Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included anti-anxiety medication. This deficient practice was identified for 1 of 12 residents (Resident #6) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 12/17/24 at 10:10 AM, the surveyor observed Resident #6 seated in their wheelchair. On 12/19/24 at 12:03 PM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #6, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 11/5/24, reflected that the resident had a Brief Interview for Mental Status score of 6 out of 15, indicating severely impaired cognition. A review of the December 2024 Order Summary Report for Resident #6 reflected a Physician Order (PO) dated 10/30/24 for Lorazepam Concentrate (an anti-anxiety medication) 2 mg (milligram)/ml. (milliliter) give 0.25 ml sublingually (administered under the tongue) every 4 hours as needed . A review of Resident #6's November and December 2024 electronic Medication Administration Record (eMAR) revealed the above PO were administered to the resident on 11/23/24 at 8:57 AM and 12/11/24 at 12:40 AM. A review of the progress notes dated 11/23/2024 at 10:12 AM revealed that Resident #6 was given Lorazepam according to the PO due to increased shortness of breath. A review of Resident #6's CP did not reflect a CP for the use of anti-anxiety medication. A review of the hospice records titled Interdisciplinary Group Meeting, dated 11/7/24 under current CP did not reflect any CP for the use of anti-anxiety medication. On 12/20/24 at 11:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the above concern. The LPN stated that if a resident was on an anti-anxiety medication, it must be addressed in the resident's CP. On 12/20/24 at 11:29 AM, the surveyor conducted a telephone interview with the Clinical Director/Registered Nurse (CD/RN) for the hospice company who did not provide any information regarding the CP for the use of anti-anxiety medication. On 12/23/24 at 1:10 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above concern. There was no additional information provided. A review of the policy titled Hospice Services with a reviewed date in May 2024 stated under Procedure: 14. Each resident's plan of care will include an integrate both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practical physical, mental, and psychological well-being. NJAC 8:39-11.2(e)(2)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of fourteen (14) residents reviewed, (Resident #40) for medication management and was evidenced by the following: On 12/18/24 at 11:45AM, the surveyor observed Resident #40 in the facility activity room. The resident was seated in a wheelchair and was observed coloring pictures. The surveyor reviewed Resident #40's medical records. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; gastrostomy status (refers to the presence of a surgical opening into the stomach, which allows for nutritional support of gastric decompression), neurocognitive disorder with Lewy bodies (type of dementia characterized by a decline in thinking abilities, including attention, visual perception, and executive function) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete painful blockage). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 11/22/24, reflected that the resident's cognitive skills for daily decision-making score was 0 out of 15, which indicated that the resident's cognition was severely impaired. A review of the December 2024 Order Summary Report (physician's order sheet) (OSR) revealed a physician's order (PO) dated 10/11/24, for Donepezil tablet 10 mg (milligrams) by mouth at bedtime related to dementia in other diseases classified elsewhere. The December 2024 OSR also revealed a PO dated 5/12/23 for NPO (not by mouth) diet NPO texture, receives Bolus Feeding. A review of the November 2024 and the December 2024 electronic medication administration record (eMAR) revealed a PO dated 10/11/24, for Donepezil tablet 10 mg by mouth at bedtime related to dementia in other diseases classified elsewhere. Donepezil was scheduled to be administered every day at 20:00 (8:00 PM). A review of the CP's evaluation reports dated 11/1/24 and 12/3/24 indicated that the CP reviewed the medication regimen for Resident #40 with no new medication recommendations indicated. On 12/18/24 at 12:50 PM, the surveyor in the presence of the Registered Nurse (RN)/ Unit Manager (UM) reviewed Resident#40's PO. At that time, the RN/UM acknowledged that Donepezil medication was ordered by the physician to be given by mouth but also acknowledged that the resident received their medications via a g-tube (gastrostomy tube). The RN/UM further stated that the CP should have identified the discrepancy during their monthly medication review. On 12/19/24 at 1:00 PM, the surveyor met with the Licensed Nursing Home Administrator and Director of Nursing to discuss the above concerns. There was no additional information provided. On 12/20/24 at 12:15 PM, the surveyor conducted a telephone interview with the CP who acknowledged that she reviewed the residents' medication regimen monthly. The CP also acknowledged that part of her reviews was to ensure that the medications for the residents were being administered via the correct route. The CP further acknowledged that Resident #40 was NPO and received medications via a g-tube. The CP stated the facility should have been notified regarding the PO for Donepezil administration route discrepancy. A review of the facility's policy for Administrative Policy and Procedures dated 07/31/24, which was provided by the DON included the following: The Consultant Pharmacist shall identify, document, and report actual and potential irregularities for review and action to the Director of Nursing and or/designee, Administrator, Medical Director and physicians (where appropriate). The physician's recommendations will be communicated to the Director of Nursing and/or Designee for distribution and action by the attending physician via email, fax (or both). NJAC 8:39-29.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 12/17/24 at 9:50 AM, the surveyor observed Resident #21 in bed watching television. Resident #21 was able to answer the surveyor's inquiry. On 12/18/24 at 11:42 AM, the surveyor reviewed the HMR of Resident #21, which revealed the following: A review of the FS revealed that Resident #21 was admitted with diagnoses that included but were not limited to dementia (loss of memory). A review of the Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 8 out of 15, which indicated that the resident had moderately impaired cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 6. On 12/17/24 at 10:10 AM, the surveyor observed Resident #6 seated in their wheelchair. On 12/19/24 at 12:03 PM, the surveyor reviewed the HMR of Resident #6, which revealed the following: A review of Resident #6's FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). A review of the Q/MDS, dated [DATE], reflected that the resident had a BIMS score of 6 out of 15 which indicated that the resident severely impaired cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 7. On 12/17/24 at 9:40 AM, the surveyor observed Resident #45 awake and was seated in the wheelchair inside the dayroom. On 12/17/24 at 11:54 AM, the surveyor reviewed the HMR of Resident #45, which revealed the following: A review of Resident #45's FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus (high blood sugar). A review of the A/MDS, dated [DATE], reflected that Resident #45 had a BIMS score of 15 out of 15 which indicated that the resident had intact cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. On 12/18/24 at 12:41 PM, the surveyor interviewed the PP, who stated he is the PP for all the residents in the facility. The PP also stated that he would come in the facility every Wednesday and most weekends. The PP further stated the resident's PPN were not in the facility's electronic charting system, but were in a separate electronic system in which only the PP would have access to them. The PP acknowledged that the PPN's were not inside resident's physical chart. On 12/18/24 at 1:01 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) who confirmed that the facility including the nursing staff does not have access to the resident's PPN and there were no PPN's observed in the physical chart. On 12/18/24 at 1:15 PM, the Director or Nursing (DON) provided the surveyor with a facility policy titled, Physician Service policy and Procedure with a revised date of 7/24. Under the policy and implementation section it states, 3. Physician orders and progress notes shall be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. On 12/19/24 at 1:12 PM, the survey team met with the DON and Director of Operations (DOO) and reviewed the above concerns. The DON stated, they were aware of the concern. No further information was provided. NJAC 8:39-35.2 (d)(5) Based on observation, interview, and record review, it was determined that the facility failed to have physician progress notes (PPN) readily accessible in the facility. This deficient practice was identified for 7 of 12 residents reviewed, (Resident #207, #5, #48, #16, #21, #6, #45) and was evidenced by the following. 1. On 12/17/24 at 10:42 AM, the surveyor observed Resident #207 in the dayroom watching television. The resident stated to the surveyor they have seen their primary physician (PP) a few times since their admission. A review of Resident #207's Face sheet (FS) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes, peripheral vascular disease, and heart failure. A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate care management dated 12/11/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:01 PM, the surveyor reviewed the hybrid medical records (HMR), (combination of the physical and electronic chart) and did not observe any PPN documentation. 2. On 12/17/24 at 11:20 AM, the surveyor observed Resident #5 in the dayroom watching television. The surveyor interviewed Resident #5 who stated they can't recall when they were seen by their PP. A review of Resident #5 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to generalized anxiety disorder, anemia, type 2 diabetes, and hyperlipidemia. A review of the Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate care management dated 11/8/24, indicated a BIMS score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:05 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 3. On 12/17/24 11:25 AM, the surveyor observed Resident #48 in the dayroom seated in the wheelchair with eyes closed. A review of Resident #48 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, Parkinson's disease, insomnia, and generalized anxiety. A review of the Q/MDS, an assessment tool used to facilitate care management dated 11/28/24, indicated a BIMS score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:10 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 4. On 12/17/24 at 12:00 PM, the surveyor observed Resident #16 in the dayroom seated in their wheelchair. A review of Resident #16 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia cognitive communication deficit, protein-calorie malnutrition, and glaucoma. A review of the Q/MDS, an assessment tool used to facilitate care management dated 10/3/24, indicated a BIMS score of 00 out of 15 which indicated that resident had severely impaired cognition. On 12/18/24 at 12:20 PM, the surveyor reviewed the HMR and did not observe any PPN documentation.

Based on observation, interview, record reviews, it was determined that the facility failed to follow a.) appropriate infection control practices for handling and storing clean clothes observed in the laundry room and b.) the policy and procedure of the facility's Water Management Program to prevent the growth of Legionella (a waterborne pathogen). This deficient practice was evidenced by the following: 1. On 12/19/24 at 9:35 AM, the surveyor together with the facility's Infection Preventionist (IP) toured the laundry room. The surveyor observed a rack of hangers of clothes covered with a clean blanket touching the laundry room floor. The surveyor interviewed the Housekeeping Manager (HM) who stated those clothes clean. The HM also stated the clothes were washed and brought to the residents who would need them. The HM acknowledged to the surveyor that the clean clothes should not touch the floor. On 12/19/24 at 10:03 AM, the surveyor interviewed the IP regarding the above concern. The IP stated that the clothes should not touch the ground because they were clean already. On 12/19/24 at 10:45 AM, the Director of Nursing (DON) provided a policy titled The Laundry Process, but it did not address handling clean clothes after washing. On 12/19/24 at 1:13 PM, the survey team met with the DON and Director of Operations regarding the above concern. The DON stated that those clothes were unlabeled and once the owner was found, they would give the clothes back. The DON also stated the clothes have been on the rack for 30 days; and they were lost-and-found clothes. 2. On 12/17/24 at 10:15 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor requested the facility's water management program and evidence of monitoring. On 12/19/24 at 9:25 AM, the surveyor interviewed the IP. The surveyor asked if there had been a case of resident diagnosed with Legionella or other waterborne pathogen illness in the facility, the IP stated that there had not been any cases reported. On 12/20/24 at 12:56 PM, the surveyor interviewed the LNHA, who stated the facility hired an outside company for the well water (water from a well, which is a hole dug into the ground to access groundwater) system. The LNHA stated they couldn't find the last water testing from the previous company. On 12/23/24 at 1:20 PM, the survey team met with the LNHA to discuss the above concern. The LNHA stated they do not have records for their water management. The LNHA also stated that the facility had no water management plan. A review of the records provided by the Director of Maintenance (DM) titled Certificate of Analysis, dated December 5, 2024, and November 11, 2024, indicated the facility monitored the chlorine and coliform levels. There was no documented evidence for the monitoring of waterborne pathogens. A review of the facility's policy titled Water Management Plan, with a reviewed date of November 15, 2023, included the following: Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens . NJAC 8:39 - 19.4(i) NJAC 8:39-19.1

Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 2 of 2 sampled residents (Resident # 29 and #50) reviewed for injuries of unknown origin. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #50 was admitted to the facility with diagnoses which included but were not limited to; Neurocognitive disorder with Lewy Bodies (chemical deposits in the brain that can affect thinking), Parkinson's disease, and malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care) dated 05/22/23 reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section 1310 B. Inattention was coded 2. Resident #50 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS). Review of Resident #50's Care Plan (CP) initiated 12/08/22, revealed the following: [Resident #50] had impaired cognitive function related to Neurocognitive Disorder with Lewy Bodies (chemical deposits in the brain that can affect thinking) and is at risk for falls related to Parkinson Disease. According to the Progress Notes dated 10/24/22 timed 10:30 AM, the Certified Nursing Assistant (CNA) reported a bruise to the resident right hip identified during care, measuring 1.5 centimeter (cm) 1.5 cm. The physician and the family were notified. A statement dated 10/23/22 from the CNA who worked the 3:00 PM-11:00 PM shift, revealed that she observed the bruise and reported it to the nurse. The root cause analysis revealed that Resident #50 had a fall on 10/13/22 and was too far back to correlate the fall with the bruise on the resident right hip. The investigation reflected that a sensor pad alarm was then added to alert the staff of Resident #50's attempt to get out of the bed without assistance. On 09/19/23 at 10:30 AM, the surveyor reviewed again the facility Accident/ Incident report dated 10/24/22. The Accident/Incident report indicated that the bruise was found to the right hip. Resident #50 could not explain how he/she got the bruise. Review of the Investigation/Nursing Administration Review, Summary and Follow up /Conclusion to the incident, submitted by the DON on 09/19/23, dated 10/24/22 was left blank. On 09/20/23 at 12:36 PM, the DON stated that the incident was not reported to the NJDOH. Upon inquiry, the DON acknowledged that the injury was unwitnessed and should have been reported to the NJDOH. On 09/20/23 at 1:40 PM, the Administrator confirmed that any injury of unknown origin should be reported to the NJDOH. The Administrator explained that the facility does not have a specific policy for reporting injuries of unknown origin to the NJDOH. On 09/21/23 at 9:18 AM the facility did not provide any further information regarding the above incident. 2. A review of the AR revealed that Resident #29 had diagnoses which included but were not limited to; Dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, and anxiety. A review of the person-centered Care Plan included a focus area dated 01/21/21, dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, physical limitations. Another focus area dated 01/24/21, has activities of daily living (ADL) self-care performance and mobility deficit related to dementia, anxiety, weakness. Interventions included but were not limited to; two staff for all care. Resident requires extensive assist. On 09/19/23, two surveyors reviewed facility provided Resident Accident/Incident Reports for Resident #29. The Reports included but was not limited to the following: Date 09/08/23 at 9:15 AM, the Hospice Aide reported to the Registered Nurse (RN) supervisor on the East unit that Resident #29 had an unwitnessed 5.5 cm x 5.0 cm reddish purple discoloration on the right elbow. Resident #29 was unable to inform the staff what happened. A statement from the Hospice Aide was attached and 3 CNA statements related to their observations on 09/7/23. Dated 01/26/23 at 1:30 PM, a description of events revealed right upper hand bruise purple in color. The resident was unable to inform staff what happened. The bruise measured 2 cm x 1.5 cm. A statement was attached from one of the two CNAs who were providing care to Resident #29 and was signed with a date of 01/24/23 and a time of 6:45 PM. The statement did not document anything about a bruise, but did document that the resident was resistive and screaming rape. There were statements dated 01/25/23 and were related to their observations on 01/25/23. No behaviors were noted from the additional three CNA statements. On 09/19/23 at 11:36 AM, the DON was interviewed in the presence of members of the survey team. The surveyor asked if the unwitnessed incidents of injury of unknown origin, or the allegation of rape were reported to NJDOH? The DON stated she had to do an investigation but did not suspect abuse. We gather the facts first and then call. The DON acknowledged the injuries of unknown origin were unwitnessed and further stated, if it is a significant injury and we suspect abuse, we call right away. [Resident #29] moves around a lot and we figured it was friction and was not significant and did not suspect abuse so we did not call it in. On 09/19/23 at 12:27 PM, the DON and LNHA were interviewed in the presence of members of the survey team. The DON stated the Abuse policy did not include injury of unknown origin. The DON further stated that abuse could be physical, emotional, financial, verbal, sexual, or neglect. The DON stated that the Accident/Incident reports were usually reviewed the day after. When asked about Resident #29's allegation of rape, the DON stated the resident has a history of this in the past and just says these things. The DON stated the resident had a history of an abusive spouse. The DON further stated that she may have known about the allegation of rape but it was the residents normal behavior. The LNHA stated that if a resident made an allegation of rape, she would expect the staff to act on that allegation, complete an assessment and report the allegation. A review of the facility provided, Abuse Identification & Prevention Program dated September 2018, included but was not limited to; G. Reporting. All alleged or suspected incidents of abuse, neglect or mistreatment shall be reported promptly to the NJDOH and Senior Services. 2. The Administrator/DON will notify the Department of Health of the alleged abuse, by telephone immediately. Notification will include the details known up to this point in time, and that the investigation has been started. 4. The DON / designee will notify the Department of Health (no later than the third working day from the date of the alleged abuse) that the investigation has been completed. 5. The Administrator / designee will communicate with the Department of Health the results of the investigation including the conclusion that A. they feel no evidence of abuse, neglect or mistreatment, or B. not able to determine, or rule out that abuse, neglect, or mistreatment occurred and their findings are inconclusive, or C. there is strong evidence to support the complaint of abuse, neglect or mistreatment. 6. The DON will ensure all documentation corresponding to the investigation has been completed and available for review by the DOH. 7. The DON / designee will notify the individual who reported the incident whether or not the DOH has been notified of the investigation or that abuse has been ruled out. N.J.A.C. 8:39-9.4 (f)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an injury of unknown origin and an allegation of rape. This deficient practice was identified for 2 of 2 residents (Resident #29 and #50) reviewed for accidents and incidents. The deficient practice was evidenced by the following: 1. According to the medical records, Resident #50 was admitted with diagnoses which included but were not limited to; Parkinson's disease and neurocognitive disorder. A review of the Care Plan (CP) revealed a focus area of impaired cognitive function related to neurocognitive disorder. Another focus area of at risk for falls related to Parkinson's Disease. A review of a facility provided, Resident Accident/Incident Report dated 10/24/22 at 10:30 AM, included but was not limited to; Description and facts of even: bruise found on R [right] hip during A.M. [morning] care. It was documented that the resident reported he/she had no idea it was there. Measurements of the bruise were documented as 1.5 centimeters (cm) x 1.5 cm. Under the section of Injury, there were three areas to be checked off known, unknown, occurred during care. The section was left blank. The resident was noted to have a Brief Interview of Mental Status (BIMS) of 15 at the time which indicated the resident was cognitively intact. Attached to the Accident/Incident Report, was one statement from the Certified Nursing Assistant (CNA) who discovered and reported the bruise. Another attachment provided was Investigation of Past 24 Hours. There were three CNA statements. The CNA who worked the 11 PM to 7 AM shift, dated 10/24/22, documented she had seen the bruise and reported it. The second CNA who worked the 3 PM to 11 PM shift, dated 10/23/22, documented she had not given care to that resident. The third CNA who worked the 7 AM to 3 PM shift, dated 10/24/23, was the CNA who found and reported the bruise. The facility failed to follow their policy and provide statements for a 48 hour look back, a 24 hour post incident statement, or to complete the Accident/Incident Report. The Director of Nursing (DON) documentation included but was not limited to; the resident had a fall 10/13/22, but it was too far out from this discovery to correlate. On 09/20/23 at 12:36 PM, the DON acknowledged that the injury was unwitnessed. On 09/20/23 at 1:40 PM, the Licensed Nursing Home Administrator (LNHA) confirmed that this was an injury of unknown origin. 2. A review of the medical record for Resident #29 revealed diagnoses which included but were not limited to; Dementia with behavioral disturbances, cognitive communication deficit, and anxiety. A review of the Care Plan included a focus area dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitation. Another focus area revealed has activities of daily living self-care performance and mobility deficit related to dementia, anxiety, and weakness. Interventions included 2 staff for care. On 09/19/23, two surveyors reviewed the facility provided, Resident Accident/Incident Report for Resident #29. The report included but was not limited to the following: Dated 01/26/23 at 1:30 PM, Description: R upper hand bruise purple in color. Resident documented as stated, why now nothing happened to my hand? The resident was documented as being non-ambulatory. Under the section of INJURY, there were three areas to choose from known, unknown, occurred during care. The section was left blank. The resident was noted as having a BIMS of 12 out of 15 which indicated mildly impaired cognition. The bruise was measured as 2 cm x 1.5 cm and purple in color. Attached to the Report was a Investigation Witness Statement Form dated 01/24/23 at 6:45 PM. The statement was completed by a CNA and indicated another CNA was present during care of the resident. The statement revealed, After PM [evening] care and [Resident #29] was in bed he/she was screaming rape. Also attached was an Investigation of Unknown Injury 24 Hour Look Back form which indicated the date/time of occurrence as 01/26/23 at 1:30 PM. The form was filled out by three CNAs who reported on the resident from 01/25/23. The facility failed to follow their policy by not obtaining any statement from the second CNA providing care on 01/24/23; obtain statements for a 48 hour look back and 24 hour post incident statements from 01/23/23 and 01/26/23; a witness statement for 01/26/23 the injury of unknown origin; had not completed the Accident/Incident Report; and had not completed either investigation within 3 days. On 09/19/23 at 11:36 AM, the DON was asked about Resident #29 and the injury of unknown origin and the allegation of rape. The DON stated she, had to do an investigation but did not suspect abuse. On 09/19/23 at 12:27 PM, the DON and LNHA were interviewed in the presence of the survey team. The DON stated the facility Abuse policy did not include injury of unknown origin. The DON stated that the Accident/Incident Reports were usually reviewed the day after the incident. The DON further stated that she may have known about the allegation of rape but it was the residents normal behavior. On 09/19/23 at 1:30 PM, the surveyors interviewed the DON and asked when she was first made aware of the allegation that Resident #29 made on 01/24/23. The DON stated the incident report was brought to morning meeting on 01/27/23. The DON stated the nursing unit contacted her via telephone, and she could not recall who she had spoken with on 01/26/23 and that was about a bruise that occurred at 1:30 PM. The DON stated that the nurses knew how to complete an investigation and would also complete a 24- hour look back to obtain statements from all caregivers 24 hours prior to the discovery/when the allegation was made. The DON reviewed the investigation in the presence of the survey team and stated that there was a missing statement from one of the CNA's who was in the room with Resident #29 at the time of the allegation. The DON stated she only received a statement from CNA#1 and not from CNA #2. The DON stated she would have CNA #2 write a statement today, 09/19/23. The DON stated she brought the Incident Report to the morning report meeting held on 01/27/23, and at that time the incident report, and the 24 hours look back had not yet been completed and that nothing else had been provided for the investigation. The DON stated she was not provided CNA #1's statement on 01/27/23 regarding rape and could not recall when she was given that statement. The DON confirmed there were two CNAs in the room with Resident #29 and she just realized that she did not have CNA #2's statement. The DON stated, I know I read it quickly knowing what had happened and stated what happened was that resident was throwing food, digging nails, a horrible scene. The DON stated Resident #29 had a history of an abusive spouse. The DON stated the expectation was to have received all the statements and that it was ultimately my [DON] responsibility. The DON stated that on 01/27/23, the Accident/Incident report had been signed as reviewed but was not complete and stated the LNHA who also signed the report was no longer at the facility. The DON stated that the investigation should have been completed within 24 hours. On 09/19/23 at 2:14 PM, during an interview with the surveyor, the Registered Nurse Unit Manager (RN UM) stated she was responsible to initiate the questions on the back page of the Accident/Investigation report, but that the floor nurse would complete the front-page information. The RN UM stated that she would ask the staff to write statements. The RN UM further stated that Resident #29 has expressed behaviors however, had never made allegations of rape. On 09/19/23 at 3:02 PM, the LPN who cared for Resident #29 on 01/24/23, was interviewed by the survey team. The LPN stated she had cared for Resident #29 and knew the resident had been combative and would also yell at people. The LPN stated the resident required two- staff assistance to provide care. The LPN's progress note was read to the LPN, and the LPN acknowledged she documented the note, and also recalled the documentation regarding the resident yelling rape. The LPN further stated the resident screamed anything, but she had not documented before that the resident had screamed rape. The LPN stated she had not reported that the resident had yelled rape because it had not happened on my watch, and that it was a normal behavior for the resident to yell things for hours. The LPN further stated, I guess looking back that was something I should have reported. I just did not because the resident would say crazy things. The LPN stated, well I guess I wouldn't know if something had happened earlier in the day to Resident #29. A review of the facility provided, Abuse Identification & Prevention Program dated September 2018, included but was not limited to; C. Prevention 4. nursing and social workers identify those residents whose personal histories render them at risk for . becoming a victim of abuse. D. Identification of Signs and Symptoms of Abuse - clues to help identify abuse 1. physical abuse clues: color of bruises red, purple, or black indicate a bruise one day old. Note: Intentional or unintentional abuses necessitate an immediate investigation. During the investigation, the resident must be protected. E. Investigation 3. obtain statements from the caregivers and others directly involved with the resident 48 hours prior and 24 hours after. Interview other residents to determine if they had been abused or mistreated. Ensure the investigation is completed with three working days of the alleged abuse. The DON will maintain an investigative package with the copy of the incident report, all statements obtained and a conclusive summary of finding which indicated why or if and how abuse has been ruled out. NJAC 8:39-4.1(a)5; 9.4(f)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a.) follow acceptable standards of clinical practice and inform the physician that Resident #28 had been refusing Insulin (a medication to control blood sugar), and b.) ensure the accuracy of physician orders for Resident #44. This deficient practice was identified for 2 of 6 residents reviewed during the medication pass observation and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a 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 with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a.) On 09/11/23 at 7:25 AM, Surveyor #1 observed the Licensed Practical Nurse (LPN) administer medications to Resident #28. Resident #28 had refused an oral diabetic medication at that time. Resident #28 stated I am not taking that. I don't have diabetes. At that time, the LPN stated that she would document that the medication was refused and that would trigger a note to be completed in the electronic medical record (EMR) progress notes (PN). A review of the admission Record revealed that Resident #28 had diagnoses which included Type 2 Diabetes. A review of the annual Minimum Data Set (MDS) an assessment tool dated 06/22/23, included Section E, Rejection of Care was exhibited 1 to 3 days of the 7 day look back. A review of the person-centered comprehensive Care Plan revealed a focus area of Diabetes Mellitus insulin dependent date initiated 06/15/23. Interventions included but were not limited to; diabetes medication as ordered by doctor. The care plan did not include behaviors of refusing Diabetic medications. A review of the Order Summary Report included a physician's order dated 07/20/23, Insulin Glargin Subcutaneous solution pen-injector 100 units/ml (milliliters) inject 10 units subcutaneously at bedtime. A review of the Medication Administration Record (MAR) dated September 2023 and included through 09/12/23, revealed that on 9/2/23, 9/4/23, 9/6/23, 9/9/23, 9/10/23, and 9/11/23, Resident #28 had refused his/her night time insulin. A review of the PN date range 08/30/23 through 09/12/23, revealed there was no documentation that the nursing staff alerted the physician about the resident refusing the night time insulin for 6 out of 11 days. On 09/12/23 at 10:18 AM, during an interview with Surveyor #1, an LPN stated the process was that if a resident refused a medication, the staff would attempt three times to administer the medication. If the resident still refused, the staff would educate the resident, call the physician, and document the refusal. The LPN further stated it was important to inform the physician if a resident refused medication. On 09/12/23 at 10:24 AM, during an interview with Surveyor #1, a Registered Professional Nurse (RN) supervisor stated that the process was if a resident refused medication, the staff would try three times and then notify the physician. The RN supervisor further stated the refusal would be documented and the care plan would be updated. On 09/12/23 at 10:32 AM, a RN stated that if a resident refused their medication, she would attempt to give it again and try to find out why the resident refused it. The RN stated if the resident refused insulin it could be more dangerous so the staff would call the physician and monitor the resident blood sugars. On 09/12/23 at 11:42 AM, the Director of Nursing (DON) stated that if a resident refused medication, the staff would be expected to educate the resident and attempt to administer the medication again. The DON stated that the staff should notify the Nurse Practioner (NP) or the physician and document in the progress notes. The DON and Surveyor #2 reviewed Resident #28's MAR. On 09/13/23 at 11:27 AM, the DON stated that a Diabetic could become hyperglycemic if they refused their diabetic medications. She stated the staff were educated to document when they call the physician or the NP but they [the staff] did not do that [regarding Resident #28 refusing insulin]. The DON further stated there were no PN documenting that Resident #28 had refused insulin or that the NP or physician had been made aware of the insulin being refused. The DON stated, I will have to talk to my staff about it. A review of the facility provided, Medication Refusal policy and procedure revised 06/2021, included but was not limited to; Policy: the facility staff will document any incident of medication refusal by a resident. Procedure: 5. The nurse will notify the resident's attending physician of the medication refusal when the refusal presents unfavorable outcomes. A review of the facility provided, Documentation Policy & Procedure reviewed 06/23, included but was not limited to; Policy: documentation is a professional tracking to enhance the continuity of care. Good clinical practice dictates what goes into a medical record. Key goals of sound clinical documentation are to describe what is happening to the resident. Enhance continuity of care on all shifts and disciplines. Monitor outcomes of care. Procedure: 1. required documentation - included in response to facility policies i.e. behavior monitoring. 2. b. what will be documented - included problem identification to resolution. c. document in the progress notes. d. document at the time of the incident. b.) On 09/11/23 at 8:15 AM, Surveyor #2 observed an RN administer medications to Resident #44. Resident #44 received the following medications as per the order on the Medication Administration Record (MAR) Tylenol 500 mg 1 tab (analgesic for pain management) Desmopressin 0.2 mg 1 tab (Antidiuretic and clotting promoter) Depakote 500 mg 1 tab (Mood Stabilizer) Depakote 250 mg 1 tab (Mood Stabilizer) Fluvoxamine 50 mg 1 tab ( anti-depressive) Fluvoxamine 50 mg 1/2 tab (anti-depressive) Colace 100 mg 1 caps.(Stool Softener) On 09/11/23 at 9:50 AM, during review of the medical record, Surveyor #2 observed 09/01/23 Physician's Orders (PO) that included a Physician's order for the resident to receive Tylenol extra strength 500 mg 2 tablets for fracture. The surveyor then observed that the RN administered one tablet only of 500 milligrams. The dose prescribed was 1000 milligrams. The surveyor reviewed the Physician Order Sheet (POS) and did not observe any change in the order. There was no verbal physician's order documented to reflect the change in dosage. Prior to administering the medications to Resident #44, Surveyor #2 asked the RN to verify the number of medications in the cup, the RN confirmed there were 7 tablets in the medication cup. During an interview on 09/15/23 at 9:47 AM, the RN stated Resident #44 should have received 2 tablets according to the POS. She further stated that she thought that she administered 2 tablets. The RN informed the surveyor that she was aware of the protocol to follow. A nursing Progress notes dated 09/11/23 timed 11:24 AM, confirmed that the Physician was called and gave an order to administer the 500 milligrams of Tylenol at 11:22 AM. During the exit conference held on 09/22/23 at 10:30 AM, the facility did not have any additional information regarding the medication omission. NJAC 8:39-11.2(b) 29.2(d).

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 2 of 2 residents, (Resident #49, Resident #50) reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: 1. On 09/06/23 at 10:22 AM, the surveyor toured the East Unit of the facility and observed Resident #49 in bed. A strong foul urine odor permeated as the surveyor approached the resident's bed. On 09/06/23 at 10:35 AM, the surveyor exited the room and while in the hallway heard an alarm sounding. The surveyor returned to the room and observed the resident was now out of the bed and was wearing a blue incontinent brief that was observed bulging in the rear. At 10:36 AM, a Certified Nurse Aide (CNA) emerged from the bathroom door inside of the resident room and observed Resident #49 was out of the bed. The CNA then escorted the resident back to bed and told the resident to wait until she had completed care for the resident next door. The CNA informed the surveyor that Resident #49 would try to get out of the bed whenever if he/she was soiled. On 09/08/23 at 08:43 AM, the surveyor interviewed the 7:00 AM -3:00 PM Certified Nursing Aide (CNA) #1 on the East Unit. The CNA stated that she currently had 12 residents on her assignment and was the only CNA on the floor. Upon inquiry regarding the workload, the CNA stated, I tried to find time and I usually finished my assignment by 12:00 PM or 1:00 PM. The CNA added, Not all of the residents would be out of bed due to staffing. The residents at risk for falls would be out of the bed almost daily. When inquired regarding if administrative staff were aware, she stated, They make the schedule they knew about it. On 09/08/23 at 11:30 AM, the surveyor interviewed the 7:00 AM - 3:00 PM CNA #2 on the East Unit who stated that she had been working at the facility for several years and currently had 13 residents on her assignment. CNA #2 stated that she only worked the 7:00 AM - 3:00 PM shift and would usually have 12 to 14 residents on her assignment on the weekends. CNA #2 further stated that the number of residents on her assignment depended upon how many staff were working. On 09/15/23 at 8:37 AM, the surveyor observed incontinence rounds in the presence of CNA #2 along with the Infection Control Preventionist (IP) on the East Unit. The surveyor observed that Resident #49 was wearing two incontinent briefs which were saturated with urine. CNA #2 stated that in the morning she made rounds to ensure that the residents were safe and in bed, however, did not check for incontinence. She further added that she had not yet provided care to Resident #49. When inquired about Resident #49 wearing two adult incontinent briefs, she stated that was not the protocol but occasionally she would observe residents wearing two incontinent briefs and would report it to the Registered Nurse/Unit Manager (RN/UM). On 09/15/23 at 11:11 AM, the surveyor interviewed the IP who assisted with incontinent care that morning. The IP confirmed that occasionally she would observe other residents wearing two incontinent briefs during incontinence care. She stated that she discussed the issue with the RN/UM and could not comment on/or if any in-service education had been completed to address the above issue. She added that the staff had to be careful because wearing two incontinent briefs could damage the skin and could be very uncomfortable. On 09/21/23 at 08:30 AM, during an interview with CNA #3 who cared for Resident #49 on 09/15/23 during the 11:00 PM-07:00 AM shift, she revealed that she began her last rounds at 4:00 AM, she provided incontinence care to Resident #49 and applied one brief. CNA #3 stated that she had some residents that were, heavy wetters on her assignment and she would change them as needed. CNA #3 added that she would place several blue bed pads on the bed, otherwise she would have to strip the whole bed in the morning. According to CNA #3's interview, approximately four hours had passed since Resident #49's incontinence brief had been changed. The surveyor reviewed the medical record for Resident #49. The admission Face Sheet (an admission summary) reflected that Resident #49 was admitted to the facility with diagnoses which included but were not limited to: Syncope and collapse, repeated falls, unspecified Dementia. The admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 08/02/23, reflected that Resident #49 had a BIMS (Brief Interview for Mental Status) of 09/15, indicative of moderate cognitive impairment. A further review of the resident's MDS, Section G - Functional Status indicated the resident required extensive assistance of one-person physical assist for personal hygiene. A review of the resident's Care Plan (CP) with revised date of 07/26/23, reflected a focus area that the resident had an ADL self-care performance deficit related to hospitalization, diagnosis of Syncope, bradycardia and recurrent falls. The goal was for Resident #49 would improve current level of function in ADL,s and mobility. The interventions for the resident CP included that Resident #49 requires assistance by 1 staff with oral care, personal hygiene, and toileting. 2. On 09/08/23 at 8:37 AM, the surveyor observed incontinence rounds in the presence of the Hospice Aide (HA) on the East Unit. The surveyor observed that Resident #50's incontinent brief was wet and yellow stained. The yellow liquid was observed to be covering the front and the back part of the resident's incontinence brief. Two blue pads were also noted on the bed and were also yellow stained. The HA stated that she worked for Hospice Monday through Friday and provided care to Resident #50. The HA added that Resident #50 would be wet every day whenever she received the resident. She reported to work and just started her shift at 8:30 AM and had not yet changed the resident. On 09/15/23 at 8:15 AM, the surveyor observed incontinence rounds in the presence of CNA #1 and the HA on the 2 East Unit for Resident #50. When the HA removed the resident's incontinence brief, the surveyor observed that two long sanitary-type pads were also inside the incontinence brief and were saturated and yellow. The contents of the sanitary-type pads had leaked through the incontinence brief and stained the blue bed pad that was placed on the bed to protect the bed. The surveyor asked CNA #1 to have a supervisor report to the room. The Licensed Nursing Home Administrator (LNHA) was located on the floor and reported to the room. She informed the surveyor that she would call the DON. The HA remained in the room at the bedside with the surveyor. During a second interview with the HA, she stated that she informed both the nurses and the CNAs that Resident #50 needed to be checked for incontinence every 2 hours. On 09/15/23 at 8:30 AM, the DON entered the room where she observed Resident #50 was in bed, two sanitary-type pads soaked with urine, the incontinent brief also saturated with urine and yellow stained. The DON stated that the sanitary-type pads were in place to prevent MASD (Moisture- Associated Skin Damage -a general term for inflammation and erosion of the skin due to prolonged exposure to moisture) and the resident should have had only one pad inside the incontinent brief. On 09/15/23 at 10:30 AM, the facility provided two packages of the sanitary-type pads for review. The surveyors reviewed the package information on the sanitary-type pad. The packages revealed the products were Bladder Pads, Fits Inside Your Own Underwear. The instructions did not correlate with what the facility indicated the intended use was regarding placing the pad inside the incontinent brief. The surveyors requested the facility provide evidenced based guidance regarding using one incontinent product (Bladder Pad) inside of an incontinent brief. On 09/18/23 at 12:00 PM, the surveyor interviewed the UM/RN of the East Unit. She stated that she was not aware that staff were using two adult incontinent brief, and two pads inside the incontinent brief. She further stated that she could not recall if the CNA or the IP alerted her prior to 09/15/23 of the above concerns. The RN/UM further stated that incontinence rounds were to be performed every two hours and as needed for the residents. The surveyor reviewed the medical record for Resident #50. Resident #50 was admitted to the facility with diagnoses which included but were not limited to: Neurocognitive disorder with Lewy Bodies, Parkinson's disease malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care) dated 05/22/23 reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section G of the MDS which addressed Activities of Daily Living (ADL) reflected that Resident #50 required extensive assistance from staff with bed mobility, transfer, personal hygiene, and toileting. A review of the resident's CP with revised date of 09/11/23, reflected a focus area that the resident had an ADL self-care performance and mobility deficit related to hospitalization, shuffling gait due to Parkinson's Disease. The goal of the resident's CP reflected that the resident would be free of complications related to immobility, skin breakdown. The interventions for the residents CP included extensive assist of 1 for dressing, toileting, hygiene. (The Care Plan failed to indicate that Resident #50 required incontinence care every two hours per the HA) When inquired regarding the facility policy for ADLs, the DON stated that the facility did not have a policy for ADL's. On 09/21/23 at 8:05, the surveyor conducted a telephone interview with CNA #3 who cared for Resident #50 on the 11:00 PM-7:00 AM shift on 09/15/23. CNA #3 revealed that Resident #50 required total care, all needs must be anticipated. You have to do everything for [Resident #50], [he/she] is a heavy wetter. She stated she started her last rounds at 4:00 AM and changed the resident around 5:00-5:30 AM. This indicated that approximately four hours had passed since the resident had been provided incontinence care by a staff member, not two hours as was indicated by the HA. CNA #3 further stated that she provided incontinence care as much as she could. CNA #3 stated had 24 residents on her assignment that night. CNA #3 added that she left the facility at 7:15 AM on 09/15/23, and only one CNA reported to the floor for the day shift. She admitted that she put 2 pads inside the brief and stated that she was never informed how many pads could be placed inside the incontinent brief. CNA #3 further added that it was the facility protocol to have the pads inside the adult brief. When asked if she received some in-service education regarding how many pads to use, she stated, No. CNA #3 then stated, The amount of pads being placed in the incontinent brief was never discussed. She acknowledged receipt of in-service education on incontinent care on 09/16/23, only after surveyor inquiry. On 09/20/23 at 12:30 PM, the above concerns were discussed with the facility administrative staff. During an interview with the DON she confirmed that the facility had been using the pads inside the adult brief. The Director of Nursing (DON) stated that the protocol dated back when the facility was managed by the County. The DON added that the residents were care planned for the use of the pads inside the adult brief. When asked about the facility policy for ADLs the DON stated that the facility does not have a policy for ADLs and did not provide any evidenced based guidance regarding utilizing one bladder product inside of another for incontinence care. The facility did not offer any information why residents were not offered more frequent incontinent care. On 09/21/23 the facility provided an in-service policy titled, Maintaining our Resident's Quality of Life which included the following: Quality of Life: to improve or at the very least, maintain the resident's level of function in all aspect of life, safeguarding against lost of ability. Health's Care: ADLs provided are appropriate for the resident's ability- do for them only what they cannot do for themselves. Incontinence Care Residents require timely care when incontinent. A review of the facility's Job Description for Certified Nursing Assistant indicated under Essential Job Functions. Assist residents with bathing, dressing, grooming, dental care, bowel and bladder functions, preparation for medical tests and exams, ear and eye care and positioning in and out of beds, chairs, etc. Performs resident related activities directed throughout the shift including assisting with lifts of residents to wheelchairs/ [recliner], assists residents In transfer activities, assist residents in donning and removing appliances or splints, and guards residents in ambulation. Nursing Care Functions Provide nursing functions as directed by Nurse Manager including daily perineal care, catheter care, turn residents in bed, sponge baths and showers. Resident's Right Functions Maintain resident confidentiality and privacy; treat residents with kindness, dignity, and respect; know and comply with Resident's Rights; and promptly report all resident complaints and incidents to supervisor. The Registered Nurse Supervisor Job Description Provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing personnel in accordance with current State, Federal, and Local standards governing the facility and as may be directed by the Director of Nursing to ensure highest level of quality care in maintained at all times. Administrative Functions Oversees day to day functions of the licensed practical nurses and the nursing assistants. Ensures that all nursing service personnel are giving proper resident care and performing their respective duties in accordance with written policies, procedures, and manuals. Nursing Care Functions Supervise direct care of resident on assigned shift. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Repeat Deficiency Based on observation, interviews, record and review of other pertinent facility documentation, it was determined that the facility failed to: a.) ensure that a cognitively impaired resident admitted with a known history of falls was appropriately supervised and/ or monitored to prevent falls including falls with injury on 08/27/23 when Resident #50 had an unwitnessed fall and sustained front forehead wound and lump measuring 1.5 centimeter x 1.3 and 0.1., and b.) follow fall prevention interventions per the Care Plan, and ensure that assistive devices to alert staff of falls were functional. This deficient practice was identified for 2 of 3 residents reviewed for incident/ accidents (Resident #49 and #50) and was evidenced by the following: On 09/06/23 at 10:22 AM, the surveyor observed Resident #49 in bed, and a strong odor of urine permeated the room. On 09/06/23 at 10:35 AM, while in the hallway of the East Unit, the alarm sounded in room [ROOM NUMBER]. Resident #49 attempted to get out of the bed, blue brief was soaked with urine and bulging from the back. The Certified Nursing Assistant (CNA) emerged from the adjacent bathroom and escorted the resident back to bed. The CNA told the the resident to wait until she could complete care for the other resident that was observed in the bathroom. The CNA informed the surveyor that whenever Resident #49 was wet he/she would try to get out of bed. On 09/06/23 at 12:30 PM, observed Resident #49 in the dayroom with 6 other residents. The residents were unsupervised and there was no staff observed in the dayroom, or at the nursing station at that time. On 09/08/23 at 8:43 AM the surveyor interviewed the CNA who cared for the resident. She stated she was the only CNA on the floor, the other CNA would report to work around 9:00 AM. The CNA further stated that most of the time 2 CNAs would be assigned to the Unit. The Census was 25 and she had 12 residents on her assignment. When inquired regarding the residents observed in the dayroom she stated that the residents who were at risk for falls would be out of the bed first and then placed in the dayroom. She further added that not all residents would be out of bed daily due to staffing issue. When inquired regarding if administrative staff was aware of the concerns with residents care and staffing, she stated, They made the schedule they were aware. On 09/11/23 at 9:39 AM, the surveyor observed Resident #49 sitting in the dayroom with 3 other residents. The residents were unsupervised as there was no staff in present in the day room or at the nursing station. On 09/11/23 at 11:30 AM, the surveyor reviewed Resident #49's medical record. The admission Face Sheet (an admission summary) reflected that Resident #49 was admitted to the facility with diagnoses which included but were not limited to: syncope (fainting) and collapse, repeated falls, unspecified Dementia. The admission Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care, reflected that Resident #49 had a BIMS (Brief Interview for Mental Status) of 09/15, indicative of moderate cognitive impairment. The MDS also reflected that Resident #49 required limited assistance of one person physical assist for bed mobility and transfer, and extensive assist for personal hygiene and toileting. A fall risk assessment completed by the facility on 08/11/23 indicated that Resident #49 was a high risk for fall. Resident #49 received a score of 90 on the Morse Fall Scale Morse Fall Scale; Scoring: High Risk 45 and higher. The surveyor reviewed a nurse Progress Note dated 08/11/23 timed 12:45 PM, which reflected that Resident # 49 was found lying on the floor on the right side and was asleep on the floor with feet inside the bathroom and head near the bed. Upon assessment, it was noted to have a circular skin tear to the left forearm measuring 3 centimeters (cm) was identified. A review of the facility's Accident/Incident Report dated 08/11/23 at 12:45 AM, indicated that Resident #49 was found asleep and was lying on the floor. At that time per the Accident report, the resident got out of the bed unassisted, climbed in and out of the bed. Interventions added: Moved to room [ROOM NUMBER]-A. Possible alarm to call bell system. Another entry in the nurse Progress Note dated 08/29/23 timed 6:30 PM, revealed that Resident #49 had another unwitnessed fall that occurred in the dayroom. According to the description of Facts and Event, the CNA heard a thud and found Resident #49 sitting on the ground with no apparent injury. Interventions added: 15 minutes monitoring, rehab screen, rule out infection. The CNA's statement revealed that she was at the nursing station and heard the thud and then observed Resident #49 on the floor. The root cause analysis of the event provided by the facility revealed that Resident #49 had poor safety awareness, required assistance with transfer and ambulation. The root cause analysis did not identify /address the lack of supervision as a factor. On 09/11/23 at 09:49 AM, the surveyor observed the Registered Nurse Unit Manager (RN/UM) sitting at the nursing station and was entering information into the computer. During an interview with the RN/UM, she stated that Resident #49 was a high fall risk and that the reason to be in the dayroom. When asked who was monitoring the dayroom, the RN/UM stated she could observed the resident while at the nursing station through the [redacted glass-type] window, but the activity staff should be in shortly. The surveyor observed that the glass window was at knee height and did not provide a full view of the dayroom. The RN/UM further stated that Resident #49 would attempt to ambulate unassisted at times,was not aware of his/her limitation, and needed to be monitored. The surveyor reviewed the following entries in Resident #49's clinical record: On 09/02/23 at 19:52 PM, the Licensed Practical Nurse documented: Resident #49 frequently leaving his/her wheelchair and attempted to ambulate, resident frequently switching seats, undressed in the dayroom. On 09/02/23 at 07:13 AM,the Registered Nurse wrote: Toileting x 8 this shift. Would not call for assistance, would jump out of the bed, unsteady walking to bathroom. Sometimes resident was already incontinent and would remove brief and throw on floor but majority of times would sit on toilet . When interviewed on 09/19/23 at 12:30 PM, in the presence of the team regarding Resident #49's falls, the Director of Nursing (DON) stated that the facility does not have staff dedicated to monitor the dayroom. The DON stated that the residents in the dayroom were being monitored by all staff including the nurse on the medication cart and whomever was in the hallway or at the nursing station. The DON further added that the facility would provide distant supervision for residents in the dayroom. The DON was unable to provide any documentation to support resident monitoring. A review of Resident #49's Care Plan revealed that the line of supervision required for Resident #49, who was identified as a high fall risk since admission, was not addressed. 2. Resident #50 was admitted to the facility with diagnoses which included but were not limited to: Neurocognitive disorder with Lewy Bodies, Parkinson's disease malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care ), dated 05/22/23, reflected that Resident #50 scored 13/15 on the Brief Interview for Mental Status (BIMS). The MDS also reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section 1310 B. Inattention was coded 2. Section G of the MDS which addressed Activities of Daily Living (ADL) reflected that Resident #50 required extensive assistance from staff with bed mobility and transfer. Resident #50 was assessed to be at high risk for fall, Resident #50 received a score of 90 on the Morse Fall Risk dated 06/19/23 and 75 on the fall risk dated 08/27/23. On 09/06/23 at 10:33 AM, the surveyor observed Resident #50 sitting in a high back chair in the dayroom, unsupervised, and not respond to the surveyor's greeting. There was no staff in the dayroom or at the Nursing station. On 09/11/23 at 9:58 AM, the surveyor observed Resident #50 unsupervised, and sitting in the dayroom with 3 other residents. There was no staff observed in the dayroom or at the nursing station. On 09/14/23 at 12:05 PM, the surveyor observed Resident #50 sitting, unsupervised, in the alcove area with 2 other residents. There was no staff present in the hallway. A review of Resident #50's Comprehensive Care Plan for falls initiated on 09/30/21, revealed the following interventions: 1. Urinal within reach initiated 11/22/21. 2. Educate to use call bell for assist initiated 11/22/21. 3. Electronic Pad Alarm on bed initiated 10/13/22. 4. Hip protectors at all times initiated 10/25/22. 5. Sensor Pad to wheelchair initiated 02/04/23. 6. Rehab screen post fall, initiated 02/04/23. 7. Common area when out of bed initiated 06/20/23. 8. Bolster mattress with egress as well as landing matt initiated 08/28/23. On 09/15/23 at 11:15 AM, the surveyor further reviewed the clinical record and noted the following entries: 10/13/22 07:10 AM, the Licensed Practical Nurse documented, (Unwitnessed fall) Resident #50 was found on the floor with an abrasion to the forearm. A review of the Accident/Incident Report revealed that upon assessment, Resident #50 was observed to have redness on left and right knees, a right forearm abrasion measuring 6 centimeters (cm) x 0.4 cm. 02/04/23 5:30 PM, (Unwitnessed fall) Resident #50 was found on the floor in front of the wheelchair in the room. The Director of Nursing documented: Interview of the nurse at the time of the fall, Resident #50 had been at the nurses station. This was just before dinner trays come to the floor. He had appropriate footwear on. No injury was noted by the nurse. The fall was unwitnessed and neuro-checks were implemented .Resident #50 is impulsive and he/she stands without assist. Root Cause analysis: Increase confusion with unpredictable due to Dementia. 06/19/23 4:20 PM, The Licensed Practical Nurse (LPN) documented, While sitting in the dayroom, Resident #50 attempted to get out of wheelchair and fell. Under observation,the LPN wrote, Resident in dayroom on the ground in front of the wheelchair Root Cause Analysis: Poor safety awareness. Overestimates his/her abilities. When inquired who was in the dayroom to monitor the residents, the DON did not provide any information. 08/27/23 11:30 PM, (Unwitnessed fall) The LPN documented that the Certified Nursing Assistant found Resident #50 on the floor in the room. The bed alarm did not sound. The facility was not aware of how long Resident #50 had been on the floor. Root cause analysis: Poor safety awareness and overestimates his/ her abilities to stand related to Dementia and Parkinson. A review of the fall investigation revealed that Resident #50 was found on the floor with a right front forehead wound and lump measuring 1.5 centimeter x 1.3 and 0.1. The root cause analysis revealed that the bed alarm did not sound at time of the fall. Section ( C ) of the Supplemental Fall Information included the following question: Were all of the care planned devices applied prior to the fall was checked? No and indicated that Resident #50 did not have the hipsters implemented (10/25/22) and non skid socks on. Section (D) If an alarm was in place was it sounding? According to the documentation, the bed alarm was in place but did not alert alert the staff of the fall. The surveyors also observed that on 3 occasions, 09/08/23 at 9:01 AM, 09/11/23 at 8:35 AM, 09/15/23 8:15 AM, Resident #50 was in bed, when checked with the CNA Resident #50 did not have the hipsters on (padded brief) implemented since 10/25/22 when Resident was observed to have a bruise of unknown origin to the right hip to minimize fall with injury. On 09/19/23 at 08:36 AM, during an interview with the Hospice CNA (HA), stated that when she cared for Resident #50 in the morning, Resident #50 never had the hip protectors on and she reported the issue to the Unit Manager and the CNAs on the unit. On 09/19/23 at 11:19 AM, the surveyor interviewed the DON, in the presence of the survey team and the Licensed Nursing Home Administrator and the Director of Operations. The surveyor asked who is supposed to supervise the residents who are placed in the dayroom. The DON stated, there is staff that floats in and out of the dayroom. The surveyor asked who the staff is, and the DON stated, CNAs, nurses and activity.The surveyor asked the DON who was monitoring Resident #50 when the resident sustained an unwitnessed fall on 06/19/23. The DON reviewed the investigation and stated, it was an unwitnessed fall. The surveyor asked who was monitoring the dayroom, and the LNHA responded that she had just left the dayroom. A statement dated 06/19/23 revealed that the LNHA left the dayroom and heard an alarm sounding and observed Resident #50 rising from the wheelchair and the alarm sounded and the resident fell to the floor. The surveyor asked the DON who can see what is happening in the dayroom if there is no one assigned to monitor, and you are relying on varied staff who float in and out of the dayroom. The DON stated, we had all the safety interventions in place,and if we thought he/she was a fighter risk we would have had someone in the room. The DON further stated, if their behaviors warrant a closer observation we would have a staff member with them. The facility failed to address supervision as a mitigating factor to prevent further falls. The DON confirmed that Resident #50 is a high risk for falls, as are a lot of residents and the resident has had a few falls. The surveyor asked if interventions added preclude supervision of a resident? The DON stated there was distant supervision, and the surveyor asked how the facility would know that was occurring and it is documented. The DON stated, no. The DON confirmed there is no documentation to confirm that there is any supervision from other staff that are around the unit, or going through the unit. On 09/20/23 at 10:28 AM, during an interview with the RN/UM, she stated that the hipsters were to be always on. She was not aware that the staff had not been compliant with the hipsters. On 09/20/23 at 10:33 AM, the RN/UM looked into the room there was no hipsters. She stated that the Resident had 3 hipsters assigned to him. The RN/UM in the presence of the surveyor searched the room and could not find any hip protectors in the room. There was no hipsters on the unit also. The UM stated that Resident #50 was to have 3 hipsters in the room they could have been soiled and sent to the laundry. On 09/20/23 at 12:30 PM, the surveyor reviewed the CNA's Care Plan initiated 09/22/21 and indicated the following: Hip protectors on at all times. On 09/20/23 at 1:30 PM, the surveyor reviewed the facility policy Titled, Falls and Fall Risk Management The policy indicated that Based on the resident's previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Procedure The Interdisciplinary Care Plan Team will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions ( i.e.; to try one or a few at a time, rather than many at once), # 4 of the procedure indicated the following: If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains irrelevant. The facility indicated on 06/23/23 that Resident #50 had increase confusion with unpredictable behavior due to Dementia. Resident #50 had recurrent falls at the facility when he /she was not being supervised, the facility did not indicate the line of supervision required to prevent falls. On 09/21/23 at 8:30 AM, the surveyor interviewed by phone, the CNA assigned to the 11:00 AM-7:00 PM shift regarding the residents placed in the dayroom. The CNA confirmed prior to leaving the facility at 7:15 AM she would cared for some residents including Resident #49 and placed him/her in the dayroom. When inquired about who was responsible to monitor the residents at risk for falls who were observed early morning in the dayroom. The CNA stated, she could not be at the facility to monitor the dayroom when her shift was over. She stated that she reported to work timely every day when she was assigned to work. The CNA further added, that the administrative staff needed to reinforce the rule and ensure that the 7:00- 3:00 PM shift reported to work on time. On 09/21/23 at 9:39 AM, during a pre-exit conference with the administrative staff which included the LNHA, DON, Regional staff and the Chief Executive Officer (CEO). When the surveyor presented multiple observations where both residents were observed in the dayroom and the alcove unsupervised, she replied, noted. The facility did not provided further information regarding the lack of supervision for the residents who sustained multiple unwitnessed falls, including falls with injury. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 165178 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to: a) provide supervision for resident's who were at risk for falls, who sustained multiple unwitnessed falls, b) consistently provide resident's with assistance to get out of bed, and c) provide appropriate incontinence care. The deficient practice occurred on two of two resident units and was evidenced by the following: Refer to 689E Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, 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 2/01/21: 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. a. On 09/06/23 at 12:30 PM, Surveyor #1 observed Resident #49 in the dayroom with six other residents. The residents were unsupervised and there was no staff observed in the dayroom, or at the nursing station at that time. On 09/08/23 at 8:43 AM, Surveyor #1 toured the East unit and interviewed a Certified Nursing Aide (CNA #1) who stated she was the only CNA for 25 residents and that most of the time there were two CNAs. Surveyor #1 asked CNA #1 if she were able to complete her assigned tasks daily. CNA #1 stated that she usually finished her assignment, but 12:00 PM or 1:00 PM and not all of the residents would be out of bed due to staffing. CNA #1 stated she focused on getting the residents who were at risk for falls out of bed. Surveyor #1 inquired to CNA #1 regarding if the management staff were aware of the staffing concerns. CNA #1 stated that they make the schedule and they know about it. On 09/11/23 at 9:39 AM, Surveyor #1 observed Resident #49 sitting in the dayroom with three other residents. The residents were unsupervised as there was no staff in attendance. A review of the medical record revealed: a fall risk assessment completed by the facility on 08/11/23 indicated that Resident #49 was at a high risk for falls. Resident #49 received a score of 90 on the Morse Fall Scale; Scoring: High Risk 45 and higher. A nurse Progress Note dated 08/11/23, timed 12:45 PM, revealed that Resident # 49 was found lying on the floor with feet inside the bathroom and head was near the bed. Upon assessment, it was noted a circular skin tear to the left forearm measuring three centimeters was identified. Another entry in the nurse Progress Note dated 08/29/23, timed 6:30 PM, revealed that Resident #49 had another unwitnessed fall that occurred in the dayroom. According to the description of Facts and Event, the [CNA] heard a thud and found Resident #49 sitting on the ground with no apparent injury. Interventions added: 15 minutes monitoring, rehabilitation screen, rule out infection. The CNA's statement revealed that she was at the nursing station and heard the thud and then observed Resident #49 on the floor. The root cause analysis of the event provided by the facility revealed that Resident #49 had poor safety awareness, required assistance with transfer and ambulation. b. On 09/06/23 at 10:33 AM, Surveyor #1 observed Resident #50 sitting in a high back chair in the dayroom, unsupervised, and not respond to the surveyor's greeting. There was no staff observed in the dayroom. On 09/11/23 at 9:58 AM, Surveyor #1 observed Resident #50, unsupervised, and sitting in the dayroom with three other residents. There was no staff observed in the dayroom or at the nursing station. On 09/14/23 at 12:05 PM, the surveyor observed Resident #50 sitting, unsupervised, in the alcove area with two other residents. There was no staff present in the hallway. On 09/15/23 at 11:15 AM, the surveyor further reviewed the medical record and noted the following entries: On 10/13/22 at 7:10 AM, Resident #50 was found on the floor with an abrasion to the forearm. On 09/19/23 at 11:19 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team along with the Licensed Nursing Home Administrator (LNHA) and Director of Operations. When the facility was interviewed regarding any staff supervision for residients left unnatended in the day room, the DON stated there was distant supervision. The surveyor asked how the facility would know that was occurring and was it documented. The DON stated, no. The DON confirmed there was no documentation to confirm that there was any supervision from other staff that were around the unit, or going through the unit. c. On 09/08/23 at 9:15 AM, Surveyor #2 observed a call bell system blinking at the un-manned nursing station. At that time, the surveyor conducted an interview with a Licensed Practical Nurse (LPN) and a CNA. The LPN stated there were 35 Residents on both the short and long hall, that she had eleven residents and that there were two CNA's for 35 residents. The surveyor asked the CNA and LPN how they managed to get all of the residents out of bed and the LPN stated, sometimes they don't, and the CNA stated sometimes we can't get everyone up, and with the machine [mechanical lift] it is not easy. On 09/11/23 at 8:52 AM, Surveyor #2 was seated at the unoccupied [NAME] nursing desk and observed a blinking call bell unit with a screen that displayed 8 min, 9 min, and 11 min and a red light was observed blinking outside of the door to room [ROOM NUMBER]. Surveyor #2 observed a nurse standing at a medication cart positioned outside of the room and a staff member was observed going into the room at 8:58 AM. On 09/11/23 at 8:56 AM, Surveyor #2 interviewed the LHNA regarding the current staffing level for CNAs. The LNHA confirmed that she was aware of the New Jersey minimum staffing ratios for CNAs and stated staffing was a concern and during the day shift we don't make it. Surveyor #2 asked the LNHA how does she ensure that residents are getting out of bed and provided with the necessary care required due to the staffing concerns. The LNHA stated that the facility prioritized the residents who get out of bed by ensuring that resident's identified as fall risks get out of bed daily. The LNHA shared the CNA recruitment incentives with Surveyor #2 and strategies, including qualified management staff who help. c. On 09/06/23 at 10:22 AM, the Surveyor #1 observed Resident #49 lying in bed and a strong urine odor permeated throughout the room. On 09/06/23 at 10:35 AM, while in the hallway of the East Unit, Surveyor #1 heard an alarm sounding in Resident #49's room. The surveyor observed the Resident attempting to get out of the bed, a blue incontinent brief was observed soaked with urine and was bulging from the back. The CNA was observed emerging from the adjacent bathroom and then escorted the resident back to bed. The CNA told the resident to wait until she could complete care for the other resident that was observed in the bathroom. The CNA informed the surveyor that whenever Resident #49 was wet he/she would try to get out of bed and disrobed. On 09/15/23 at 8:15 AM, Surveyor #1 performed an incontinence tour with CNA #2, and also in the presence of the facility Infection Preventionist Nurse (IPN). Resident #49 was observed wearing two incontinent briefs and was saturated with urine. At that time, CNA #1 stated that wearing two incontinent briefs was not the protocol and Resident #49 should have been wearing one brief. At 9:06 AM, Surveyor #1, in the presence of Surveyor #2 conducted a follow-up interview with CNA #2 regarding the double incontinent briefs. CNA #2 stated staffing was a concern and that it might take all day to complete her assignment, but she would complete it. CNA #2 stated she was trained to only use one incontinent brief and that Resident #49 should have had one incontinent brief on because it was a dignity issue and could affect resident's skin. CNA #2 stated she has observed two briefs on Resident #49 in the past and she always alerted the supervisor who informed her that it would be addressed. CNA #2 stated Resident #49 was suppose to be taken by the staff to use the toilet not be wearing two briefs. CNA #2 stated there were two CNA's at present, and a third CNA was due to start at 11:00 AM and typically she had twelve residents on any given day. A review of the Facility Assessment 2023, Sufficiency Analysis Summary revealed a daily meeting reviews the staffing for the day as well as projected needs over the next several days to ensure appropriate, sufficient staffing. On 09/19/23 at 10:55 AM, Surveyor #2 interviewed the LNHA, in the presence of the survey team and with a Corporate Manager regarding the purpose of the Facility Assessment. The LNHA stated to identify our strength and weaknesses annually or more than annually if something changed. Surveyor #2 inquired as to how the staffing had been completed. The LNHA stated a computer program was used to assist with CNA staffing and what areas of the facility would be short. The LNHA stated she and the DON would be made aware of when staffing would be short and when asked if there were days that were short she stated, yes. When asked if there was a system to monitor call bell response, the LNHA stated no. A reivew of the Promoting/Maintaining Resident Dignity Policy, Effective 09/02/15 was reviewed by Surveyor #2 and revealed the following: It is the practice of this facility to protect and promote resident rights and treat each residnent with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recogniting each resident's individuality. Compliance Guidelines included 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, 4. Respond to requests for assistance in a timely manner. NJAC 8:39- 4.1(a)11; 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The surveyor reviewed the hybrid medical records of Resident #49 which revealed the following: The resident's admission Record listed diagnoses that included Lewy Body Dementia [a disease process affecting chemicals in the brain that overtime leads to a decline in thinking, reasoning, and independent function] and Hypotension (low blood pressure). The admission MDS assessment dated [DATE], indicated the facility assessed the resident's cognitive status using a BIMS. The resident was unable to complete the interview for a BIMS score and was coded as having short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. The June/July 2022 physician's orders and eMAR indicated Resident #49 had an order, dated 5/23/22, that read, Midodrine HCl Tablet 10 mg Give 1 tablet by mouth three times a day related to HYPOTENSION, UNSPECIFIED (I95.9) HOLD FOR SBP [Systolic Blood Pressure] GREATER THAN 130. The June 2022 and July 2022 eMAR revealed that the Midodrine 10 mg tablet was administered 22 out of 90 times in June 2022 and 5 out of 13 times in July 2022, when the medication should have been held for an SBP that was greater than 130. On 7/5/22 at 11:59 AM, the surveyor interviewed LPN #2 about residents who have medication orders with parameters. LPN #2 stated that parameters would be listed with the medication order, and that she would follow the parameters as ordered by the physician. The surveyor asked LPN #2 about the midodrine medication order for Resident #49. LPN #2 reviewed the eMAR and stated that the midodrine medication order had a parameter to hold the medication for SBP greater than 130. The surveyor reviewed with LPN #2, the June 2022 and July 2022 eMAR. LPN #2 acknowledged that the resident was administered midodrine at times when the medication should have been held for an SBP that was greater than 130, as per the physician's orders. On 7/5/22 at 12:08 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about medication orders with parameters. The RN/UM stated it was expected for the nurses to follow the parameters as ordered by the physician. The surveyor reviewed with the RN/UM the June 2022 and July 2022 eMAR of Resident #49. The RN/UM stated the nurses should have held the midodrine medication when the SBP was greater than 130. On 7/5/22 at 1:15 PM, the surveyor informed the LNHA and DON regarding the above concerns of the administration of midodrine medication for when the medication should have been held according to the physician's orders. The surveyor reviewed the facility policy titled, Medication Administration, with a reviewed date of 06/2022. Under Policy, it read, The facility staff will provide safe and accurate medication administration to the residents. Under Procedure, it read, 7. The nurse takes and records any vital signs as indicated or the order on the Medication Administration Record (pulse, BP, etc.). If vital sign readings are outside the parameter established by the medication order and/or facility policy, the nurse will hold the medication and if necessary, contact the physician for further instruction. NJAC 8:39-11.2 (b); 29.2(d) Based on observation, interview, and record review, it was determined the facility failed to consistently follow standards of clinical practice in regard to a.) accurately documenting medication administration in the electronic Medication Administration Record (eMAR) and b.) correctly following the physician's orders for 2 of 19 residents, Resident #61, and Resident #49. The deficient practice is evidenced by the following: Reference: New Jersey Statuses 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 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 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 6/27/22 at 10:09 AM, the surveyor observed Resident #61 in bed with eyes closed. The surveyor could not interview Resident #61. The surveyor reviewed Resident #61's hybrid medical records (paper and electronic) that revealed the following: The admission Record revealed that Resident #61 was admitted to the facility with diagnoses that included Hypertension (high blood pressure) and Unspecified Diastolic Congestive Heart Failure (a heart disorder that causes shortness of breath). The admission Minimum Data Set (MDS) an assessment tool dated 6/8/22, revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated that the resident was cognitively intact. The June and July 2022 eMAR included Physician's orders for: a.Diltiazem CD Capsule Extended Release 24 Hour 120 mg 1 capsule by mouth one time a day related to Essential (Primary) Hypertension. Hold for Systolic Blood Pressure (SBP) less than 110 or Heart Rate (HR) less than 60. A review of the documentation on the eMAR demonstrated that the Diltiazem CD Capsule Extended Release 24 Hour 120 mg was administered five times in June 2022 and once in July 2022 when the medication should have been held due to low SBP. b. Metoprolol Tartrate Tablet 50 mg 1 tablet by mouth one time a day related to Essential (Primary) Hypertension. Hold for SBP less than 110 or HR less than 60. A review of the documentation on the eMAR demonstrated that the Metoprolol Tartrate Tablet 50 mg was administered five times in June 2022 and once in July 2022 when the medication should have been held due to low SBP. On 7/5/22 at 11:28 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) and discussed the above concerns. LPN #1 stated, That's an error. That's my fault. I should have held the medications. A review of the facility policy titled Medication Administration with a review date of 6/22 indicated under Policy: The facility staff will provide safe and accurate medication administration to the residents. Procedure: 7. The nurse takes and records any vital signs as indicated for the order on the Medication Administration Record (pulse, BP, etc.). If the vital sign readings are outside the parameter established by the medication order and/or facility policy, the nurse will hold the medication and if necessary, contact the physician for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of facility documentation, it was determined the facility failed to a.) ensure a resident was receiving supplemental oxygen as prescribed by the physician; b.) failed to accurately document in the electronic Treatment Administration Record (eTAR) to indicate that the oxygen was administered to 1of 2 residents (Resident #61) reviewed for the use of oxygen. This deficient practice was evidenced by the following: On 6/23/22 at 11:34 AM, the surveyor observed Resident #61 in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy) attached to an oxygen concentrator. The surveyor observed that the oxygen concentrator was set to 2.5 liters per min (LPM). The surveyor reviewed Resident #61's hybrid medical record which revealed the following: The admission Record revealed that Resident #61 was admitted to the facility on [DATE] with diagnoses that included but not limited to Unspecified Diastolic Congestive Heart Failure (a heart disorder that causes shortness of breath), Hypertension (high blood pressure), and Anxiety Disorder. The admission Minimum Data Set an assessment tool dated 6/8/22, revealed a Brief Interview of Mental Status score of 14 out of 15, which indicated that the resident was cognitively intact. The June 2022 Medication Review Report indicated that Resident #61 had an order dated 6/1/22 for Oxygen at 1.5 liters per minute via Nasal Cannula PRN as needed for shortness of breath/wheezing. On 6/27/22 at 10:09 AM, the surveyor observed Resident #61 in bed wearing a nasal cannula attached to an oxygen concentrator. The surveyor observed that the oxygen concentrator was set to 2.5 LPM. On 6/27/22 at 10:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The surveyor asked why Resident #61 was on oxygen. The LPN stated that Resident #61 was on oxygen as needed (PRN) at 2 LPM for comfort. The LPN further stated that a lot of times the resident wears it more at night while in bed. On 6/27/22 at 10:44 AM, the surveyor brought the LPN to Resident #61's room to check the oxygen rate that was administered to the resident. The LPN stated to the surveyor that the rate on the oxygen concentrator was set to 2 LPM. The LPN further stated that the physician's order was for the oxygen to be administered at 1.5 LPM PRN. The surveyor reviewed June 2022 eTAR and revealed that there were no signatures indicating that the oxygen was administered to the resident on 6/23/22 and 6/27/22. On 6/27/22 at 11:54 AM, the surveyor interviewed the LPN and acknowledged that the PRN oxygen should have been signed for the dates that it was administered. The LPN stated, I guess it gets to be a habit that we see it on the resident, we don't get to sign it. On 6/27/22 at 1:16 PM, the surveyor expressed her concerns to the Licensed Nursing Home Administrator and Director of Nursing (DON). The DON agreed that the oxygen was not administered as per physician's orders. The DON further stated that the eTAR should have been signed. A review of the facility policy titled Respiratory Therapy Administration and Equipment Policy and Procedure with a review date of 6/22 indicated under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A review of the facility policy titled Medication Administration with a review date of 6/22 under Procedure: 11. Nurse records the medication given on the Medication Administration Record. 15. Result of administration of PRN medications will be noted on the Medication Administration Record. NJAC 8:39- 29.2 (d)

Refer to F689 Based on interview, review of medical records, and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) 1. failed to ensure that the facility's Policy and Procedures for Falls were in place, updated, and implemented, 2. failed to ensure appropriate review, reassessment, and revision of a resident's care plan interventions, and 3. failed to ensure Resident #35 was safely supervised and did not sustain injuries from the multiple falls that included the comminuted fracture of the right mandibular (chin) condyle with a dislocation of the right tempo-mandibular joint requiring hospitalization. The deficient practice was identified for 1 of 4 residents, for 8 out of 10 falls that resulted in injuries, which occurred from 5/12/22-7/8/22, and failed to provide increased supervision to maintain the resident's safety. This deficient practice was evidenced by the following: On 7/6/22 at 11:26 AM, the surveyor observed Resident #35 sitting in the day room with other residents and there were no staff present. The resident stood up and the surveyor observed the resident wearing a pair of oversized men's pajama pants. The men's pajama pants were loose fitting in the waist and very long in length. On 7/7/22, from 10:52 AM to 11:09 AM, the surveyor observed Resident #35 sitting alone in the alcove/hallway. The resident was out of view of the nurse's station, while sitting in the alcove hallway, and there was no staff nearby. The Director of Nursing (DON) provided the surveyor with Resident #35's Accident/Incident Reports for the last three months. The surveyor reviewed the reports that indicated Resident #1 had fallen 10 times in the last three months of which eight of the falls resulted in injuries. The dates of the falls included May 12, 2022, the resident had one fall with injuries; May 28, 2022, the resident had two falls, the second fall the resident sustained an injury; June 3, 2022, the resident had two falls sustaining an injury on the second fall; June 15, 2022, the resident had one fall with injuries; June 16, 2022, the resident had one fall with injuries; July 4, 2022, the resident had two falls with both falls resulting in injuries; and July 8, 2022, the resident had one fall which the resident sustained a comminuted fracture. The resident's current fall care plan reflected an initiation date of 1/24/22 and a revision date of 6/16/22 and revised again on 7/5/22, which indicated that Resident #1 was at risk for fall/injury, had poor safety awareness, anxiety, impulsiveness, behaviors, frequent falls, and an increased risk of injury from falls due to diagnosis of Osteopenia. Interventions that were put into place included 15-minute monitoring after each fall for 72 hours, neuro checks, and ED visits (if there were injuries). There was also testing completed to rule out infection and psych consults completed for medication review. The resident was seen by the Occupational Therapist (OT) after the 5/13/22, 5/28/22, 6/15/22, 6/16/22, and 7/4/22 falls and made the recommendations to provide constant supervision, and redirection for increased safety. On 6/21/22, the OT recommended the resident received supervision at all times to reduce risk of falls. The interventions listed on the Accident/Incident Reports were not consistently documented in the resident's fall care plan. The facility included the same 15-minute monitoring for 72 hours post fall, however the facility failed to properly reassess the interventions that were already put into place nor address the recommendations given by OT on 5/13/22, 6/7/22, or 6/21/22 to increase the resident's level of supervision to prevent further falls and injuries. In addition, there was no documentation that interventions were reviewed or revised after the resident had the second falls, which occurred on 5/28/22 and 6/3/22, nor for the fall which occurred on 6/16/22, and lastly, not for either of the two falls which occurred on 7/4/22. On 7/11/22 at 10:15 AM, the surveyor interviewed the DON concerning the OT recommendations for increased supervision. The DON stated the recommendations were not presented to the physician or the Advanced Practice Nurse because the wording for constant supervision was incorrectly used. The DON stated the resident received distant monitoring and the staff was aware of the resident's location at all times. The DON was unable to show where the distant monitoring were being documented and at the time of the interview, the DON had not met with OT for clarification or revision of any of the previously made recommendations. On 7/12/22 at 10:06 AM, the DON and the Administrator discussed the fall incidents regarding Resident #1. The DON provided background information on the resident's behavior and frequent falls. The DON stated they were at their wits end. The DON stated that 1:1 staff supervision or shadowing the resident increased the resident's anxiety, and the resident gets upset. The DON further stated that their team looked at each fall and felt the interventions put into place were all they could do. The Administrator was present during the DON's presentation and was in agreement with the DON's explanation of how difficult the resident was to keep from falling and that the interventions put in place were appropriate. The facility provided the surveyor with the Incident Reporting for Residents and Visitors policy and procedure. The surveyor reviewed the policy that had no documentation specific to falls which identified the 15-minute monitoring for 72 hours post fall. The DON stated that this was the only policy the facility had specific for falls. The surveyor reviewed the job description for the LNHA titled Administrator Job Description. Under General Purpose indicated the following, To direct the overall operations of the facility in accordance with current Federal, State, and Local standards governing the facility, to ensure the highest degree of quality of care is maintained at all times. Under Administrative Functions included the following Ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status. Plan, develop, organize, implement, evaluate, supervise, and direct all facility departments and overall operations, its programs and activities and implement changes where necessary. Assist department directors to develop, maintain and periodically update written policies, procedures, manuals, objectives, and philosophies. NJAC 8:39-27.1 (a) (b)

Based on observation, interview, and record review, it was determined the facility failed to a.) consistently schedule sufficient nursing staff to meet the needs of residents and b.) failed to schedule sufficient staff to ensure residents received adequate supervision to prevent falls, which occurred for 1 of 7 residents (Resident #35) reviewed for falls. The deficient practice is evidenced by the following: a.) Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift. (2) 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 certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties: and (3) 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 certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the weeks beginning 6/5/22 and 6/12/22 revealed the following information. The facility was not in compliance with the State of New Jersey minimum staffing requirements of CNAs during the 7:00 AM - 3:00 PM shift for 10 of 14 days beginning 6/5/22 and ending 6/16/22 as evidenced by the following: The facility was deficient in CNA staffing for residents on 10 of 14 day shifts as follows: -06/05/22 had 7 CNAs for 73 residents on the day shift, required 9 CNAs. -06/06/22 had 8 CNAs for 73 residents on the day shift, required 9 CNAs. -06/07/22 had 7 CNAs for 73 residents on the day shift, required 9 CNAs. -06/08/22 had 8 CNAs for 73 residents on the day shift, required 9 CNAs. -06/09/22 had 6 CNAs for 73 residents on the day shift, required 9 CNAs. -06/10/22 had 7 CNAs for 73 residents on the day shift, required 9 CNAs. -06/11/22 had 7 CNAs for 75 residents on the day shift, required 9 CNAs. -06/12/22 had 7 CNAs for 75 residents on the day shift, required 9 CNAs. -06/14/22 had 8 CNAs for 75 residents on the day shift, required 9 CNAs. -06/16/22 had 7 CNAs for 74 residents on the day shift, required 9 CNAs. b.) On 7/06/22 at 11:28 AM the surveyor observed Resident #35 seated in the dining room with other residents. There was no staff member in the dining at the time of the observation. On 7/07/22 at 10:52 AM the surveyor observed the resident sitting alone in a hallway alcove. There were no staff members visible in the area. A review of fall investigations occurring over May 2022, June 2022, and July 2022 revealed the resident had eight falls. Six of the falls were unwitnessed by staff members. Five of the falls resulted in facial lacerations and the last fall dated 7/8/22 resulted in a comminuted fracture of the mandible. NJAC 8:39- 25.2

Based on observation, interview and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection on the COVID-19 positive unit. This deficient practice was for 2 of 4 COVID-19 positive residents reviewed, Resident #24 and #31, and evidenced by the following: On 6/23/22 at 11:31 AM, in the COVID-19 unit, the surveyor observed personal protective equipment (PPE) hanging on Resident #24's and Resident #31's doors and a STOP sign was observed on each resident's door as well. The surveyor interviewed the License Practical Nurse (LPN #1), who stated that both residents were COVID-19 positive and on droplet precautions. Residents #24 and #31 were in their rooms lying in bed. The surveyor reviewed Resident #24's and Resident #31's medical records which revealed the following: According to the admission Record, Resident #24 was admitted to the facility with diagnoses that included COVID-19. There was a Physician's Order (PO) dated 6/20/22 for Droplet Isolation Precautions: Positive COVID-19 Virus x 10 days. According to the admission Record, Resident #31 was admitted to the facility with diagnoses that included COVID-19. There was a PO dated 6/17/22 for Droplet Isolation Precautions: Positive COVID-19 Virus x 10 days. On 6/27/22 at 11:35 AM, the surveyor observed LPN #2 and a Certified Nursing Assistant (CNA) at the COVID-19 positive unit nurse's station. The CNA was wearing an N95 face mask under her chin with her nose and mouth exposed and she had no eye protection on. The CNA stated that she did not know that she needed to wear the N95 or eye protection on the COVID-19 positive unit while at the nurse's station. The LPN #2 replied to the CNA and said Yes, you do, it is a COVID-19 positive unit, and it is our facility policy to wear the N95 mask and eye protection even when you are at the nurse's station. On 6/27/22 at 12:24 PM, the surveyor observed that the lunch tray truck arrived on the COVID-19 positive unit and the lunch tray truck was located near Resident #24's door. The surveyor observed the CNA at the entrance of Resident # 24's room and the CNA donned (put on) a gown, N95 mask and eye protection and no gloves were put on her hands. The CNA entered Resident #24's room, holding the disposable lunch tray and then LPN #2 walked toward the resident's door and from the hallway LPN #2 said to the CNA You need to wear gloves. The CNA said No, I do not need to wear gloves, I'm only putting the lunch tray in the room. The surveyor observed the CNA place the disposable lunch tray onto the resident's bedside table, which was next to the resident who was in the bed. The CNA walked toward the doorway and doffed (took off) her gown, eye protection and N95, she put alcohol-based hand rub (ABHR) on her hands and replaced her N95 mask and eye protection. On 6/27/22 at 12:35 PM, the surveyor and LPN #2 observed the CNA push the lunch tray truck near the doorway of Resident #31's room. The CNA donned a gown, N95 and eye protection and again, no gloves were put on her hands. The CNA entered Resident #31's room, holding the disposable lunch tray and LPN #2 said again, You need to wear gloves, the CNA said No, I'm only putting the lunch tray in the room. The CNA put the disposable lunch tray onto the resident's bedside table, which was located next to the resident, who was in the bed. The CNA took a spoon from the resident's disposable lunch tray and gave it to the resident. The resident gave the spoon back to the CNA and the resident said, I need a fork. The CNA took the spoon from the resident with her bare hands, placed in on the resident's disposable lunch tray, picked up the fork and gave it to the resident. The CNA walked to Resident #31's doorway and LPN #2 said, You need to wash your hands. The CNA walked to the sink inside the resident's room, turned on the faucet, placed her hands under the running water, put soap on her hands and placed them back under the running water while rubbing her hands for three seconds. She turned off the faucet with a paper towel and walked toward the resident's doorway. The CNA doffed her face shield, gown and N95 mask. The CNA was observed holding her doffed N95 and without putting on another face mask, she walked to the resident's bedside and discarded the N95 in the trash container which was located next to the resident's bed. The CNA exited the resident's room and used ABHR on her hands. On 6/27/22 at 12:40 PM, the surveyor interviewed the CNA, who stated that she did not wear gloves because she only entered the room to put the tray down. At 1:12 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing. The surveyor reviewed the policy and procedure titled Hand Washing with a review date of 6/2022, which revealed that the procedure for hand washing at the facility is to lather and scrub hands, wrists and forearms vigorously with friction for 20-30 seconds and to not place hands under running water while scrubbing. The surveyor reviewed the policy and procedure titled Droplet Precautions Policy and Procedure with a review date of 6/2022, which revealed that the personal protective equipment required for a resident who is on COVID-19 droplet precautions are an N95 mask, protective eyewear, isolation gowns and gloves. NJAC 8:39-19.4 (a)

4. Resident #59's hybrid medical records were reviewed and revealed that the resident's physician had not hand signed or electronically signed the monthly physician order for June 2022. In addition, there was no Physician's Order Sheet (POS) in the resident's medical record for June 2022. 7. Resident #6's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for May 2022 and June 2022. 8. Resident #65's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for May 2022 and June 2022. 5. Resident #1's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for May 2022 and June 2022. 6. Resident #56's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022. Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 10 of 18 residents (Resident #64, #25, #35, #59, #56, #1, #6 ,#65, #20 and #48) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents: 1. Resident #64's hybrid medical records (paper and electronic) revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for May 2022 and June 2022. 2. Resident #25's hybrid medical records revealed that the resident's physician had not hand signed or electrically signed the April 2022 and May 2022 monthly physician's orders. 3. Resident #35's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the June 2022 monthly physician's orders. 9. Resident #20's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for May 2022 and June 2022. 10. Resident #48's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's order for May 2022 and June 2022. On 7/05/22 at 10:16 AM the surveyor interviewed the Registered Nurse Unit Manager (RNUM) regarding the process for physicians signing monthly orders. The RNUM stated physician orders are signed electronically. The RNUM reviewed the May and June 2022 physician orders on the electronic record with the surveyor. The RNUM was unable to provide evidence that the physician had signed electronically. The RNUM then stated physician orders are signed by the physician both electronically and on paper. She was unable to provide evidence of physician signatures on the paper record for May and June 2022. On 7/05/22 at 10:20 AM the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated the physician does not sign orders electronically. The DON stated the physician signs on the paper record. The surveyor reviewed the unsigned May and June physician orders in the paper medical record. The DON did not offer an explanation as to why monthly orders were unsigned by the physician. On 7/6/22 at 1:53 PM, the surveyors met and interviewed the Medical Director (MD) who was responsible for signing the monthly physician's orders. The MD stated, I've been overwhelmed. The facility's policy titled Physician's Visits with a revised date of 2/2020 indicated under Policy the following: Attending Physicians will visit their patients a minimum of each month and as needed. Under Purpose the following was listed: To ensure that residents receive medical care as needed; To reduce inappropriate hospitalizations; To comply with regulations related to physician visits; and To ensure residents achieve highest practicable level of well-being. NJAC 8:39-23.2(b)