last documented day of coverage for Medicare Part A service was 5/22/24. The resident was discharged either to home or to a lesser level of care. The facility was required to provide a NOMNC form to the resident/responsible party. A NOMNC was not presented to the resident. On 10/29/24 at 11:00 a.m., the surveyor informed the Administrator and the Director of Nursing of the above-noted concerns regarding insurance termination notification omissions. The Administrator stated there was a change in social service staff who were responsible for providing notification to residents which may have caused the errors. No additional information was provided. NJAC 8:39-5.4 (b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 172317, NJ 172237; NJ 174618; NJ 175890 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 7 of 8 residents (Resident #82, #199, #48, #13, #86, #24, and #14) observed for incontinence care on 2 of 4 units (North Unit and [NAME] Unit). This deficient practice was evidenced by the following: On 10/24/24 at 7:35 AM, the surveyor completed an incontinence tour on the North Unit and observed the following: a. On 10/24/24 at 7:40 AM, the surveyor accompanied by Registered Nurse (RN #1) observed Resident #82 in bed. RN #1 exposed Resident #82's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed which was saturated with urine. RN #1 stated that no resident should be wearing two incontinence briefs. A review of Resident #82's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus, and anxiety disorder. A review of Resident #82's admission Minimum Data Set (MDS) an assessment tool dated 3/14/24 revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated Resident #82 had a severe cognitive impairment. The MDS further revealed that the resident required assistance from staff for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 82's Individualized Care Plan (ICP) initiated on 3/12/24 included a focus area: Activities of Daily Living (ADL) self care deficit with interventions that included but were not limited to: resident is dependent on staff for toileting. b. On 10/24/24 at 7:45 AM, the surveyor accompanied by RN #1 observed Resident #199 in bed. RN #1 exposed Resident #199's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed which was saturated with urine. RN #1 stated that it did not appear as if the night aide had changed the resident recently. A review of Resident #199's admission record reflected Resident #199 was admitted to the facility with diagnoses which included but were not limited to Parkinson's Disease, dementia and anxiety disorder. A review of Resident #199's admission MDS dated [DATE] revealed Resident #199 had short-term and long-term memory problems and was assessed as having a moderate cognitive impairment. The MDS further reflected that Resident #199 required supervision from staff for personal hygiene, and was frequently incontinent of urine and bowel movements. A review of Resident 199's ICP initiated on 10/15/24 included a focus area: Resident has bowel and bladder incontinence with interventions which included but were not limited to: check resident approximately every 2 hours and provide incontinence care as needed. c. On 10/24/24 at 7:50 AM, the surveyor accompanied by RN #1 observed Resident #48 in bed. The surveyor observed that Resident #48's adult pull- up was saturated with urine. The surveyor and RN #1 observed that Resident #48's sheets were also saturated with urine. A review of Resident #48's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited dementia, depression and an overactive bladder. A review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 7 out of 15 which indicated Resident #48 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision for personal hygiene, and he/she was occasionally incontinent of bowel and bladder. A review of Resident 48's ICP initiated on 11/21/23, included a focus area: Resident is on diuretic therapy with interventions which included but were not limited to: Resident may need to void frequently and quickly. Routinely check and offer/provide toileting assistance. d. On 10/24/24 at 7:53 AM, the surveyor accompanied by RN #1 observed Resident #13 in bed. RN #1 exposed Resident #13's pull up. At that time when RN #1 exposed the pull up an incontinence brief was observed under the pull up. The surveyor and RN #1 observed both the pull up and incontinence brief were saturated with urine. The surveyor and RN #1 observed Resident #13's perineal area was very red. RN #1 stated that no resident should be wearing a diaper and pull up as it could cause skin breakdown. A review of Resident #13's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hypertension and chronic obstructive pulmonary disease (a lung disease that causes permanent damage to the lungs.) A review of Resident #13's most recent MDS revealed Resident #13 had a BIMS score of 2 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 13's ICP initiated on 11/16/23, included a focus area: Resident is on diuretic therapy with interventions which included but were not limited to: Resident may need to void frequently and quickly. Routinely check and offer/provide toileting assistance. e. On 10/24/24 at 8:00 AM, the surveyor accompanied by RN #1 observed Resident #86 in bed. RN #1 exposed Resident #86's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed. The surveyor and RN #1 observed both incontinence briefs were saturated with urine. The surveyor and RN #1 observed Resident #86's blanket was also saturated with urine. A review of Resident #86's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia and cognitive communication deficit. A review of Resident #86's admission MDS revealed Resident #86 had a BIMS score of 4 out of 15 which indicated Resident #86 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 86's ICP initiated on 7/3/24, included a focus area: Resident has bowel and bladder incontinence with interventions which included but were not limited to: check resident approximately every two hours and provide incontinence care as needed. On 10/24/24 at 8:10 AM, the surveyor interviewed RN #1 who stated that the facility policy was to use only one incontinence brief as two briefs could cause the resident's skin to breakdown. RN #1 further stated that incontinence care should be provided every two hours. f. On 10/24/24 at 8:15 AM, the surveyor observed RN #2 during medication administration observation on the North unit. The surveyor observed RN #2 prepared to administer an injection in Resident #24's abdomen. RN #2 exposed Resident #24's incontinence brief. At that time the surveyor and RN #2 observed another incontinence brief. The surveyor and RN #2 observed both incontinence briefs were saturated with urine. RN #2 stated that residents should not be wearing two incontinence briefs as it could cause skin breakdown. A review of Resident #24's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, muscle weakness and hypertension. A review of Resident #24's quarterly MDS revealed Resident #24 had a BIMS score of 3 out of 15 which indicated Resident #24 had a severe cognitive impairment. The MDS further assesses that the resident required moderate staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 24's ICP initiated on 10/29/21, included a focus area: Resident has episodes of incontinence of bowel and bladder with interventions which included but were not limited to: Check and change resident as needed. On 10/24/24 at 8:30 AM, the surveyor interviewed RN #2 who stated the facility policy was for the residents not to be double diapered and that they should be provided incontinence every 2 hours. g. On 10/24/24 at 10:30 AM, during the resident council meeting, Resident #14 stated that staff used a mechanical lift to transfer her/him from the bed to the wheelchair and that once he/she was lifted out of the bed into the chair she/he has to stay there and doesn't receive incontinence care until she/he was transferred back to bed in the evening. The resident stated that if she/he requested to go back to bed to be changed the staff would refuse to transfer her/him back into the chair and therefore stay in bed for the remainder of the day. On 10/24/24 at 12:20 PM, the surveyor interviewed Resident #14 who stated that she/he was transferred out of bed with the mechanical lift at approximately 8:30 AM. The Resident confirmed that she/he had not received any incontinence care since that time. A review of Resident #14's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease, depression and overactive bladder. A review of Resident #14's annual MDS dated [DATE] revealed Resident #14 had a BIMS score of 15 out of 15 which indicated Resident #14's cognition was intact. The MDS further revealed that the resident was dependent on staff for toileting hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident 14's ICP initiated on 10/30/2023, included a focus area: resident has bowel and urinary incontinence with interventions which included but were not limited to: check resident approximately every 2 hours and provide incontinence care as needed. On 10/24/24 at 12:30 PM, the surveyor interviewed the Certified Nursing Assistant on [NAME] Unit (CNA-W) assigned to provide care for Resident #14, who stated that she provided incontinence care for all residents every 2 hours which included residents who required mechanical lifts for transfers. The surveyor asked CNA-W if Resident #14 was incontinent of bowel and bladder. The CNA-W confirmed that she/he was. The surveyor asked the CNA why she had not provided incontinence care for Resident #14. The CNA replied it was because the resident had not asked to be changed. On 10/24/24 at 12:50 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the care of Resident #14 who stated that the facility policy was to provide incontinence care every 2-2 ½ hours to all residents who were incontinent of bowel and or bladder. The surveyor stated that the CNA had not provided incontinence care for Resident #14 since that morning. The LPN replied that Resident #14 was alert and oriented and did not ask to be changed. On 10/24/24 at 12:55 PM, the LPN and CNA transferred Resident #14 back to bed with the use of a mechanical lift. The CNA exposed the incontinence brief and at that time, the LPN, CNA and surveyor observed a second incontinence brief in place. The surveyor, LPN and CNA all observed that both incontinence briefs were saturated with urine. At that same time, the resident stated that she/he requested 2 incontinence briefs because by the evening when she/he gets transferred back to bed she is saturated with urine. She/he further stated that even her/his clothing and mechanical lift pad were saturated with urine. Resident #14 stated that she/he bought a new spray to use on the mechanical lift pad so that he/she did not smell like urine. On 10/24/24 at 1:00 PM, the LPN stated that it was unacceptable that Resident #14 was saturated with urine and further stated that even though the resident was alert and oriented she/he should be offered incontinence care and be permitted to get back out of bed if that was her/his preference. On 10/24/24 at 1:54 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that incontinence care should be provided every 2 hours on all shifts and that if residents requested 2 incontinence briefs it should be care planned. The surveyor attempted phone interviews with the assigned 11 PM-7 AM, CNAs for Resident #82, #199, #48, #13, #86, and #24. The surveyor left messages for both CNAs with no return calls. A review of the facility's Urinary and Fecal Incontinence policy, undated reflected .the purpose of this procedure is to provide guidelines that will aid in preventing the resident's exposure to urine and feces . NJAC 8:39-27.1 (a), 27.2 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#NJ00168013 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one resident (Resident (R) 8) out of three residents investigated for falls, remained free from accident hazards. This had the potential to cause serious harm to a resident with Alzheimer's disease. Findings include: Review of a policy provided by the facility titled Falls-Clinical Protocol, dated 03/2018, failed to address falls that were not caused by a medical condition. The policy stated, Falls often have medical causes; they are not just a nursing issue. Review of a document provided by the facility titled Profile Face Sheet, indicated R8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, major depressive disorder (MDD). Review of a document provided by the facility titled Care Plan, dated 06/07/21 indicated that R8 was total dependent as to care due to impaired mobility secondary to contractures both upper and lower extremities. R8 has chronic incontinence to both urine and bowel and needs extensive assistance for his toileting needs, bed mobility, other activities of daily living, and transfers via Hoyer lift and two person assist. Care Plan, dated 04/01/24, indicated R8 had a witnessed fall in his room. Nursing assessment was performed with noted small abrasion on the anterior forehead. The intervention in place was to in-service staff on proper positioning and safety strategies when doing turning and repositioning total care residents. Review of R8's quarterly Minimum Data Set (MDS) provided by the facility with an Assessment Reference Date (ARD) of 04/14/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated the resident was severely cognitively impaired. The MDS also indicated the resident needed two staff persons for total assistance with care. An incident report was provided by the facility stating that on 04/01/24 at 8:30 AM, Certified Nursing Assistant (CNA) 4 was rendering care to R8 when he/she accidentally fell onto the floor on a floor mat and sustained an abrasion on the anterior forehead. CNA 4 was using the bed control to lower the bed to the floor. R8's[spouse] was present in the room and called out to staff that My [spouse] is on the floor. Licensed Practical Nurse (LPN) 3 entered the room and found R8 face down on the floor mat and CNA 4 was at the bedside. The resident was assessed with no bruising or discoloration noted and was able to move all extremities. A small abrasion was noted on the forehead. The neuro check was initiated with Physician notification. Resident received one dose of hydralazine (blood pressure medication) for high blood pressure and Tylenol. No distress at present time. Interview on 05/09/24 at 9:41 AM with the Director of Nursing (DON) revealed that she wrote the incident report. The DON stated CNA 4 stated that she was putting a new brief on the resident. She was lowering the bed and had rolled [him/her] on [his/her] side. The resident rolled out of bed, face down on the floor mat. When the DON was asked why CNA 4 was providing care by herself when R8 is a two person assist, and the DON stated, CNA 4 liked to do things herself. Interview on 05/09/24 at 9:52 AM with the Regional Director of Operations (RDO) revealed I was in the facility at the time of the incident. The CNA stated that she was waiting for assistance when while lowering the bed, the resident became agitated with care. [He/She] fell out of bed. When the [spouse] entered the room and found [his/her] [spouse] on the floor, [he/she] started yelling for help. Review of CNA 4's personnel file provided by the facility revealed a hire date of 03/14/24 with orientation on 03/12/24 that included resident safety. On 04/01/24, CNA 4 was suspended and then discharged due to violation of company policy and code of conduct Phone interview with CNA 4 on 05/09/24 at 12:03 PM, revealed I was washing the resident and had finished [his/her] front side. I turned the resident to [his/her] side to wash [his/her] back and [he/she] started shaking and rolled out of bed onto the floor mat. [His/Her] [spouse] walked into the room and completely freaked out. I opened the door and hollered for help. When CNA 4 was asked what kind of assistance the resident needed, she stated [He/She] was a two person assist and used the Hoyer lift. When asked why she did not wait for help, she stated There is not enough help, and I just did it myself. I could not catch [him/her] when [he/she] fell because [he/she] was wet, and my hands were wet. Phone interview with LPN 3 on 05/09/24 at 2:34 PM revealed I heard the [spouse] of R8 screaming from [his/her] room that [his/her] [spouse] fell. I ran into the room and R8 was face down on the fall mat. The bed was in a low position. CNA 4 stated to me that R8 rolled off the bed. An assessment was completed and R8 had a scratch on [his/her] forehead. NJAC 8:39-27.1a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the manufacturer's specifications for Flomax (tamsulosin), under section 1. Indication and Usage included an indication for the treatment of the signs and symptoms of benign prostatic hyperplasia (non-cancerous enlargements of the prostate glands which potentially slows or blocks the urine). The surveyor reviewed the medical record for Resident #293. The resident's AR reflected that Resident #293 was admitted to the facility with diagnoses that included but were not limited to atherosclerotic heart disease without angina pectoris (narrowing or hardening of the arteries in the heart that can cause reduced blood flow to the heart), hyperlipidemia (high concentration of fats in the blood), acute subdural hemorrhage (bleed inside the skull from a fall) and an overactive bladder According to the admission MDS dated [DATE], Resident #293 was documented as having a Brief Interview for Mental Status (BIMS) score of 3 (three) out of 15, indicating that the resident had a severely impaired cognition. A review of the 8/07/23, Order Summary report revealed a physician's order (PO) dated 8/02/23 for Flomax 0.4 milligram, give 1 (one) capsule in the evening for osteoporosis. Take with dinner. The Discharge summary dated [DATE], revealed the resident had some urinary retention after a foley [catheter; used to drain the urine from the bladder]. Flomax was started and was to be assessed for the ability to empty the bladder in rehabilitation when the resident was more mobile. A review of the pharmacy consultant progress note dated 8/04/23, revealed the admission medication regimen review was conducted and no irregularities was identified by the Consultant Pharmacist (CP #1) On 8/07/23 at 11:04 AM, the surveyor and CP #2 reviewed the medical record for Resident #293. At that time, CP #2 confirmed that CP #1 reviewed the admission record and did not identify an irregularity. The CP #2 stated she would have questioned the incorrect indication for the Flomax as it was not used for osteoporosis. At that time, the surveyor asked CP #2 if Flomax indication was appropriate. CP #2 stated urinary retention was an off-label use and would look for data to support it but that would be after confirming the documented/reviewed indication of osteoporosis. No additional information was received. On 8/07/23 at 11:07 AM, during an interview with the surveyor, the Registered Nurse (RN) stated the resident was evaluated and was aware of who they were and where they were. The resident had no fevers, no difficulty breathing and walked using a walker with the assistance of one person. The RN stated the resident was continent of bowel and bladder. On 8/07/23 at 02:16 PM, during a meeting with the surveyors, the surveyor discussed the concern regarding the failure of the CP #1 to identify the irregularity upon the admission medication review with the RDO, LNHA, and the DON. A review of the facility provided policy; Reconciliation of Medication on admission dated/revised July 2017 included: General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. A review of the undated facility provided policy; Pharmacy Services - Role of Consultant Pharmacist included: Policy Interpretation and Implementation 2. The facility will give the consultant pharmacist a current rosed and will inform the consultant pharmacist of all new admissions and readmissions to the facility. 5. The consultant pharmacist will provide specific activities related to medication regimen review including: b. appropriated communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities . On 8/08/23 a 12:38 PM, during a meeting with the surveyors, the RDO stated the order for Flomax was clarified after surveyor inquiry. N.J.A.C. 8:39-11.2 (b), 29.3(a)1 . Complaint # NJ00159269 Based on interview, record review, and review of other pertinent facility documents, it was determined that facility failed to ensure: a) staff consistently and accurately documented that residents received showers or the reason why residents did not receive a shower for 1 (one) of 2 (two) residents reviewed for Activities of Daily Living (ADLs), (Resident #16) according to the standards of clinical practice and b) an order for Flomax (medication used to treat symptoms of benign hyperplasia or enlarged prostate) had the appropriate indication and was identified during the admission medication review. This deficient practice was identified during the medication reconciliation review for 1 (one) of 5 (five) residents observed for medication administration (Resident #293). 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 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. 1. On 8/03/23 at 9:34 AM, the surveyor observed Resident #16 seated in a high back wheelchair at a table in the North wing unit dayroom and there was a book opened on the table. The resident's eyes were closed. The resident did not respond to surveyor. On 8/10/23 at 9:24 AM, the surveyor reviewed Resident #16's medical record. Resident #16's admission Record (AR; or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and hypertension (when the pressure in your blood vessels is too high). A review of Resident #16's quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 6/02/23, reflected that the resident had a Staff Assessment for Mental Status, which indicated that Resident #16's cognitive skills for daily decision making was severely impaired. A review of Resident #16's Documentation Survey Report for October 2022 indicated that Resident #16's CNA (Certified Nursing Aide) Task included that the resident was to receive a Shower/Bath on Tuesday and Friday. The Report included the question of Did the resident get a shower? to be answered by the CNA with a Y-Yes or N-No. On the bottom of the report there was additional responses available for all questions which included RR-Resident Refused. Further review included the following: Tuesday 10/04/22 Y Friday 10/07/22 N Tuesday 10/11/22 N Friday 10/14/22 Y Tuesday 10/18/22 Y Friday 10/21/22 N Tuesday 10/25/22 N Friday 10/28/22 Y Resident #16 received a shower one time a week during the 4 (four) week period reviewed. Further review of the Documentation Survey Report for October 2022 indicated that Resident #16 was documented to have the behavior of resisting care on the shower day of 10/25/22. The other remaining shower days did not document that the resident resisted care. The surveyor reviewed Resident #16's Progress Notes for October 2022. There was no documentation that the resident refused the showers on the days that were answered with a N (no). On 8/10/23 at 10:29 AM, the surveyor interviewed the CNA#1 assigned to Resident #16 regarding showers. CNA #1 stated that residents received showers two times a week. He added that sometimes the unit was short staffed and that he might do the shower on another day then what was the assigned day. He also added that if a resident refused that he would try to do it on another day. The surveyor asked CNA #1 if the showers were documented. CNA #1 stated that he documented them in the computer system when they were done. On 8/14/23 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #16 regarding showers. The LPN stated that residents received showers two times a week unless the family requested the resident to have more showers than that. The surveyor then asked the LPN if the showers were documented. The LPN stated that she was not sure how it worked in the computer system for the CNAs to document but that the showers should be documented. She then added if the CNA did not give the shower, then the CNA would tell the nurse and the nurse would document that the shower was not given and the reason would probably be that the resident refused. On 8/14/23 at 10:43 AM, the surveyor asked CNA #1 how the showers were documented in the computer system. CNA #1 stated that there was a yes, not available or refused to choose from. He added that if a resident refused that he would tell the nurse and that he would try to give the resident a shower another day. On 8/14/23 at 10:49 AM, the surveyor interviewed the North wing Unit Manager/Registered Nurse (UM/RN) regarding showers. The UM/RN stated that showers were given two times a week unless the family requested more days. The surveyor asked the UM/RN what N documented for shower meant. The UM/RN stated that N meant no and that the resident did not get a shower. She added that the resident's regular CNA might give the shower on another day. The surveyor asked if the shower was given on a different day then what was in the computer system if the CNA was able to document it on another day. The UM/RN stated that she was not sure. She then stated that the CNA would tell the nurse if the resident refused and that usually the nurse would document it, especially if the resident had behaviors. On 8/14/23 at 10:56 AM, the surveyor interviewed CNA #2 who had documented N for Resident #16's showers on 10/7/22 and 10/21/22. CNA #2 stated that N meant the resident refused. She added that if a resident refused that she would tell the nurse. The surveyor asked CNA #2 why Resident #16 did not receive a shower on those days. CNA #2 stated that she did not remember. On 8/14/23 at 11:06 AM, the surveyor interviewed the Director of Nursing (DON) regarding showers. The DON stated that residents received showers two times a week or more frequently if requested. She added that it was documented in the computer system and that the staff would click if the resident received the shower or refused it. The surveyor then asked the DON what N would mean. The DON viewed the computer system and then stated that N was no and that if the resident did not receive the shower then the staff would document the reason and tell the nurse. The surveyor then asked the DON how someone would know why the resident did not receive the shower when the staff documented N. The DON stated that there would have to be a note for the reason the shower was not given. On 8/14/23 at 01:36 PM, in the presence of the survey team, the surveyor notified the Regional Director of Operations (RDO) and DON, the concern that Resident #16 did not receive showers two times a week according to the documentation in the resident's medical record. On 8/15/23 at 10:54 AM, in the presence of the survey team, Licensed Nursing Home Administrator (LNHA) and DON, the RDO stated that stated that there was an order for the nurse to give Resident #16 a shampoo in the shower for that time period. She added that the nurse could not just write a no and that the nurse would have to explain why it was not given. The RDO stated that the resident had the showers. The surveyor reviewed the document that the facility provided which included the following: Sched (Schedule) for Oct (October) 2022; Bath/shower and skin check 7-3 shift twice weekly. Initials of LN indicates completion of Bath/Shower and Skin check one time a day every Tue (Tuesday), Fri (Friday). The surveyor notified the LNHA, DON and RDO that they did not provide the order for the shampoo and that the document they provided did not indicate if Resident #16 received a shower. On 8/15/23 at 12:15 PM, in the presence of the survey team, LNHA and DON and RDO the surveyor asked if the documentation for the showers should be the same when two different staff members were documenting if a shower was given. The RDO stated that the documentation should reflect the same. The surveyor then asked if the order indicated that it was a shower that was given. The RDO stated that the order did not indicate if it was a shower. The surveyor then asked if a resident refused a shower, should the refusal be documented as refused or no. The RDO stated that it should be documented as R for refused. The RDO stated that Resident #16 had an order for a shampoo that the nurses administered when the resident was in the shower. The surveyor asked the RDO to provide the document. On 8/15/23 at 12:40 PM, the RDO stated that she was wrong and that the order for Resident #16's shampoo was daily and that it would have been administered in the bed. A review of the facility provided policy titled, Bathing and Showering with an updated date of June 1, 2023, included the following: Policy Statement The facility will offer showers and tub baths to residents in accordance with their preferences. Policy Interpretation and Implementation 1. The facility will offer showers and tub baths to residents at least twice per week . 5. Provision and refusals of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse.

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to ensure a) that a physician's wound care order was followed and clarified, b) provide wound care in accordance with the facility's policy and professional standards of clinical practice and Centers for Disease Control and Prevention (CDC) guidance for 1 (one ) of 2 (two) residents (Resident #27) reviewed for pressure ulcers. 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 state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimen 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 state: 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 U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 01/08/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. In addition, wear gloves, according to Standard Precautions, when it can be anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment could occur; gloves are not a substitute for hand hygiene; if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment, and after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. On 8/02/23 at 10:58 AM, the surveyor observed Resident # 27's room was closed with an Enhanced Barrier Precaution (EBP; involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multidrug-resistant organisms are bacteria that have become resistant to certain antibiotics] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) sign outside the room. There was with PPE (personal protective equipment) box outside the room with a gown and gloves. On that same date and time, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the resident was on EBP because the resident had wounds in the upper back, an arterial wound in the leg, and facility acquired wound to the sacrum. The RN/UM stated that the sacrum wound was a stage two and unsure what stage now because the Wound doctor came yesterday (8/01/23) and I have to read the wound doctor notes on what stage the wound was. The RN/UM further stated that the resident used to have a behavior of refusing meds and care but now managed and has no behavior. The surveyor reviewed Resident #27's medical record. The resident's admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), major depressive disorder, heart failure unspecified (when the heart muscle doesn't pump blood as well as it should), essential hypertension (high blood pressure that doesn't have a known secondary cause), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). The resident's most recent comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident's cognition was moderately impaired. Further review of the CMDS Section M Skin Conditions, indicated the resident was at risk for developing pressure ulcers and had no pressure ulcer. Section M also included that the resident had a total of six venous and arterial ulcers present. A review of the facility provided a personalized care plan, with a focus and dated 7/20/23 for a new stage two pressure ulcer on the sacrum. A goal was to show signs of healing and remain free from infection by/through the review date. Interventions dated 7/20/23 included but were not limited to administer treatments as ordered and monitor effectiveness, continue evaluations by wound care clinicians and monitor wounds for healing, and report s/s (signs/symptoms) of infection as appropriate. A review of the August 2023 electronic Treatment Administration Record (eTAR) included and revealed the following: 1. Enhanced Barrier Precautions every shift for wound. Start date 5/01/23 2. Zinc oxide (commonly used to prevent or to treat diaper rash by forming a protective barrier between the skin and the diaper) to the sacral area every shift. Start date 02/15/23. 3. Santyl ointment (approved prescription medicine that removes dead tissue from wounds so they can start to heal) 250 unit/gm (unit/grams) apply to sacral area topically every day shift for wound care, apply zinc oxide to peri-wound cover with border foam post NSS (normal saline solution; a mixture of sodium chloride and water; some uses in medicine including cleaning wounds) cleansing. Start date 8/03/23. On 8/07/23 at 10:55 AM, the surveyor observed outside the resident's door a posted sign for EBP that included instructions to STOP Everyone Must: 1. Clean their hands, including before entering and when leaving the room. 2. Providers and Staff Must also: wear gloves and a gown for the following high-contact resident care activities including Wound Care: any skin opening and requiring a dressing. On that same date and time, the Licensed Practical Nurse/Supervisor (LPN/S) that he will be the one to do wound care of Resident#27 and will be assisted by the RN/UM and Certified Nursing Aide (CNA). During the wound treatment observation, the LPN/S did not read an order for wound treatment to the sacrum, did not perform hand hygiene, immediately donned (applied) a new pair of gloves, and entered the resident's room and assessed resident for pain. The LPN/S was wearing a surgical mask. The LPN/S went outside the room, took his keys from his uniform pocket then went inside the resident's room again, took the side table, removed the drinking cup and other personal belonging of the resident, and disinfected the table. At that same time, the CNA took an isolation gown from the PPE box outside the resident's room without performing hand hygiene, donned gloves, and immediately entered the resident's room to reposition the resident towards the left side, facing the window. At that time, the RN/UM informed the surveyor that she will help the LPN/S for wound care and the CNA. The RN/UM did not perform hand hygiene and entered the resident's room without donning an isolation gown. Afterward, the LPN/S removed gloves, performed handwashing inside the resident's room, then went outside the room to get an isolation gown from the PPE box and donned the gown, entered the resident's room, set up treatment supplies that were taken from the treatment cart: NSS bottle, tongue depressors, 4 x 4 gauze, santyl tube, zinc oxide tube and placed on top of the side table with liner and next to it was a plastic. There was a mounted ABHR (alcohol base hand rub) on the resident's room wall towards the foot part. Later on, the LPN/S donned gloves without performing hand hygiene. Then the LPN/S removed the sacral dressing, doffed off (removed) gloves, and then performed handwashing. The LPN/S donned gloves and cleansed the sacral area with soaked NSS 4 x 4 gauze that LPN/S squeezed in the clean field (barrier) the extra NSS. The LPN/S immediately took the tongue depressor from the clean field area after cleansing the wound without performing hand hygiene and and did not change gloves. At that time, the RN/UM and CNA were present in the room. When the LPN/S was about to get the santyl tube from the clean field, the RN/UM took it from the LPN/S and instructed the LPN/S to change gloves. The LPN/S doffed off gloves and did not perform hand hygiene and immediately donned a new pair of gloves. The LPN/S took the tongue depressor and santyl was poured by the RN/UM, LPN/S applied the santyl cream to the sacral area, discard the tongue depressor, took another tongue depressor and the RN/UM poured towards the tongue depressor the Zinc oxide, and the LPN/S applied it to the surrounding peri-wound. Afterward, the LPN/S applied the border foam without dating and signing the dressing. After the LPN/S removed gloves and gown and performed handwashing, he informed the surveyor that the wound care was finished. During an interview of the surveyor with the LPN/S outside the resident's room, the LPN/S informed the surveyor that the posted EBP sign outside the resident's door was because the resident had wounds. The LPN/S stated that the EBP sign should be followed by all staff and other people before entering and before exiting the room who will perform direct care like wound care. The surveyor then asked the LPN/S if he performed hand hygiene before entering the room for wound care, and the LPN/S did not respond. Then the surveyor asked the LPN/S if he performed hand hygiene when the RN/UM instructed him to change gloves after he cleansed the resident's wound, and the LPN/S stated I can't remember. The surveyor asked the LPN/S if he should perform hand hygiene after cleaning the wound and removing gloves and he stated yes, he should wash his hands. The surveyor then asked the LPN/S where to donn gown before entering the room or inside the room, the LPN/S stated that staff should donn gown before entering the room and remove the used gown inside the room before exiting the room then perform hand hygiene before exiting the room according to facility practice and protocol. At that same time, the surveyor asked the LPN/S what was the order for the sacral wound and why he did not read an order for the wound treatment that was done for the sacral wound before beginning the wound treatment. The LPN/S informed the surveyor that the resident's sacral wound was a facility acquired wound and that he read the order for the sacral wound before the surveyor came. At that time, the treatment cart that was used for wound care did not have a computer where the orders can be read. The surveyor then asked the LPN/S why there were two different orders in the eTAR for the sacral wound, one was ordered on 02/15/23 for zinc oxide to the sacral area, and on 8/03/23 for santyl for the sacral wound and zinc oxide for peri-wound. Immediately the LPN/S checked the eTAR from the medicine cart that was parked in the next resident's room, and informed the surveyor that the order for 02/15/23 should have been discontinued (d/c) when the new order on 8/03/23 was obtained and I don't know why it was not d/c. He acknowledged that the orders for sacral should have been clarified because there were two order existing at that time, one order dated for 02/15/23 and the other one was dated 8/03/23. Afterward, the surveyor interviewed the RN/UM outside the resident's room in the presence of the LPN/S and CNA regarding her instructions to the LPN/S to change gloves after cleansing the sacral wound, the surveyor asked the RN/UM if she saw the LPN/S performed hand hygiene after cleansing the wound and removed used gloves, the RN/UM stated no, I did not see him, performed hand hygiene. The RN/UM acknowledged that the LPN/S should have removed gloves and performed hand hygiene after cleansing the sacral wound. The surveyor asked also the RN/UM why she did not perform hand hygiene before entering the resident's room, the RN/UM responded that she came out the restroom room before going to the resident's room and that she had performed hand hygiene prior to leaving the restroom. On 8/07/23 at 11:25 AM, the surveyor interviewed the CNA. The surveyor asked the CNA about the EBP posted sign outside the resident's room and what it meant about hand hygiene before entering the resident's room. The CNA informed the surveyor that she came from another resident's room but was unable to remember what room. The CNA stated that she should have washed her hands before entering the EBP room. She acknowledged that she should followed the instructions from outside the door because she entered the room to provide direct care which was assisting the nurses with wound care. On 8/07/23 at 11:33 AM The surveyor notified the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations (RDO) regarding the above findings and concerns with the wound observation of Resident #27. The surveyor asked the facility management when staff should donn PPE. The RDO informed the surveyor that the gown should be donned outside, before entering the resident's room. The RDO stated also that hand hygiene should be done in EBP before entering the room, remove gloves and gowns inside the room and dispose of them inside the room into the covered bin. On 8/07/23 at 01:46 PM, the RDO to the surveyor showed the camera surveillance in the South unit from 10:55 AM onwards. The RDO stated that according to the video/camera surveillance, the LPN/S should have performed hand hygiene prior to entering the resident's room for wound treatment. She further stated that the staff should perform hand hygiene according to the EBP posted sign outside the resident's room. The RDO also stated that the video surveillance showed that the RN/UM came out of the restroom which was in front of the nursing station, then walked until the RN/UM reached the resident's room. On 8/08/23 at 12:38 PM, the survey team met with the RDO, LNHA, and DON. The RDO stated that the LPN/S followed the wound treatment order on 8/03/23 order for sacral and peri-wound. She further stated that the RN/UM failed to discontinue the previous order on 02/15/23, and should have been clarified the order for sacral when the new order obtained on 8/03/23. A review of the undated facility's Wound Care Policy that was provided by the LNHA included that the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation included verify that there is a physician's order for this procedure, and review the resident's order and care plan for the special needs of the resident. Steps in the procedure included to mark the dressing label or tape with the date, time, and initials. Also included in the steps is to apply a prepared label with the date, time, and initial to dressing. A review of the facility's Medication and Treatment Orders Policy that was provided by the RDO with a revised date of July 2016 included that orders for medications and treatments will be consistent with principles of safe and effective order writing. A review of the undated facility's Personal Protective Equipment Policy that was provided by the RDO revealed that soiled or contaminated PPE clothing and equipment must be removed and discarded at the location where the soiling or contamination occurred. The policy did not include information on when and where to donn PPE, if it is before entering the room or inside the room. On 8/09/23 at 12:03 PM, the survey team meet with the LNHA, DON, RDO. There was no additional information provided by the facility management. NJAC 8:39-11.2(b), 19.4(a), 27.1(a), 29.2(d)

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that the left thumb splint was consistently applied according to the physician's order. This deficient practice was identified for 1 (one) of 2 (two) residents reviewed for limited range of motion (ROM), Resident #57, and was evidenced by the following: During the initial tour on 8/02/23 at 10:36 AM, the surveyor observed Resident #57 in bed, with a left thumb dressing that appeared stained with yellow and brown discoloration. The resident had limited movement of the left thumb. There was not a date or initials on the gauze. On 8/03/23 at 10:31 AM, the surveyor observed the resident, in bed, with a left thumb dressing that was visibly stained with yellow and brown discoloration. The resident had limited movement of the left thumb. The gauze was not dated or initialed. On 8/08/23 at 10:31 AM, the surveyor observed the resident, in a reclining chair, the left thumb dressing was not present. The surveyor asked the resident what had happened to the dressing, and the resident replied, I took it off because it was dirty. On 8/10/23 at 9:33 AM, the surveyor observed the resident in bed, the left thumb dressing was not present. The surveyor asked the resident what had happened to the dressing, and the resident replied, Oh, that thing? It was dirty. The surveyor reviewed the medical records of Resident #57. According to the admission Record (admission summary), Resident #57 was admitted to the facility with medical diagnoses which included but not limited to; chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), osteoarthritis (the most common form of arthritis), repeated falls, displace fracture of proximal phalanx of left thumb. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/08/23, revealed 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 Physician Orders (PO) in the Electronic Medical Record (EMR) revealed active orders for: -No weight bearing on left hand with splint every shift. Active 6/08/2023 -Monitor left thumb splint every shift. Active 8/01/2023 A review of the Treatment Record for August 2023 revealed that the nurses signed monitor left thumb splint every shift with a start date of 8/01/23 for day shift (7 am -PM) on 8/08/2023, day shift, evening shift (3 PM-11 PM), and night shift (1-7 am) on 8/09/23. The surveyor had observed the splint not in place since 8/08/23-8/09/23. A review of radiology results for left finger 2 (two) views, dated 6/20/23 at 7:49 PM, findings revealed Fracture of Distal phalanx on the left thumb. Soft tissue swelling, some bone healing. Comminuted appearance. A review of radiology results for left finger 2 (two) views, dated 7/12/23 at 4:31 PM, findings revealed fracture distal phalanx of the thumb. Bandage material obscures bony detail. Some bone healing is seen. Mildly improved since 2023. Soft tissue swelling. The ongoing Care Plan revealed a focus; resident has a left thumb fracture r/t (related to) fall, date initiated 6/07/23 with interventions that included-I will remain free of complications related to fracture, such as contracture formation, embolism, and immobility through review date and splint on left thumb, follow up with orthopedic provider as ordered. The consultation report dated 6/16/23 by orthopedic provider. Which listed recommendation that included to keep left thumb splint, can change as needed (which was not seen as an order on the PO). A review of general Progress Notes (PN) dated 7/06/23 at 2:49 PM showed she must keep splint in place per MD order. Further review of general (PN) revealed that the last nursing progress note was written on 8/05/23 at 11:11 PM. The facility was not able to provide additional general progress notes for 8/08/23, 8/09/23, or 8/10/23 for the monitoring of the left thumb splint. A review of the occupational therapy treatment encounter notes dated 8/09/2023 showed under precautions: non-weight baring (NWB) pending medical doctor (MD) clearance. Further review revealed, under 97535: adhere to the NWB in the left thumb. On 8/15/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDO). The surveyor asked the facility management if there will be additonal information regarding Resident #57's concerns and findings. The facility management did not provide an additional information. A review of the facility's Policy: ROM Devices with a reviewed date of March 2023. The policy read as follows: Residents with limited ROM may be candidates for the use of orthotic devices such as splints and braces. When used, these devices will be maintained to increase and/or prevent a further decrease in ROM and to reduce the risk for complications. Procedure 1. Physical and occupational therapists may make recommendations for the use of ROM devices within their scope of practice. a. The primary physician will review the therapist's recommendations and provide orders for use of the ROM device, as appropriate. 2. When a ROM device is to be utilized, the primary physician or consulting physician will provide orders specifying the type of device, the frequency of application, and the duration of application. a. If applicable, the physician's order will specify the don and doff times for the device to be applied and removed. 3. The physician's orders will include the type and frequency of monitoring for potential complications of the device to be used (e.g., presence of pain, indications of impaired skin integrity, impaired circulation). 4. The licensed nurse will document in the medical record the type, duration, and frequency that the device was donned and doffed. 5. The licensed nurse will document in the medical record the completion of monitoring for potential complications as ordered by the physician. a. In the event that a complication or potential complication is observed, the nurse will document details of the observation in the medical record. i. The physician will be notified of the licensed nurse's observations and the nurse will obtain and carryout any new orders, if applicable. ii. The resident (or resident representative) will be notified of the change in condition and any follow-up actions. NJAC 8:39-27.1 (a)

Complaint # NJ00151595 and NJ00159657 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored. The deficient practice was identified for one (1) of two (2) residents reviewed for dietary concerns (Resident #7) and was evidenced by the following. On 8/02/23 at 11:01 AM, the surveyor observed Resident #7 within their room and conversant. Resident #7 stated, they were supposed to be on a low carbohydrate and low salt diet because of their diabetes and kidney disease. The resident stated they had informed the dietician of their preferences but there were still no available choices for their needs. On 8/02/23 at 12:46 PM, Resident #7 informed the surveyor that he/she had fettuccine alfredo for lunch today and the food was not bat. The resident further stated that lunch was still all carbohydrates. The surveyor reviewed the medical record for Resident #7. The admission Record (or face sheet; an admission summary) reflected the resident was admitted to the facility with diagnoses that included acute chronic diastolic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM), morbid (severe) obesity due to excess calories, chronic kidney disease, hypercholesteremia (high levels of cholesterol), hypertension (high blood pressure) and gout (caused by build up of uric acid in the body). A review of the Minimum Data Set, an assessment tool used to facilitate the management of care dated 5/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the Resident's Care Plan (CP) revealed a focus that the resident had nutritional problems related to therapeutic diet, DM, hypertension, morbid obesity, moderate protein calorie malnutrition. The interventions included food preferences will be recorded and updated as needed, initiated on 11/28/21. The resident's Orders Summary Report that included a diet order dated 7/07/23, for a heart and healthy (low fat, low cholesterol 2 to 2.5 grams of sodium), regular texture, thin consistency and consistent, constant, or controlled carbohydrate diet (CCHO). A review of the Week at a Glance menu, dated 7/30/23 to 8/05/23, included the lunch meal for 8/02/23, which was fettuccine alfredo with mushrooms, broccoli florets, bread roll with butter or margarine and the alternative was egg salad sandwich with three bean salad. The corresponding therapeutic menu for 8/02/23, revealed that a CCHO/NAS (no added salt) were served items on a regular diet and NAS was achieved by removing saltshaker and salt packets. Further review of the sampled therapeutic diet from 7/23/23 through 8/07/23, reflected the same information. The Registered Dietician's (RD's) Nutritional Risk Assessment (NRA) dated 4/20/23, under recommendation and plan did not include the resident's diet preference. Further review of the RD's NRA dated 5/25/23, under recommendation and plan did not include the resident's diet preference. On 8/07/23 at 9:36 AM, the surveyor interviewed the Registered Dietician (RD) who stated she was responsible for the dietary, appropriate goals, interventions, and food preferences which she included into the resident's CP. The resident's food preferences were updated quarterly, yearly or upon significant change. At that time, the RD stated the resident had never communicated their diet preference to her but confirmed the resident's preference should have been obtained within 48 hours of admission. On 8/07/23 at 01:24 PM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) assigned to resident stated that Resident #7 was verbal, alert and was able to communicate their needs at any time. The resident had the ability to speak with anybody. On 8/07/23 at 01:47 PM, during an interview with the surveyor, the Food Service Director stated that the resident's preferences were the responsibility of the dietician to obtain and document. On 8/07/23 at 02:16 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns regarding Resident #7's food preferences that were not collected, documented, and honored. On 8/08/23 at 12:38 PM, during a meeting with the surveyors, the RDO acknowledged that the RD should have gathered and updated the resident's dietary preference to be more specific and resident centered. At that time, The RDO informed the surveyors that the resident was ordering from the select menu as opposed to the therapeutic diet menu. The menus were available at the main lobby. The resident placed meal orders and did not receive all the choices from select menu because it would have been replaced with therapeutic diet. The RDO informed the surveyor that moving forward the resident's menu would be delivered to their room. Furthermore, the RDO stated that the facility conducted a facility wide audit to ensure all resident's preferences were included into their care plan. The RDO further acknowledged that the RD should have recommended appropriate diet to the physician based on the resident's health condition and laboratory values. A review of the facility provided policy Resident Food Preferences revised July 2017, included under policy statement that individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the residents or representative's consent. Under policy interpretation and implementation: 1. Upon the residence admission the dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The dietitian and the nursing staff assisted by the physician will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 7. The resident has the right not to comply with the therapeutic diets. 8. If the resident refuses or is unhappy with his or her diet the staff will create a care plan that the resident is satisfied with. A review of the undated Clinical Dietician Job Description under responsibilities and duties included consult with physician and other health care personnel to conduct independent assessment as to the dietary restrictions and nutritional needs of the residents. Communicate with residents to assess overall nutrition and provide individualized assessments. NJAC 8:39-17.4 (c), (e)

Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) used COVID test kits were not stored inside the Central Bath (where staff provides showers to residents) and b) sharp container was sealed and replaced with a new container when reached the full line (75% to 80% full) according to the standard of practice and facility policy. This deficient practice was evidenced by the following: On 8/02/23 at 9:02 AM, the survey team entered the facility and there was a posted sign on the door upon entry that there was a COVID case in the facility. The Receptionist instructed the surveyors to use the kiosk (automated health screening for COVID-19 questions). Later on, the Director of Nursing (DON) informed the surveyors that there was a COVID outbreak at the facility, with two residents remained in isolation. On 8/08/23 at 9:30 AM, the surveyor and the Housekeeping Director (HD) went to [NAME] Central Bath (CB), and later on, the District Manager (DM) followed. The surveyor, HD, and DM both observed inside the [NAME] CB that there was one covered garbage receptacle with a red plastic bag inside, and inside the red plastic bag were multiple used COVID-19 test kits. On that same date and time, the surveyor asked the HD and the DM if it was appropriate for the used COVID-19 test kit garbage to be inside the CB, and both the HD and the DM did not respond. On 8/08/23 at 9:35 AM, the surveyor, HD, and the DM went to South Central CB and observed the sharp container attached to the wall was above the full line (the line where the sharp container should have been replaced for safety). Inside the sharp container were multiple different colors of used razors and different kinds of used syringes. The surveyor asked the HD who was responsible for replacing the sharp container with a new one once reached the full line, and the HD stated that she was not sure but it was not their responsibility (Housekeeping Department). The HD stated that it was probably Nursing's responsibility to replace the sharp container when full. On that same date and time, the HD called the Unit Manager/Registered Nurse (UM/RN). The UM/RN went to South CB and saw the sharp container. The UM/RN acknowledged that the sharp container should have been replaced because it was full. The UM/RN informed the surveyor that she did not know who was responsible for replacing the sharp container and will have to call the Supply Clerk (SC) who also had the key to remove the full sharp container. Later on, the UM/RN stated that it was probably the Infection Preventionist Nurse (IPN) responsibility to check and replace the sharp container. At 9:46 AM, the SC with a key to the sharp container met with the surveyor, UM/RN, and HD in South CB. The SC also stated that it was the IPN's responsibility to check the sharp container and replace it. Furthermore, the surveyor asked the UM/RN why it was important to replace the sharp container when it was above the full line (above 75% to 80%). The UM/RN stated that it was important because it was for the safety of the staff and infection control prevention. On 8/08/23 at 11:48 AM, the surveyor in the presence of another surveyor interviewed the IPN. The IPN informed the surveyors that she was not responsible for replacing the sharp containers, but when I do rounds for infection control and observe it full, I notify the nurse. The IPN stated that part of her responsibility was to rounds for infection control at the facility which included the Central Baths. She further stated that I don't remember the last time I did rounds for the bath area for south and west stations. On that same date and time, the surveyor notified the IPN of the above findings regarding the sharp container and the used COVID-19 test kits garbage receptacle in the CB. On 8/08/23 at 12:06 PM, the surveyor and the IPN went to [NAME] CB and observed the garbage container with a red plastic bag with multiple used COVID-19 test kits inside. The surveyor asked the IPN if the used COVID-19 test kits should be inside the [NAME] CB, and the IPN stated that she will get back to the surveyor because she was not sure. On that same date and time, the IPN stated that it was not her responsibility to replace the sharp container. She further stated that it was an expectation that when it was above the line (full line), whoever put the last one beyond the full line should be the one to report to the nurse and the nurse should replace it with a new one (new sharp container). She acknowledged that it was the Certified Nursing Aides (CNAs) and nurses who use the sharp container in the CB and they (nurses and CNAs) were responsible for the sharp container to prevent bloodborne pathogens (microorganisms such as viruses or bacteria that are carried in the blood and can cause disease in people) related infections. On 8/08/23 at 12:38 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON). The surveyor notified the facility management of the above findings. On 8/09/23 at 12:03 PM, the survey team meet with the LNHA, DON, and RDO. The LNHA stated that according to the facility's policy, the Maintenance designated person was responsible to check and replaced full sharp containers. The RDO stated that the Maintenance Director was the designated Maintenance person who missed it, and it should have been replaced because it was full. On 8/15/23 at 12:16 PM, the survey team met with the LNHA, DON, and RDO. The surveyor followed up facility's response concerning the used COVID-19 test kits inside the [NAME] CB. The RDO stated that the used COVID kits should not be there, and not to be stored inside the CB. A review of the facility's Sharps Disposal Policy that was provided by the RDO with a revised date of January 2012 included that during use, containers for contaminated sharps will be handled as follows: designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. On 8/15/23 at 12:54 PM, the survey team met for an Exit Conference with LNHA, DON, and RDO. The facility management had no additional information provided. NJAC 8:39-19.4

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe and sanitary environment in 1 (one) of 1 (one) laundry room in accordance with the facility procedures. This deficient practice was evidenced by the following: On 8/15/23 at 8:47 AM, the surveyor toured the laundry room in the presence of the Housekeeping Director (HD), District Manager (DM), and Laundry Staff (LS). The surveyor observed in the drying area and folding area of the laundry room an electric fan that was on the wall that was in use and vent#1 above the ceiling with an accumulation of white substance and dust wherein below were folded clean towels, linens, blankets, and house gowns. There was also a cable wire connected to a wall with an accumulation of dust. The surveyor asked the housekeeping management and LS what was above the folded clean towels, linens, blankets, and gowns, and the DM stated that was the vent with lint. The surveyor asked if it was appropriate that the electric fan was in use while there was an accumulation of lint above the cleaned supplies, and both housekeeping management and LS did not respond. On that same date and time, the surveyor observed the laundry room floor with brown and black scattered discoloration of dried substances and an accumulation of dust. The surveyor also observed in the presence of the HD, DM, and LS the second and third vents near the exit door next to the drying area with an accumulation of dust. On 8/15/23 at 10:29 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON ), and the surveyor notified the facility management of the above findings. A review of the facility's Complete room clean checklist that was provided by the DM revealed that high dusting included ceiling/wall corners. Room cleaning should also include dust cable wires and dust/mop floors. On 8/15/23 at 12:16 PM, the survey team met for an Exit Conference with the LNHA, DON, and Regional Director of Operations (RDO). The facility management had no additional information provided. NJAC 8:39-31.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to: a) ensure a safe, clean, comfortable, and homelike environment for 2 (two) of 7 (seven) residents, (Residents #69 and #143) and b) ensure that the residents Central Bath (use for shower by the residents) was safe, clean, and not used as a storage room for 2 (two) of 2 (two) Central Baths (CB) observed during environment tour. This deficient practice was evidenced by the following: 1. On 8/02/23 at 9:02 AM, the survey team entered the facility and there was a posted sign on the door upon entry that there was a COVID case in the facility. The Receptionist instructed the surveyors to use the kiosk (automated health screening for COVID-19 questions). Later on, the Director of Nursing (DON) informed the surveyors that there was a COVID outbreak at the facility, with two residents remained in isolation in room [ROOM NUMBER]. The surveyor reviewed the medical records of Resident #69. The admission Record (AR or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to other abnormalities of gait and mobility, COVID-19 (also known as coronavirus), chronic obstructive pulmonary disease unspecified (COPD; a group of lung diseases that block airflow and make it difficult to breathe), unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), depression unspecified, and peripheral vascular disease unspecified (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/04/23 revealed that the Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognition was intact. A review of the provided Detailed Census Report for August 2023 by the Licensed Nursing Home Administrator (LNHA) revealed that Resident #69 was in room [ROOM NUMBER]W-D (room [ROOM NUMBER] [NAME] wing bed D) from 8/01/23 through 8/04/23 and in room [ROOM NUMBER]W-A (room [ROOM NUMBER] [NAME] wing bed A) from 8/05/23 through 8/08/23. On 8/08/23 at 8:37 AM, the surveyor went to see Resident #69 in room [ROOM NUMBER] and the resident was not there. The Registered Nurse (RN) informed the surveyor that she was the assigned nurse of the resident and that Resident #69 was moved back to their room in 12 A (by the door). The RN further stated that she was unable to remember when the resident was moved. On 8/08/23 at 8:39 AM, the surveyor observed Resident#69 seated on their bed with oxygen in use. The resident informed the surveyor that the resident was taken off the isolation from room [ROOM NUMBER] last Saturday (8/05/23) where the resident stayed for a total of 12 days and now returned to their previous room (room [ROOM NUMBER]). The resident stated that he/she had an unpleasant experience in room [ROOM NUMBER] because the room was not cleaned for 8 (eight) days by housekeeping staff. The resident further stated that he/she had also seen ants, the garbage was full because no one picked it up, and the floor was dirty. The resident stated that it seems the staff was hesitant to enter the room because they have to gown up (to use PPE or personal protective equipment). On 8/08/23 at 8:51 AM, the surveyor went back to room [ROOM NUMBER] and observed the three residents inside the room. Beds A, B, and C were occupied. Bed D was unoccupied (this was the bed where Resident #69 came from). Certified Nursing Aide#1 (CNA#1) was inside the room, left, and later came back. CNA#1 informed the surveyor that she was the regular aide of room [ROOM NUMBER] and just came back for personal reasons. Both the surveyor and CNA#1 observed the environment inside room [ROOM NUMBER]. CNA#16 stated that the room needs cleaning. The following were observed in each bed in room [ROOM NUMBER] in the presence of CNA#1: Bed A=surrounding the flooring area had a brown substance and an accumulation of dust. The top closet with an accumulation of dust and had one pillow with no pillowcase cover. CNA#1 stated that the pillow was considered dirty, otherwise, it should not be on top of the closet. The privacy curtain was not properly installed, some hooks were out of the railing. The overhead light with dust accumulation. Bed B=scattered pieces of paper and tissues, a wet floor and the two garbage receptacles both uncovered near the bathroom were almost full of garbage. Bed C=the surrounding bed and environment with an accumulation of dust on the floor and some scattered pieces of small papers and tissues. The privacy curtain was not properly installed, some hooks were out of the railing. Bed D=there was a basin under the bed, the bed was made (with a bed sheet, linen, and blanket) with two pillows, one pillow with a pillowcase, and the other one had no pillowcase. On top of the bed a magazine and one sock with Resident#5's name on it, a plastic bag, towel, and gown. At that time, the CNA stated that I don't know why it was there, and that if the bed was clean there should be no magazines and other things on top of the bed and the basin should not be below the bed. CNA#1 informed the surveyor that Resident #5 was the one in Bed A. On that same date and time, the surveyor asked the CNA to open the bed D nightstand table, CNA#1 showed the surveyor the open nightstand table with small pieces of paper and an accumulation of dust. The CNA used her bare hand to wipe the inside drawer and the CNA stated that the table should have been cleaned. The CNA also confirmed and acknowledged the high dusting on the head part light of bed D and the top of bed D closet. Then the CNA opened bed D's closet and found two crumpled diapers and a pack of wipes, on top of the closet was a wheelchair cushion brown in color and a splint. The CNA stated that it (crumpled diapers, pack of wipes, wheelchair cushion, and the splint) should not be there. The inside closet was observed with accumulation of dust as confirmed by the CNA. Furthermore, the floor around bed D had scattered pieces of paper and brownish discoloration. The side wall of the window with a brownish scattered dried lumpy substance which the CNA acknowledged and stated It should have been cleaned. The vent inside the room with an accumulation of dust. The room [ROOM NUMBER] bathroom's garbage receptacle was also almost full and the vent inside the bathroom with an accumulation of dust which CNA#1 confirmed. On 8/08/23 at 9:12 AM, the surveyor interviewed the Housekeeping Director (HD) in the housekeeping office; who informed the surveyor in the presence of the District Manager (DM) that she's been working for two months as a contracted employee. The HD stated that the housekeeping department was all contracted employees. The HD further stated that there were two housekeepers in the 7-3 shift, one for North and one for South, and the two housekeepers split the [NAME] wing. In addition, the HD stated that there was another housekeeper who comes in for the 12 PM-8 PM shift. On that same date and time, the HD informed the surveyor that the isolation rooms were the last to be cleaned every day. The HD stated that there was a checklist that the housekeepers log after cleaning the room and it was her responsibility as HD to check if rooms were cleaned. On 8/08/23 at 9:24 AM, the surveyor and the HD went to room [ROOM NUMBER] and both observed the above concerns with dust accumulation, chair cushion and pillows on top of the closets, vents with dust, garbage receptacles, personal belongings on top of bed D, and the curtains in bed A and C. The HD stated that the room needs some cleaning and acknowledged the surveyor's concern. On 8/08/23 at 01:41 PM, the surveyor reviewed the documents provided by the Regional Director of Operations (RDO) about the [name redacted] Pest Control & Termite report for the service date of 7/31/23 revealed that room [ROOM NUMBER] was inspected and treated for ants. The report also included that residents stated seeing ants in bathroom and by windows. Two small odorous ants (also called sugar ants, are one of the most common types of ants found trailing through kitchens; this ant is especially attracted to sweets, such as fruit juices and pastries, but it will also eat a variety of foods, including meats and pastries) were seen crawling in bathroom . On 8/09/23 at 01:24 PM, the surveyor interviewed the HD and the DM in the presence of another surveyor regarding the environmental concerns in room [ROOM NUMBER]. The HD acknowledged that the room was not clean and the HD agreed that the floor was not cleaned well when both the surveyor and the HD saw room [ROOM NUMBER]. The HD stated that according to the cleaning checklist that was provided to the surveyor, it showed that the housekeepers went to room [ROOM NUMBER] to clean, Now I know we should be checking when the housekeeper cleaned the room because they probably cleaned the room but not properly. At that same time, the HD informed the surveyors that she knew the room needed to be cleaned on Monday (8/07/23) which was why she asked the Housekeeper (HK) to clean room [ROOM NUMBER] as part of the HK's responsibility. On 8/09/23 at 01:48 PM, the surveyor in the presence of another surveyor and HD interviewed the HK. Later on, HD left the conference room and had to call CNA#2 to translate because HK speaks Creole. Afterward, the surveyor in the presence of another surveyor and CNA#2 interviewed the HK. The HK informed the surveyors via translator CNA#2 that on Monday (8/07/23) that she knew that she had to clean room [ROOM NUMBER] as part of her assignment. The HK stated that she cleaned room [ROOM NUMBER] beds A, B, and C environment except for bed D. She further stated that she did not check bed D's nightstand table and closets because she thought it was clean already because there was no resident on bed D. At that same time, the HK informed the surveyors that whoever moved the resident last week should have cleaned the room. The HK stated that she knew that Resident #69 was moved from room [ROOM NUMBER] bed D to room [ROOM NUMBER] bed A. She further stated that also on Monday (8/07/23) that she saw beds A and C's privacy curtain hooks were not properly installed to the railing, and it was been like that since last week. 2. On 8/02/23 at 11:06 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and the DON in the presence of the RDO the whereabouts of Resident #143 and the RDO informed the surveyor that the resident was discharged (d/c) on 01/27/22 to another facility. The surveyor reviewed the medical records of Resident #143 as follows: The AR reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to unspecified cerebral infarction (also known as stroke), type two diabetes mellitus with unspecified complications, muscle weakness (generalized), unspecified abnormalities of gait and mobility, cognitive communication deficit, depression unspecified, and essential hypertension (high blood pressure that is not due to another medical condition). The admission MDS with an ARD of 12/30/21 revealed the Section C BIMS score of 15 out of 15 which indicated that the resident's cognition was intact. A review of the provided Detailed Census Report for January 2022 by the LNHA revealed that Resident #143 was in room [ROOM NUMBER]W-A (room [ROOM NUMBER] [NAME] wing bed A) from 01/01/22 through 01/13/22 and in room [ROOM NUMBER]W-A (room [ROOM NUMBER] [NAME] wing bed A) from 01/14/22 through 01/26/22. A review of the 02/09/22 attached document to the phone interview of another surveyor to the resident's Power of Attorney (POA) revealed that according to the POA, the facility shower was used as storage. 3. On 8/08/23 at 9:30 AM, the surveyor and the HD went to [NAME] CB (WCB), and later on, the DM followed. The surveyor, HD, and DM both observed inside the WCB that there were two black covered bins (used as garbage disposal inside the resident's room on isolation) one with plastic inside and one without. The black covered bin with plastic inside had a white paper on top with information should be retained inside the resident's room. Inside the black covered bin were multiple soiled towels and gowns. Also, there was one wheelchair inside the WCB. On that same date and time, the surveyor asked the HD and the DM if it was appropriate for the used COVID-19 test kit garbage to be inside the WCB and stored in two black covered bins and a wheelchair, and both the HD and the DM did not respond. On 8/08/23 at 9:35 AM, the surveyor, HD, and DM went to South CB (SCB) and observed in one area inside the SCB next to the shower room there were two wheelchairs (w/c), two commodes, one hoyer lift, overflow of soiled personal clothing of residents inside a big receptacle and unable to close due to overflow, there was a stuffed toy on top of one commode. The HD informed the surveyor that the two w/c were considered dirty and once clean should be moved to the clean utility room. The DM acknowledged that the soiled personal clothing of the residents was overflowing from the receptacle and should have been picked up by the laundry staff. On that same date and time, the surveyor, HD, and DM observed in the shower area that a radiator cover was not properly installed and was open. The DM stated that he will call Maintenance to fix it and that it should not be like that. In the second shower room observed the ceiling open area and the DM stated that was a small panel access that was next to a vent. The DM stated that it should not be left open. The surveyor observed the DM immediately screwed the small panel area. At this time, the surveyor asked the HD and the DM who was responsible for the central baths, and the HD stated that it should have been checked by the assigned housekeeper. On 8/08/23 at 12:38 PM, the survey team met with the RDO, LNHA, and DON and were made aware of the above findings and concerns. On 8/09/23 at 12:03 PM, the survey team meet with facility LNHA, DON, and RDO. The RDO stated that there should be no equipment in the CB, everything now was removed except for the commode, and should not be used as a storage room. On 8/14/23 at 11:18 AM, the surveyor and the Maintenance Director went inside the SCB. During an interview of the surveyor with the Maintenance Director, the Maintenance Director stated that he was aware of the surveyor's concern regarding the cover of the radiator and the small panel near the vent in the shower areas. The Maintenance Director informed the surveyor that it was not the first time because it happened maybe two months ago and had to fix it because the CNA who provided the shower to the resident accidentally bumped it with the shower chair and the cover came out. He stated that when the surveyor saw it on 8/08/23, he was not notified by the staff, not until the surveyor's inquiry. He further stated that staff should notify him immediately if that happen because it was considered a hazard to staff and residents. On that same date and time, the Maintenance Director informed the surveyor that it was his fault that the small panel was left open near the vent because two days ago he was fixing something on it and probably I did not close it the right way. The surveyor asked Maintenance Director why is it important the small panel be closed at all times. The Maintenance Director stated that it was considered a hazard because any animals can get inside. He further stated that the cover was for the water valves in the ceiling. A review of the provided facility's 5-Step Daily Patient Room Cleaning dated 01/01/2000 the DM included that 5-Step Patient Room Cleaning Procedure: a. Empty Trash=collect trash from all rooms as first priority . d. Dust Mop=the entire floor must be dust mopped-especially behind dressers and beds . e. Damp Mop=the most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily A review of the Discharge Room Cleaning protocol that was provided by the DM included the following: Purpose: To have a system that ensures that once a patient is discharged , the room is disinfected on a timely basis. This will allow the admission of the next resident to a clean and sanitized room. Discharge Cleaning Procedure: disinfect all high dusting areas and walls using germicide solution; completely clean the bed, including mattress, frame, springs, headboard, and handrails; damp wipe and disinfect dressers (inside and out), bedside tables; be sure the closet is emptied and disinfected . Items for discussion: if the patient is simply being moved to another room, many times moving the bed and dresser with the patient is a better solution. On 8/15/23 at 12:54 PM, the survey team met for an Exit Conference with LNHA, DON, and RDO. The facility management had no additional information provided. NJAC 8:39-31.3, 31.4(a,c,f), 31.8(c)(13)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 8/02/23 at 11:01 AM, Resident #7 was observed sitting in a wheelchair, ambulating within their room and was conversant. At that time, the resident informed the surveyor about previous concerns and stated there weren't enough aids to pass the meal trays that food was received cold at times. The surveyor reviewed the medical record for Resident #7. A review of the AR reflected the resident was admitted to the facility with diagnoses that included acute chronic diastolic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus (DM), morbid (severe) obesity due to excess calories, chronic kidney disease, hypercholesteremia (high levels of cholesterol), hypertension (high blood pressure) and gout (caused by build up of uric acid in the body). The MDS dated [DATE] showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the requested staffing for the weeks of 01/23/2022 to 01/29/2022 showed that the NJDOH Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -01/23/22 had 8 CNAs for 102 residents on the day shift, required at least 13 CNAs. -01/24/22 had 7 CNAs for 102 residents on the day shift, required at least 13 CNAs. -01/25/22 had 8 CNAs for 102 residents on the day shift, required at least 13 CNAs. -01/26/22 had 7 CNAs for 102 residents on the day shift, required at least 13 CNAs. -01/27/22 had 9 CNAs for 101 residents on the day shift, required at least 13 CNAs. -01/28/22 had 7 CNAs for 96 residents on the day shift, required at least 12 CNAs. -01/29/22 had 5 CNAs for 96 residents on the day shift, required at least 12 CNAs. Review of the requested staffing for the weeks of 11/20/2022 to 11/26/2022 showed that the NJDOH Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -11/20/22 had 7 CNAs for 88 residents on the day shift, required at least 11 CNAs. -11/21/22 had 9 CNAs for 87 residents on the day shift, required at least 11 CNAs. -11/22/22 had 8 CNAs for 86 residents on the day shift, required at least 11 CNAs. -11/23/22 had 10 CNAs for 86 residents on the day shift, required at least 11 CNAs. -11/24/22 had 9 CNAs for 86 residents on the day shift, required at least 11 CNAs. -11/25/22 had 9 CNAs for 86 residents on the day shift, required at least 11 CNAs. -11/26/22 had 9 CNAs for 87 residents on the day shift, required at least 11 CNAs. A review of the facility provided policy titled, Staffing, Sufficient and Competent Nursing with a reviewed date of March 2023, included the following: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation Sufficient Staff 1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating planning and implementing resident care plans; and d. responding to resident needs . 4. Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. 5. Nurse aides/nursing assistants are individuals providing nursing or related services to resident in the facility, including those who provide services through an agency or under a contract with the facility. Licensed health professionals, registered dieticians, paid feeding assistants and individuals who volunteer to provide nursing or related services without pay are not considered nursing assistants and are not posted or reported as direct care staff. 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. 7. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. 8 Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. On 8/15/23 at 12:54 PM, the survey team met for an Exit Conference with LNHA, DON, and RDO. The facility management had no additional information provided. N.J.A.C. 8:39-27.1(a) Complaint # NJ00159269, NJ00160307, NJ00164302, NJ00152188 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 resident's 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 and 3-11 PM shifts were staffed to provide the ADLs (activities of daily living) with regard to toileting need and assistance in distribution of meal trays for 2 (two) of 4 (four) residents, (Residents#143 and #7) 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 8/02/23 at 9:00 AM, the surveyors entered the facility and observed that the Nursing Home Resident Care Staffing Report that was posted at the reception desk for the staffing of the facility included the following: 8/02/2023-Day Shift; Current Resident Census: 92; Certified Nurses Aide (CNA) # of Staff-10; Staff to Resident Ratio-1 CNA:9.2 Residents. The facility staffing did not meet the required minimum direct care staff-to-shift ratios as mandated by the state of NJ. On 8/02/23 at 9:53 AM, the surveyor toured the North wing unit of the facility which was a locked unit for cognitively impaired residents. The surveyor interviewed the North wing Unit Manager/Registered Nurse (UM/RN) regarding the staffing for that unit. The UM/RN stated that the resident census was 43 and that 4 (four) CNAs were working on the unit. The surveyor calculated the staff-to-resident ratio and it was 1 (one) CNA to 10.8 residents. The North wing unit was not staffed to meet the minimum direct care staff-to-shift ratios as mandated by the state of NJ. On 8/03/23 at 12:31 PM, the surveyor toured the North wing unit of the facility. The surveyor interviewed the North wing UM/RN regarding the staffing for that unit. The UM/RN stated that the resident census was 43 and that 4 (four) CNAs were working on the unit. The surveyor calculated the staff-to-resident ratio and it was 1 (one) CNA to 10.8 residents. The North wing unit was not staffed to meet the minimum direct care staff-to-shift ratios as mandated by the state of NJ. On 8/08/23 at 01:24 PM, the surveyor requested the Licensed Nursing Home Administrator (LNHA) to provide the CNA assignment sheets for the North wing unit for the weeks of 02/13/22, 02/27/22, 10/23/22, 10/30/22, 11/6/22 and 5/14/23. On 8/10/23 at 01:12 PM, in the presence of another surveyor, the surveyor interviewed the Staffing/Ancillary Coordinator (S/AC) regarding staffing. The S/AC stated that she did the staffing, ordered supplies, and sometimes worked as a CNA. She stated that she staffed the building according to the mandated ratio depending on the facility census. The S/AC stated the correct ratios for each shift and was aware of the day shift ratio of 1 (one) CNA to 8 (eight) residents. The surveyor then asked the S/AC if she staffed the CNAs for the census of the building or the census for each unit. The S/AC stated that she normally staffed the CNAs for the census of the building. She added that some days the facility met the ratio and sometimes they did not. On that same date and time, the surveyor then asked how the North wing unit would be staffed. The S/AC stated that if the census would be 48 then there would be 6 (six) CNAs. The surveyor notified the S/AC that the North wing unit had 4 (four) CNAs on 8/02/23 and 8/03/23. The S/AC stated that she was not sure why the unit was short of the mandated ratio. The surveyor then asked the S/AC if she notified anyone if the staffing for a day did not meet the minimum direct care staff-to-shift ratios as mandated. The S/AC stated that she would let the Director of Nursing (DON) know. A review of the facility provided CNA assignment sheets and census report for the North wing unit included the following for the day shift: On 02/13/22 there were 3 CNAs with a census of 45. The ratio was 1 CNA to 15 residents. On 02/19/22 there were 3 CNAs with a census 46. The ratio was 1 CNA to 15.3 residents. On 10/23/22 there were 3 CNAs with a census 45. The ratio was 1 CNA to 15 residents. On 10/27/22 there were 3 CNAs with a census 45. The ratio was 1 CNA to 15 residents. On 10/29/22 there were 3 CNAs with a census 45. The ratio was 1 CNA to 15 residents. On 10/30/22 there were 3 CNAs with a census 45. The ratio was 1 CNA to 15 residents. On 11/01/22 there were 3 CNAs with a census 45. The ratio was 1 CNA to 15 residents. On 11/6/22 there were 3 CNAs with a census 47. The ratio was 1 CNA to 15.7 residents. On 12/27/22 there were 3 CNAs with a census 46. The ratio was 1 CNA to 15.3 residents. On 12/30/22 there were 3 CNAs with a census 46. The ratio was 1 CNA to 15.3 residents. On 12/31/22 there were 2 CNAs with a census 44. The ratio was 1 CNA to 22 residents. On 5/11/23 there were 3 CNAs with a census 42. The ratio was 1 CNA to 14 residents. On 5/15/23 there were 3 CNAs with a census 43. The ratio was 1 CNA to 14.3 residents. On 5/16/23 there were 3 CNAs with a census 41. The ratio was 1 CNA to 13.7 residents. On 5/17/23 there were 3 CNAs with a census 43. The ratio was 1 CNA to 14.3 residents. On 5/19/23 there were 2 CNAs with a census 43. The ratio was 1 CNA to 21.5 residents. On 5/20/23 there were 3 CNAs with a census 43. The ratio was 1 CNA to 14.3 residents. On 8/14/23 at 11:03 AM, the surveyor interviewed the North wing UM/RN regarding the staffing of the unit. The UM/RN stated that the North wing unit was usually staffed with 4 (four) or 5 (five) CNAs depending on the census. She added that for a census of 46, there would be 5 (five) CNAs and a census of 41 or 42 might have 4 (four) CNAs. The surveyor then asked the UM/RN if she was aware of the minimum direct care staff-to-shift ratios as mandated by the state of NJ. The UM/RN stated that the day shift was 1 (one) CNA to 8 (eight) residents. On that same date and time, the surveyor then asked the UM/RN if she was aware that the facility was not meeting the ratio for her unit. She stated that she was aware. The surveyor then asked the UM/RN if she notified anyone when the unit did not meet the ratio. She stated that she would let S/AC, DON, and Human Resources know. She added that they were trying to hire more CNAs. On 8/14/23 at 11:12 AM, the surveyor interviewed the DON regarding if she was involved with staffing the facility. The DON stated that she was involved to a certain extent and that she was aware of the staff-to-resident ratios. The surveyor then asked the DON if the facility was meeting the ratios. The DON stated that the facility generally met the ratio for the building. The surveyor then asked if she was aware that the North wing unit was not meeting the ratio. The DON stated that she looked at the schedule and that she would have extra staff help on the unit. The surveyor asked if those extra staff would help with direct care. The DON stated that they could help with direct care but that they would not be listed on the assignment sheet. On 8/14/23 at 01:34 PM, in the presence of the survey team, the surveyor notified the Regional Director of Operations (RDO) and DON the concern that the North wing unit was not sufficiently staffed. On 8/14/23 at 01:46 PM, in the presence of the survey team and DON, the RDO stated that it was a challenge. She stated that the facility met the acuity for nurses but that they did not always meet the CNA ratio. 2. On 8/02/23 at 11:06 AM, the surveyor asked the LNHA and the DON in the presence of the RDO the whereabouts of Resident #143 and the RDO informed the surveyor that the resident was discharged (d/c) on 01/27/22 to another facility. The surveyor asked for the closed record, grievances, incidents/accident reports, and reportable events since the last recertification and the facility management stated that they will get back to the surveyor. The surveyor reviewed the medical records of Resident #143 as follows: The admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to unspecified cerebral infarction (also known as stroke), type two diabetes mellitus with unspecified complications, muscle weakness (generalized), unspecified abnormalities of gait and mobility, cognitive communication deficit, depression unspecified, and essential hypertension (high blood pressure that is not due to another medical condition). The admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 12/30/21 revealed that the Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognition was intact. The aMDS in Section G Functional Status for toilet use was coded 3/2 (extensive assistance with one person physical assist). The aMDS in Section H Bladder and Bowel was coded 2/2 (urinary and bowel continence both frequently incontinent). A review of the 02/09/22 at 3:42 PM phone interview of another surveyor to the resident's Power of Attorney (POA) revealed that according to the POA, the resident had five fall incidents and 4 (four) out of 5 (five) when transferring the resident to the toilet with no injuries per staff. Also, the POA was not sure if staff members were present during toilet use because the resident had to wait to be toileted. A review of the provided Detailed Census Report for January 2022 by the LNHA revealed that Resident #143 was in room [ROOM NUMBER]W-A (room [ROOM NUMBER] [NAME] bed A) from 01/01/22 through 01/13/22 and in room [ROOM NUMBER]W-A (room [ROOM NUMBER] [NAME] bed A) from 01/14/22 through 01/26/22. A review of the Full QA Report (Investigation Report) dated 01/14/22 that was provided by the RDO revealed that Resident #143 had a fall incident in the resident's bathroom at 3:00 PM, was found next to the toilet lying on the resident's right side by a staff member (Occupational Therapist). The investigation also showed that the full body assessment was done with no apparent injury noted and that the resident was educated on the use of the call bell and not to use the toilet by himself/herself. The assigned caregiver was CNA#1. A review of the provided nursing schedule for 01/14/22 by the RDO showed the following information: CNA#2 called off for the 7 AM to 3 PM South CNA shift, The total assigned CNA for the 7 AM-3 PM shift was 8.0, West wing with 1.0 CNA that included CNA#1's name, South wing with 3.0 CNAs that included Nurse Aide#1 (NA#1), NA#2, and CNA#3 Further review of the above nursing schedule for 01/14/22 showed that no one called off from the 7 AM to 3 PM shift for [NAME] wing and was originally scheduled for one CNA (CNA#1). A review of the provided [NAME] Wing CNA Assignment (7 AM-3 PM/Morning Shift) by the RDO showed Post 1 was CNA#1 had a total of 14 residents that included Resident #143, Post 2 was crossed out (no assigned CNA, and residents were divided to Post 1 and Post 3), and Post 3 was NA#1 had a total 15 residents. Further review of the provided [NAME] Wing CNA Assignment (3 PM-11 PM/Evening Shift) showed Post 1 was CNA#2 had a total of 14 residents that included Resident #143, Post 2 was crossed out, and Post 3 was CNA#3 had a total of 15 residents. Review of the requested staffing for the weeks of 01/09/2022 to 01/15/2022 showed that the NJDOH Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 2 of 7 overnight shifts as follows: -01/09/22 had 7 CNAs for 93 residents on the day shift, required at least 12 CNAs. -01/09/22 had 6 total staff for 93 residents on the overnight shift, required at least 7 total staff. -01/10/22 had 8 CNAs for 93 residents on the day shift, required at least 12 CNAs. -01/11/22 had 7 CNAs for 93 residents on the day shift, required at least 12 CNAs. -01/12/22 had 9 CNAs for 93 residents on the day shift, required at least 12 CNAs. -01/12/22 had 6 total staff for 93 residents on the overnight shift, required at least 7 total staff. -01/13/22 had 9 CNAs for 99 residents on the day shift, required at least 12 CNAs. -01/14/22 had 8 CNAs for 99 residents on the day shift, required at least 12 CNAs. -01/15/22 had 6 CNAs for 99 residents on the day shift, required at least 12 CNAs. On 8/14/23 at 11:07 AM, the surveyor interviewed the Registered Nurse (RN) at [NAME] wing 1 (one) unit. The RN informed the surveyor that she's been working in the facility as a full-time nurse in the [NAME] unit for 20 years. She further stated that there were 2 (two) units in the [NAME] wing; [NAME] wing 1 (one) unit from rooms one through nine and [NAME] wing 2 (two) unit from rooms 10 through 16. The RN stated that for the day shift (7 AM -3 PM) there should be three CNAs to cover for [NAME] 1 and 2 units and the same way for the 3 PM-11 PM shift. On that same date and time, the surveyor asked the RN if she knew about the NJ state mandated staffing ratio. The RN stated that she was not aware of the NJ nurse staffing ratio to residents in the facility but knew that there should be three CNAs assigned for 7 AM-3 PM and 3 PM-11 PM shifts because that was the practice in the facility. She further stated that there was short staff in the unit. The RN also stated that in the morning it was hard and CNA needs to attend to more residents. The RN was unable to determine which shift and if it was on weekdays or weekends the most short staff, but it happens. At that same time, the surveyor asked the RN if she remembered Resident #143. The RN stated that she was unable to remember Resident#143 because it was over a year and unable to remember the fall incident on 01/14/22. The RN acknowledged that she was the assigned nurse on that day for the 7 AM-3 PM shift. Later on, the surveyor then showed the [NAME] Wing CNA Assignment (7 AM-3 PM/Morning Shift) on 01/14/22 where she was assigned as the nurse and CNA#1 with 14 residents on Post 1 (one). The RN confirmed that was her name and that the CNA had 14 residents because Post 2 (two) had no CNA and had to divide the assignment on Post 2 (two) between Post 1 (one) and Post 3 (three) CNA. On 8/14/23 at 11:28 AM, the surveyor interviewed CNA#1 who was assigned on Post 1 (one), and the caregiver on the 01/14/22 fall incident of the resident who toileted self. The CNA informed the surveyor that she was a regular aide in the South unit for the 7-3 shift. The CNA stated that she was aware of the NJ Nurse Staffing ratio of CNA to resident which was 1 (one) CNA to 8 (eight) residents for the 7 AM-3 PM shift. She further stated that it was not being followed for some time and there was a short staff at the facility and was unable to specify specifics (weekdays, weekends, and what shift), she added, It's happening. The surveyor then asked the CNA if care was affected due to short staff in the facility and the CNA did not respond. On that same date and time, the surveyor asked CNA#1 if she had worked in the [NAME] unit, and CNA#1 stated she can not remember. Then the surveyor showed the CNA the [NAME] Wing CNA Assignment (7 AM-3 PM/Morning Shift) on 01/14/22 where she was assigned as the CNA with 14 residents on Post 1 (one). The CNA confirmed that was her name and she had 14 residents because Post 2 (two) had no CNA and had to divide the assignment on Post 2 (two) between Post 1 (one) and Post 3 (three) CNA. The CNA acknowledged that it was probably short staff which was why she was assigned to the [NAME] wing because she normally work at the South wing. At the same time, the surveyor asked the CNA to describe the [NAME] wing and the residents. CNA#1 stated that the [NAME] unit was considered subacute and of course, residents wanted to be toileted and helped all at the same time. The surveyor then asked the CNA if she remembered Resident#143 and the incident of fall on that same date that she was assigned on 01/14/22 when the resident was found on the floor in the bathroom in the resident's room when the resident toileted self. The CNA stated that she can not remember the 01/14/22 incident. On 8/14/23 at 01:02 PM, the survey team met with RDO and DON. The surveyor notified the facility management of the above findings with regard to the short staff and discussed the Facility assessment. The RDO stated that for the 7-3 shift, the facility follows the NJ mandates for staff to resident ratio of 1 (one) CNA to 8 (eight) residents. The RDO further stated that staffing was a challenge in the facility and acknowledged the concerns. A review of the Quality Assurance Performance Improvement (QAPI) Audit Review agenda for the month of January, February, and March 2023 that was provided by the LNHA revealed that in concern/problem, staffing compliance was included and that the compliance goal (# or percentage) for meeting the state regulations regarding staffing was left blank. Attached to the QAPI above was the QAPI Action Plan (QAPI/AP) dated 5/01/23 with a goal to meet the state staffing requirements while reducing the need for agency nursing staff. Included in the QAPI/AP was tabulated information that included: Tasks=to evaluate the current amount of nursing staff wherein to plot all nurse and CNA schedule templates based on assigned shifts Discipline (who will be involved)=LNHA, DON, HR Director, and Staffing Coordinator Target Date=started 5/01/23 Intervention/Progress/Resolution=was left blank

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented. Specifically, the facility: - failed to ensure residents on transmission-based precautions had signage posted outside their rooms to inform staff and/or visitors of the need for precautions for 7 (Residents #1, #2, #6, #7, #8, #9, and #10) of 9 residents observed for transmission-based precautions. - failed to ensure staff were fit-tested for the specific make, model, and size of N95 respirator masks that were in use. Findings included: 1. Review of a facility policy titled, Isolation - Categories of Transmission-Based Precautions, revised 10/2018, revealed, Transmission-Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected. The policy also indicated, 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE [personal protective equipment], and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. During initial rounds of the facility on 12/03/2022 at 10:28 AM, the doors to Rooms 1, 3, 5, 7, and 9 were observed to be closed and covered with plastic sheeting that covered the door frame. Down the middle of the plastic sheeting was a zipper. Outside each door was an isolation (ISO) cart with PPE. There was nothing posted on those doors to inform staff or visitors of isolation precautions. On 12/03/2022 at 10:30 AM, Licensed Practical Nurse (LPN) #1 was interviewed. LPN #1 stated the staff knew the above listed rooms were for the COVID-19 positive residents, since the doors had plastic over them. LPN #1 stated he knew what type of PPE was to be worn when he entered those rooms, even though there was no signage on the door. On 12/03/2022 at 11:00 AM, the Regional Director of Operations (RDO) was interviewed while walking past Rooms 1, 3, 5, 7, and 9. The RDO stated it was her expectation that each door should have a sign that indicated what type of isolation the residents were on and another sign to indicate what type of PPE was to be worn, along with how to don and doff the PPE correctly. Observations on 12/03/2022 at 3:40 PM revealed signs had been posted outside Rooms 1, 3, 5, 7, and 9, indicating the residents in those rooms were on droplet precautions. There was no signage to inform staff or visitors of what type of PPE to wear in those rooms, nor instructions for how to don and doff the PPE correctly. Observations on 12/03/2022 at 4:40 PM revealed there was still no signage posted to inform staff and visitors of the type of PPE to wear in rooms [ROOM NUMBER]. The doorways to rooms [ROOM NUMBERS] now had the additional signage that included the type of PPE to wear in those rooms and how to don and doff the PPE correctly. On 12/03/2022 at 5:43 PM, the Infection Preventionist (IP) Nurse was interviewed. The IP nurse stated it was her expectation that rooms for the COVID-19 positive residents had a stop sign and signage that indicated what type of precautions to follow in those rooms. She stated the facility educated the staff and visitors about what type of PPE should be worn, so she did not necessarily expect to see the donning/doffing sign on the door. On 12/03/2022 at 6:38 PM, the Director of Nursing (DON) was interviewed. The DON stated anyone who approached a doorway of someone on isolation should be aware of what was going on when they got to that door, based on the signage posted and by the plastic covering over the door with the zipper down the middle. The signage should be a stop sign that also indicated the type of precautions and another sign that stated what type of PPE was required in the room. The DON indicated the PPE sign should be a picture sign that showed what kind of PPE to use and how to put it on and take it off. On 12/03/2022 at 7:11 PM, the RDO was interviewed. The RDO stated her expectation was each COVID-19 positive room should have signage on the doors that indicated the type of precautions to follow in those rooms, as well as the proper PPE to wear and how to put it on and take it off. 2. Review of the facility policy titled, Respiratory Protection Program, dated 10/2020, revealed, Fit Testing Employees who are required to wear tight-fitting respirators will be fit tested: Prior to being allowed to wear any tight-fitting respirator; Annually; and When there are changes in the employee's physical condition that could affect respirator fit (e.g. [for example], obvious change in body weight, facial scarring, etc. [et cetera]). Employees will be fit tested with the make, model, and size of respirator that they will actually wear. The Program Administrator will ensure fit tests are conducted in accordance with any appropriate and OSHA [Occupational Safety and Health Administration]-approved protocol from Appendix A of the Respiratory Protection Standard: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppA. Review of OSHA Standard Number 1910.134 - Respiratory protection revealed, 1910.134(f) Fit testing. This paragraph requires that, before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece [mask], the employee must be fit tested with the same make, model, style, and size of respirator that will be used. On 12/03/2022 at 10:30 AM, Licensed Practical Nurse (LPN) #1 was interviewed. LPN #1 stated he had not been fit tested for the N95 mask he was wearing. The mask he was wearing was an HDX N95 respirator mask, size medium/large (M/L). Observations at this time revealed this was the type of mask that was present on five of the six isolation (ISO) carts for the residents who were on transmission-based precautions (TBP). The five carts for the COVID-19 positive residents were stocked with the HDX N95 mask, and the ISO cart for the residents on contact precautions was stocked with both the HDX N95 masks and the Makerite Sekura N95 masks. On 12/03/2022 at 4:52 PM, Certified Nursing Assistant (CNA) #4, CNA #5, and LPN #6 were all observed to be wearing the HDX N95 respirator masks, size M/L. All three were interviewed at this time and stated this mask was what was available on the ISO carts for them to use with residents who were COVID-19 positive. They stated it was not the mask they used when they were fit tested, but they did not know they needed to use the specific brand/size mask for which they were fit tested. CNA #5 stated she liked the soft mask that folded. CNA #4, CNA #5, and LPN #6 stated they did not know who stocked the ISO carts or where the masks came from. Review of a random sampling of Qualitative Fit Test Records for facility employees, including the record dated 07/12/2022 for CNA #5, revealed fit testing was completed using Makerite N95 masks. On 12/03/2022 at 5:43 PM, the Infection Preventionist (IP) Nurse was interviewed and stated she was unaware that when someone was fit tested for an N95 mask, they were tested for the specific make, model, and size of the mask. She stated it was the facility staffer who ordered supplies and that it was the IP Nurse's role to make sure N95 masks were being used with the COVID-19 positive residents. The facility staffer was not available for interview during the survey. On 12/03/2022 at 6:38 PM, the Director of Nursing (DON) was interviewed and stated it was her expectation that staff wore the N95 mask for which they were fit tested. The DON stated if the facility was going to change the type of N95 masks they were going to order, then all staff would need to be fit tested again for the new masks. She stated staff should only be wearing the masks for which they were fit tested. On 12/03/2022 at 7:11 PM, the Regional Director of Operations (RDO) was interviewed and confirmed that fit testing for an N95 mask was specific to the make, model, and size. The RDO stated if the facility staff were fit tested for the Makerite brand masks, it was her expectation to see all the employees wearing the Makerite masks and not the HDX masks. The RDO stated the company's corporate office had a stockpile of the Makerite N95 Sekura masks, and the RDO had no idea why someone would have ordered the HDX masks. New Jersey Administrative Code § 8:39-19.4(a)&(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) a resident in a broda chair was not positioned in a manner in which the broda chair acted as a physical restraint. This deficient practice was identified for 1 of 6 residents reviewed observed to be in broda chairs (Resident #34). The evidence was as follows: According to the facility's undated Use of Restraints policy included that, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition (i.e. side rails are put back down, rather than climbed over); and this restricts his/her typical ability to change position or place, that device is considered a restraint .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: .placing a resident in a chair that prevents the resident from rising; and placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising.Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve symptoms . Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). On 5/24/21 between 11:53 AM to 12:04 PM, two surveyors observed Resident #34 sitting in a Broda wheelchair (a specialized low-sitting recliner that has the ability to tilt in space and is typically used for positioning and comfort tension) in the common dining/activity area in front of the nursing station. The Broda chair had wheels that were in the locked position, and the resident was sitting in front of a dining table that was positioned against an affixed half wall. The surveyor observed the resident swing his/her legs over the arm rests of the broda chair in an attempt to get out of the broda chair. Because of the locked broda chair that was positioned against the affixed half wall, it prevented the resident from standing. The surveyor then observed the resident swing his/her legs on the other side of the arm rest. During that time, a staff member repositioned the resident in the locked broda chair and kept the resident in front of the table. The resident continued attempting to move their legs over the edge of the arms of the Broda chair and the resident was unable to stand. The resident was not offered an opportunity to stand up with assistance or ambulate when he/she attempted to swing his/her legs on either side of the broda chair. The surveyor observed the resident eat his/her lunch meal from at 12:12 PM when the meal trucks arrived to approximately 12:40 PM at the table in the locked broda chair. At that time, the surveyor attempted to interview Resident #34, but the resident did not respond in English. The surveyor reviewed the medical record for Resident #34. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/29/21, reflected the resident was not able to complete a brief interview for mental status (BIMS). The staff performed a cognitive assessment which reflected the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. In addition, the MDS reflected that the resident had functional abilities that required extensive assist with one person assisting to walk in the corridor and on the unit. In addition, the resident had no functional limitation in range of motion (ROM) and no impairment to the upper or lower extremities. According to the MDS, the resident had a walker as a mobility device. A review of the section to assess for the use of restraints, reflected that the resident utilized no physical restraints, including the use of a chair that prevents rising. A review of the resident's admission Record face sheet (an admission summary) revealed the resident had a diagnosis of dementia, anxiety disorder and muscle wasting and atrophy. A review of the resident's interdisciplinary care plan (IDCP) revealed that the resident had a focus of being at risk for falls related to confusion, gait balance problems and being unaware of safety needs. In addition, the IDCP reflected that the resident kept trying to get out of bed and chair unassisted with a date initiated of 3/22/21. The interventions that were initiated on 3/22/21 included to keep frequently used items within reach and anticipate and meet the resident's needs. The interventions initiated 3/23/21 were to allow the resident to sit by the nursing station and if restless ask the resident if toileting was needed. An intervention dated 5/3/21 was to remind the resident to use the rolling walker. The resident also had a focus of limited physical mobility related to weakness initiated 3/22/21 and a goal of increasing mobility by being able to ambulate 100 feet using the rolling walker with a target date of 6/15/21. The resident also had a focus of using anti-anxiety medications related to an anxiety disorder with a date initiated of 4/6/21 and an intervention of having someone sit with the resident when the resident was anxious and provide time for the resident to discuss feelings. The resident had an intervention initiated 5/21/21 to use a Broda chair when the resident was tired. A review of the medical record revealed that there was no assessment or consent providing risks versus benefits for the use of a Broda chair. A review of the physician Order Listing revealed a physician's order (PO) dated 3/22/21 for an Occupational Evaluation and treatment: five times a week for four weeks with no discontinuation date. In addition, there was a PO dated 4/30/21 for discontinuation of PT. There was no PO for the use of a Broda chair. On 5/27/21 at 9:22 AM, the surveyor observed Resident #34 sitting in a standard wheelchair. At that time a Certified Nursing Aide (CNA) stated to the surveyor that Resident #34 had asked her to use the bathroom in his/her primary language. She stated that the resident used to be in a broda chair but was re-evaluated and was now using a regular wheelchair. The CNA continued that the resident was a high fall risk and kept trying to stand up throughout the day. At that time, the surveyor observed the CNA assist the resident to a standing position, and had the resident hold on to the handle bars of the standard wheelchair. The resident ambulated by pushing the wheelchair in front of him/her to the bathroom with the CNA providing contact guard supervision. On 5/28/21 at 11:01 AM, the surveyor observed the resident sitting in the standard wheelchair in front of a table in the common area by the front of the nursing station. The surveyor attempted to interview the resident and the resident did not respond appropriately. On 5/28/21 between 11:06 AM and 11:17 AM, the surveyor interviewed the resident's family representative (FR) who stated that the resident had dementia, spoke mostly Spanish and was confused. The FR also stated that the resident had a fall that day when he/she stood up and went to use another resident's rolling walker. The FR added that the resident had been using a walker and lost the use of his/her legs at home because the resident had become weak. On 6/2/21 at 9:38 AM, the surveyor interviewed the Temporary Nursing Aide (TNA) who stated that he was familiar with Resident #34 when he had to monitor the common dining/activity area in front of the nursing station. The TNA stated that the resident frequently tried to stand up and walk on his/her own when it wasn't safe for him/her to do so. The TNA stated that he could speak some Spanish and would try to engage the resident in an activity when that occurred. On 6/2/21 between 9:40 AM to 9:46 AM, the surveyor observed a CNA propelling the resident in a wheelchair to the resident's room and asking in Spanish if the resident had to go to the bathroom. The surveyor observed the resident shake his/her head no in response. The CNA then asked in Spanish if the resident was cold and held up a sweater. The surveyor observed the resident shake his/her head in a yes response. The surveyor observed the CNA help the resident put on the sweater. The surveyor observed the CNA propel the resident in the wheelchair to the common dining/activity area by the nursing station and placed the resident in the wheelchair at a table with another resident sitting at the same table. On 6/2/21 at 9:46 AM, the surveyor interviewed the CNA who stated that she was the usual CNA for Resident #34 and was familiar with the resident. The CNA stated that the resident tries to stand up and walk on his/her own. The CNA added that she would assist the resident walking and sometimes had the resident use a rolling walker or hold onto the back of the wheelchair. The CNA also stated that the resident had been receiving physical therapy (PT) and thought the resident was still receiving PT. The CNA stated that the resident usually sat in a wheelchair. The CNA also stated that she had seen the resident in a Broda wheelchair a few times when she came on shift at approximately 7 AM. The CNA added that the resident sometimes had trouble sleeping and would get up at night so the night shift would put the resident in a Broda wheelchair when the resident had not wanted to go back to bed. The CNA added that she knew about the resident having trouble sleeping because the night shift would report the reason for the resident being in the Broda chair. The CNA stated that the Broda chair was a low-sitting recliner and was more comfortable. The CNA then stated that when the resident was in the Broda chair in the morning she would switch the resident to a standard wheelchair if agreeable or would walk the resident and then put the resident in a standard wheelchair. The CNA stated that the resident was usually in a standard wheelchair and several staff members would walk the resident. On 6/2/21 at 10:01 AM, the surveyor observed the Registered Nurse (RN) assisting the resident to walk around the common dining/activity area. On 6/2/21 at 11:17 AM, the surveyor observed the resident sitting in a standard wheelchair at a table with two other residents in the common dining/activity area. At that time, the resident slowly stood up and an alarm sounded. The Activity Director responded to the alarm and went to the resident and helped the resident back to his/her standard wheelchair. On 6/2/21 at 11:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she was familiar with the resident and that the resident liked to walk around a lot and needed assistance when walking. The LPN stated that she was unsure if the resident used a rolling walker. The LPN added that the resident had not been using a Broda wheelchair and usually sat in a standard wheelchair. The LPN also stated that she thought the physical therapy/occupational therapy (PT/OT) department decided which kind of chair was appropriate for a resident. On 6/3/21 at 10:02 AM, the surveyor interviewed the Occupational Therapist (OT) who stated that she was familiar with the resident. The OT added that she was responsible for wheelchair management. The OT stated that the resident received PT/OT from 3/22/21 until 4/30/21. The OT added that the resident was discharged from PT/OT services on 4/30/21 because the resident had reached maximum goals. The OT also stated that she thought the resident was sitting in a Broda wheelchair after the resident had a fall. The OT reviewed the PT/OT notes and was unable to define a date that the resident was assessed for the use of a Broda chair. The OT stated that there was a fall screen done by OT on 5/4/21 and thought the resident was in a Broda chair because the notes indicated that the resident had balance and positioning difficulties. The OT acknowledged that the OT notes had not reflected whether a Broda wheelchair was being used or an assessment for its use. The OT added that on 5/21/21 there was an assessment that the resident was evaluated for use of a standard wheelchair because the resident had improved sitting ability and positioning and balance had improved. The OT could not speak to the need for a PO from the physician. A review of the resident's OT Discharge summary dated [DATE] to 4/30/21 reflected that the discharge recommendation was a restorative nursing program (RNP) and the resident can safely complete functional transfers with supervision and minimal verbal cues. In addition, the Discharge Summary reflected that the CNA and nursing was educated. There was no assessment for the use of a Broda wheelchair. A review of the PT Discharge summary dated [DATE] to 4/30/21 reflected that the discharge recommendation was that a restorative program was established and trained. The PT Discharge Summary reflected that the resident was able to ambulate around the unit using a rolling walker with supervision. There was no assessment for the use of a Broda chair. A review of the investigative fall reports for the last six months reflected that the resident had several falls in the facility. On 6/3/21 at 9:55 AM, the Regional Director of Operations informed the surveyor that Resident #34 began using the Broda chair when the care plan indicated that he/she was supposed to use it when it was initiated on 5/21/21. She confirmed there was no formal assessment for the Broda chair, and no consent was provided to the surveyor. At 12:18 PM, the Regional Director of Operations stated in the presence of the survey team that the broda chairs were not used as a restraint to keep anyone from standing up. The facility administration including the Licensed Nursing Home Administrator and the Director of Nursing (DON) acknowledged that if a broda chair was locked in front of a table positioned against a wall, and the resident had the capability of standing up, it could prevent the resident from standing and result in a physical restraint for the resident. On 5/24/21 when the resident was attempting to stand out of the broda chair, he/she was not offered an opportunity to ambulate, but instead repositioned in the chair. The Regional Director of Operations stated that it wasn't purpose to restrain the resident when the two surveyors observed the resident trying to get out of the locked broda chair when it was against the table on 5/24/21, and indicated that because it wasn't intended to be used as a restraint, it wasn't a restraint. NJAC 8:39-27.1(c)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00141821 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) toilet a resident who was dependent on staff upon their request in a timely manner, b.) ensure an appropriate care plan for the resident's activities of daily living (ADL) toileting status, and c.) apply a barrier cream to prevent skin breakdown due to incontinence. This deficient practice was identified for 1 of 6 residents reviewed for ADL services (Resident #74). In addition, the facility failed to ensure table heights were of the appropriate level for residents eating in low-sitting broda chairs. This deficient practice was identified for 5 of 5 residents reviewed in Broda Chairs (Resident #9, #25, #34, #40 and #74) on 1 of 2 units (North unit). The evidence was as follows: 1. On 5/24/21 from 9:30 AM to approximately 1:15 PM during the initial pool/tour process, two surveyors interviewed two residents who requested to remain anonymous. One resident stated that staff are attentive to his/her needs, but residents that have dementia have to wait longer to get care. Another resident stated that sometimes during the night shift it takes up to two hours to get assistance. The resident denied an adverse outcome from having to wait two hours for assistance. On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a four ounce cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. At 12:07 PM, the surveyor observed that the resident was still in the dining room. At that time, the surveyor observed the resident attempt to stand up from the broda chair, and the Certified Nursing Aide (CNA) redirected the resident to sit back down. After the resident sat back down, the CNA propelled the resident in the broda chair to the center isle of the open dining room and two staff members moved a dining table in front of the resident. At 12:13 PM, the surveyor continued to observe Resident #74 in the locked broda chair. The resident pushed forward on the table, causing the table to move forward slightly. Then, Resident #74 began slowly sliding down in the broda chair, and two staff repositioned the resident back up in a seated position in the broda chair. At that time, the Registered Nurse/Unit Manager (RN/UM) asked the resident's assigned CNA to toilet the resident. At 12:16 PM, the surveyor observed Resident #74 still in the broda chair at the dining table. A Speech Language Pathologist (SLP) sat next to the resident at the table and began talking to him/her. At that time, the SLP called over the resident's assigned CNA to tell the CNA that Resident #74 was requesting to use the bathroom. The CNA replied to the SLP that she had just finished washing her hands and that she was about to pass out the lunch trays so she was not available to assist the resident to the bathroom. The CNA continued to pass out lunch trays to the other residents. (The CNA never told the SLP that she had just toileted the resident with the RN before the lunch trays came). The SLP then informed the resident's assigned Registered Nurse (RN) that Resident #74 had informed him that he/she had to use the bathroom. The RN addressed the SLP, and she proceeded to assist in the lunch service. The SLP observed that the resident was sliding out of the broda chair and two staff repositioned the resident to sit him/her into an upright position. The resident was seated at a table without other residents. At 12:25 PM, the surveyor observed an Activities Assistant place the resident's lunch tray in front of Resident #74 which included macaroni and cheese, chopped carrots, and mandarin oranges. The Activities Assistant opened a can of gingerale and placed it next to the resident's plate. The surveyor observed the resident eat some chopped carrots with his/her hand. The resident then reached for the gingerale and poured it all over his/her macaroni and cheese. The resident had not yet been taken to be toileted after his/her request. At 12:31 PM, the surveyor observed the resident pick up a fork and throw it on the floor. At 12:34 PM, the surveyor observed the Food Service Director (FSD) deliver another tray for the resident which included a hot dog on a bun. At 12:39 PM, the SLP sat with the resident and attempted to encourage the resident to eat the cut up hot dog. The resident did not show interest in eating. At 12:54 PM, the surveyor observed a staff member clean up the resident's lunch area. The resident had not yet been toileted by staff after he/she requested to use the bathroom at 12:16 PM, (This was a period of 38 minutes from the time the resident requested it, and 41 minutes since the RN/UM had asked the CNA to toilet the resident). At 12:55 PM, the surveyor interviewed the RN. The RN stated that Resident #74 was alert and oriented to self only and had that the resident had no sense of time because they had changed the resident's incontinent brief a little while ago. She stated that if any resident states that they have to go to the bathroom we respond right away but stated that they didn't do it this time because the resident is incontinent all of the time. She stated that sometimes the resident will ask to use the bathroom, and when they take him/her to the toilet, the resident does not void anyway. She stated that the resident was confused, and toileting usually happened after lunch anyway. She stated that she also didn't do it when the SLP asked her to because she was passing out the lunch trays and because the resident required two staff members to assist in toileting because of the resident's behaviors. She stated that she would do it after lunch. At that time, she saw that the resident's lunch had been cleaned up and the RN stated that she would take the resident to the bathroom now. At 1:00 PM, the surveyor observed the RN and the CNA propel the resident in the broda chair to toilet him/her. According to an electronic Progress Note (ePN) dated 5/24/21 indicated that the resident was toileted at 1:05 PM and the resident's incontinent brief was dry and did not go when placed on the toilet. (This was a period of 49 minutes from the time the resident requested to be toileted at 12:16 PM, and and 52 minutes from the time the RN/UM asked the CNA to toilet the resident at 12:13 PM.) The surveyor continued to review the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, muscle wasting and atrophy, and diabetes. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily which intruded on the privacy/ activities of others, and that he/she was always continent of bladder and bowel. A review of the resident's individualized comprehensive care plan reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia initiated on 4/30/21. Interventions were to Administer meds as ordered; Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion . The care plan also had a focus that he/she had a communication problem related to the resident's voice being of low volume. Interventions included to: Anticipate and meet my needs. Inventions if the resident began to wander included: If I am wandering assess for unmet needs hunger, toileting, thirst, boredom. It further included that the resident had diabetes and to monitor/document/report to MD as needed signs and symptoms of high blood sugar including: increased thirst, .frequent urination . It further included that the resident had an activity of daily living (ADL) deficit due to activity intolerance and dementia; For toileting it included that the resident was able to complete toileting with [Minimal Assistance]. It did not address a toileting program or schedule, that the resident had incontinence and any means to protect the skin due to incontinence episodes, that he/she required two people to assist with toileting or fluctuations in staff assistance to meet toileting needs, or that the resident had a history of not producing any output when staff attempted to toilet him/her. A review of the physician's Order Summary Report for May 2021 did not address a physician's order related to the resident's incontinence or evidence of a toileting schedule or program to promote continence. A review of the electronic Medication Administration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for April 2021 and May 2021 did not reflect documented evidence related to the resident's toileting or measures to address the resident's incontinence. A review of the Activities of Daily Living (ADL) task record Documentation Survey Report v2 for April 2021 reflected that the resident was having incontinent episodes of bowel and bladder since the second day of admission, and other days the resident was fully continent. It further reflected that the skin was checked by the CNA every shift and that the resident had no skin breakdown. A review of the ADL task record Documentation Survey Report v2 for May 2021, reflected that the resident was continent of bladder 4 out of 27 day shifts, 3 out of 27 evening shifts, and 1 out of 27 night shifts, and the remaining shifts the resident was incontinent. on 5/26/21 at 10:59 AM, the surveyor observed a second RN (RN #2) take the resident to be toileted because he/she kept standing up from the broda chair. The RN #2 stated that sometimes when the resident gets restless, they try to toilet the resident. The surveyor observed the RN #2 wheel the resident in the broda chair to the bathroom. Resident #74 stated I don't even know what to do. The RN #2 explained to the resident that she was taking him/her to the bathroom. The RN #2 placed the resident on the toilet and the resident had a dry incontinent brief. The resident stated that I peed a lot before. The RN #2 asked the resident if he/she was going to pee again while on the toilet and the resident nodded his/her head no and replied nuh uh. Five minutes later at 11:04 AM, the RN #2 stood the resident back up, pulled up the incontinent brief, his/her pants, and sat the resident down in the broda chair. The resident did not have any skin barrier cream on his/her perineal area, nor did the RN #2 apply a skin protectant/barrier cream to protect the skin if the resident had an incontinent episode after her attempt to toilet the resident. At 11:08 AM, the surveyor attempted to interview Resident #74 in the privacy of his/her room. The resident responded with his/her name, but did not respond appropriately to other questions. The resident stated, I want to go home and began pulling at his/her pants. The surveyor asked if he/she used the toilet and the resident stated, I don't know. The next day on 5/27/21 at 9:05 AM, the surveyor observed another CNA (CNA #2) in the bathroom with Resident #74. She stated that she was trying to collect a urine sample and that the resident was not voiding on the toilet. On 5/27/21 at 9:08 AM, the surveyor interviewed the CNA #2 who stated that the resident was really confused most of the time and would often not follow commands due to his/her cognition and behaviors. She stated that the resident liked to drink a lot of fluids and that she would offer fluids to the resident every morning. The CNA #2 stated that the resident was incontinent most of the time. She stated that sometimes the resident would be able to say if he/she had to be toileted. She stated that she performed incontinence care on the resident that morning and applied a skin barrier cream to the perineal area to protect the skin, and that the resident used a pull-up incontinent brief during the day that would get changed in the bathroom and not in the resident's bed. She further stated that after breakfast and after lunch she would usually ask the resident if he/she wanted to be toileted, adding that if she asked the resident, Resident #74 would usually answer. The CNA #2 stated that if the resident asked to be toileted she would not delay. On 6/1/21 at 9:17 AM, the surveyor interviewed the Physical Therapy Assistant (PTA) who stated that she was familiar with Resident #74 and that the resident had dementia and his/her mobility fluctuated depending on his/her moods or level of agitation that day. She stated that sometimes the resident would be more steady on his/her feet, and other days he/she would need closer supervision including more physical assistance for safety. She stated that the resident had a lack of safety awareness. The surveyor asked about toileting a resident. The PTA stated that if a resident asks to be toileted, she can assist in toileting the resident as well as the Physical Therapists and Occupational Therapists. She stated that if the resident already soiled themselves, they would bring them back to the nurses station to have the nurse assist in providing incontinence care. She stated that the SLP does not toilet residents. She stated that the toileting would happen immediately if a resident requested it, or as soon as possible in a reasonable time frame. She stated that if the CNA and RN was tied up doing something else, she would inform the Unit Manager. The surveyor asked what is a reasonable amount of time to toilet the resident if he/she makes the request and the PTA stated that while she didn't know the response time but that 15 minutes was reasonable. She stated that waiting over 45 minutes was just too long. At 9:31 AM, the surveyor interviewed the SLP who stated that he was also the Director of Rehab. He stated that Resident #74 had been having a cognitive decline at home due to visual hallucinations and due to his/her dementia diagnosis. He stated that the resident's cognitive decline here at the facility was expected. He stated that he had been working with the resident for some minor difficulty in swallowing and reduction in appetite since admission to the facility. The surveyor asked the SLP about the resident's request to be toileted prior to lunch on 5/24/21. The SLP acknowledged that he had asked both the CNA and the RN to toilet the resident that day when the resident had informed him that he/she needed to go to the bathroom. He stated that I thought it had been addressed and I didn't think it was urgent .I can't tell you how long ago they had toileted the resident but that it had been recent. The SLP acknowledged that he doesn't toilet the residents but that if the CNA and RN were unable to assist the resident to the toilet if the resident was asking to be toileted again, he should have let the Unit Manager know. The SLP acknowledged that even if the resident had been toileted recently, there could be other medical reasons that the resident could need to be toileted again. On 6/1/21 at 1:00 PM, the Regional Director of Risk Management stated in the presence of the survey team and the Licensed Nursing Home Administrator, Director of Nursing (DON), and the Regional Director of Clinical Services and the Regional Director of Operations, acknowledged that on 5/24/21, a SLP, a CNA, and a RN all were aware that the resident had requested to be toileted before lunch and that it did not happen until surveyor inquiry, 49 minutes after the resident made the initial request to be toileted. The Regional Director of Risk Management stated that the resident had just been toileted by the CNA and the RN and that the resident had voided and had a bowel movement. The surveyor asked why the CNA didn't tell the SLP at that time that she had just toileted the resident when the SLP informed her that Resident #74 was requesting to go to the bathroom, and instead told him that she had just finished washing her hands and had to pass out lunch trays. The Director of Risk Management provided statements from the CNA and the RN, indicating that they had toileted the resident before lunch. The statements did not specify what time the resident had last been toileted. The RN statement indicated that they had just taken Resident #74 to the bathroom just before the trays came out. The RN statement included that Sometimes [Resident #74] repeats things and says [he/she] needs to go to the bathroom even though [he/she] just went. The surveyor asked the facility administration if there were other reasons that could cause the resident to need to go to the bathroom again even if he/she had allegedly been recently taken; In addition the surveyor asked if it was appropriate to not address the resident's request regardless of the last time he/she had been toileted? The facility administration acknowledged the surveyors questions but stated they had investigated the incident and the Regional Director of Risk Management stated that the facility believed that resident's toileting needs were met because the resident had a dry incontinent brief after lunch that day. She continued to add that the resident had incontinence since admission to the facility and acknowledged that there was no care plan for incontinence/promote skin integrity related to incontinence, and that it was also not addressed in the care plan about fluctuations in staff assistance for toileting was necessary and that the resident sometimes doesn't void during toileting attempts. The Regional Director of Risk Management stated that the resident was hospitalized on [DATE] for what she believed was a Urinary Tract Infection (UTI). The facility administration clarified that they had not received official confirmation of that yet. A review of a fall investigation dated 5/27/21 provided by the facility reflected that the resident had a fall, and was subsequently sent out to the hospital for a medical evaluation and was admitted with a UTI. On 6/3/21 at 12:20 PM, the LNHA and the DON stated to the survey team that they had attempted to get the hospital records regarding the resident's admission, and that they still were waiting on the official hospital diagnosis. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines for Urinary Tract Infection (UTI) updated 8/27/2019, included that signs and symptoms of UTI may include: frequent urination; feeling the need to urinate despite having an empty bladder . According to the American Diabetes Association (ADA) copyright 2021, symptoms of high blood sugar can include symptoms such as urinating often and feeling thirsty. A review of the facility's undated policy for Urinary Continence and Incontinence-Assessment and Management included, The physician and staff will provide appropriate services and treatment to help restore or improve bladder function and prevent urinary tract infections to the extent possible. Relevant information related to urinary continence includes: .Previous treatment/management attempts and response to interventions, pertinent diagnoses, including .diabetes mellitus; Functional and/or cognitive capabilities or limitations that could affect continence, including impaired cognitive function or dementia, impaired mobility . 2. On 5/24/21 from 12:12 PM to 1:00 PM and on 5/26/21 from 12:35 PM to 1:00 PM during the lunch meal service, two surveyors observed five residents Resident #9, #25, #34, #40 and #74 in the dining room for lunch. The five residents were all sitting in broda chairs (a reclining chair that sits low to the ground) at various dining tables spread throughout the room. The surveyors observed that the dining tables were of standard height, and the table surface was at the level of the five residents' shoulders or chin. The surveyors observed the residents self-feeding their lunch meals and having to reach up above their shoulders to access their drinks and food positioned on the table. On 6/1/21 at 9:31 AM, the surveyor interviewed the Speech Language Pathologist (SLP) who also introduced himself as the Director of Rehab. The SLP acknowledged that the broda chairs had seats that were lower to the ground than a standard chair or wheelchair. The surveyor asked if the heights of the dining tables were adjustable, and he stated that he thought they were. The surveyor asked about the height of tables for eating when the residents are sitting in the low sitting broda chairs, and he acknowledged that the standard table heights are not appropriate for positioning for residents that need to eat in the broda chairs. He stated that the therapy department had re-evaluated several of the residents who were previously in the broda chairs and that they were be trialed for use of standard wheelchairs anyway, but that they would look at the heights. He acknowledged that the appropriateness of the standard table heights for those sitting in broda chairs had not yet come to his attention. On 6/3/21 at approximately 12:30 PM, the surveyor interviewed the Regional Director of Clinical Services, the Regional Director of Operations, the Director of Nursing (DON) and the Licensed Nursing Home Operations stated that she believed that the table heights in the dining room were adjustable, and acknowledged that if a resident was going to eat in a low-sitting broda chair, the table height would have to be adjusted to accommodate the resident's positioning with meals as well as activities to promote their highest practicable well-being. A review of the facility's undated policy Assistance with Meals included that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. It further included that assistance will be provided to ensure that residents can use and benefit from special eating equipment and utencils The nursing staff will prepare residents for eating. The policy did not address the appropriate positioning of the resident at the table. NJAC 8:39-27.1(a), 27.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. There was music being played in the day room of the North Unit, but there was no formal activity in progress. The resident had nothing in his/her arm, no activity mat or vest or other means of activity diversions. At 12:07 PM, the surveyor observed Resident #74 attempting to stand up from the broda chair, and the CNA redirected the resident to sit back down. After the resident sat back down, the CNA propelled the resident in the broda chair to the center isle of the open dining room and the CNA locked the wheels on the broda chair which were unable to be accessed by the resident. The surveyor observed the resident attempt to scoot him/her-self while in the broda chair. At that time, the Licensed Nursing Home Administrator (LNHA) directed staff to move some tables in preparation for lunch service, and the surveyor observed two staff members pick up a dining table and place it in front of Resident #74 who was sitting in the broda chair. At 12:13 PM, the surveyor observed Resident #74 in the locked broda chair push forward on the empty table, causing the table to move forward slightly. Then, Resident #74 began slowly sliding down in the broda chair, and two staff repositioned the resident back up in a seated position in the broda chair. On 5/26/21 at 10:37 AM, the surveyor observed that on the North Unit there was a live musician singing and walking around the main dining room. The surveyor observed Resident #74 displaying signs of interest in the music and sitting at an empty dining table. The surveyor observed the resident stand up from the broda chair. A Certified Occupational Therapy Assistant (COTA) was in the room, and redirected the resident to sit back down into the broda chair. At 10:45 AM, the surveyor observed Resident #74 try to stand up again from the broda chair by pushing down on the arm rests, the resident was able to slowly stand up, but he/she sat back down. At 10:56 AM, the surveyor observed the resident slowly stand up from the broda chair again, and staff redirected the resident to sit back down. The resident was sitting alone and did not have any means of a diversion activity in front of him/her at the table. The resident was also not offered to ambulate when he/she kept attempting to stand up when he/she was not showing interest in the live music. At 10:58 AM, the resident stood up a fourth time, and began to make small steps by holding onto the table in front of him/her. A Registered Nurse (RN) asked the resident to sit back down because he/she was only wearing one shoe. The surveyor observed the resident's other shoe on his/her broda chair seat where he/she was sitting. The RN assisted the resident in reapplying the shoe, then propelled the resident in the broda chair to his/her room to attempt to toilet. The RN stated that when the resident gets restless, sometimes that meant that he/she needed toileting. At 11:08 AM, the surveyor attempted to interview Resident #74 in his/her room after the RN attempted to toilet the resident, but the resident did not respond back to the surveyor's questions appropriately. The resident stated that he/she wanted to go home and began pulling on his/her pants. On the same day on 5/26/21 at 12:12 PM, the surveyor observed the RN talking to Resident #74 while he/she was in a broda chair. The surveyor observed that the resident had not been offered a tactile activity or other means of recreational engagement when he/she was not showing interest in participating in the music activity. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, insomnia, and psychophysical visual disturbances. A review of the admission MDS dated [DATE] reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily which intruded on the privacy/activities of others. The MDS assessment reflected that the resident was interviewed for his/her preferences and that it was Very Important to keep up with the news, participate in favorite activities, to go outside to get fresh air when the weather was good, and participate in religious services or practices. A review of the resident's individualized comprehensive care plan reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia initiated on 4/30/21. Interventions were to Administer meds as ordered; Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion . The care plan also had a focus that he/she had a communication problem related to the resident's voice being of low volume. Interventions included to: Anticipate and meet my needs. Inventions if the resident began to wander included: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.If I am wandering assess for unmet needs hunger, toileting, thirst, boredom. Further interventions within the resident's care plan included to Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc; .Give me as many choices as possible about care and activities. Interventions for the recreational care plan not initiated until 4/30/21 included that the resident enjoys playing cards and place me next to a peer who is actively engaged. There was no other resident-specific preference for activities listed on the resident's recreational care plan A review of an Activities Initial assessment dated [DATE] reflected that the resident enjoyed, watching TV, playing games on [his/her] tablet, Taking walks, Puzzles. It further reflected that the resident participated in Baptist Church and it was unknown if the resident wished visits from a clergy member. It further reflected that the resident liked independent activities such as reading and puzzles. A subsequent Activities Initial assessment dated [DATE] reflected that the resident enjoyed Watching TV and taking walks and attended Baptist church prior to admission. The assessment indicated that activities should be modified to accommodate a cognitive deficit. Accommodations to participate in activities included, Provide assistance with independent activities when needed. Provide simple task activities. The assessment was not clear what the impendent activities or simple task activities were for the resident. It did not evaluate the resident's response to any activity that may have been provided to the resident thus far, or any activity that the resident may not prefer to participate in. A review of the resident's attendance log for activities reflected from 4/21/21 to 4/25/21 reflected visitation from family and a daily chronicle provided on 4/22/21 but the resident declined it on 4/23/21. There was no evidence of alternate activities offered to the resident when he/she declined a daily chronicle or other means of the facility's involvement with recreational engagement. The log reflected that on 4/26/21 the resident participated in a craft at 11:30 AM, but no other activity for the day. Further the log reflected the following: On 4/27/21 at 10 AM the resident had an outside visit, and at 11:30 AM listened to music. There was no other activity listed. On 4/28/21 the resident participated in a crossword puzzle for 30 minutes and the Daily Chronicle at 10:30 AM, there were no other activities listed on the attendance log after 10:30 AM. On 4/29/21 the resident had a 2 PM outside visitation, but no other evidence of offering, involvement or response to an activity from 4/29/21 through 5/1/21, and on 5/2/21 the only activity offered to the resident was an outdoor visitation at 2 PM. From 5/6/21 to 5/9/21 there was no documented evidence of any involvement in a morning activity. Further from 5/16/21 to 5/24/21 the activity log listed a visit or Visitations and a vanilla pudding social. The activities attendance log for April and May 2021 did not include any evidence of an opportunity to engage in spiritual/religious music or services, taking walks, offering the resident his/her tablet in accordance with the resident's Initial Activities Assessment. A review of the Behavior Monitoring flow sheet for April and May 2021 and the electronic Progress Notes (ePN) for April and May 2021 reflected that nursing staff were not consistently providing diversional activities in accordance with the resident's recreational preferences. On 5/28/21 at 11:15 AM, the surveyor interviewed the Recreation Director who stated that she was the only activities personnel working that day because her Activities Assistant was coming in late that day and she didn't know when he/she was going to make it in to work. She stated she was familiar with Resident #74. The surveyor asked about what she knew of the resident, and the Recreation Director stated that the resident was very supportive and have frequent visitations. She stated that they tried a beaded sculpture with the resident this week, coloring and a jigsaw puzzle and the resident did not seem interested in that. She stated that if her activity staff perform any activities with the resident, they would let her know and it would be added to the resident's attendance log in the activities software system. She stated that the resident used to volunteer in the community, enjoyed word puzzles, liked dogs but the pet therapy program had to be stopped due to the COVID-19 pandemic. The surveyor asked if they tried any of those items with the resident yet, and she stated that she had not tried any means of pet involvement or pet videos, religious activities through online services or gospel music, or word puzzles yet because she had just spoken to the resident's daughter yesterday to get more ideas. She stated that she didn't get any formal training on activities for dementia residents and acknowledged that there was no activity mat or other means of tactile stimulation offered to the resident. She acknowledged that the recreational care plan was not initiated until 4/30/21 and did address the resident's preferences listed on the MDS and the initial activities assessment. On 5/28/21 at 12:01 PM, the Recreation Director informed the surveyor that the facility had just restarted recreational activities in group settings the end of April 2021. On 6/1/21 at 12:48 PM in the presence of the survey team, the surveyor interviewed the Regional Director of Risk Management, the Regional Director of Operations, the Regional Director of Clinical Services, with the DON and LNHA present. The Regional Director of Risk Management stated that the resident had a progressive decline associated with his/her dementia diagnosis. She stated that the resident was evaluated and re-evaluated for activities twice on 4/23/21 and 5/7/21 and that they were trying the table top beaded sculpture and other kinds of activities but that the resident refused it. She stated that the resident was refusing the magazines and the electronic tablet was taken home by the family representative because the resident was not seeking it out or using it. The Regional Director of Risk Management acknowledged that the care plan wasn't comprehensive for the resident's preferences for activities and that the resident's request to participate in religious services wasn't done. She stated that there was documentation of the resident refusing activities dated 5/26/21, but not prior to surveyor inquiry. The surveyor also asked about the nursing involvement with providing diversion activities, and the facility administration all acknowledged that diversion activities were an interdisciplinary team effort and that it should be documented in the resident's medical record. A review of the facility's undated policy for Activity Programs included that the programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.All activities are documented in the resident's medical record.Reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. NJAC 8:39-7.3(a) Based on observation, interview and record review, it was determined that the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences as identified in the resident's assessment. This deficient practice was observed for 3 of 4 residents reviewed for activities (Resident #32, #51, and #74), and was evidenced by the following: 1. On 5/27/21 at 11:00 AM, the surveyor observed four residents seated in the day room of the South Unit at separate tables with no activity except that Resident #32 was staring at a picture of dyed eggs in a magazine. The resident stated that there were Easter pictures in the magazine in which he/she was provided. The surveyor and Resident #32 observed the front cover and noted that the magazine was from April 2021. The resident stopped reading the magazine, placed it on the table, and joined the other three residents at the table who had nothing in front of them to keep them occupied. On 5/28/21 at 10:34 AM, the surveyor observed Resident #32 was conversing with another resident on the South Unit. Resident #32 had a crossword puzzle on the table, the other resident had a magazine. Resident #32 was not interested in the crossword puzzle. Resident #32 stated that the day before he/she was working with a regular puzzle and really enjoying it and a nurse came along and swept up all the pieces and I don't know why. On 5/28/21 at 10:39 AM, the Infection Preventionist (IP) offered to take the residents to the North Unit for a sing-a-long and [NAME] activity. The IP brought the unsampled resident with the magazine. The surveyor observed that when the resident arrived to to the North Unit, he/she wasn't given any rhythm instrument for the [NAME] activity. In addition, the resident was not singing along, nor were the other residents in the activity area. The Activities Director used a tambourine type of instrument that she handed to one resident. In the meantime, Resident #32 explained to the IP that a nurse took his/her puzzle away the day before. They said they needed the table to eat, but there were plenty of tables. On 5/28/21 at 10:42 AM, a nurse on the South Unit brought Resident #32 the 300 piece puzzle in a box that he/she was working on previously. On 6/1/21 at 11:01 AM, the surveyor observed Resident #32 working on new jigsaw puzzle. The resident claimed, I didn't finish the puzzle from last week. They pulled it away again. They said the people had to eat, but they had plenty of tables. The surveyor observed on all survey days that there were several empty tables on the South Unit, even when residents were eating in the day room. The surveyor reviewed the medical record for Resident #32. A review of the Face Sheet (an admission summary) reflected that the resident was recently admitted to the facility and had diagnoses which included arthropathic psoriasis (which can cause stiffness and swelling in the joints), muscle wasting of the leg, difficulty walking, lack of coordination and unspecified dementia. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/5/2021, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This score indicated a moderately impaired cognition level. A review of the preferred activities listed in the admission MDS included books, newspapers, magazines, keeping up with news, group activities, going outside and religious services. The resident's most recent updated Interdisciplinary Care Plan included the following Activity Interests: I am independent in fulfilling my leisure time such as watching TV, socializing. My family is very supportive. I will be content with items provided for my leisure and invite me to group activities of interest through next review. Family visitations with my family. I enjoy group activities such as virtual spin class, [NAME] fitness, food, socials. Provide me with independent leisure materials when needed/requested such as reading material. While the facility staff did offer Resident #32 some of the activities on the care plan, he/she expressed no interest in them when observed during the survey including providing an outdated magazine. In fact, Resident #32 was most interested on 5/27, 5/28 and 6/1 in completing a jigsaw puzzle. The resident became verbally frustrated when the puzzles were disassembled before they could be completed on at least two occasions. 2. On 5/27/21 at 12:21 PM, the surveyor observed 22 residents in the North Unit day room with no activity, including Resident #51. All residents were seated at tables waiting for lunch. Music from The Beach Boys and later Elvis [NAME] was playing from a speaker on the wall. One resident was reading a magazine. On 5/28/2021 at 9:24 AM, the surveyor observed that breakfast service was finished on the North Unit. There was 1950's and 1960's music playing on a Music Choice TV channel. There were two residents reading a newspaper or magazine. Ten other residents were just sitting at empty tables doing nothing, including Resident #51. On 5/28/2021 at 10:45 AM, the surveyor observed the North Units Activity called [NAME]. There were 18 residents in the room. Three were given wooden drumsticks to click together to the tune of Run Around Sue playing on the audio player. Three residents clicked the drum sticks together along with the Activity Director. One resident just left the drumsticks on the table. One resident was provided with a large beaded sculpture on the table and the resident was neither looking at it nor moving the beads along the wire. The other 14 residents were not provided with any rhythm instruments or supplies for tactile stimulation, including Resident #51. The Daily Chronicle, a newsletter, was available on several tables. None of the residents were observed reading the newsletter. The surveyor also did not observe any staff member reading aloud from The Daily Chronicle to engage the residents in the news of the day or reflections of the past. On 5/28/2021 at 11:59 AM, the surveyor observed that a Certified Nursing Assistant (CNA) was singing Karaoke to the North Unit residents. The surveyor observed Resident #51 sleeping while seated at a table with no other activity in front of him/her. On 5/28/21 at 11:15 AM, the surveyor interviewed the Recreation Director who stated that she was the only activities personnel working that day because her Activities Assistant was coming in late that day and she didn't know when he/she was going to make it in to work. She stated that she has been the Recreation Director of seven years, but the facility had previously had a Recreation Director specifically for Dementia but that they no longer work at the facility as of the end of April 2021. She stated that each resident had an activity attendance log in a software system that was not part of the resident's medical record nor was it accessible to the surveyors unless she printed it out for them. She stated that she has had no formal training on dementia and specific activities geared toward residents with dementia and that she was just filling in until the vacancy can be filled. On 6/2/2021 at 9:34 AM, the surveyor observed Resident #51 seated in the North Unit day room in a wheelchair at a table alone. The surveyor observed that the resident was just playing with the clothing he/she was wearing. The surveyor observed that the Activities Director came to speak to Resident #51 momentarily. The surveyor then observed Resident #51 to smile and gaze off in the distance. However, nothing was provided to keep the resident occupied, only a cup of water with a straw on the table. On 6/2/2021 at 9:57 AM, the surveyor observed Resident #51 trying to get out of his/her wheelchair. A nurse came by with the resident's medication and she assisted Resident #51 back into the wheelchair. The surveyor reviewed the medical record for Resident #51. A review of the Face Sheet (an admission summary) reflected that the resident was recently admitted to the facility with a diagnosis of Alzheimer's Disease. A review of the resident's admission MDS dated [DATE], the resident had a BIMS score that could not be determined. The assessment indicated that Resident #51 had short and long term memory problem with a severely impaired decision-making capacity. The Activity Section F of the MDS indicated that, according to the resident's family member or significant other, Resident #51 preferred to read books, newspapers, and magazines. Music was also important. The assessment also indicated that it was very important to get fresh air when the weather is good. Somewhat important to go to religious services. The surveyor reviewed the resident's current undated Interdisciplinary Care Plan which did not reference the resident's preferences for books, newspapers, music, fresh air, and religious services as referenced in the MDS. The care plan for activities only indicated a preference to schedule video calls with relatives. On 6/2/21 at 1:35 PM, the surveyor reviewed the findings with the facility administration, including the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). On 6/3/21 at approximately 9:30 AM, the facility provided the surveyor a copy of an activity log for Resident #51. The activity log reflected that on 4/19/21 [NAME] Fitness was offered to the resident but was not interested in the activity. It did not specify what was offered as an alternative and his/her response to an alternative activity. There was no accountability for activity involvement on 4/20, 4/21, from 4/24-5/1, 5/3, 5/8, 5/10-5/19, 5/22-5/25, and 5/29-6/1. The activities that were documented as being provided from 4/19/21 to 5/21/21 only included Watching TV and family Visitations. No other documentation was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to ensure: a.) a resident with recurring falls in the facility was thoroughly evaluated for possible causative factors for those and initiate appropriate interventions to prevent further falls, b.) fall risk re-assessments were consistently done to evaluate fall risk potential, c.) the care plan was appropriately implemented to prevent further falls, and d.) a resident was transferred using a mechanical lift with a two person assistance in accordance with safety practices to prevent incidents/accidents. This deficient practice was identified for 2 of 4 residents reviewed for accidents/falls (Resident #38 and #74). The evidence was as follows: 1. On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. The broda chair was not in a locked position. At 12:07 PM, the resident attempted to stand up from the broda chair, and the CNA redirected the resident to sit back down. After the resident sat back down, the CNA propelled the resident in the broda chair to the center isle of the open dining room and the CNA locked the wheels on the broda chair which were unable to be accessed by the resident. The surveyor observed the resident attempt to scoot him/her-self while in the broda chair. At that time, the Licensed Nursing Home Administrator (LNHA) directed staff to move some tables in preparation for lunch service, and the surveyor observed two staff members pick up a dining table and place it in front of Resident #74 who was sitting in the broda chair. The surveyor observed that the broda chair sat low to the ground and the table height was set at the level of the resident's shoulders. At 12:13 PM, the surveyor observed Resident #74 in the locked broda chair push forward on the table, causing the table to move forward slightly. Then, Resident #74 began slowly sliding down in the broda chair, and two staff repositioned the resident back up in a seated position in the broda chair. On 5/26/21 at 10:37 AM, the surveyor observed Resident #74 standing up from the the broda chair in the main dining room. A Certified Occupational Therapy Assistant (COTA) was in the room, and redirected the resident to sit back down into the broda chair. The broda chair was in the locked position. The surveyor observed that there was no cushion or non-slip mat on the broda chair seat to prevent sliding. At 10:45 AM, the surveyor observed Resident #74 try to stand up again from the broda chair by pushing down on the arm rests, the resident was able to slowly stand up, but he/she sat back down. At 10:56 AM, the surveyor observed the resident slowly stand up from the broda chair again, and staff redirected the resident to sit back down. At 10:58 AM, the resident stood up a fourth time, and began to make small steps by holding onto the table in front of him/her. A Registered Nurse (RN) asked the resident to sit back down because he/she was only wearing one shoe. The surveyor observed the resident's other shoe on his/her broda chair seat where he/she was sitting. The RN assisted the resident in reapplying the shoe, then propelled the resident in the broda chair to his/her room to attempt to toilet. The RN stated that when the resident gets restless, sometimes that meant that he/she needed toileting. At 11:08 AM, the surveyor attempted to interview Resident #74 in his/her room after the RN attempted to toilet the resident, but the resident did not respond back to the surveyor's questions appropriately. The resident stated that he/she wanted to go home and began pulling on his/her pants. From 11:36 AM to 11:50 AM, the surveyor observed Resident #74 in the rehab gym receiving rehab services. The surveyor observed the resident slowly ambulate using a rolling walker with the Physical Therapist (PT) providing contact guard and using a gait belt. The resident ambulated one and a half laps around the rehab gym with the rolling walker before he/she sat back down in the broda chair. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, muscle wasting and atrophy, a lack of coordination, and diabetes. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily which intruded on the privacy/ activities of others, and that he/she had a history of falls in the last six months prior to admission, but to date, had no falls in the facility. A review of a Fall Risk assessment dated [DATE] reflected that the resident was at low risk for falls. A review of the resident's individualized comprehensive care plan initiated on 4/21/21 reflected that the resident was at risk for falls related to a history of falls, using psychoactive medications, arthritic pain, noncompliance with using a rolling walker, poor balance when walking, and having cataracts. The care plan indicated that the resident was supposed to have cataract surgery prior to the COVID-19 pandemic, but that it was canceled due to the COVID-19 restrictions. Interventions on 4/21/21 included that the resident was supervised with bed mobility, transfers, and ambulation on the unit. Physical Therapy/Occupational Therapy evaluation and treatment as ordered or as needed and Anticipate and meet my needs. A review of the Physical Therapy (PT) Evaluation and Plan of Treatment for the Certification Period 4/21/21-5/18/21 reflected that the resident was receiving Physical Therapy upon admission to the facility. The surveyor reviewed within the resident's medical record which reflected that he/she had ten falls in the facility from 4/28/21 through 5/27/21. Fall #1: According to the electronic Progress Notes (ePN) dated 4/28/21 at 9:28 AM, reflected that the resident had a witnessed fall while walking out of his/her room with the rolling walker. The resident stated that he/she was okay but was unable to explain how [he/she] had fallen due to dementia. A review of the investigative fall report/QA Report for the first fall dated 4/28/21 indicated that at 1:30 AM, the resident had a witnessed fall without an injury while using the rolling walker. The resident's footwear indicated socks. Actions taken included that assessments were completed, the resident was assisted to a standing position and into a chair, the supervisor was notified. The LPN provided a statement, but there was no CNA statement in the investigation. The conclusion indicated that the resident had lost his/her balance while using the rolling walker while ambulating in the hallway, and the Interdisciplinary Team (IDT) recommended that as a post fall intervention to be referred to Physical Therapy (PT) for an evaluation post fall. (The investigative report did not identify or address the use of regular socks to be a possible causative factor, any use of specific psychoactive medications, specific behaviors leading up to the incident, or interventions to address mitigate the use of regular socks when in bed. In addition, the resident was already receiving PT and OT services since 4/21/21). A review of the ePN dated 4/28/21 reflected that Occupational Therapy (OT) performed the evaluation following the resident's fall. The OT created a restorative nursing program for supervision for the resident to be reminded to use the rolling walker, and the therapist went over safety precautions when completing functional mobility. A review of the care plan for falls reflected that it was updated on 4/28/21 to include a PT evaluation for the fall that occurred on 4/28/21. There were no additional interventions for fall prevention updated for that date, or the OT recommendation to have staff remind the resident to use the rolling walker for functional mobility. Fall #2: A review of the ePN dated the next day on 4/29/21 at 2:58 PM reflected that the resident had a second fall in the facility in which he/she slid down to the floor without an injury. The resident claimed that he/she was having a dream of riding a roller coaster and that caused him/her to fall. A review of the investigative fall report/QA Report for the second fall dated 4/29/21 reflected that the resident had a witnessed fall at 2:15 PM in which he/she was sitting in a chair in the dining room and the resident was lowered him/her-self to the floor. The resident was wearing shoes. The investigation only included the resident statement and a statement by the Registered Nurse (RN). There was no CNA statement. Actions taken included assessments and notification of parties. The conclusion indicated that the resident had dementia with poor safety awareness and impaired judgment. Intervention included a second time, referred to PT evaluation. Care plan was reviewed and revised to reflect this post intervention. A review of the updated care plan for the fall on 4/29/21 included to assess B/P [blood pressure] for signs of hypotension [low blood pressure] and inform MD [Medical Doctor]. A review of the ePN for subsequent dates in April 2021 did not reflect documented evidence of attempts to obtain orthostatic blood pressures to assess for orthostatic hypotension as being a cause for the resident's fall. The ePN dated 4/29/21 reflected a right arm blood pressure was taken while the resident was lying down which read 108/57, but there was no blood pressure taken while sitting, or while standing to determine if there were fluctuations possibly contributing to the falls. A review of the At Risk IDT Meeting Note dated 4/30/21 inaccurately reflected that the resident only had one fall since admission and was at risk for wandering, elopement and had use of psychotropic drugs. The note included that the resident often forgets to use the rolling walker while ambulating and staff continue to remind the resident to use the rolling walker. Fall #3: A review of the ePN dated 5/4/21 reflected that the resident had a third fall in the facility at 10:30 AM. The resident was found lying on the floor and unable to explain what happened. The resident was assessed and denied pain from the fall. The ePN reflected that at 10:45 AM when the physician was notified, it was recommended to get an order for a CT scan of the head. The resident returned at 8 PM from the emergency room and the CT scan results were of normal findings. A review of the investigative fall report/QA Report for the third fall on 5/4/21 at 10:30 AM, indicated that the resident was previously sitting in a chair in the dining area and that the walker was in use at the time of the fall. The witness statement indicated that the Licensed Practical Nurse (LPN) was performing a medication pass and observed the resident walking with the rolling walker and when the resident made a turn, it caused the resident to trip over the walker. The resident fell and hit his/her head. The conclusion indicated that the resident was using the rolling walker and wearing the appropriate footwear and tripped leading to the fall. Interventions included to obtain lab work to rule out an acute infection which may be causing the falls. The investigation did not address the CT scan, or the results of the CT scan. The care plan was updated to reflect that the resident had a CT scan of the head which was negative and labs were ordered to rule out acute infection as a cause for the falls. The care plan indicated that I refused the UA (urinalysis) and Labs were unable to be done because [Resident #74] was so combative. There were no new interventions incorporated into the residents care plan to address any increased level of supervision, diversion activities, appropriate footwear, or other methods to prevent falls from reoccurring. Fall #4: A review of an ePN dated 5/5/21 reflected that the resident had a fourth fall at 6:20 PM. The ePN reflected that the resident was ambulating in the hallway and suddenly lost his/her balance and fell to the floor. The note indicated that the resident did not sustain any injury or hit his/her head. The resident was walked to the day room and all parties were notified. A review of the investigative fall report/QA Report for the fourth fall dated 5/5/21 reflected that the resident was previously seen at 6:15 PM but did not specify what the resident was doing at that time, such as when he/she had last been toileted, potential boredom or thirst, or other reasons that resident may have been ambulating without a device. It indicated that he/she was only wearing regular socks and not shoes and was not using the rolling walker. The investigation only included a nurse interview but did not include an interview from the resident's assigned CNA. The conclusion for the fall indicated that the resident was walking without an assistive device (walker) and lost his/her balance and fell. The resident was resistive to redirection and encouragement to use the rolling walker and became combative with staff when redirected. As a post fall intervention, the IDT recommended that the resident be referred for a psych consult for behavior evaluation and medication review. The investigation addressed that the resident was already seen by Psych. It did not address why the resident was only wearing socks instead of shoes, nor did it evaluate the lack of footwear as a possible cause for the fall. A review of the At Risk IDT Meeting Note dated 5/6/21 and signed by the Director of Nursing (DON) reflected that the resident has had 4 falls since admission and that interventions are not effective at this time .continues to wander and was aggressive towards staff when redirected .seen by Psych today for behavioral review. (There were no additional interventions incorporated into the resident's plan of care at that time when the current interventions were evaluated to be ineffective.) Fall #5: A review of the ePN dated 5/6/21 at 7:18 PM reflected that the resident had a fifth fall on 5/6/21 at 5:10 PM in which the CNA reported that while he was behind the nurses station he saw the resident fall to his/her buttocks from a standing position. The resident was unable to explain what had happened but there was no injury. The resident was aggressive during care that evening at 9 PM. A review of the investigative fall report/QA Report for the fifth fall dated 5/6/21 reflected that the resident was last seen at 4:10 PM visiting with family. The resident was wearing shoes and socks and a wheelchair was in use at the time of the fall. The conclusion from the call indicated that the resident fell on the buttocks for an unknown reason.The main reason for the falls is to be resident's forgetfulness. indicated that the resident forgets to use the rolling walker, unsteady gait, impulsive behavior and poor safety awareness. As post fall intervention, the IDT recommended that the resident be placed on around the clock pain medication for arthritic pain. A review of the care plan reflected it was updated on 5/6/21 to obtain an Eye MD consultation when Eye Doctor comes into the facility and that the resident was placed on around the clock pain medication for arthritic pain. The care plan was also updated on 5/13/21 included: I may sit in a broda chair if I am tired. A review of the physician's Order Summary Report for May 2021 reflected a physician's order (PO) dated 5/7/21 to start Tylenol 650 milligrams three times a day around the clock for arthritic pain. Fall #6: A review of an ePN dated 5/19/21 at 8:39 AM, reflected that the resident had a sixth fall when he/she was observed to be sitting on the floor wearing no clothes from the waist down, when he/she had been previously sleeping in bed. The resident showed no sign on injury and all parties were notified. A review of the investigative fall report/QA Report for the sixth fall dated 5/19/21 reflected that the resident was found on the floor without injury at 3:45 AM and was scooting toward the nurses station barefoot. The call light had been within reach but was not turned on. The bed was in a low position and no ambulation devices were in use at the time of the fall. The conclusion indicated that a bed alarm wound be used so as to alert staff if the resident tries to get up from bed at night. The investigation did not include a statement from the CNA to determine what the resident had been assisted to wear in bed, if the resident had removed the clothes, or when the resident had last been toileted to determine other possible causes of the fall. It also did not address the resident's bare feet or implement interventions to mitigate the falls related to the resident's lack of non-skid footwear. A review of the care plan indicated that a bed alarm was placed on the resident's bed on 5/19/21 and to check it for proper placement and function. Fall #7: A review of the ePN dated 5/22/21 at 5:26 AM reflected that the resident had a seventh fall on 5/21/21 at 6:50 PM. The ePN reflected that at 4 PM the resident was toileted and snacks were offered and was under staff supervision, and at 5 PM the resident remained in the day room under staff supervision, and at 6:50 PM during the medication pass, the nurse saw the resident stand up and couldn't get to him/her in time and was already on the floor. The resident was assessed and parties were notified and the resident ate dinner with a poor appetite, and the resident was given an anti-anxiety medication which was not effective. A review of the investigative fall report/QA Report for the seventh fall dated 5/21/21. The investigation revealed that fluids were given to the resident at 6:45 PM, and fell five minutes later. The report reflected that te resident was wearing shoes and fell while standing up from the broda chair. The conclusion indicated to perform an activity assessment for diversion activities that the resident may enjoy .to keep resident busy and engaged during the day. A review of the updated care plan reflected that on 5/21/21 a post-fall intervention included to conduct an Activities assessment for diversional activities that the resident may enjoy for post fall 5/21/21. A review of the Recreational activity care plan for Resident #74 initiated and last updated on 4/30/21 did not address any updates to the resident's recreational programming interests and preferences following the fall on 5/21/21. A review of the Clinical Assessments for Resident #74 reflected that the resident already had an Activities-Initial Review assessment completed on 4/23/21, and an Activities Initial Review was completed again on 5/7/21. A review of the ePN did not reflect updated recreational preferences until 5/26/21 when the Social Worker called the family representative for further information on the resident's social history and past interests. There was no documented assessment in the resident's medical record to evaluate the resident's involvement in activities or diversional activities until 5/26/21 at 13:41 PM (two days after the survey team entered to conduct a survey). The Activity Note indicated that the resident was refusing a beaded sculpture, magazines, and that the resident did not participate in a jigsaw puzzle. Fall #8: A review of the ePN dated 5/25/21 at 4:20 PM reflected that Resident #74 had an eighth fall in the facility on 5/25/21. The note reflected that the resident was refusing to sit on the wheelchair and the resident was assisted to the floor. The resident refused to be assessed and stated that staff were not helping. After a few minutes on the floor the resident agreed to be transported to the wheelcahir without injury. The note included that all parties were notified, vital signs were obtained and the resident had an elevated blood sugar reading of 168. A review of the investigative fall report/QA Report for the eighth fall dated 5/25/21 at 12:00 AM, reflected that the resident was with staff and was holding onto the exit door and the resident was lowered to the ground by staff without injury. Actions taken included that the resident was kept under continuous supervision and placed in a chair located closer to the nurses station, a blood sugar was assessed, and activities were provided, but it did not specify what specific activities were provided and the resident's response to those activities. Statements revealed that the resident was sitting on a wheelchair forcing the door to open and when standing up refused to be assisted back to the wheelchair. As the resident was walking away from the wheelchair, the resident began to slide on his/her right side while pulling on the door, and staff assisted in lowering the resident to the floor. The conclusion indicated that the fall happened as the resident stood up while being resistive and aggressive toward staff, and not receptive to re-direction. A post-fall intervention included that the resident was referred again to the Psych NP [Nurse Practitioner] for continued display of behaviors. The report indicated that adjustments to medications were made including increasing the anti-anxiety medication of Ativan 0.5 milligrams from as needed to routinely twice a day. A review of the care plan reflected that it was updated on 5/25/21 with the medication changes from the Psych NP. Fall #9: A review of the ePN dated the next day on 5/26/21 and timed at 3:45 PM reflected that the resident had a ninth fall when he/she slid out of the broda chair in the dining room and landed sitting on the ground without injury and all parties were notified. A review of the investigative fall report/QA Report for the ninth fall dated 5/26/21, reflected that the resident was in the broda chair at 2:30 AM and staff saw the resident slide down to the floor. Actions taken included that assessments were done, activities were provided and monitoring of further behaviors was being implemented. The Investigation did not include a CNA statement as to when the resident was last assisted, what he/she was doing at the time of the fall, why he/she was in a broda chair at a dining table at 2:30 AM or evaluating other possible contributing factors. The conclusion indicated that the resident would be changed from a broda chair to a standard wheelchair with a sensor alarm, in addition to an ambulation program. Staff to ambulate resident 150 feet with rolling walker twice a shift on days and evenings and as needed. A review of the resident's individualized care plan was updated on 5/26/21 with the ambulation program and the utilization of a standard wheelchair with a sensor alarm instead of the broda chair. Fall #10: A review of the ePN dated 5/27/21 and timed at 1:32 PM, reflected that the resident had a tenth fall in the facility and was found on the floor, confused and verbally responsive. The resident was assessed and able to move all extremities without limitations and pain. The resident was transferred back to the wheelchair with a two person assist, and all parties were notified of the fall. A review of the investigative fall report/QA Report for the tenth fall dated 5/27/21 reflected that the resident was last visualized one minute before he/she fell and that staff was sitting with the resident in the dining room when the resident was seen sliding down from the wheelchair at 1:00 PM. The chair alarm sounded and the wheelchair was in the locked position at the time of the fall. The report indicated that the fall was caused by the residents behaviors or intent, but neither the ePN nor the investigative report indicated what behaviors the resident was exhibiting at the time of the fall. The CNA statement indicated that she was sitting with the resident in the dining room and when she stood up to return a lunch tray back on the cart, the chair alarm sounded and the resident w as sliding down from the wheelchair and she couldn't get to the resident in time. The conclusion indicated that since previous lab work could not be drawn to rule out infection or other medical reason, the resident was sent to the emergency room for an evaluation to evaluate underlying medical conditions. The report indicated that the resident was admitted with UTI [Urinary Tract Infection]. The investigations for each fall were not consistently and thoroughly being evaluated for causative factors including what the resident was last doing, when any form of activity of daily living (ADL) care had last been provided, if the resident had been incontinent at the time of the fall, a review of recent anti-anxiety medication administered to determine if it contributed to the resident's fall, assessing a fingerstick blood sugar readings in accordance with the resident's care plan for diabetes, incorporating and determining the resident's response to non-pharmacological diversional activities, and address the use of appropriate footwear and include interventions to mitigate the recurrence of falls from the use of improper footwear. In addition, there was no intervention for an enhanced level of supervision when possible medical causes were unable to be ruled out due to the resident's refusal for blood draws and a urine sample collection due to his/her dementia diagnosis. Subsequent Fall Assessments dated 4/28/21 and 5/1/21 reflected that the resident was now at Moderate Risk for falls. Fall Assessments conducted on 5/22/21, 5/25/21, 5/26/21, and 5/27/21 reflected that the resident was at High Risk for falls with the risk scores increasing with high risk fall assessment. There was no documented re-assessments to evaluate for fall risk potential after the falls that occurred on 5/4/21, 5/5/21, 5/6/21, and 5/19/21. The surveyor conducted the following interviews with facility staff regarding the resident's falls: On 5/26/21 at 12:00 PM, the surveyor interviewed the Physical Therapist (PT) assigned to Resident #74. The PT stated that she worked full time at the facility and had been working with Resident #74 for the last month since the resident's admission to the facility. The PT stated that the resident had a history of dementia, physical aggression, and was confused. She stated that the confusion had been getting worse and at times the resident was difficult to redirect. She stated that the resident could ambulate with a rolling walker, adding that the resident has had some cognitive decline but was physically okay. She stated that the resident used the rolling walker in therapy sessions which she believed was newer to him/her, because he/she had previously ambulated independently at home. The surveyor asked what the purpose of the broda chair was if he/she could ambulate with a rolling walker? The PT responded that the resident has had multiple falls and a lack of safety awareness and that it was to keep [him/her] from getting up .the lower the seat the harder it is to get up. We want to minimize [Resident #74] getting up. The PT elaborated that when the resident was in a regular wheelchair he/she stood up and fell out of the wheelchair, so they opted for the broda chair. The surveyor asked if the resident was still able to stand up in the broda chair, and the PT stated that the resident was able to stand up in the broda chair but that it was much harder to stand up in one, and therefore the resident would attempt to stand up less frequently when positioned in a broda chair versus a standard chair or wheelchair. The PT stated that the broda chair was for safety and to reduce the number of falls because if the resident was in a broda chair, staff could get to the resident quicker and prevent a fall if it was more challenging for him/her to stand up in the broda chair. The PT stated that the resident had no injuries from any sustained falls. (The use of the broda chair for this stated purpose was not what was reflected in the resident's individualized care plan for falls which indicated to use the broda chair if the resident became tired). Over a period of 22 minutes from 10:37 AM to 10:58 AM on 5/26/21, the surveyor observed Resident #74 stand up from the broda chair four times and staff redirected the resident to sit back down. Resident #74 was not exhibiting tiredness, but staff continued to utilize the broda chair. The next day on 5/27/21 at 9:08 AM, the surveyor interviewed the resident's assigned CNA who stated that the resident was really confused most of the time. She stated that the resident was at high risk for falls and so staff rotate every 30 minutes who was in the dining room for resident supervision. The CNA stated that Resident #74 was in a broda chair for fall prevention adding that it is harder for [Resident #74] to get up in the broda chair. The CNA continued that when the resident was in the wheelchair, he/she tried to get up even more, so the broda chair might be more relaxing. The CNA confirmed that the resident still would try to get up out of the broda chair, and that he/she could successfully do so independently, but that the broda chair made it harder for him/her. The CNA confirmed that the resident seemed to have less falls when in the broda chair versus being in the standard wheelchair, and confirmed that the resident was now back in a standard wheelchair as of last night. At 9:37 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident was very confused and the broda chair was used for his/her safety because he/she kept sliding out of the wheelchair even with a dycem (non-slip mat). (There was no documented evidence that a dycem was trialed for the resident and its effectiveness evaluated within the resident's medical record to prevent falls). The RN/UM stated that the resident was very difficult to redirect and was combative with staff during redirection. She stated that the resident was unsteady on his/her feet and the broda chair forced the resident to take longer to get stand up allowing the staff to try to get to her in time before he/she fell. She stated that the staff can't stay beside him/her all the time. She stated that the resident had poor safety awareness and that he/she could still rise out of the broda chair. She stated that therapy evaluated the resident last night and that they re-assessed her for being in a standard wheelchair and not a broda chair. The surveyor asked the RN/UM about the care plan to use the broda chair if tired, and if the resident kept standing up out of the broda chair if that indicated he/she was tired. The RN/UM acknowledged that the resident attempted to stand up no matter if he/she was in a wheelchair or a broda chair. She acknowledged that the broda chair was not being used only if the resident was tired in accordance with the care plan. The surveyor asked the RN/UM why they were using the broda chair then if the resident made efforts to stand just as much seated in both devices, and the RN/UM stated that she wasn't exactly sure. The RN/UM stated that the facility tried redirection, toileting, and snacks and ongoing supervision to prevent falls but the resident would often not be redirectable. She confirmed that the resident refused lab work at the facility in the past, but that it wasn't re-attempted. The surveyor asked what interventions were tried to prevent falls and the RN/UM s[TRUNCATED]

Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times from 5/13/21 until surveyor inquiry on 6/1/21. This deficient practice was identified for 1 of 1 residents reviewed receiving dialysis services (Resident #75), 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. On 5/24/21 at 10:24 AM, the surveyor interviewed Resident #75 who stated that he/she went to the dialysis center, and believed that the days the resident went were Tuesday, Thursday, and Fridays weekly. On 5/28/21 at 9:14 AM, the surveyor observed Resident #75 in bed with their eyes closed. The surveyor attempted but was unable to interview the resident. On 5/28/21 at 9:17 AM, the surveyor interviewed the Registered Nurse Supervisor (RNS) who stated that she was familiar with Resident #75. The RNS stated that the resident was picked up at approximately 3 PM to 3:30 PM every week on Tuesday, Thursday and Saturday, and taken to the dialysis center to receive hemodialysis (a procedure that uses special equipment to clean the blood). The surveyor reviewed the medical record for Resident #75. A review of a significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/26/21, reflected the resident had a brief interview for mental status (BIMS) score of 8 out of 15, indicating that the resident had a moderately impaired cognition. A review of the resident's admission Record face sheet revealed a diagnosis of a left leg below knee amputation, diabetes (high blood sugar), hypertension (high blood pressure), peripheral vascular disease (a circulatory condition which constricts blood flow to the limbs), depression and end stage renal disease (ESRD) (a longstanding kidney disease which causes kidneys to fail causing waste and excess fluid to build up in the blood). A review of the resident's undated interdisciplinary care plan (IDCP) revealed that the resident received hemodialysis and was picked up between 3 PM and 3:30 PM every Tuesday, Thursday, and Saturday. In addition, the IDCP reflected that the resident had renal disease with an intervention to give medications as ordered. A review of the Dialysis Communication Forms dated 5/13, 5/15, 5/18, 5/20, 5/22, 5/25, 5/27 and 5/29 that were completed by the facility and the dialysis center indicated that the resident had received dialysis. A review of the resident's progress notes dated 5/15/21 indicated that the resident returned from dialysis at 10 PM and the progress notes dated 5/20/21 indicated that the resident returned from dialysis at 8:40 PM. In addition, the progress notes dated 5/22/21 indicated that the resident left for dialysis at 3:30 PM and returned at 11:08 PM. A review of the Order Listing Report reflected a physician's orders (PO) dated 5/6/21 for Dialysis treatment received at a dialysis center on Tuesdays, Thursdays and Saturdays, pick up time 3-3:30 PM via stretcher. Further review of the Order Listing Report reflected the following PO with the date the PO started: -Calcium Acetate (PhosLo) (a medication used to prevent high phosphate levels in the blood) 667 MG, give two capsules by mouth with meals for ESRD, dated 5/7/2021. -Depakote (a medication used to help with mood disorder) 125 MG, give one tablet by mouth two times a day for mood disorder, dated 5/10/21. -Fluoxetine (Prozac) (a medication used to help with depression) 20 MG, give one capsule by mouth one time a day for depression, dated 5/7/21. -Tamsulosin (Flomax) (a medication used to treat an enlarged prostate) 0.4 MG, give one capsule by mouth two times a day dated 5/7/21. -Prosource (a nutritional supplement used to promote wound healing) 30 milliliters (ML), dated 5/10/21. -Blood Glucose Monitoring (BGM) (a fingerstick procedure used to obtain results of the blood sugar level) without insulin coverage two times a day, notify physician if blood sugar level is below 70 or above 350, dated 5/5/21. In addition, the Order Listing Report reflected a discontinued PO dated 5/7/21 for May revise medication schedules (times) as per dialysis schedule on Tuesdays, Thursdays and Saturdays every shift for ESRD. A review of the May 2020 EMAR and progress notes dated 5/25/21 reflected that the 5 PM dose of PhosLo, Depakote, Prozac, Flomax, and Prosource were not administered, and the BGM was not completed, because the resident was out to dialysis. Further review of the May 2020 EMAR and progress notes dated 5/27/21 reflected that the 5 PM dose of PhosLo was not administered and the 4 PM BGM was not completed because the resident was out to dialysis. The EMAR also reflected that the Depakote, Prozac, Flomax, Prosource were administered when the resident was out of the facility at the dialysis center. In addition, the May 2020 EMAR reflected that on the dialysis days of 5/13, 5/15, 5/18, 5/20, 5/22 and 5/29, the following medications and a blood glucose monitoring (BGM) were administered at times when the resident was out of the facility at the dialysis center: -PhosLo 667 MG with an administration time of 5 PM. -Depakote 125 MG with an administration time of 5 PM, -Prozac 20 MG (a medication used to help with depression) with an administration time of 5 PM, -Flomax 0.4 MG with an administration time of 6:30 PM. -Prosource 30 ML with an administration time of 6 PM. -Blood Glucose Monitoring (BGM) with an administration time of 4 PM. On 6/1/21 at 10:19 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she was able to administer the resident's medications during her shift because the resident does not leave for dialysis until 3 PM to 3:30 PM. The RN stated that the resident was not given medications to take at dialysis. The RN also stated that the resident had a history of refusing medications and dialysis in the past but has been more compliant since being readmitted in May 2021. The RN stated that if the resident refused going to dialysis or refused medications then there would be a progress note indicating that the resident did not go to dialysis or the resident refused medications. The RN added that if medications were not able to be administered because the resident was at dialysis then the physician would have to be called and the times of administration changed. The RN was unsure of when the resident returned from dialysis. The RN added that dialysis does take a while so the return time would be at least 3 to 4 hours after leaving the facility. The RN could not speak to the medications that were due on the evening shift of 3 PM to 11 PM. On 6/1/21 at 10:45 AM, the surveyor interviewed the Unit Manager/RN (UM/RN) who stated that she was unsure of what time the resident returned from dialysis and thought the time would be noted on the Dialysis Communication Form or in the progress notes. The UM/RN stated that dialysis can take at least 3 to 4 hours before returning and that medication times should be adjusted to accommodate the resident being out of the facility. On 6/2/2021 at 10:22 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that she does make recommendations to adjust medication times of administration to accommodate dialysis times. The CP added that she had not reviewed the resident's medications because the resident had returned to the facility after she had completed her monthly review. The CP added that she had reviewed the resident's medications as requested by the administration after surveyor inquiry and acknowledged that the medication times of administration had not accommodated dialysis times. The CP also stated that she could not speak to why the nurses were documenting on the EMAR for medication administration for times when the resident was out to dialysis. On 6/2/2021 at 1:35 PM, the survey team met with the facility administrative team. The Regional Director of Operations stated that the resident returned from dialysis at varying times usually between 8 PM and 8:30 PM, unless there was a problem at the dialysis center. She acknowledged that the medication administration times needed to be adjusted to accommodate the resident being out to dialysis. She was unable to speak to the documented administration of medications on the EMAR during the time the resident was at the dialysis center. A review of the facility undated policy for Care of a Resident with End Stage Renal Disease provided by the Regional Director of Operations reflected that residents will be cared for according to currently recognized standards of care. In addition, the education and training of the staff included the timing and administration of medications, in particular the medications before and after dialysis. A review of the facility policy dated as revised 9/2020 for Administering Medications reflected that medications are to be administered in a timely manner as prescribed. Further review reflected that medications are to be administered within 1 hour of the prescribed time or at a specified prescribed time which included before a meal or after a meal. A review of the Manufacturer specifications for PhosLo reflected that the medication be administered with a meal. A review of the Manufacturer specifications for Flomax reflected that the medication be administered 30 minutes after a meal. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure a resident's preferences for nutritional health shakes were honored when the resident was experiencing weight loss. This deficient practice was identified for 1 of 5 residents reviewed for dietary preferences (Resident #74). The evidence was as follows: On 5/26/21 at 11:08 AM, the surveyor attempted to interview Resident #74 in his/her room . The resident was sitting in a broda chair and mumbling to him/her-self. The resident responded to his/her name but did not respond back to the surveyor's questions appropriately. The resident stated that he/she wanted to go home and began pulling on his/her pants. The surveyor was unable to complete the interview. The surveyor reviewed the medical record for Resident #74. A review of the hospital records dated for the hospitalization encounter of 3/31/21 indicated that during his/her hospitalization the Physician wrote a progress note that staff had requested to stop the Glucerna shakes because [Resident #74] was refusing them and several Glucerna shakes were seen at the bedside untouched. The hospital Registered Dietician (RD) also indicated in nutrition assessment that the resident had a poor/varying oral intake and was refusing all meal supplements. Many untouched on bed table. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, muscle wasting and atrophy, and diabetes. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The assessment indicated that the resident was able to eat independently with meal set-up by staff and that he/she had no known weight loss. A review of the facility's initial Nutrition Risk assessment dated [DATE] included that the resident had a diagnosis of diabetes. The assessment revealed that labs were not available from the hospital records but the Registered Dietician (RD) was able to interview the resident. The Evaluation indicated per hospital documentation, resident received Glucerna. Rt [Resident] reports disliking Glucerna supplements, is agreeable to try SF [Sugar Free] Health Shake TID with meals to help meet estimated nutritional needs. Recommendations included to provide a SF Health Shake TID (600 kilocalories/21 grams of protein). A review of the resident's individualized comprehensive care plan initiated on 4/21/21 reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia and a communication problem related to the resident's voice being of low volume. Interventions included to: Anticipate and meet my needs. The care plan indicated to provide and serve a nutritional supplement as ordered: Ensure Plus eight (8) ounces three times a day (TID) (1050 kilocalories/39 grams of protein) initiated on 4/21/21 due to a potential nutritional problem due to resident's diagnosis of dementia, difficulty swallowing, and a mechanically altered diet. (This intervention for Ensure Plus did not correspond with the RD recommendation on 4/1/21 for the Sugar Free Health Shakes TID). The care plan did not address a SF health shake. In addition the care plan did not address the resident's dislike for Glucerna in accordance with the hospital records and the initial Nutritional Assessment. A review of the electronic Progress Notes (ePN) for April and May 2021 did not reflect documented evidence that a rationale or a risk versus benefit with using Ensure Plus was the appropriate supplement of choice for a resident with diabetes and on an oral hypoglycemic medication (a medication that lowers the blood sugar). A review of the physician Order Review Report for all physician orders (PO) from admission to the facility through 5/27/21, reflected that the Ensure supplement was changed to a Glucerna supplement three times a day with meals on 5/21/21. (This did not correspond with the known resident preferences as referenced in the hospital records and the initial Nutrition Evaluation assessment dated [DATE] in which the resident informed the RD that he/she disliked Glucerna supplements. A review of the electronic Medication Administration Record (eMAR) for May 2021 reflected that physician's order dated 5/21/21 for the Glucerna supplement with meals. The Glucerna was plotted to be administered at 8 AM, 12 PM and 5 PM daily. The eMAR reflected that the resident consumed between 2 ounces to 8 ounces of Glucerna from 5/21/21-5/23/21, and the resident refused it on 5/24/21 at 8 AM and 12 PM, and again on 5/25/21 at 8 AM. The order for the Glucerna was clarified on 5/25/21 to give Glucerna 8 ounces by mouth with meals. The eMAR reflected that the resident consumed all 8 ounces of the Glucerna supplement on 5/25/21 at 5 PM, and 5/26/21 at 8 AM, 12 PM and 5 PM. On 5/26/21 at 12:35 PM, the surveyor observed a Certified Nursing Aide (CNA) deliver the lunch meal to Resident #74 at the table. The resident received an 8 ounce carton of chocolate Glucerna with the lunch meal. The CNA set up the resident's lunch tray but left the Glucerna supplement in its container closed. The resident began to eat meat loaf with a spoon. At 12:41 PM, the surveyor observed the RD sit with the resident briefly, and the RD encouraged the resident to try some more of the food. The RD then stated to the resident that she would give the resident privacy to eat. At 12:50 PM, the resident's Glucerna had not yet been opened and there was no cup on the tray to drink it from. At that time, the CNA approached the medication cart to obtain a straw and returned to open the resident's Glucerna and placed the straw in it. She then put the straw in the resident's mouth to drink the Glucerna, but the resident did not even take a sip. The CNA stated to the resident as she was attempting to give the Glucerna shake: You aren't going to drink it? Let me try the ginger ale. The resident took a sip of the ginger ale. At 1:05 PM, the surveyor observed the CNA clear the resident's lunch setting. The CNA left the resident's 8 ounces of chocolate Glucerna on the table with the straw in it. The resident was sitting quietly in the broda chair with his/her eyes closed and had not yet taken any sips from the Glucerna carton. A review of the resident's lunch meal ticket dated for the lunch meal on 5/26/21 indicated that supplements on the tray included: Glucerna. The section on the meal ticket to record the resident's dislikes, read: None. On 6/1/21 at 10:44 AM, the surveyor interviewed the RD who stated that she started working at the facility in April 2021. The RD stated that she was familiar with Resident #74 and that on admission the resident was able to express preferences, likes and dislikes and seemed to answer questions appropriately. She stated that the resident had had a decline in weight since admission and that she was aware that the resident had been previously supplemented with Glucerna shakes. However at that time, the resident had reported to her that he/she did not like the Glucerna health shake which was why the Sugar Free health shake was recommended to him/her and the resident seemed agreeable. The RD stated that the Medical Doctor (MD) changed supplement order to Ensure three times a day to add more calories and protein with every meal. The RD stated that she wasn't aware that the MD had ordered the Ensure and stated that she was not sure if Ensure was appropriate for diabetics or if it came in a formulary appropriate for diabetics. She stated that although the resident has lost weight, he/she had remained within a normal BMI (Body Mass Index). The surveyor asked about the order for the Glucerna when the resident had told her that he/she didn't like it, and the RD acknowledged that it was in the hospital records as well as in her Nutritional Assessment, but stated that she was not aware that the MD changed the order to Glucerna. She stated that she didn't make the recommendation to change it to Glucerna. She stated that she knew the resident didn't like it. She stated that it was documented in the eMAR that the resident was consuming it at times. The surveyor discussed what was observed with the resident not drinking the Glucerna during lunch on 5/26/21 and that the RD was there with the resident at the time. The RD was unable to provide documented evidence of the documented justification for the use of the Ensure supplement when the resident had diabetes and was on an oral hypoglycemic medication with a varying oral intake. She acknowledged that without documented blood sugar readings, it was difficult to justify the use of the Ensure. In addition the RD acknowledged that the resident' should not have received the Glucerna if he/she had reported not liking it. She stated that when it was identified on 5/27/21, it was switched to a Two-Cal nutritional supplement. On 6/1/21 at approximately 12:50 PM, the surveyor interviewed the Regional Director of Risk Management in the presence of the survey team and the Director of Nursing and Licensed Nursing Home Administrator (LNHA). The Regional Director of Risk Management confirmed that the resident's nutrition preferences should have been more clear on the resident's plan of care. No additional documents were provided regarding the justification for the nutritional supplements when the resident had a diagnosis of diabetes as well as preferences of not liking Glucerna, but it was still being served to the resident. A review of the facility's undated Care Plans, Comprehensive Person-Centered policy included that the resident's personal .preferences in developing the goals of care would be incorporated. In addition it included that the resident's expressed wishes would be reflected regarding care and treatment goals. NJAC 8:39-17.4 (c), (e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) a resident who repeatedly spilled liquids during their meals was assessed and provided an adaptive drinking cup to prevent spills. This deficient practice was identified for 1 of 17 residents reviewed for dining services (Resident #74). The evidence was as follows: On 5/24/21 at 12:25 PM, the surveyor observed Resident #74 sitting in a broda chair at a dining room table. The surveyor observed an Activities Assistant place the resident's lunch tray in front of Resident #74 which included macaroni and cheese. The Activities Assistant opened a can of ginger ale and placed it next to the resident's plate. It was not poured into an alternate cup. After the Activities Assistant walked away, the resident, while sitting alone, then reached for the can of ginger ale and poured it all over his/her macaroni and cheese and placed the emptied can on top of the food. At 12:34 PM, the surveyor observed the Food Service Director (FSD) deliver another tray for the resident which included a hot dog on a bun. At 12:39 PM, the surveyor observed a Speech Language Pathologist (SLP) sitting with the resident and attempted to encourage the resident to eat the cut up hot dog. The resident did not show interest in eating. On 5/26/21 at 11:08 AM, the surveyor attempted to interview Resident #74 in the privacy of his/her room. The resident responded to his/her name, but did not respond appropriately to other questions. The resident stated, I want to go home and began pulling at his/her pants. On 5/26/21 at 12:35 PM, the surveyor observed a second meal for Resident #74. The resident was sitting in a broda chair by him/her-self at a dining table positioned at the height of the resident's chin. The surveyor observed a Certified Nursing Aide (CNA) cut up the resident's meat loaf, and prepare hot tea in a regular mug. At 12:50 PM, after the resident ate almost all of the meatloaf, the surveyor observed the resident reach for the hot tea and the resident spilled it all over the rest of his/her lunch. At 12:54 PM, the surveyor observed the CNA return to check on the resident and saw that the resident's lunch plate was covered in the hot tea. The CNA then attempted to feed the resident a spoonful of some mashed potatoes that were not moistened from the hot tea. She stated to the resident I have to make sure you eat something. She then saw that a nutritional health shake carton had not been opened, so she walked over to the medication cart in the room, and accessed a straw and placed a straw in the health shake. The resident did not drink the health shake from the straw. She then offered the resident some ginger ale and with the CNA holding the ginger ale the resident took a small sip of it. There were no adaptive cups provided to the resident or any adaptive equipment listed on his/her lunch meal ticket. At 1:05 PM, the surveyor observed the CNA clean up the resident's lunch meal and plate with the hot tea that was spilled in the food. The CNA left the nutritional health shake in front of him/her with a straw in it. The surveyor observed the resident with his/her eyes closed, sitting in the broda chair at the table. On 5/27/21 at 9:23 AM, the surveyor observed a third meal service for Resident #74. The surveyor observed the resident sitting in a standard wheelchair and cutting up his/her egg breakfast with a fork and knife appropriately. The resident was served hot tea from a regular mug, orange juice from a reusable plastic cup and four ounces of water in a disposable plastic cup. There were no lids on the cups or adaptive cups on the tray. After the resident completed eating 50% of the breakfast, he/she spilled the hot tea all over the floor in front of him/her. After the tea was spilled, the mug of hot tea was observed to have only a small amount of remaining in the mug. On the same day on 5/27/21 at 9:44 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who was present in the dining room during the breakfast meal service. The RN/UM acknowledged that Resident #74 had spilled the hot tea all over the floor and that she would have to get housekeeping to assist in the clean up. She stated that the resident utilized regular cups for meal service. She stated that she knew that the resident also improperly pours milk on the food as well at times. She stated that the resident is always spilling. The surveyor asked what the plan was if the resident was always spilling. The RN/UM stated that the facility believed that it may be the resident's behaviors, and that they were focused on managing those behaviors. The surveyor asked if the resident had always been spilling, if he/she had been assessed for an adaptive cup with a lid or other adaptive cup to prevent spilling, and the RN/UM stated that it was a good idea and that no-one had thought of that. The surveyor discussed with the RN/UM that the surveyor had observed three (3) of three (3) meals in which the resident had spilled his/her liquids either on the food or on the floor. She acknowledged that if a resident was having difficulty using regular eating utensils during meal service, the nurses could request a referral for Occupational Therapy to evaluate for any adaptive eating/drinking equipment. She stated that it had not been done prior to surveyor inquiry. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, muscle wasting and atrophy, and diabetes. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident was able to eat independently with set-up by staff at the time of the assessment. A review of the resident's individualized comprehensive care plan reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia initiated on 4/30/21. Interventions were to Administer meds as ordered; Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion . The care plan did not address the resident as always spilling or the means to prevent further spilling of liquids, including an assessment for the use of an adaptive drinking cup. A review of the electronic Progress Notes (ePN) for May 2021 did not address the resident spilling liquids on their food for the lunch meal on 5/24 and 5/26, and it wasn't until the surveyor inquired on 5/27/21 that the spilling of liquids was addressed. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment for Certification Period 4/21/21-6/19/21 did not address a referral for an adaptive cup due to spilling of liquids. On 6/1/21 at 9:31 AM, the surveyor interviewed the SLP who had sat with the resident during the lunch meal on 5/24/21, and had observed that the resident had spilled the ginger ale on the macaroni and cheese. The SLP introduced himself and stated that he was also the Director of Rehab Services. He stated that Resident #74 was confused and difficult to redirect with a decline in cognition. He stated that he had been seeing the resident for some minor oral dysphagia (difficulty swallowing) and reduction of appetite. He stated that the resident was being seen by OT to also assist in promoting self-feeding strategies. She stated that the resident did not like to be fed and can become resistant if he/she felt that staff were leaning over [him/her] to eat. She stated that the resident had no hand tremors when eating. The surveyor asked the SLP about the resident spilling liquids on the macaroni and cheese on 5/24/21. He acknowledged that the resident had spilled liquids onto the food and that was the first time he had seen that from the resident. He stated that it was possible that the resident was misunderstanding what the object was stating that with the resident's dementia, he/she may be thinking that the drinks may be a condiment and mistakenly the resident may pour it onto their food for that purpose. He stated that they were trying to figure that out. He acknowledged that staff had not brought up that the resident had been spilling liquids on their tray until the surveyor inquired about it on 5/27/21. The surveyor asked if the facility had adaptive cups available, and he stated that they did not have a stock of adaptive cups and that one had to get specially ordered for the resident. He stated that the facility maintained a stock of adaptive plates and utensils, but not cups. He stated that if the facility needed it, the nurses would request a referral and it would get ordered right away. On 6/1/21 at 1:46 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated that the facility had adaptive utensils but no adaptive cups on hand, but added that their sister-facilities had adaptive cups that they could use until any purchased item arrived. He stated that the residents wouldn't have to wait for an adaptive cup if he/she needed it right away. The Regional Director of Risk Management stated that there was no documentation of the resident spilling in the ePN, and that this was new for the resident with regard to spilling during the meal service. The surveyor asked why the RN/UM would tell the surveyor that the resident was always spilling if he/she was not always spilling? The surveyor also asked if it wasn't documented in the ePN that the resident spilled his/her liquids for the lunch meal on 5/24/21 and 5/26/21 when the surveyor observed it happen, could it be also be possible that the resident spilled during other meals as the RN/UM stated to the surveyor, and it just not be documented in the ePN? The facility's Regional administration including the DON and the Licensed Nursing Home Administrator (LNHA) were unable to speak to those questions. They acknowledged the spilling wasn't addressed in the care plan either. They stated that out of respect to the surveyor's findings of the resident spilling the liquids for 3 of 3 meals, the resident was subsequently assessed for an adaptive cup and one was ordered and provided to the resident. On 6/3/21, the Regional Director of Clinical Operations provided the surveyor a copy of the facility's undated Assistive Devices and Equipment policy which included, that Certain devices and equipment that assist with resident .independence are provided for residents. These may include (but are not limited to): Specialized eating utensils and equipment.Recommendations for the use of devices and equipment are based on the comprehensive assessment and documentation in the resident's care plan.Requests or the need for special equipment should be referred to the Nursing, Rehabilitation, or Social Services Departments. NJAC 8:39-27.5(b); 46.5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 5/26/21 at 10:40 AM during the initial tour of the facility, the surveyor observed Resident #35 lying in bed with a blanket. The surveyor also observed a broda chair next to the resident's bed. At that time the surveyor attempted to interview Resident #35, but he/she was unable to be interviewed. The surveyor reviewed the medical record for Resident #35. A review of an admission Record face sheet for Resident #35 reflected that the resident was admitted to the facility with a diagnosis which included, but not limited to: muscle weakness, muscle atrophy (muscle wasting), difficulty in walking and cognitive communication deficit. A review of the significant change MDS dated [DATE] reflected that the resident had a BIMS of 99 which indicated the facility was unable to complete the interview with the resident. The staff performed a cognitive assessment which resident that the resident had a short and long term memory problem with an impaired decision-making capacity. It further reflected that the resident required extensive assistance with activities of daily living (ADL), which included bed mobility, transferring, dressing and toileting. A review of Resident #35 individualized, Interdisciplinary Plan of Care, dated 3/6/21 reflected that the resident had an ADL self-care performance deficit related to activity intolerance, dementia, fatigue, impaired balance, limited mobility range of motion (ROM) and musculoskeletal impairment. In addition to a risk for falls related to confusion, gait/balance problems, and unaware of safety needs. The interventions included Physical Therapy (PT)/ Occupational Therapy (OT) evaluations and treat as ordered or as needed (PRN). A review of the OT Discharge summary dated [DATE] reflected the discharge recommendation for Resident #35 was the restorative nursing program (RNP) which included the restorative ROM program and the restorative transfer program. A review of the OT Treatment Encounter Notes, dated 4/26/21 reflected that the therapist educated the Certified Nursing Assistant (CNA) and nursing staff on the RNP for passive range of motion (PROM - when movement is created by someone else) and transferring the resident into the geriatric chair for Resident #35. The RNP for PROM included to perform gentle PROM to the bilateral upper extremities (BUE) elbow and shoulder to decrease the risk of further joint contractures and stiffness. The resident was assessed for the geri-chair to assist and aid with proper positioning of head, shoulder and spine as the resident demonstrated incorrect and inappropriate positioning in bed. A review of the Documentation Survey Report for April, May and June 2021 reflected the CNA ADL task accountability for Resident #35, which included mobility/locomotion (how the resident moved for example in a geri-chair and/or broda chair), mobility (boosting in bed/wheelchair), turning and positioning (was the resident turned and repositioned during the shift). Upon further review it reflected there was no documentation or accountability for the PROM to the BUE exercises that was recommended in the OT discharge summary on 4/26/21. Upon further review of the PT and OT therapy service notes from April 2021 to May 2021, reflected Resident #35 was assessed for a geri-chair but it did not address the use or assessment of the broda chair. Upon further review of Resident #35 individualized, Interdisciplinary Plan of Care, dated 3/6/21 reflected on 5/19/21 Resident #35 was given a broda chair for positioning as a fall invention. A review of the physician's Order Listing Report for January 2021 to June 2021, reflected the physician order (PO) dated not until 5/27/21 for a broda chair: Resident #35 may sit in the broda chair for positioning and comfort. A review of the OT treatment Encounter Notes dated 5/28/21, reflected a wheelchair (w/c) management analysis of Resident #35 for body alignment and functional skills in a new or existing w/c did not address an assessment for the use of the broda chair. On 5/26/21 at 12:18 PM, the surveyor interviewed the RN/UM. The RN/UM stated Resident #35 was a fall risk and once he/she was awake they placed him/her into the broda chair. She further stated the resident was in a geri-chair prior, but after the resident fell out of the geri-chair on 5/19/21 the interdisciplinary team (IDT) which consisted of the Director of Nursing (DON), Unit Managers (UM), Therapy and the Administrator, they decided on a broda chair for Resident #35. On the same day at 12:56 PM, the surveyor observed CNA #1 bring Resident #35 out to the dayroom in a broda chair. On 5/27/21 at 12:04 PM, the surveyor observed Resident #35 sitting in a broda chair at a table in the dayroom. On 05/28/21 at 10:37 AM, the surveyor observed the CNA #1 performing morning care on Resident #35 with the assistance of the Registered Nurse/Unit Manager (RN/UM). At that time the surveyor did not observe the CNA #1 and/or the RN/UM perform PROM exercises to the resident's extremities. The surveyor interviewed the CNA #1. The CNA #1 stated his daily routine was to perform morning care, get the resident dressed in his/her clothes and then place the resident into the broda chair. On 6/1/21 at 9:59 AM, the surveyor observed the CNA #1 putting a shirt and pair of pants on Resident #35. At that time the surveyor did not observe the CNA #1 perform PROM exercises to the resident's extremities in accordance with the RNP. On 6/2/21 at 9:49 AM, the surveyor interviewed the RN #1. The RN #1 stated, Resident #35 was in a broda chair because he/she had frequent falls. She further stated, the broda was soft and the resident was able to put his/her feet on the floor. On 6/2/21 at 10:26 AM, the surveyor observed CNA #1 performing morning care for Resident #35. At that time, the surveyor did not observe the CNA #1 perform PROM exercises to the resident's BUE. On 6/2/21 at 10:32 AM, the surveyor interviewed the RN/MDS Coordinator. The RN/MDS Coordinator stated, she was one of the staff members that updated the care plan. She stated Resident #35 had been in the broda chair since 5/19/21 and that it was the best for the resident because he/she would fidget a lot and now that the resident was in a broda chair he/she can relax in it safely. On the same day at 12:47 PM, the RN #1 stated to the surveyor that when a resident had a broda chair an assessment would be done by the IDT during their meetings. At 12:48 PM, the RN/UM stated to the surveyor for residents in the broda chair during the IDT meetings, the DON, UM, therapists (PT/OT), Infection Preventionist (IP) and the Administrators recently discussed if the broda chairs are appropriate for the residents (after surveyor inquiry). The RN/UM further stated the facility used the broda chair as a fall risk prevention for residents. She concluded an assessment can be done by either the IDT or therapy. On 6/3/21 at 11:18 AM, the surveyor interviewed CNA #2 regarding a restorative nursing program (RNP). She stated, if there was any RNP for ROM, it would be documented in the computer system specifically in the resident's electronic Medical Record, through the CNA's ADL task record. On 6/3/21 at 12:08 PM, the surveyor interviewed the RN/UM. She stated she was not sure if Resident #35 was on a RNP and didn't think he/she was. She further stated, if Resident #35 was on a RNP for ROM then it would be performed when the staff was turning and washing the resident in the bed. The RN/UM emphasized those tasks were considered ROM. On 6/3/21 at 12:22 PM, in the presence of the survey team the DON stated during their IDT meetings they discussed that the broda chair was appropriate for Resident #35, but acknowledged there was no formal assessment for the use of the broda chair and no physician's order for its use prior to surveyor inquiry. The DON further stated therapy was also included in the IDT meeting. On the same day at 12:35 PM, in the presence of the survey team the RN/Director of Clinical Services (RN/DCS) stated the RNP discharge recommendation was for proper Hoyer lift (a mechanical device designed to lift patients safely) transfer. The RN/DCS did not speak on the OT discharge recommendation for the PROM to the BUE. 6. On 5/26/21 at approximately 12:45 PM, the surveyor observed Resident #9 sitting in a broda chair at a dining table eating lunch. The surveyor observed the resident pick at the side of peas with his/her hands. The surveyor reviewed the medical record for Resident #9. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to metabolic encephalopathy (an alteration in mental status caused by the failure of other internal organs), unspecified dementia without behavioral disturbance and essential hypertension (high blood pressure). A review of the resident's admission MDS dated [DATE], reflected that the resident had a BIMS score of 4 out of 15, indicating a severely impaired cognition. The assessment included that the resident could walk in room with extensive assist (resident involved in activity, staff provide weight-bearing support) and one person physical assist. The assessment included that the resident normally used a walker and a wheelchair as mobility devices. The assessment included that the resident could walk 10 feet with partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). The assessment included that the resident did not have any physical restraints or alarms in use. A review of the resident's individualized, comprehensive care plan included a focus for at risk for falls which included the following intervention: I may sit in a Broda wc [wheelchair] if I am tired which was initiated on 5/10/21. The intervention was resolved on 5/27/21 after surveyor inquiry. The intervention was then changed to the following: Allow me to sit by the nurse's station in a wc if I am restless, which was initiated on 5/27/21. A review of the Physician Order Listing Report for 1/1/21 to 6/30/21 did not include a physician's order for a Broda wheelchair. A review of the electronic Nurses Notes (eNN) revealed a care plan progress note dated 5/21/21 which included the following: Pt has tendency to stand up from Broda chair-however is able to be redirected. Pt is a fall risk-however has had no falls this quarter. The review also revealed a mood/behavior note dated 5/4/21 which included the following: resident was ambulated with assistance in the hallway and was assisted back to the wheelchair but keeps on getting up and trying to walk. Resident is a fall risk with very unsteady gait. A review of the Physical Therapy Discharge summary dated [DATE] included the resident able to ambulate from the bed to toilet using rolling walker with minimal assist. A review of the Physical Therapy Recert, Progress Report and Updated Therapy Plan, for certification period of 3/30/21 to 5/28/21, included the short term goal that resident will safely ambulate on level surfaces 100 feet using two-wheeled walker. The functional skills assessment included ambulation on level surfaces equaled minimum assist. On 6/3/21 at 12:18 PM, the facility administration were unable to provide any documentation that an assessment was performed for the use of the Broda chair, why it was being used for a resident during lunch when he/she was not exhibiting signs of tiredness in accordance with the plan of care for Resident #9 or any physician's order or accountability for the use of the Broda chair. The Regional Director of Operations stated that none of the residents had a functional decline as a result of the use of the broda chair. They stated that Resident #74 started the Broda chair on 5/13/21, Resident #9 started the Broda chair on 5/10/21, Resident #34 started the Broda chair on 5/13/21, Resident #35 started the Broda chair on 5/19/21, and Resident #40 started in the Broda chair on 2/21/20. She stated that most of the residents only just started using the broda chairs this month according to the medical records. A review of the facility's undated Assistive Devices and Equipment policy, included that Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include (but are not limited to): .Mobility devices (wheelchairs, walkers and canes).Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan.Staff and volunteers will be trained on the use of devices and equipment prior to assisting or supervising residents. The policy further included that various factors would be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment, including the Appropriatness for resident condition .Personal fit .Device condition .Staff practices. There was no policy provided on the implementation of an RNP. NJAC 8:39 - 27.1(a) Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) residents who were observed to be in a broda chair were appropriately assessed for them and used in accordance with each resident's individualized plan of care, and b.) the restorative exercise programming was consistently implemented and documented to prevent deconditioning or decline. This deficient practice was identified for 6 of 10 residents reviewed for positioning and functional mobility (Resident #9, #32, #34, #35, #40, and #74). The evidence was as follows: 1. On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. The broda chair was not in a locked position. At 12:07 PM, the resident attempted to stand up from the broda chair, and the CNA redirected the resident to sit back down. After the resident sat back down, the CNA propelled the resident in the broda chair to the center isle of the open dining room and the CNA locked the wheels on the broda chair which were unable to be accessed by the resident. The surveyor observed the resident attempt to scoot him/her-self while in the broda chair. At that time, the Licensed Nursing Home Administrator (LNHA) directed staff to move some tables in preparation for lunch service, and the surveyor observed two staff members pick up a dining table and place it in front of Resident #74 who was sitting in the broda chair. The surveyor observed that the broda chair sat low to the ground and the table height was set at the level of the resident's shoulders. At 12:13 PM, the surveyor observed Resident #74 in the locked broda chair push forward on the table, causing the table to move forward slightly. Then, Resident #74 began slowly sliding down in the broda chair, and two staff repositioned the resident back up in a seated position in the broda chair. On 5/26/21 at 10:37 AM, the surveyor observed Resident #74 standing up from the the broda chair in the main dining room. A Certified Occupational Therapy Assistant (COTA) was in the room, and redirected the resident to sit back down into the broda chair. The broda chair was in the locked position. At 11:08 AM, the surveyor attempted to interview Resident #74 in his/her room after the RN attempted to toilet the resident, but the resident did not respond back to the surveyor's questions appropriately. The resident stated that he/she wanted to go home and began pulling on his/her pants. From 11:36 AM to 11:50 AM, the surveyor observed Resident #74 in the rehab gym receiving rehab services. The surveyor observed the resident slowly ambulate using a rolling walker with the Physical Therapist (PT) providing contact guard and using a gait belt. The resident ambulated one and a half laps around the rehab gym before he/she sat back down in the broda chair. After completing therapy, the resident was transported back to the main dining room in the broda chair. On the same day on 5/26/21 at 12:00 PM, the surveyor interviewed the Physical Therapist (PT) assigned to Resident #74. The PT stated that she worked full time at the facility and had been working with Resident #74 for the last month since the resident's admission to the facility. The PT stated that the resident had a history of dementia, physical aggression, and was confused. She stated that the confusion had been getting worse and at times the resident was difficult to redirect. She stated that the resident could ambulate with a rolling walker, adding that the resident has had some cognitive decline but was physically okay. She stated that the resident used the rolling walker in therapy sessions which she believed was newer to him/her, because he/she had previously ambulated independently at home. The surveyor asked what the purpose of the broda chair was if he/she could ambulate with a rolling walker? The PT responded that the resident has had multiple falls and a lack of safety awareness and that it was to keep [him/her] from getting up .the lower the seat the harder it is to get up. We want to minimize [Resident #74] getting up. The PT elaborated that when the resident was in a regular wheelchair he/she stood up and fell out of the wheelchair, so they opted for the broda chair. The surveyor asked if the resident was still able to stand up in the broda chair, and the PT stated that the resident was able to stand up in the broda chair but that it was much harder to stand up in one, and therefore the resident would attempt to stand up less frequently when positioned in a broda chair versus a standard chair or wheelchair. The surveyor asked if that was then considered a restrictive device if the intent was to keep the resident from standing up, and the PT replied that we can't restrict or restrain them adding that it was for safety and to reduce the number of falls because if the resident was in a broda chair, staff could get to the resident quicker and prevent a fall if it was more challenging for him/her to stand up in the broda chair. The PT stated that the resident had no injuries from any sustained falls. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, muscle wasting and atrophy, and a lack of coordination. A review of the admission MDS dated [DATE] reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, or physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily that intruded on the privacy of activities of others, the resident independently transferred from surface to surface and ambulated independently with a steady gait using a rolling walker, and to date that he/she had no falls in the facility. The section to document if restraints were in use, included an option for chair that prevents rising; the facility marked not used. A review of the resident's individualized care plan initiated 4/21/21 included that the resident was at risk for falls and an intervention dated 5/13/21 indicated, I may sit in a Broda chair if I am tired. (The broda chair was not addressed in any other areas of the resident's care plan). A review of the physician's Order Summary Report for May 2021 did not include a physician's order for the use of the broda chair. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment for Certification Period 4/21/21-6/19/21 did not address the use or an assessment of a broda chair. A review of the OT Therapy Progress Notes and Report for the certification period did not address an assessment for the use of a broda chair or its risks versus benefits. Further review of an In-Service Training Report dated 4/28/21 from occupational therapy indicated a training to a nurse and a Certified Nursing Aide (CNA) that the resident was able to ambulate around [his/her] unit using R/W [rolling walker] requiring staff supervision for safety as [Resident #74] is forgetful and tends to walk without the assistive device which can will will put the resident at greater risk for a fall. The goal was to prevent de-conditioning. A review of the Physical Therapy Evaluation and Plan of Treatment for the Certification Period 4/21/21-5/18/21 did not address the use or an assessment of the broda chair. A review of the PT Progress Notes and Report for the certification period did not address an assessment for the use of a broda chair or its risk versus benefits. A review of the physician progress notes in the electronic Medical Record (eMR) for April or May 2021 did not include documented evidence for an assessment for the use of the broda chair or address the risks versus the benefits of using a broda chair. A review of the electronic Progress Notes (ePN) for April and May 2021 did not address an assessment for the use of the broda chair, its intended use, under what circumstances the resident was placed in the broda chair, and the resident's response to being in the broda chair. In addition there was no documented evidence that the risks versus benefits were discussed with the resident's Power of Attorney (POA). A review of the Activities of Daily Living (ADL) task record Documentation Survey Report v2 for May 2021 indicated that the CNA's were documenting every shift for the resident's Mobility/Locomotion, the Mobility/Locomotion in Resident's Room and the Mobility/Locomotion off Unit. The ADL task record did not reflect accountability for the use of the broda chair. A review of the electronic Medication Administration Record (eMAR) for April and May 2021 and the electronic Treatment Administration Record (eTAR) for April and May 2021 also did not reflect accountability for the use of the broda chair. The next day on 5/27/21 at 9:05 AM, the surveyor observed the Certified Nursing Aide (CNA) taking Resident #74 off the toilet. The CNA stated that the resident was unable to void. The CNA observed that the resident was now in a standard wheelchair and not in the broda chair. At 9:08 AM, the surveyor interviewed the resident's assigned CNA who stated that the resident was really confused most of the time. She stated that the resident was at high risk for falls and so staff rotate every 30 minutes who was in the dining room for resident supervision. The CNA stated that Resident #74 was in a broda chair for fall prevention adding that it is harder for [Resident #74] to get up in the broda chair. The CNA continued that when the resident was in the wheelchair, he/she tried to get up even more, so the broda chair might be more relaxing. The surveyor asked if the broda chair was being used as a restrictive device if it was being used to keep the resident from standing up, if he/she was capable of standing up? The CNA replied, not exactly, because it is for fall prevention. The CNA confirmed that the resident still would try to get up out of the broda chair, and that he/she could successfully do so independently, but that the broda chair made it harder for him/her. The CNA confirmed that the resident seemed to have less falls when in the broda chair versus being in the wheelchair, and confirmed that the resident was now back in a standard wheelchair as of last night. At 9:37 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident was very confused and the broda chair was used for his/her safety because he/she kept sliding out of the wheelchair even with a dycem (non-slip mat). She stated that the resident was very difficult to redirect and was combative with staff during redirection. She stated that the resident was unsteady on his/her feet and the broda chair forced the resident to take longer to get stand up allowing the staff to try to get to her in time before he/she fell. She stated that the staff can't stay beside him/her all the time. She stated that it was not a restrictive device because it was used for his/her poor safety awareness and that he/she could still rise out of the chair. The surveyor asked if that assessment was documented anywhere. She stated that therapy evaluated the resident last night and that they re-assessed her for being in a wheelchair and not a broda chair. The surveyor asked the RN/UM about the care plan to use the broda chair if tired, and if the resident kept standing up out of the broda chair if that indicated he/she was tired. The RN/UM acknowledged that the resident attempted to stand up no matter if he/she was in a wheelchair or a broda chair. The surveyor asked the RN/UM why they were using the broda chair then if the resident made efforts to stand just as much seated in both devices, and the RN/UM stated that she wasn't exactly sure. The surveyor asked where the documentation would be for the broda chair that was implemented 5/13/21, and she stated that it should be in the ePN. On 5/28/21 at 10:30 AM, the surveyor interviewed the Registered Nurse (RN) assigned to care for Resident #74. The RN stated that the resident was confused and combative, difficult to redirect and that he/she kept standing and if you turn your back the resident would fall. The RN confirmed that the resident was no longer in the broda chair to prevent falls, and that any documentation should be in the ePN. On 6/1/21 at 9:57 AM, the surveyor conducted a phone interview with the resident's Attending Physician (MD). The MD stated that the resident was admitted to the facility awake and alert but was unsteady on his/her feet and had multiple falls. She stated that the resident had a diagnosis of dementia and was confused. She continued that the resident was refusing to have blood work drawn and had aggressive behaviors in which a consult for psychiatry was ordered. She stated that it seemed as though the resident was not easily re-directable. The surveyor asked about the broda chair, and the MD stated that she was not involved in the broda chair adding that physical therapy recommends and the Physiatrist (Rehabilitation Physician) would make the decision to order it. The surveyor asked what the purpose of the broda chair for the resident was, and she stated possibly for set-up, maybe. The MD then had to abruptly end the call before the surveyor could ask for any further clarifying questions. On 6/1/21 at 1:32 PM, the Regional Director of Risk Management stated in the presence of the survey team and the Licensed Nursing Home Administrator, Director of Nursing (DON), and the Regional Director of Clinical Services and the Regional Director of Operations, that Resident #74 had falls. She stated that the resident was sliding out of the wheelchair at times and that the broda chair would be more comfortable for the resident because of how it contours to the body. She stated that the intent of the broda chair was for the resident's comfort despite what staff may have told the surveyor. She stated that it was not a restrictive device. The Regional Director of Risk Management confirmed that there was no formal assessment done for the use of the broda chair. She acknowledged that the broda chairs have seats that are lower to the ground which can affect a resident's ability to easily stand. She stated that the resident was still attempting to stand up from the broda chair regardless of the intervention for comfort. The surveyor asked if a device (such as a broda chair) even if used for comfort could have risks associated with it, such as potentially decreased conditioning, and the Regional Director of Risk Management stated that it was not restricting the resident's movement. She stated that there should have been better documentation surrounding the assessment of the broda chair and its use. The facility provided an undated statement from the OT on 6/3/21. The OT statement indicated that the resident demonstrated a decrease in sitting tolerance/balance due to increased forward lean/pelvic flexion, therefore upon assessment patient was deemed appropriate for the broda chair at the time. The chair did not pose as a restraint for the patient as the patient was still able to get up from the chair independently. There was no documented evidence that the assessment for the broda chair had been done prior to surveyor inquiry, or documentation why the broda chair was no longer to be indicated on 5/27/21 after the surveyor had inquired to staff about its use. In addition, there was no documentation regarding the risk versus benefit of using the broda chair, when the broda chair was being used for reasons other than if the resident was tired. 5. On 5/24/21 between 11:53 AM to 12:04 PM, the surveyor, in the presence of another surveyor, observed Resident #34 sitting in a Broda chair in the common dining/activity area in front of the nursing station. The Broda chair was locked in position in front of a table in an upright position. The resident was attempting to climb out of the chair by lifting their legs over the edge of the left side of the arms of the chair and then switched to the right side of the chair. During that time, a staff member repositioned the resident and the resident continued attempting to move their legs over the edge of the arms of the Broda chair and was unable to move freely. The surveyor reviewed the medical record for Resident #34. A review of the admission MDS dated [DATE], reflected the resident was not able to complete a BIMS score. The staff performed a cognitive assessment which reflected the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. In addition, the MDS reflected that the resident had functional abilities that required extensive assist with one-person assisting to walk in the corridor and on the unit. In addition, the resident had no functional limitation in range of motion (ROM) and no impairment to the upper or lower extremities. According to the MDS, the resident had a walker as a mobility device. A review of the resident's admission Record face sheet revealed a diagnosis of dementia, anxiety disorder, muscle weakness and muscle wasting and atrophy. A review of the resident's interdisciplinary care plan (IDCP) revealed that the resident had a focus of being at risk for falls related to confusion, gait balance problems and being unaware of safety needs. In addition, the IDCP reflected that the resident kept trying to get out of bed and chair unassisted with a date initiated of 3/22/21. The interventions initiated 3/22/21 were to keep frequently used items within reach and anticipate and meet the resident's needs. The interventions initiated 3/23/21 were to allow the resident to sit by the nursing station and if restless ask the resident if toileting was needed. An intervention dated 5/3/21 was to remind the resident to use the rolling walker. The resident also had a focus of limited physical mobility related to weakness initiated 3/22/21 and a goal of increasing mobility by being able to ambulate 100 feet using the rolling walker with a target date of 6/15/21. The resident also had a focus of using anti-anxiety medications related to an anxiety disorder with a date initiated of 4/6/21 and an [TRUNCATED]

2. On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a four ounce cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. On 5/26/21 at 11:08 AM, the surveyor attempted to interview Resident #74 in the privacy of his/her room. The resident responded to his/her name, but did not respond appropriately to other questions. The resident stated, I want to go home and began pulling at his/her pants. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, insomnia, and psychophysical visual disturbances. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily which intruded on the privacy/activities of others. A review of the resident's individualized comprehensive care plan reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia initiated on 4/30/21. Interventions included to, Administer meds as ordered . A review of the physician's cumulative Order Review Report for April and May 2021 reflected a physician's order (PO) dated 4/22/21 for the controlled drug/anti-anxiety medication, Lorazepam (Ativan). The order specified to administer 0.5 milligrams (mg) by mouth every six (6) hours as needed (PRN) for anxiety for 14 days. The PO for the Ativan 0.5 mg every six (6) hours PRN for anxiety was renewed on 5/6/21 and the order included to continue for 30 more days. A review of the Individual Patient's Controlled Drug Record (IPCDR, a declining inventory sheet used for the accountability of controlled drugs) for the resident's Ativan 0.5 mg, reflected that 30 tablets of 0.5 mg were delivered to the facility on 4/22/21. The surveyor reviewed the IPCDR with a comparative review of the electronic Medication Administration Record (eMAR) for May 2021. The review revealed that the Ativan 0.5 mg was removed from the resident's active inventory but not signed as administered in the eMAR on the following dates and times: 5/2/21 at 1 PM, 5/4/21 at 3:30 AM, 5/6/21 at 12 AM and 2 PM 5/12/21 at 6:15 AM, 5/17/21 at 12 AM, 5/19/21 at 2 PM, 5/20/21 at 9 PM, 5/21/21 at 9 PM 5/24/21 at 12:30 AM. Further review of the documents revealed in the IPCDR that one tablet of Ativan 0.5 mg was removed on 5/19/21 at 3:35 AM, but the eMAR was signed that the dose was administered at 2:30 AM. A review of the ePN dated 5/6/21 at 8:53 AM, reflected that Ativan was administered due to inability to be redirected and combativeness. It was not signed in the eMAR as administered. There was no corresponding ePN for the doses of Ativan signed out from active inventory on the IPCDR for the removal date and time of: 5/2/21 at 1 PM, 5/4/21 at 3:30 AM, 5/17/21 at 12 AM, 5/19/21 at 2 PM and 5/20/21 at 9 PM. A review of the ePN dated 5/12/21 at 8:31 AM, reflected that the resident had refused blood work and stating that he/she would not take any of the medications but about a half hour later [Resident #74] took the Ativan. This dose signed out on the IPCDR on 5/12/21 at 6:15 AM was not signed as administered in the eMAR. In addition, there was a dose removed from active inventory on 5/21/21 at 11:30 AM, and another dose removed at 9 PM, but the eMAR was signed to reflect that only one dose was given that day at 5:41 PM, which does not correspond with the times it was documented as removed from active inventory. Further, the electronic Progress Notes (ePN) dated 5/21/21 at 2:30 PM, reflected that the resident returned from a physician appointment at 11 AM that morning with episodes of agitation and that the Ativan was given. (There was no documented evidence that a dose of Ativan was administered before 2:30 PM on 5/21/21 on the eMAR). A review of the ePN dated 5/24/21 at 7:20 AM reflected that the nurse administered Ativan because the resident attempted to get out of bed x2. Ativan Administered. (This dose was not signed as administered in the eMAR). On 5/28/21 at 10:30 AM, the surveyor interviewed the resident's assigned Registered Nurse (RN) who stated that the resident was confused, and had behaviors of, keeps standing and if staff tried to touch him/her to provide redirection the resident would sometimes become combative or not follow commands. She added that the resident also had a history of wandering into other resident rooms and she stated that the resident could also be combative toward staff for no reason. The RN stated that after a dose of Ativan was removed from active inventory, the nurse would sign in the IPCDR that a tablet was removed and how many tablets were remaining. She stated that after administering the tablet to the resident, the nurse was then responsible to sign the eMAR. The surveyor showed the RN the IPCDR for the Ativan 0.5 mg tablet and the discrepancies with the eMAR for May 2021. The RN acknowledged that the eMAR wasn't always signed when a tablet was removed from the active inventory. She stated that sometimes the resident would spit out the Ativan with his/her other medications and that was probably why it wasn't signed as administered in the eMAR. The surveyor asked about the process if a resident refuses to take a controlled drug that was prepared for administration, and she replied that nurses are supposed to sign that the dose was wasted on the IPCDR form. The RN confirmed that there was no documented evidence on the IPCDR form that any tablets of the Ativan had been wasted by two nurses. She stated that there should be documentation in the ePN to clarify why it was removed, but she stated that she could not show the surveyor right now because she had to pass out medications to other residents. On 5/28/21 at 10:44 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who confirmed that the resident had a diagnosis of Dementia and was on an anti-anxiety medication, Ativan. The RN/UM stated that the resident had behaviors of refusing lab work, trying to stand up unassisted and ambulate with an unsteady gait. She stated that when trying to re-direct the resident, he/she would kick and fight making it more dangerous for the resident because it would affect his/her balance. The surveyor reviewed the discrepancies within the IPCDR for the Ativan 0.5 mg and the eMAR for May 2021 with the RN/UM. The RN/UM acknowledged that surveyor's findings. She acknowledged that nurses should be documenting in the ePN, if its not documented in the eMAR. She further stated that the resident would sometimes refuse his/her medications when given and spit them out, but the Ativan tablet was very small and that often the resident would swallow the smaller tablets and spit out the larger ones. She stated that if the resident had spit out any tablets of Ativan, that dose should be documented on the IPCDR as wasted with two nurses. She acknowledged there were no tablets documented as wasted in the IPCDR for the Ativan 0.5 mg. She stated that if a resident spit out a dose of Ativan, it should be recorded in the ePN. She stated that sometimes the nurses may not know what tablets the resident swallowed or not because it gets mixed in applesauce, stating that could be another reason of the eMAR not being signed as administered when it was removed from active inventory. She stated that she would look into it. On 6/1/21 at 1:18 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team and the Regional Director of Risk Management, the Regional Director of Operations, the Regional Director of Clinical Services. The DON stated that they reviewed the discrepancies with the IPCDR for the Ativan and the eMAR for May 2021. He stated that in their investigation they saw that there were four nurses who weren't signing for the doses administered in the eMAR. He stated that the nurses reported that they stayed with the resident after giving the medication and had forgot to sign for the administration of the Ativan thereafter. He stated that the four nurses reported through means of a statement that the resident always swallowed the tablets of the Ativan that was given, and that failing to sign that a dose of the Ativan was wasted in the IPCDR was therefore not a possibility. He acknowledged there wasn't consistent documentation in the ePN regarding the discrepancies. He stated that on 5/21/21 when two doses of Ativan were removed from active inventory at 11:30 AM and 9 PM but only one dose was signed as administered at 5:41 PM, the DON stated that this occurred because during a shift-to shift count, the nurse had realized she forgot to sign the eMAR for the administration of the medication earlier in the day at 11:30 AM when the resident came back from an appointment. The DON acknowledged that surveyors findings. A review of the facility's undated policy for Behavioral Assessment, Intervention and Monitoring included that The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. A review of the facility policy dated as revised September 2020 for Administering Medications reflected that medications were to be administered in accordance with the prescribers' orders. In addition, the medication label was to be checked three times to verify the right dosage and the individual administering medications was to initial the medication administration record after giving a medication. NJAC: 8:39-29.2(a)(d), 29.4(k), 29.7(c) Based on observation, interview, and record review, it was determined that the facility failed to maintain accurate accountability and reconciliation for two (2) controlled drugs, an antianxiety medication Lorazepam (Ativan) and an analgesic Oxycodone Immediate Release. This deficient practice was identified for 2 of 5 residents reviewed for medication management, (Resident #74 and #75), and was evidenced by the following: 1. On 5/24/21 at 10:24 AM, the surveyor interviewed Resident #75. The resident stated that he/she had pain and would tell the nurse and would get a pain medication which helped. On 5/28/21 at 9:17 AM, the surveyor interviewed the Registered Nurse Supervisor (RNS) who stated that she was familiar with Resident #75. The RNS stated that the resident had just finished having care rendered and was probably tired and that the resident had received a medication for pain earlier. At that time, the surveyor with the RN reviewed the resident's Individual Patient's Controlled Drug Record (IPCDR) dated as received 4/14/21 for Oxycodone Immediate Release (IR) 5 milligram (MG) tablets. The surveyor and the RNS verified the count for Oxycodone IR 5 MG was 19 tablets remaining in inventory. There was no documentation of any wastage. The surveyor reviewed the medical record for Resident #75. A review of the resident's admission Record revealed a diagnosis of a left leg below knee amputation. A review of a significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/26/21, reflected the resident had a brief interview for mental status (BIMS) score of 8 out of 15, indicating that the resident had a moderately impaired cognition. A review of the Order Listing Report reflected a physician's order dated 5/7/21 for Roxicodone (Oxycodone IR) 5 MG, give one tablet every 4 hours as needed (PRN) for moderate pain. A review of the electronic Medication Administration Record (eMAR) for May 2021 reflected the same physician's order dated 5/7/21 for Roxicodne (Oxycodone IR) 5 MG, give one tablet every 4 hours PRN for moderate pain. Further review of the IPCDR revealed entries of removal from inventory of the resident's Oxycodone IR 5 MG tablets on the following dates, times and number of tablets removed: 5/8/21 at 7 PM, two tablets 5/9/21 at 11 AM, two tablets 5/14/21 at 7 PM, one tablet, 5/20/21 at 6 AM one tablet 5/20/21 at an unreadable administration time, one tablet 5/21/21 at 10 AM, one tablet 5/24/21 at 9 AM, one tablet. Further review of the eMAR for May 2021 reflected that there were no corresponding administration dates, times and number of tablets administered for the above entries on the IPCDR. On 6/2/2021 at 10:22 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that entries for removal on the IPCDR should correspond with the eMAR for the same dates, times, and number of tablets. The CP added that if there was wastage of any controlled drug then that would be documented on the IPCDR. In addition, the CP stated that a refusal of a medication by the resident would be reflected in the eMAR. The CP also stated that she had reviewed the IPCDR for the Oxycodone IR for Resident #75 after surveyor inquiry and acknowledged that the IPCDR had removal entries that did not correspond with the eMAR. The CP added that she does a spot check of IPCDR and the resident had not been readmitted to the facility before she had completed her monthly review. The CP added that the nurses who removed the Oxycodone IR tablets from inventory had not documented on the EMAR for the administration. The CP also stated that she would be checking the IPCDR and corresponding eMAR moving forward. On 6/2/2021 at 1:35 PM, the survey team met with the facility administrative team. The Regional Director of Operations stated that a review of the resident's IDCP and eMAR was done after surveyor inquiry and acknowledged that the IDCP and eMAR did not correspond. She stated that she had spoken with the nurses who had signed for removing the Oxycodone IR from inventory and the nurses had said that the Oxycodone IR tablets were administered to the resident. She added that the nurses stated that they had been distracted and forgot to document the medication administration. She also stated that the nurses were written up, educated and completed a Statement of Witness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) an anti-anxiety medication (Ativan) prescribed to be given as needed for agitation had a documented rationale for why it was being administered, and any non-pharmacological interventions trialed before administering the medication, b.) a clinical rationale was documented for why the as needed anti-anxiety medication exceeded the 14-day period. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #74), and was evidenced by the following: On 5/24/21 at 11:56 AM, the surveyor observed Resident #74 sitting in a broda chair at the nurses station. After finishing a four ounce cup of water that a Registered Nurse (RN) provided to the resident, the resident began reaching in the sky and began trying to maneuver the broda chair to turn. On 5/26/21 at 11:08 AM, the surveyor attempted to interview Resident #74 in the privacy of his/her room. The resident responded to his/her name, but did not respond appropriately to other questions. The resident stated, I want to go home and began pulling at his/her pants. The surveyor reviewed the medical record for Resident #74. A review of the admission Record face sheet (an admission summary) reflected that the resident had been recently admitted to the facility with diagnoses which included Dementia without behavioral disturbances, a cognitive communication deficit, insomnia, and psychophysical visual disturbances. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/21 reflected that the resident had a BIMS of 11 out of 15 indicating that on admission he/she had an intact cognition with moderate forgetfulness. It included that the resident had no signs or symptoms of delirium, nor had any physical or verbal behaviors in the last seven days. The MDS included that the resident wandered on the unit daily which intruded on the privacy/activities of others. A review of the resident's individualized comprehensive care plan reflected that the resident had an impaired cognitive function or impaired thought processes related to dementia initiated on 4/30/21. Interventions were to Administer meds as ordered; Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion . The care plan also had a focus that he/she had a communication problem related to the resident's voice being of low volume. Interventions included to: Anticipate and meet my needs. Inventions if the resident began to wander included: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.If I am wandering assess for unmet needs hunger, toileting, thirst, boredom. The care plan was also updated on 5/6/21 and included that the resident had the potential to demonstrate physical behaviors directed at me by other residents related to Dementia and history of harm to others. It indicated that the resident was resistant and combative when redirected, refused laboratory blood work following a fall, a history of pushing on the exit doors wanting to get out, and hitting staff when being redirected. The goal for the behaviors was that the resident would not harm him/her-self or others through the next review date of 7/14/21. Interventions included to Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc; .Give me as many choices as possible about care and activities. The care plan focus initiated on 5/7/21 reflected that the resident used anti-anxiety medication related to an Anxiety disorder. Interventions included, Give anti-anxiety medications ordered by the physician. Monitor/document side effects and effectiveness. The side effects were listed on the care plan. Another intervention indicated that I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety. Interventions for the recreational care plan initiated on 4/30/21 included that the resident enjoys playing cards and place me next to a peer who is actively engaged. A review of the physician's cumulative Order Review Report for April and May 2021 reflected a physician's order (PO) dated 4/22/21 for the controlled drug/anti-anxiety medication, Lorazepam (Ativan). The order specified to administer 0.5 milligrams (mg) by mouth every six (6) hours as needed (PRN) for anxiety for 14 days. A PO dated 4/22/21 included to monitor for Anxiety with interventions that may include but are not limited to: 1. Redirection, 2. (1:1), 3. Activity, 4. Toilet, 5. Food/Fluid offered, 6. Position Change, 7. Other intervention (specify in progress notes), 8. Medication. The order specified to monitor for the anxiety every shift (day, evening and night shift) for 14 days. There was also an order dated 4/22/21 to monitor for side effects of the anti-anxiety medications every shift. The PO to monitor for the resident's anxiety behaviors and the side effects of the medication was discontinued on 5/6/21 and never re-ordered. Further there was a PO dated 4/22/21 included to monitor for Psychosis behaviors with interventions that may include but are not limited to: 1. Redirection, 2. (1:1), 3. Activity, 4. Toilet, 5. Food/Fluid offered, 6. Position Change, 7. Other intervention (specify in progress notes), 8. Medication. The order specified to monitor for the anxiety every shift. There was no stop date on this order. A PO dated 4/22/21 also included to monitor for side effects of any antipsychotic medications and document every shift. The PO for the Ativan 0.5 mg every six (6) hours PRN for anxiety was renewed on 5/6/21 and the order included to continue for 30 more days. A review of the Psychiatric Evaluation dated 5/6/21 reflected that Resident #74 was observed to be confused, irritable and physically aggressive when redirected by staff. The history of present illness indicated that the resident had memory loss, delusions, hallucinations, agitation, aggression, and impaired sleep. The consultation indicated that the resident had a history of past psychotropic medication use prior to admission to the facility. The Psychiatric Nurse Practitioner (NP) adjusted the resident's antipsychotic medication, Zyprexa, and recommended to Continue Ativan PRN x 30 days. The clinical rationale for exceeding a 14-day PRN order for Ativan was not documented in the Psychiatric Evaluation. A review of the Individual Patient's Controlled Drug Record (IPCDR, a declining inventory sheet used for the accountability of controlled drugs) for the resident's Ativan 0.5 mg, reflected that 30 tablets of 0.5 mg were delivered to the facility on 4/22/21. A review of the electronic Medication Administration Record (eMAR) for May 2021 reflected the PO dated 4/22/21 to administer the anti-anxiety Medication Ativan 0.5 mg every six (6) hours PRN for anxiety for 14 days. The eMAR was signed to reflect the resident received doses on the following dates and time without consistent documented evidence as to why, including: 5/1/21 at 12:38 AM and 7:05 PM, 5/3/21 at 8:30 PM, 5/6/21 at 8:45 PM, 5/12/21 at 8:40 PM, 5/17/21 at 8:30 PM, 5/19/21 at 2:30 AM, 5/21/21 at 5:41 PM, 5/22/21 at 10:44 AM, 5/24/21 at 5 PM. A review of the Behavior Monitoring flow sheets for April and May 2021 indicated the PO dated 4/22/21 to monitor for Anxiety every Day shift (7 AM to 3 PM), Evening shift (3 PM - 11 PM) and Night shift (11 PM - 7 AM) and to document interventions that may include but are not limited to: 1. Redirection, 2. (1:1), 3. Activity, 4. Toilet, 5. Food/Fluid offered, 6. Position Change, 7. Other intervention (specify in progress notes), 8. Medication. The order specified to monitor for the anxiety every shift for 14 days. The Behavior Monitoring flow sheet reflected that Behavior monitoring for Anxiety was discontinued on 5/6/21, and therefore there was no behavior monitoring for specific target behaviors of anxiety after 5/6/21. The surveyor reviewed the electronic Progress Notes (ePN) for April and May 2021 in comparison with the Behavior Monitoring flow sheets for April and May 2021 to determine what the resident's target behavior was specific to anxiety for each dose of Ativan signed as administered in the eMAR and any interventions trialed and failed prior to administering the anti-anxiety medication, Ativan. The following was revealed: For the Ativan dose signed in the eMAR as administered on 5/1/21 at 12:38 AM, the Behavior Monitoring flow sheet reflected that the resident had NO behaviors that shift, and there was no ePN that corresponded with resident's behaviors that warranted the use of the Ativan. For the Ativan dose given on 5/1/21 at 7:05 PM, the Behavior Monitoring flow sheet reflected that the resident had 2 episodes of anxiety and was offered redirection, toileting, and food/fluids. It did not specify that a medication was given. There was no corresponding ePN that specified what specific behavior the resident was exhibiting that presented as anxiety. For the Ativan dose given on 5/6/21 at 8:45 PM, the nurses did not document in the behavior monitoring section for Anxiety as it had been discontinued on 5/6/21. Instead the nurses began documenting resident behaviors under the behavior monitoring for Psychosis, as the resident was also on an anti-psychotic medication, Zyprexa. The Behavior Monitoring flow sheet revealed that the resident had six episodes of Psychosis and was offered redirection, toileting and food/fluids. There was no corresponding ePN for the dose given that specified what specific target behavior the resident was exhibiting and if that differed from the Psychosis to warrant the use of the anti-anxiety medication, Ativan. For the Ativan dose given on 5/12/21 at 8:40 PM, the Behavior Monitoring flow sheet revealed that the resident had four episodes of psychosis and was offered redirection, toileting and food/fluids. There was no corresponding ePN for the dose given that specified what specific target behavior the resident was exhibiting and if that differed from the Psychosis to warrant the use of the anti-anxiety medication Ativan. For the Ativan dose given on 5/17/21 at 8:30 PM, the Behavior Monitoring flow sheet revealed that the resident had two episodes of psychosis and was offered redirection, toileting and food/fluids. There was no corresponding ePN for the dose given that specified what specific target behavior the resident was exhibiting and if that differed from the Psychosis to warrant the use of the anti-anxiety medication Ativan. For the Ativan dose given on 5/19/21 at 2:30 AM, the Behavior Monitoring flow sheet revealed that the resident had NO episodes of psychosis. There was no corresponding ePN for the dose given at 2:30 AM that specified what specific target behavior the resident was exhibiting, what non-pharmacological interventions were trialed and failed prior to administering the anti-anxiety medication, Ativan. For the Ativan dose given on 5/21/21 at 5:41 PM, reflected an ePN dated 5/22/21 which indicated that Ativan was given on 5/21/21 during the evening shift when the resident was seen to be sitting on the floor. The note specified that all the resident's medications were given and tolerated well, but the Ativan that was given was not effective. There was no documented evidence of the resident's specific target behavior, if any non-pharmacological interventions were trialed prior to administering the dose of Ativan and what target behaviors the resident continued to exhibit for the anti-anxiety medication to not be effective. The ePN also did not reflect if the resident being found to be sitting on the floor was a possible side effect of the anti-anxiety medication. The Behavior Monitoring flow sheet was signed to reflect during that evening shift (3 PM to 11 PM) on 5/21/21 the resident exhibited NO behaviors of Psychosis. No trialed interventions were listed. For the Ativan dose given on 5/22/21 at 10:44 AM, the Behavior Monitoring flow sheet revealed that the resident had four episodes of Psychosis and was offered redirection, toileting and food/fluids. There was no corresponding ePN for the dose given that specified what specific target behavior the resident was exhibiting and if that differed from the Psychosis to warrant the use of the anti-anxiety medication, Ativan. For the Ativan dose given on 5/24/21 at 5 PM, the Behavior Monitoring flow sheet revealed that the resident had two episodes of Psychosis and was offered redirection, toileting and food/fluids. There was no corresponding ePN for the dose given that specified what specific target behavior the resident was exhibiting and if that differed from the Psychosis to warrant the use of the anti-anxiety medication, Ativan. A review of the ePN dated 5/24/21 at 7:20 AM reflected that the nurse administered Ativan because the resident attempted to get out of bed x2. Ativan Administered. There was no documented evidence of non-pharmacological interventions trialed prior to administering Ativan, and if administering Ativan due to trying to get out of bed without further documentation was an appropriate use for the Ativan. Further review of an ePN on dated 5/21/21 at 2:30 PM, reflected that the resident returned from a physician appointment at 11 AM that morning with episodes of agitation and that the Ativan was given. There was no documented evidence of what was potentially causing the resident's agitation, what specific specific target behaviors the resident was exhibiting that presented as agitation, and any non-pharmacological interventions trialed and failed prior to administering the dose of Ativan. (This dose was also not signed as administered in the eMAR for May 2021). In addition, a review of the Behavior Monitoring flow for May 2021 revealed that the resident exhibited NO behaviors of Psychosis that shift on 5/21/21 during the day shift or any shift that day. No interventions were listed as trialed. A comparative review of the eMAR for May 2021, the Behavior Monitoring flow sheets for April and May 2021 and the ePN for April and May 2021 revealed that Resident #74 was not trialed with an activity of interest as a means to evaluate if any behaviors that may have been exhibited were associated with boredom in accordance with the resident's plan of care. A review of the physician's Order Summary Report for May 2021 reflected a PO dated 5/25/21 to increase the frequency of Ativan from PRN to give the Ativan 0.5 mg twice a day for anxiety/agitation related to psychophysical visual disturbances. A review of the eMAR for May 2021 reflected that the nurses were signing twice a day (during the day shift and evening shift) routinely for the administration of the anti-anxiety medication, Ativan 0.5 mg. A review of a follow-up Psychiatric Evaluation performed by the Psychiatric NP and dated 5/25/21 reflected that the resident presented calm with confusion, and as per staff, [Resident #74] has been combative with care, hits staff. The recommendations included to discontinue the PRN Ativan and start the Ativan 0.5 mg twice a day for anxiety. It further included a recommendation to add Ativan 0.5 mg every 24 hours PRN for a 14 day trial. A review of the physician's Order Summary Report for May 2021 reflected the physician's orders for the recommendations made by the Psychiatric NP. On 5/27/21 at 9:08 AM, the surveyor interviewed the resident's assigned Certified Nursing Aide (CNA). The CNA stated that Resident #74 was really confused most of the time and that he/she had behaviors of standing up repeatedly from the chair and would be difficult to redirect. She stated that the facility watched him/her and rotated who was responsible for supervising the dining room every 30 minutes. She stated that the majority of the time, she assists with feeding the resident but the family brought in snacks like muffins and oranges that she would give to the resident. She stated that the resident also always asked for fluids to drink so she would give the residents fluids also. She stated that she can tell if the resident wants to walk and she would try to walk the resident if his/her gait was steady. She stated that the facility had also implemented a broda chair (a reclining chair that sits low to the ground) to assist in relaxing the resident and to keep him/her from standing up so much. She stated that it had implementing the broda chair helped reduce the number of falls, even though the resident was still able to stand up from the broda chair. On 5/28/21 at 10:30 AM, the surveyor interviewed the resident's assigned Registered Nurse (RN) who stated that the resident was confused, and had behaviors of, keeps standing and if staff tried to touch him/her to provide redirection the resident would sometimes become combative or not follow commands. She added that the resident also had a history of wandering into other resident rooms and she stated that the resident could also be combative toward staff for no reason. She stated that sometimes she would call the resident's family representative a non-pharmacological intervention, stating that it would help initially, but then would exhibit the behaviors again one hour later. She stated that they would offer the resident food but he/she would spit it out, including the medicine sometimes. She added that they try to toilet the resident at times too, but he/she would be dry. The surveyor showed the RN the IPCDR for the Ativan 0.5 mg tablet, the eMAR for May 2021, and the Behavior Monitoring flow sheet for April and May 2021. The RN acknowledged that there was not consistent documentation for the use of the Ativan stating that ideally all specific target behaviors should be addressed in the ePN. She could not speak if there was always documentation of trialed interventions prior to administering the Ativan, but she stated that there should be documentation associated with each dose given. The surveyor asked what the resident enjoyed doing and the RN could not speak to what he/she enjoyed or used to enjoy other than having visits with family representatives, to offer as a means to distract or prevent boredom in accordance with the resident's plan of care. On 5/28/21 at 10:44 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who confirmed that the resident had a diagnosis of Dementia and was on an anti-anxiety medication, Ativan. The RN/UM stated that the resident had behaviors of refusing lab work, trying to stand up unassisted and ambulate with an unsteady gait. She stated that when trying to re-direct the resident, he/she would kick and fight making it more dangerous for the resident because it would affect his/her balance. She stated that when the resident exhibited these behaviors of anxiety, the resident would be offered snacks and toileting but most of the time they weren't effective. The surveyor asked what she knew about the resident and his/her past regarding what preference for activities the resident enjoyed, and the RN/UM stated that the resident loved to shop, cook, and he/she enjoyed leisure activities. She elaborated and stated that she was aware that the resident was very social and liked church. The RN/UM was not sure what religion the resident was, and further stated that she didn't offer the activities to the resident, but stated that the activities department handled that. She added that the resident had only been at the facility for a month and initially when he/she was admitted , the resident was calm. The surveyor asked if the nurses don't offer diversional activities that he/she had been previously known to enjoy, what non-pharmacological interventions are done prior to giving a dose of Ativan? The RN/UM replied they would offer fluids, snacks, redirection, toileting, reassurance and acknowledging feelings, and do whatever [Resident #74] wanted to do. The RN/UM was not sure what triggered the resident's anxiety. The surveyor reviewed the IPCDR, the eMAR for May 2021, and the Behavior Monitoring flow sheets with the RN/UM who acknowledged that nurses were not consistently documenting what non-pharmacological interventions were trialed prior to administering the Ativan. She acknowledged that nurses should be documenting in the ePN what specific target behavior the resident was exhibiting and what non-pharmacological interventions were trialed prior to administering the medication. On 6/1/21 at 11:21 AM, the surveyor conducted a phone interview with the Psychiatric NP who stated that the resident had [NAME] Bonnet Syndrome which caused him/her to visually hallucinate. She stated that the resident thought he/she was on a roller coaster at one point. The surveyor asked the Psychiatric NP if the roller coaster hallucination caused the resident emotional distress, and the Psychiatric NP stated that from what she understood, the resident was having a hallucination and that it would cause him/her to reach out and grab at staff. She stated that the resident's target behaviors were hitting staff, aggression, kicking. She stated that the resident also had a diagnosis of dementia, psychosis, depression and insomnia. She stated that the reason for the Ativan PRN was that the resident had episodes that he/she had to get something even if it wasn't there, and the resident would get very upset, causing him/her distress. She stated that in addition, the resident was unable to consistently articulate what it was he/she wanted or needed. The surveyor asked the Psychiatric NP if she was involved in recommending any diversional activities or non-pharmacological interventions, and she stated that she was not aware of any activity preferences that the resident enjoyed, and indicated that she always encourages non-pharmacological interventions such as speaking with a calm approach and trying to minimize external stimulation/noises. The Psychiatric NP stated that nursing staff may be able to speak better on the resident's diversional non-pharmacological preferences. On 6/1/21 at 1:18 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team and the Regional Director of Risk Management, the Regional Director of Operations, the Regional Director of Clinical Services. The DON stated that they reviewed the surveyor's findings regarding the Ativan being given without evidence of a documented behavior and non-pharmacological interventions being trialed first. He stated that when he interviewed the nurses that mostly worked in the evening shifts, most weren't saying Ativan is a last resort if non-pharmacological interventions had failed. He stated that all documentation should be charted in the ePN. He stated that the had a history of seeing images of babies without eyes, sleeping with a knife, stabbing holes in a couch, and when the resident was brought to the emergency room by their family, the resident had been newly diagnosed with the [NAME] Bonnet Syndrome. The DON stated that the resident had stated that he/she saw sheet rock and needed to get to it, but there was no sheet rock. The surveyor asked where this would be documented and he stated that it should be in the ePN. He stated that the RN/UM does the monthly psychotropic drug summary but that it was just up for review. He acknowledged there wasn't consistent documentation to warrant the use of the Ativan on the dates in question. The DON provided the surveyor statements from four nurses, but no additional documentation was provided from the resident's medical record. A review of the facility's undated policy for Behavioral Assessment, Intervention and Monitoring included that The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have been contributed to the resident's change in condition, including: .Emotional, psychiatric and/or psychological stressors (for example): Depression; Boredom; Loneliness; Anxiety; and/or Fear.Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms documentation will include: other approaches and interventions tried prior to the use of the antipsychotic medication NJAC 8:39-11.2 (b); 27.1 (a)

Based on interviews and facility document review, the facility failed to ensure staffing ratios were met for 55 of 66 shifts reviewed. There was no increase in the resident census for a period of nine consecutive shifts. This deficient practice had the potential to affect all residents. Findings include: 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. On 5/24/21 between 9:30 AM and 1:00 PM, during initial pool tour, surveyors interviewed residents and 7 residents complained that the facility did not have a sufficient number of staff and that impacted their perception of care. One of the residents stated that he/she knew that the New Jersey staffing laws required to have one CNA for every eight residents during the day shift but that the facility never followed it. All 7 residents stated that the short staffing ratios had them wait longer than necessary if they needed something. On 6/3/21, the surveyor reviewed the facility provided Nursing Home Resident Care Staffing Reports from 5/13/21 to 6/3/21 which included the following staff to resident ratio for each shift: 5/13/21-(Census-86) Day shift 1 CNA:12.3 residents 5/14/21-(Census-84) Day shift 1 CNA:14 residents 5/15/21-(Census-84) Day shift 1 CNA:12 residents 5/16/21-(Census-83) Day shift 1 CNA:11.9 residents 5/17/21-(Census-83) Day shift 1 CNA:11.9 residents 5/18/21-(Census-82) Day shift 1 CNA:13.7 residents 5/19/21-(Census-84) Day shift 1 CNA:10.5 residents 5/20/21-(Census-85) Day shift 1 CNA:12.1 residents 5/21/21-(Census-86) Day shift 1 CNA:12.3 residents 5/22/21-(Census-86) Day shift 1 CNA:17.2 residents 5/23/21-(Census-86) Day shift 1 CNA:14.3 residents 5/24/21-(Census-86) Day shift 1 CNA:10.8 residents 5/25/21-(Census-87) Day shift 1 CNA:10.9 residents 5/26/21-(Census-87) Day shift 1 CNA:10.9 residents 5/27/21-(Census-87) Day shift 1 CNA:10.9 residents 5/28/21-(Census-84) Day shift 1 CNA:10.5 residents 5/29/21-(Census-87) Day shift 1 CNA:12.4 residents 5/30/21-(Census-87) Day shift 1 CNA:14.5 residents 5/31/21-(Census-85) Day shift 1 CNA:12.1 residents 6/1/21-(Census-86) Day shift 1 CNA:12.3 residents 6/2/21-(Census-86) Day shift 1 CNA:10.8 residents 6/3/21-(Census-85) Day shift 1 CNA:12.1 residents 22 of 22 day shifts did not meet the minimum required ratio of 1 CNA to 8 residents. 5/13/21-Evening shift 1 CNA:12.3 residents 5/14/21-Evening shift 1 CNA:12 residents 5/15/21-Evening shift 1 CNA:14 residents 5/16/21-Evening shift 1 CNA:11.9 residents 5/17/21-Evening shift 1 CNA:13.8 residents 5/18/21-Evening shift 1 CNA:13.7 residents 5/19/21-Evening shift 1 CNA:12 residents 5/20/21-Evening shift 1 CNA:12.1 residents 5/21/21-Evening shift 1 CNA:14.3 residents 5/22/21-Evening shift 1 CNA:17.2 residents 5/23/21-Evening shift 1 CNA:17.2 residents 5/24/21-Evening shift 1 CNA:12.3 residents 5/25/21-Evening shift 1 CNA:10.9 residents 5/26/21-Evening shift 1 CNA:12.4 residents 5/27/21-Evening shift 1 CNA:10.9 residents 5/28/21-Evening shift 1 CNA:12 residents 5/29/21-Evening shift 1 CNA:17.4 residents 5/30/21-Evening shift 1 CNA:17.4 residents 5/31/21-Evening shift 1 CNA:14.2 residents 6/1/21-Evening shift 1 CNA:12.3 residents 6/2/21-Evening shift 1 CNA:12.3 residents 6/3/21-Evening shift 1 CNA:12.1 residents 22 of 22 evening shifts did not meet the minimum required ratio of 1 CNA to 10 residents. 5/13/21-Night shift 1 CNA:17.2 residents 5/15/21-Night shift 1 CNA:16.8 residents 5/16/21-Night shift 1 CNA:20.8 residents 5/22/21-Night shift 1 CNA:17.2 residents 5/23/21-Night shift 1 CNA:17.2 residents 5/25/21-Night shift 1 CNA:17.4 residents 5/26/21-Night shift 1 CNA:14.5 residents 5/27/21-Night shift 1 CNA:17.4 residents 5/29/21-Night shift 1 CNA:14.5 residents 5/30/21-Night shift 1 CNA:21.8 residents 6/3/21-Night shift 1 CNA:17 residents 11 of 22 night shifts did not meet the minimum required ratio of 1 CNA to 14 residents. On 6/3/21 at 9:46 AM, the surveyor interviewed the Staffing/Ancillary Clerk, who stated she also had a CNA background, about the staffing of CNAs. She stated that she would staff each shift by the census of the facility. She would try to utilize 8 CNAs on the day and evening shift but would try to get 9 if she could, and try to get 5 or 6 aides for the night shift. She further stated that normally that 1 CNA to 10 or 11 residents were the final results. The surveyor then asked the Staffing/Ancillary Clerk if the facility had sufficient staff in which she replied that they need more staff and have been trying to hire more people. The surveyor then asked her if the facility used agency staff or had implemented their emergency staffing strategies, in which she replied that the facility did not use agency staff and that it was not her call to use agency staff if needed. The surveyor then asked if she was aware of the minimum direct care staff to resident ratio which became effective 2/1/21 in which she stated that she was aware of the mandate and the facility had been talking to see how they could hire more staff. At 10:21 AM, the surveyor interviewed the Director of Nursing (DON) regarding the staffing of the facility. The DON stated that the facility had staffing meetings and that there was a formula that the Staffing/Ancillary Clerk used. The surveyor then asked the DON if he was aware of the minimum direct care staff to resident ratio (which had became effective 2/1/21) in which he stated that he had read about it in the news but was not sure if it had been implemented yet. The surveyor then asked the DON if the facility used agency staff, and the DON replied that the facility did not use agency staff. The surveyor then asked the DON if the facility had sufficient staff in which he stated that the facility had good staffing until COVID-19 started. He then added that right now the facility had good staffing unless there were call outs. At 10:26 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the staffing of the facility. The surveyor asked if the facility had sufficient staff in which he stated that the facility had enough staff and that they use a formula which was based off the assessed needs of the residents and the ability of staff. The surveyor then asked if he was aware of the minimum direct care staff to resident ratio which became effective 2/1/21 in which he stated that he was aware of the ratio but that he did not know what the ratio was off hand. The surveyor then asked the LNHA if the facility used agency staff in which he stated that the facility did not use agency staff and that the reason was when they used them in the past there was not a continuity of care for the residents and it impacted resident care. He further stated that the facility was actively seeking full-time, part-time and per diem (as needed) staff. After review of the requirements, the LNHA acknowledged that the facility was not meeting the New Jersey minimum staffing ratios that went into effect on 2/1/21. He stated that they had hired and implemented the Concierge employee about three weeks ago who goes around to check on the residents and answer call bells as needed, because the facility had noticed that many times when the resident's needed assistance, it was an non-nursing issue that could be addressed but non-direct care staff. He acknowledged that the Concierge would not fulfill the direct care staff ratio requirements for New Jersey. He stated that the also utilized Temporary Nurse Aides and will be assisting them as they transition to get certified as a CNA. At 10:29 AM, during surveyor interview of the LNHA in the presence of the survey team, the Regional Director of Operations added that the reason the facility did not use agency staff to provide direct was that they were not dependable. She further added that the agency staff in the past would commit to a shift and then they would call out or not show up. A review of the facility provided policy titled, Staffing, with a revised date of October 2017 included the following: Policy Statement Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementations 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met. 4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. The facility policy did not include information regarding the state mandated minimum direct care staff (CNA) to resident ratio. N.J.A.C. 8:39-5.1(a)