Based on observation, interview, review of the medical record and review of other facility records, it was determined that the facility failed to follow a physician's order for a urinalysis to rule out a urinary tract infection (UTI). This deficient practice was identified for 1 of 2 resident's (Resident #43) reviewed for catheter/UTI. This deficient practice was observed by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. On 06/13/2024 at 11:16 AM, during the initial tour of the facility the surveyor observed Resident #43 lying in bed. Resident #43 has a urinary catheter. The catheter bag was observed to have cloudy urine in the catheter tubing. A privacy bag in place. Resident #43 denied any urinary pain when interviewed. According to the most recent admission Record, Resident #43 was admitted to the facility with the following but not limited to diagnoses: Unspecified abdominal pain, unspecified dementia, retention of urine, personal history of urinary tract infections, and extended spectrum beta lactamase (ESBL) resistance (an enzyme found in some strains of bacteria. ESBL producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections). According to the quarterly Minimum Date Set (MDS), an assessment tool, dated May 27, 2024, Resident #43 had a brief Interview for Mental Status score of 9/15, which indicated moderate cognitive impairment. According to section GG Resident #43 required was dependent on staff for most activities of daily living except eating. Section H revealed that Resident #43 had an indwelling catheter and Section I revealed that Resident #43 had an active diagnosis of retention of urine. A review of the electronic medical record (EMR) of Resident #43 under the Orders section of the EMR revealed that Resident #43 had the following order dated 06/03/2024: UA reflex to PCR UTI W/ABR for Dysuria /R/o UTI. The surveyor then reviewed the Results section of the EMR to obtain the results of the 06/03/2024 ordered urinalysis to assess Resident #43. A review of the results section did not contain a urinalysis conducted on or after 06/03/2024. A review of Resident #43's comprehensive care plan revealed the following Focus: Potential for UTI AEB (as evidenced by) hx (history) of UTI. Resident #43 had the following care plan Goal: [resident name] will remain free from s/s (signs/symptoms) UTI, revised on: 01/04/2024. Resident #43 had the following but not limited to Interventions/Tasks: Monitor labs as ordered, keep MD aware of abnormalities. Date Initiated: 05/25/2022. On 06/18/24 at 01:40 PM, the surveyor requested a copy of the 06/3/2024 UA and copy of urinary catheter policy from the facility Director of Nursing (DON). On 06/19/2024 at 09:36 AM, the surveyor conducted an interview with the facility DON. The DON could not provide the surveyor with a copy of the results of Resident #43's urinalysis ordered on 06/03/2024 by the physician assistant (PA). The DON explained, I realized that there was no documentation since 5/30 2024. I reached out to the PA to find out why the UA/PCR was ordered. The PA said that it was written in error. We educated him and he admitted that it was written in error. The surveyor then asked if facility staff addressed the order from 06/03/2024 prior to the surveyor making the facility aware that there was no result for the lab. Did anybody in the facility address the order? The DON responded, No. The surveyor then asked the DON what the facility practice was for responding to a physician/practitioner order. The DON replied, The nurse should ask the Unit Manager. The unit manager was not aware that there was an order for the UA/PCR. The surveyor asked the DON if the order should have been addressed on 06/03/2024. The DON acknowledged that yes it should have been addressed on the 3rd by facility staff. The DON agreed that the facility staff should have addressed the order on 6/3/2024 because the order was visible under the Orders tab in the EMR and that the 11-7 nurse should have picked up on the order during their 24 hour chart check. The facility was unable to provide a policy or procedure for physician orders when requested by the surveyor. NJAC 8:39-27.1(a)

2. On 6/17/2024 from 8:05 AM through 8:31 AM, Surveyor #2, during the Medication Pass observation of LPN #2, made the following observations: LPN #2 was standing at her medication cart when Surveyor #2 approached her for medication pass observation. LPN #2 prepared the oral medications for Resident #135, set them aside and began preparing for the resident's insulin (a medication used to treat high blood sugar) injection. LPN #2 donned (put on) disposable gloves and administered the insulin to Resident #135. Once administered, LPN #2 doffed (removed) her gloves and without performing hand hygiene, proceeded to hand Resident #135 the prepared cup of oral medications as well as a cup of water. After completing medication pass for Resident #135, LPN #2 documented the medication administration in the computer and touched both the keyboard and the mouse, again without performing hand hygiene. LPN #2 then grasped the medication cart with both hands and wheeled the cart to the room of Resident #81. LPN #2 then proceeded to prepare Resident # 81's oral medication, without performing hand hygiene. LPN #2 then proceeded into Resident #81's room, administered their oral medications and after she exited Resident #81's room she performed hand hygiene using alcohol based hand rub (ABHR) at the medication cart. On 6/17/2024 at 8:31 AM, Surveyor #2 interviewed LPN #2 who acknowledged she should have performed hand hygiene before donning gloves and after doffing her gloves and between caring for Resident #135 and Resident #81, and confirmed not doing so was an infection control issue. On 6/20/2024 at 9:45 AM, Surveyor #2 interviewed the facility's Infection Preventionist (IP) who stated LPN #2 should have performed hand hygiene before preparing the insulin syringe. The IP stated the nurse should have done hand hygiene first, then she should have gotten the insulin pen primed and ready, then used hand hygiene again and donn gloves, administered the mediation, removed her gloves and again performed hand hygiene, either washing with soap and water or using ABHR. The IP stated nurses should always use hand hygiene between residents. On 6/20/2024 at 11:09 AM, the survey team met with the facility Administration which included the ADON who confirmed that staff should perform hand hygiene before and after wearing gloves and it must be performed between caring for each resident to prevent infection. A review of the facility provided Medication Administration General Guidelines for the Administration of Medications policy undated, included . The nurse washes his/her hands appropriately before and after medication administration . A review of the facility provided Medication Pass Observation form revised 6/17, included . Hand washing (alcohol based hand rub or soap and water . between every resident even if patient contact is not made . immediately before and after use of gloves . A review of the facility provided untitled Hand Hygiene policy last reviewed 1/24, revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. . the preferred method of hand hygiene is with alcohol-based hand rub . .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents .before donning sterile gloves . before preparing or handling medications .Before handling clean or soiled dressings, gauze pads, etc.; . after removing gloves .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and after removing gloves. Hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. A review of the facility policy, Enhanced Barrier Precautions (Created 03/25/24/Revised 06/19/24) revealed the following: Enhanced Barrier Precautions (EBP)-refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact activities. .Examples of high-contact resident care activities requiring a gown and gloves for Enhanced Barrier Precautions include: .Wound care for chronic wounds requiring a dressing NJAC 8:39-19.4(n) Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow appropriate infection control procedures: 1) during the provision of a wound treatment and 2) during medication administration. This deficient practice was identified for 1 of 1 nurses Registered Nurse (RN #1) who administered a wound treatment to 1 of 2 residents (Resident #177) reviewed for pressure ulcers and for 1 of 3 nurses Licensed Practical Nurse (LPN #2) observed during the medication administration observation. This deficient practice was evidenced by the following: 1. On 06/18/2024 at 10:21 AM, Surveyor #1 observed a stop sign posted outside of Resident #177's room which indicated the resident was on Enhanced Barrier Precautions (EBP), which required use of both gown and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDRO), bacteria that are resistant to three or more classes of antimicrobial drugs, to staff hands and clothing. The sign cautioned that everyone must: Clean their hands, including before entering and when leaving the room, and providers and staff must also wear gloves and gowns for the following high-contact resident care activities: .wound care: any skin opening requiring a dressing. Beneath the stop sign there was a cart that contained Personal Protective Equipment (PPE), (equipment worn to protect the body from infection). The surveyors entered the room and observed the resident seated in a wheelchair at the bedside. The resident stated that he/she had a wound near their tailbone and was agreeable to permit the surveyors to observe wound treatment. On 06/18/2024 at 10:58 AM, Surveyor #1 observed RN #1 wash her hands for 15 seconds before she donned (put on) gloves, and failed to donn a gown as indicated on the signage outside of Resident #177's room, before she proceeded to remove the resident's soiled sacral (triangular bone at the base of the spine) dressing. At 10:59 AM, RN #1 performed hand hygiene with alcohol based hand rub (ABHR) before she donned gloves and proceeded to cleanse the resident's sacral wound with Dakin's Solution (a mixture of sodium peroxide and hydrochloric acid). RN #1 patted the wound dry, applied Skin Prep (adhesive aid) to the border of the wound, and cut a piece of calcium alginate (highly absorbent dressing) to size before she placed it in the wound bed and covered it with a border foam dressing. At 11:03 AM, after RN #1 finished Resident #177's wound treatment she opened the door with her gloved hand, doffed (removed) her gloves and discarded them, before she proceeded to obtain a disinfectant wipe from the treatment cart and wiped down the marker used to date the dressing and the scissors used to cut the wound treatment to size. RN #1 then donned gloves without first performing hand hygiene, placed the scissors in a plastic bag, reached into her pocket with her gloved hands and obtained the keys to the treatment cart and accessed the treatment cart, and the computer that was located on top of the treatment cart. At 11:05 AM, RN #1 doffed her gloves and washed her hands for ten seconds before she signed the treatment as administered in the computer. At 11:07 AM, RN #1 obtained the garbage bag from Resident #177's room that contained soiled wound treatment supplies and placed the bag in the soiled utility room. At 11:08 AM, the surveyor observed RN #1 as she washed her hands for 13 seconds. At 11:10 AM, when interviewed about what PPE needed to be worn during a wound treatment for a resident on Enhanced Barrier Precautions, RN #1 stated staff were required to wear both a gown and gloves to protect their clothing. RN #1 then stated, I did not put a gown on, did I ? When interviewed about hand hygiene requirements RN #1 stated she was required to clean her hands prior to entry, before dressing removal, and after the wound treatment for 20 seconds. RN #1 stated she sang Happy Birthday once to ensure that she had washed her hands for a full 20 seconds. RN #1 stated hands would not be cleaned if they were washed for less than 20 seconds. RN #1 further stated there was a chance of contamination if she failed to wash her hands after she doffed her gloves post wound treatment and then reached into her pocket and obtained the keys to the treatment cart, cleaned her scissors, marker and then accessed the treatment cart and computer. On 06/18/2024 at 11:26 AM, Surveyor #1 interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated both a gown and gloves were needed for Enhanced Barrier Precautions to prevent infection. LPN/UM #2 stated with direct care and touch, a gown should be worn as it could put the resident at risk for infection when care was rendered. LPN/UM #2 stated that hands were required to be washed for 30 seconds. LPN/UM #2 stated staff were required to wash their hands when gloves were doffed to ensure nothing got under the gloves. LPN/UM #2 further stated the main goal was infection prevention. On 06/18/2024 at 3:35 PM, Surveyor #1 interviewed the Infection Preventionist (IP) who stated for Enhanced Barrier Precautions staff should minimally wear a gown and gloves when wound care was rendered for a sacral wound. The IP stated if a gown were not worn there was a concern the nurse could give the resident an infection of some sort. The IP stated that if a resident were colonized (germs are on the body but do not make you sick) with an infection than the nurse risked infection as well. The IP stated the main concern was the patient. At that time, Surveyor #1 interviewed the IP regarding handwashing. The IP stated that staff were required to wash their hands for a minimum of 20 seconds and sing Happy Birthday twice. The IP stated if hands were washed for less than 20 seconds, then your hands were obviously not cleaned and you did not kill or get off the germs that were possibly still on your hands. The IP stated you could possibly contaminate everything you touched if your hands were not washed after you doffed your gloves post wound treatment because there was a possibility that an organism could be spread to the scissors or items that were cleaned and spread to the next person. The IP stated the keys to the treatment cart were touched multiple times a day and were then passed off with the possibility for infection to spread down the line. On 06/19/2024 at 12:40 PM, Surveyor #1 interviewed the Director of Nursing (DON) in the presence of the survey team, who stated Enhanced Barrier Precautions required both gloves and gown for the protection of the patient and staff during a sacral wound treatment. The DON stated hand hygiene should be performed for 20 seconds or more, as there was a potential for contamination if hands were washed for less than 20 seconds. The DON stated there was a chance of cross contamination if hands were not washed after gloves were doffed post wound treatment. On 06/19/2024 at 11:09 AM, the DON provided Surveyor #1 with RN #1's Hand Hygiene Competency Validation and Wound Treatment Observation Competency both of which were dated 04/02/24. A review of a Wound Treatment Observation a tool the facility uses (revised 06/2022) revealed the following: .Perform hand hygiene before beginning the procedure (rub hand [sic.] with soap for 20 seconds) Put on gloves, loosen tape and remove soiled dressing, place in garbage. Wash hands and don gloves. (Rub hands with soap for 20 seconds). Pour cleaning solutions on gauze sponges. Cleanse wound and pat dry. Wash hands and don gloves (rub hands with soap for 20 seconds). Apply treatment as ordered. Cover wound with clean dressing (add the labeled dressing or tape). Remove gloves and Perform Hand hygiene. (rub hand [sic.] with soap for 20 seconds) *Sanatize [sic] pen Reposition resident if necessary and place call light within easy reach. Perform hand hygiene (rub hand [sic.] with soap for 20 seconds) Sanatize [sic.] over bed table. Perform Hand Hygiene (rub hand [sic.] with soap for 20 seconds) Discard garbage in soiled utility room. Perform hand hygiene (rub hand [sic.] with soap for 20 seconds) .

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 7 sampled residents, (Resident #11, Resident #30, Resident #49, Resident #60, Resident #69, Resident #120 and Resident #128) identified upon inspection of 2 of 4 medication carts (Birch Unit A cart, and Birch Unit B cart). This deficient practice was evidenced by the following: On 6/18/2024 at 1:10 PM, the surveyor in the presence of the Licensed Practical Nurse #3 (LPN #3) inspected Birch unit, A cart. The surveyor and LPN #3 reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic inventory sheet, the surveyor identified the following concerns: Resident #60's pregabalin 75 milligram (mg) capsule, a medication used for nerve pain, did not match the physical inventory. The blister pack contained #20 capsules and the declining inventory sheet indicated there should be 21 capsules remaining. Resident #69's pregabalin 100 mg capsules also did not match. The blister pack contained 13 capsules and the declining inventory sheet indicated there should be 14 capsules remaining. At that time, the surveyor interviewed the LPN #3 who stated she had administered the medications earlier to both residents and had not signed the declining inventory sheet for the doses she had administered. The LPN acknowledged the declining inventory sheet should be signed when the medication was removed from the packaging. On 6/18/2024 at 1:29 PM, the surveyor in the presence of the Licensed Practical Nurse #1 (LPN #1) inspected Birch unit, B cart. The surveyor and LPN #1 reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns: Resident #11's oxycodone immediate release (IR) 5 mg tablet, a medication used for severe pain, did not match the physical inventory. The blister pack contained 10 tablets and the declining inventory sheet indicated there should be 12 tablets remaining. Resident #30's lorazepam 1 mg tablet, a medication used for anxiety, did not match the physical inventory. The blister pack contained #13 tablets and the declining inventory sheet indicated there should be 14 tablets remaining. Resident #49's pregabalin 225 mg capsule, did not match the physical inventory. The blister pack contained 9 capsules and the declining inventory sheet indicated there should be 10 capsules remaining. Resident #120's oxycontin extended release (ER) 20 mg tablet, a medication used for severe pain, did not match the physical inventory. The blister pack contained #27 tablets and the declining inventory sheet indicated there should be 28 tablets remaining. Resident #128's Xtampza ER 9 mg capsule, a medication used for severe pain, did not match the physical inventory. The blister pack contained #21 capsules and the declining inventory sheet indicated there should be 22 capsules remaining. At that time, the surveyor interviewed LPN #1 who stated she had given the medications earlier and should have signed the declining inventory sheets when she removed the medications from their packaging. On 6/18/2024 at 1:56 PM, the surveyor interviewed the Unit Manager Licensed Practical Nurse #3 (UM/LPN #3) who stated the nurse should be signing the declining inventory sheets at the time they remove the medication from inventory. On 6/20/2024 at 11:09 AM, the survey team met with facility Administration. The Director of Nursing stated nurses should be signing the declining inventory sheets as soon as the medication was removed from the packaging. A review of the facility's undated Medication Dispensing; Controlled Substances policy included . Accountability of controlled dangerous substances . When a CDS (controlled Dangerous Substance) medication is administered . the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. A review of the facility's undated Medication Administration General Guidelines for the Administration of Medications policy included . Administration of controlled Dangerous substances is also recorded on the declining inventory form. NJAC 8:39-29.2(d), 29.7(c)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 6/13/2024 from 9:30 to 10:23 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On an upper shelf, a previously opened bag of egg noodles had no opened or use by dates. The FSD removed the noodles from storage. 2. In the paper storage area on a middle shelf a previously opened plastic bag of coffee filters was stored opened and exposed. The FSD removed the filters from storage. 3. A clean and sanitized stand-up mixer in the food production area was covered with plastic and not in use per the FSD. The FSD removed the plastic covering. The surveyor observed unidentified food debris on the support arm of the mixer behind the bowl and above the beater shaft. The FSD stated, I'll have that re-cleaned and sanitized. 4. After observing the Starter Refrigerator, the surveyor went to the designated hand washing sink in the kitchen. Upon completion of hand washing and drying their hands the surveyor attempted to throw their used hand towel into the trash. There was no waste can at the sink. The FSD stated that the waste can was removed from the area. to be emptied and showed the surveyor the waste can that was located near the tray line. Observation of the waste can contents did not reveal any used hand towels in the contents. 5. The Beverage Box contained two (2) Ready Care Vanilla shakes (a nutritional supplement) that had a date of 6-8. When interviewed the FSD stated, They are good for 14 days once pulled from the freezer. They are old. I'm discarding them. 6. In Walk-In refrigerator #4 on a lower shelf a previously opened roll of liverwurst was wrapped in plastic wrap. The liverwurst had no dates. The FSD removed the liverwurst to the trash. On 06/18/2024 at 9:18 AM, the surveyors made the following observations in the Laurel Unit designated resident pantry: 1. Review of the [facility name] DATES/TEMPERATURE SHEET with MONTH: 6/2024, revealed the following: Freezer Temps: 0 Degrees or Below ALL ITEMS MUST BE DATED 2. Observation of the freezer revealed that the freezer did not contain an internal thermometer to monitor the freezer temperature. In addition, no freezer temperatures were recorded on the temperature sheet. 3. The surveyor observed a single slice of pizza on the bottom shelf of the refrigerator. The pizza was in a zip lock bag and had no dates. On the shelf of the refrigerator door two (2) separate plastic portion control cups contained an unidentified white sauce and one contained a red/orange sauce that appeared to be hot sauce. The portion control cups had no dates. On interview Licensed Practical Nurse (LPN #5) agreed that all foods require a name and use by date. The surveyor made LPN #5 aware that freezer temperatures had to monitored, in addition to refrigerator temperatures. LPN #5 replied, Ok. The surveyor reviewed the facility policy titled [facility name] Policy and Procedure Food Safety Education, April 2018. The following was revealed under POLICY: Residents are permitted to store and consume food that is obtained from outside the center. As a result, it is the policy of this facility to: Provide storage space for outside food/beverages that are distinct from the facility food storage units. The policy also had an attachment that revealed the following: All food and beverage items stored in the facility pantry/refrigerator must be thrown out: 1. On the manufacturer's expiration date. 2. 72 hours after the date it was brought in. 3. Upon spoiling. In addition, the attachment also revealed that Facility is responsible for discarding any expired, spoiled, or unlabeled food that is discovered and All food and beverage items being stored in the facility pantry or refrigerator must be: Labeled with the resident's name and Labeled with the date brought in (unless the items are in their original containers marked with a manufacturer's expiration date). The surveyor reviewed a facility policy titled Receiving, with Revised dated of 9/2017. The following was revealed under the heading Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. The following was revealed under Procedures: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The surveyor reviewed the facility policy titled Equipment, Revised 9/2017. The following was revealed under the heading Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. The following was revealed under the heading Procedures: 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and free of debris. The surveyor reviewed the facility policy titled Food Storage: Dry Goods, Revised 2/2023. The policy revealed the following under Policy Statement: All dry goods will be appropriately stored in accordance with the FDA Food Code. The following was revealed under the heading Procedures: 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. NJAC 18:39-17.2 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: 1. For the week of Complaint staffing from 03/05/2024 to 03/11/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -03/05/23 had 11 CNAs for 170 residents on the day shift, required at least 21 CNAs. -03/06/23 had 14 CNAs for 168 residents on the day shift, required at least 21 CNAs. -03/07/23 had 14 CNAs for 166 residents on the day shift, required at least 21 CNAs. -03/08/23 had 17 CNAs for 166 residents on the day shift, required at least 21 CNAs. -03/09/23 had 20 CNAs for 165 residents on the day shift, required at least 21 CNAs. -03/10/23 had 19 CNAs for 165 residents on the day shift, required at least 21 CNAs. -03/11/23 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. 2. For the week of Complaint staffing from 04/02/2023 to 04/08/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -04/02/23 had 14 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/03/23 had 15 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/04/23 had 16 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/05/23 had 14 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/06/23 had 19 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/07/23 had 20 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/08/23 had 15 CNAs for 172 residents on the day shift, required at least 21 CNAs. 3. For the week of Complaint staffing from 08/27/2023 to 09/02/2023, the facility was deficient in CNA staffing for residents on 6 of 7-day 0shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -08/27/23 had 7 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/27/23 had 12 total staff for 180 residents on the evening shift, required at least 18 total staff. -08/27/23 had 4 CNAs to 12 total staff on the evening shift, required at least 6 CNAs. -08/28/23 had 15 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/29/23 had 17 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/31/23 had 16 CNAs for 186 residents on the day shift, required at least 23 CNAs. -09/01/23 had 17 CNAs for 185 residents on the day shift, required at least 23 CNAs. -09/02/23 had 14 CNAs for 185 residents on the day shift, required at least 23 CNAs. 4. For the week of Complaint staffing from 09/10/2023 to 09/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -09/10/23 had 13 CNAs for 194 residents on the day shift, required at least 24 CNAs. -09/11/23 had 16 CNAs for 194 residents on the day shift, required at least 24 CNAs. -09/12/23 had 17 CNAs for 193 residents on the day shift, required at least 24 CNAs. -09/13/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/14/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/15/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/16/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. 5. For the week of Complaint staffing from 11/19/2023 to 11/25/2023, the facility was deficient in CNA staffing for residents on 7 of 7-day shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in total staff for residents on 1 of 7 overnight shifts as follows: -11/19/23 had 9 CNAs for 186 residents on the day shift, required at least 23 CNAs. -11/20/23 had 13 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/21/23 had 13 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/22/23 had 14 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/23/23 had 15 CNAs for 183 residents on the day shift, required at least 23 CNAs. -11/23/23 had 16.5 total staff for 183 residents on the evening shift, required at least 18 total staff. -11/23/23 had 10 total staff for 183 residents on the overnight shift, required at least 13 total staff. -11/24/23 had 11 CNAs for 183 residents on the day shift, required at least 23 CNAs. -11/25/23 had 12 CNAs for 183 residents on the day shift, required at least 23 CNAs. 6. For the week of Complaint staffing from 01/07/2024 to 01/13/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -01/07/24 had 12 CNAs for 185 residents on the day shift, required at least 23 CNAs. -01/08/24 had 13 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/09/24 had 13 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/10/24 had 17 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/11/24 had 20 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/12/24 had 22 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/13/24 had 14 CNAs for 184 residents on the day shift, required at least 23 CNAs. 7. For the week of Complaint staffing from 02/18/2024 to 02/24/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -02/18/24 had 13 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/19/24 had 10 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/20/24 had 12 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/21/24 had 14 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/22/24 had 15 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/23/24 had 16 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/24/24 had 13 CNAs for 182 residents on the day shift, required at least 23 CNAs. 8. For the week of Complaint staffing from 03/17/2024 to 03/23/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -03/17/24 had 13 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/18/24 had 12 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/19/24 had 12 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/20/24 had 15 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/21/24 had 17 CNAs for 174 residents on the day shift, required at least 22 CNAs. -03/22/24 had 16 CNAs for 174 residents on the day shift, required at least 22 CNAs. -03/23/24 had 12 CNAs for 174 residents on the day shift, required at least 22 CNAs. 9. For the week of Complaint staffing from 04/28/2024 to 05/04/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -04/28/24 had 15 CNAs for 181 residents on the day shift, required at least 23 CNAs. -04/29/24 had 11 CNAs for 181 residents on the day shift, required at least 23 CNAs. -04/30/24 had 13.5 CNAs for 181 residents on the day shift, required at least 23 CNAs. -05/01/24 had 15 CNAs for 181 residents on the day shift, required at least 23 CNAs. -05/02/24 had 16 CNAs for 180 residents on the day shift, required at least 22 CNAs. -05/03/24 had 14.5 CNAs for 180 residents on the day shift, required at least 22 CNAs. -05/04/24 had 16 CNAs for 179 residents on the day shift, required at least 22 CNAs. 10. For the 2 weeks of staffing prior to survey from 05/26/2024 to 06/08/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -05/26/24 had 14 CNAs for 184 residents on the day shift, required at least 23 CNAs. -05/27/24 had 13 CNAs for 183 residents on the day shift, required at least 23 CNAs. -05/28/24 had 11 CNAs for 183 residents on the day shift, required at least 23 CNAs. -05/29/24 had 16 CNAs for 182 residents on the day shift, required at least 23 CNAs. -05/30/24 had 15 CNAs for 182 residents on the day shift, required at least 23 CNAs. -05/31/24 had 18 CNAs for 182 residents on the day shift, required at least 23 CNAs. -06/01/24 had 15 CNAs for 182 residents on the day shift, required at least 23 CNAs. -06/02/24 had 11 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/03/24 had 15 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/04/24 had 14 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/05/24 had 16 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/06/24 had 9 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/07/24 had 15.5 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/08/24 had 14 CNAs for 189 residents on the day shift, required at least 24 CNAs. On 06/13/24 at 10:28 AM, during an interview with the surveyor, the 3rd floor Unit Manager (LPN/UM #4) when asked how staffing has been, replied, So-so, it could be better some days. At that time the LPN/UM #4 provided the Dogwood Court Assignment Sheet for the 7-3 shift that revealed a census of 58 residents with four CNA's indicating a ratio of 1 CNA to 15 residents. During an interview with the surveyor on 06/18/24 at 10:24 AM, CNA #3 stated that he/she had 14 residents on his/her assignment. When asked, can you get all your work done on your 8 hours shift, CNA #3 stated, If I move fast enough, we only have 2 CNAs on the unit. On 06/13/24 at 10:41 AM, Resident #161 stated that call bells are not answered timely, and his/her roommate has waited up to 7 hours for assistance. Resident #161 added that at times, he/she must find help for her roommate and other residents when call bells go unanswered for long periods of time. On 06/13/24 at 11:59 AM, during an interview with the surveyor, Resident #145 stated that he/she must wait a long time for assistance. During an interview with the surveyor on 06/18/2024 at 11:03 AM, the Staffing Coordinator indicated that it is difficult to meet the staffing requirements. The Staffing Coordinator said that she was aware of the minimum staffing requirements for CNA's which is 1 to 8 residents for 7-3 shift, 1 to 10 residents for the 3-11 shift, and 1 to 14 for the 11-7 shift. We use agency staffing that is unreliable. We are not always able to meet staffing requirements. During an interview with the surveyor on 06/18/2024 at 12:14 PM, CNA #2 stated, I typically have between 12-15 residents on day shift. Weekends are the same. Today, I have 3 Hoyer lifts which requires 2 CNA's to safely transfer; it is difficult to get assistance when staffing is limited. When asked, if he/she was able to complete all assignments during his/her shift, he/she replied, no. On 06/19/2024 at 12:33 PM, in the presence of the survey team, the Director of Nursing (DON) stated the facility staffing is determined by the New Jersey Department Of Health (NJDOH) requirements which are, 1:8 for 7-3 shift, 1:10 for 3-11 shift and 1:14 for 11-7 shift. The DON acknowledged that the facility was not meeting those requirements. The DON added that based on a full census of 204 residents, the staffing plan for CNA's is 4-5 on larger units: Dogwood and Birch during the day, 3 CNA's for SMART Unit, 2 CNA's for Oak unit, a 1 CNA for Laurel Unit. A review of the Facility assessment dated [DATE], under supportive documentation, revealed the following: Under Direct Care Staff (Certified Nurse Aides) 8 Aides Birch Court 7-3 and 5 Aides on 3-11; 3 Aides on 11-7 8 Aides Dogwood 7-3 and 5 Aides on 3-11; 3 Aides on 11-7 4 Aides on SMART Unit all three shifts 2 Aides on Laurel Unit all three shifts 4 Aides on Oak Court 7-3 and 3-11; 3 aides on 11-7 A review of a policy provided by the facility titled, Nursing Policy and Procedure, with a revision date of June 2020 and a review date of January 2024, revealed; It is the policy of this facility to determine the appropriate staffing on a unit based on the census, acuity, shift and needs of the residents and staffing ratio required by the NJDOH. NJAC 8:39-5.1(a), 27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter drainage bag off the floor to prevent the spread of infection and according to the facility protocol. This was identified for 1 of 2 residents (Resident #18) reviewed for indwelling urinary catheters. This deficient practice was evidenced by the following: On 10/04/2022 at 10:34 AM, the surveyor observed Resident #18 in a wheelchair in the hallway near the nurse's station. The surveyor observed a urinary catheter drainage bag was attached to his/her wheelchair and the urinary drainage bag had direct contact with the floor. On 10/06/2022 at 12:00 PM the surveyor observed Resident #18 in bed. The surveyor observed the urinary catheter drainage bag had direct contact with the floor on the window side of the bed. A review of the medical record revealed Resident #18 had diagnoses which included but were not limited to; obstructive uropathy (Obstructive uropathy is a disorder of the urinary tract that occurs due to obstructed urinary flow). A review of the Minimum Data Set (MDS), an assessment tool, dated 07/04/2022, revealed that Resident #18 was identified as having an indwelling urinary catheter. A review of the Physician's Orders dated 7/18/2022, included an order for catheter care every shift. During an interview with the surveyor on 10/17/22 at 11:01 AM, the Licensed Practical Nurse Unit Manager stated that the urinary catheter drainage bag should not be on the floor. During an interview with the surveyor on 10/17/22 at 11:43 AM, the Director of Nursing stated that a urinary catheter drainage bag should not be on the floor. A review of a facility Foley Catheter Protocol with a reviewed date of 1/2022, included: 10. Urinary catheter Bag must not touch the floor or be placed above resident's bladder. NJAC 8:39-19:4(a) (1-6)

Based on observation, interview and record review, it was determined that the facility failed to follow professional standards of clinical practice by not carrying out physician ordered treatment for 1 of 37 residents (Resident #2) and was evidenced by the following: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission Record (AR) dated 2/27/2020, Resident # 2 had the diagnoses of Edema (swelling), Venous insufficiency, and Lymphedema (localized swelling of the body caused by an abnormal accumulation of lymph). The quarterly Minimum Data Set (MDS) an assessment tool, dated 2/16/2020 indicated that Resident # 2 was cognitively intact and able to understand information and communicate information. The MDS also reflected that the resident required set up help with dressing, bathing and personal hygiene. On 02/25/20 at 10:17 AM, the surveyor observed Resident # 2 sitting in a lounge chair with both feet raised. Resident # 2 was interviewed at this time and said that he/she had a lot of swelling and fluid in his/her lower legs. The resident added that he/she goes out to the vascular doctor who told him/her to wear compression stocking to help and relieve the swelling. He/ she also added that he/she was supposed to be wearing TED (Thrombo-Embolic-Deterrent) stockings (Compression stockings) but did not think the stockings were ordered yet. The resident stated Where are they ordering the stockings from, fifth and jabit. He/she said it had been a week or two since the staff put the TED stocking on his/her legs. The surveyor observed that the resident was not wearing TED stockings at this time. On 02/26/20 11:35 AM, the surveyor interviewed Resident # 2 who said that the staff had not applied TED stockings to his/her lower legs since last week. The resident then showed the surveyor their legs and the surveyor observed that the resident was again not wearing the TED stockings. The Physician Order Sheet (POS) dated 2/6/2020 contained a physician order for TED stockings to be applied in the morning and to be removed in the evening. The surveyor reviewed Resident # 2's Care Plan which indicated that Resident # 2 had increased swelling in both lower legs due to the diagnoses of Lymphedema and wears compression stockings. The Vascular Surgery Consultation dated 1/25/2020, indicated that Resident # 2 had chronic severe Lymphedema stage 3 of the lower extremities, Venous Insufficiency, Lipodermatosclerosis and morbid obesity. The consultation also indicated the physician had advised the resident to utilize compression stockings daily to both lower extremities. The Treatment Administration Record (TAR) dated 2/25/2020 and 2/26/2020 at 6:00 AM hours contained nursing signatures that documented TED stockings were applied for the diagnoses of lymphedema of the lower extremities, however the surveyor did not observe the TED stockings on Resident # 2's legs on the dates the nursing staff documented that the stockings had been applied. On 02/26/20 at 11:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) that was caring for Resident # 2 who said that the resident required partial care for his/her activities of daily living (ADL's) and required treatments to his/her lower extremities. The LPN added that Resident # 2 also wore compression stockings during the day and removed at night. The LPN revealed that the compression stockings were supposed to be applied around 6 am and that she was not aware that the resident did not have the TED stockings on as ordered, because she did not apply them and was not working at the time they were supposed to be applied. On 02/26/20 at 12:11 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM) who said that she was not sure why Resident #2 was not wearing the TED stockings as ordered, but would check and obtain the correct compression stockings for the resident. The LPN UM was able to locate the appropriate compression stockings that were ordered by the physician in the facility central supply room. On 02/27/20 at 10:08 AM, the surveyor interviewed the LPN UM who stated that the resident was not wearing the TED stockings as ordered on 2/26/2020 and that the resident also informed her that the stockings had not been put on since Saturday 2/23/2020. The Director of Nursing (DON) provided the surveyor with a statement dated 2/28/2020 at 11:22 AM from the LPN that worked on 2/25/2020 at 11:00 PM to 2/26/2020 at 6:00 AM. The LPN documented in the statement that she charted in error that the compression stockings were in place and was wrong for charting that she applied the stockings. The statement read I charted in error at the time of application. I should have written a note about the refusal and I was wrong for charting that I applied them. There was no documentation in the medical record that Resident #2 refused the application of the compression stockings on 2/25/2020 and 2/26/2020 at 6:00 AM. On 03/03/20 at 02:56 PM, the surveyor interviewed the DON who said that the facility did not have a policy specific to the application of compression stockings, but indicated that this was a physician's order that should have been followed. The policy titled Administration Procedures for all Medications dated April 2019, indicated that after administration of a treatment or medication the nurse was to document administration in the Medication Administration Record (MAR) or TAR. The policy also indicated that if a resident refuses a treatment, the refusal is to be documented on the TAR. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.) During the initial tour on 02/25/20 at 9:52 AM, the surveyor observed Resident #121 sitting in his/her wheelchair awake and alert changing his/her colostomy appliance. The surveyor observed a nebulizer treatment machine (a device used to change liquid respiratory medication into a mist for administration to treat respiratory conditions) lying directly on the resident's bedside table with the tubing and facemask attached to the machine. The tubing and face mask were not labeled or dated and were uncovered and exposed to air. Resident #121 said that he/she used the nebulizer machine only occasionally for shortness of breath. Resident #121 said, I let my nurse know and then she helps me set it up. According to the admission Record, Resident #121 was admitted to the facility with a diagnosis that included Chronic Obstructive Pulmonary disease (COPD). The Order Summary Report indicated that Resident #121 had an order for Albuterol Sulfate Nebulization Solution 1.25mg/3ml 1 vial inhale orally via nebulizer every 4 hours as needed for shortness of breath and wheezing with a start date of 2/13/2020. (Albuterol sulfate inhalation solution is a medication used to keep the lung airways open). The Annual MDS (minimum data set) dated April 30, 2019 indicated that Resident #121 had a BIMS (Brief interview for Mental Status) summary score of 15, which indicated Resident #121 with intact cognitive responses On 03/02/20 at 2:22 PM, the surveyor observed Resident # 121 in bed with eyes closed. On the dresser, across the room from the bed and under the television, the surveyor observed a nebulizer with a facemask attached. The nebulizer machine, the mask and the tubing were not dated, and the mask was placed directly on top of the dresser, uncovered and exposed to air. On 03/03/20 at 11:28 AM, the surveyor observed Resident #121 sitting in a wheelchair in his/her room watching TV. The surveyor did not observe a nebulizer treatment machine in the resident's room. The surveyor asked Resident #121 where his/her nebulizer treatment machine was located today. Resident #121 said Oh, I used it a few days ago, it's right here in my bottom drawer. Resident #121 opened the bottom drawer of his/her nightstand and the surveyor observed the nebulizer treatment machine, with tubing wrapped around the facemask and face mask attached to the nebulizer treatment machine. The tubing and face mask were uncovered and lying on top of the residents' personal belongings. On 03/03/20 at 12:36 PM, the surveyor Interviewed the Unit Manager (UM) who said that if residents are on routine and scheduled oxygen and nebulizer treatments, the respiratory equipment, tubing, and facemasks should be labeled, dated, and covered. In addition, the UM said that the respiratory tubing and masks get changed every Friday on the 11:00 AM to 7:30 PM shift. If the resident is on a as needed nebulizer treatment, the respiratory tubing and facemask does not have to be dated and covered. The UM added, because the resident is not always using the respiratory equipment. The surveyor asked the UM for a copy of the facility's policy regarding the care and maintenance of respiratory equipment. The UM stated that he/she will direct the request for a copy of such policy to the Director of Nursing (DON). On 03/03/20 at 2:53 PM, the Director of Nursing (DON) stated to the surveyor that there is no facility policy for management of respiratory equipment. The DON said, We only use standards of care with regard to management of respiratory equipment. The DON also stated that the nursing staff is educated on the storage, labeling, and changes of respiratory equipment. It is part of their orientation skill area. A policy titled, Infection Prevention and Control Program Guidelines 2019-20; on page 67 with subtitle, Oxygen Tubing and Respiratory Products revealed that when all nebulizer tubing and equipment shall be dated and stored in a oxygen bag when not in use and replaced every 7 days. It is the responsibility of both nurse and CNA to ensure that the tubing and oxygen bag are clean, dated and the tubing is stored properly when not in use at all times. N.J.A.C. 8:39-19.4(a) Based on observation, interview and record review, it was determined that the facility failed to adhere to the accepted standards of infection control practices for (a) a resident on contact isolation precautions for Resident #170, 1 of 1 resident's reviewed for infection and (b) proper storage of respiratory equipment for Resident #121, 1 of 4 residents observed for respiratory care. This deficient practice was evidenced by the following: A.) On 02/25/20 at 11:25 AM, the surveyor observed the Licensed Practical Nurse (LPN), at Resident #170's bedside handling the resident's respiratory equipment. During the observation, the LPN was observed wearing gloves but not a gown or mask. When the LPN exited Resident 170's room, she informed the surveyor Resident #170 tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA), a multi drug resistant organism. The LPN said she should have been wearing a gown and stated, She knows better. Situated outside the door of Resident 170's room was a rolling cart containing personal protective equipment (PPE). There was a STOP sign taped to the room number on the wall outside the resident's door, indicating to see the nurse before entering. There was a sign attached to the isolation cart which read, Contact precautions. This sign indicated gloves and a gown should be worn when entering the resident's room. The surveyor attempted to interview Resident #170 but the resident declined to be interviewed. According to the admission Record, Resident #170 was originally admitted to the facility on [DATE] with diagnosis which included chronic respiratory failure, tracheostomy status and carrier or suspected carrier of methicillin resistant staphylococcus aureus. A review of the Order Summary Report revealed Resident #170 was on contact isolation precautions for MRSA in the nares. A review of Resident #170's care plan revealed a focus of MRSA in the sputum with an intervention of contact precautions. A review of hospital interdisciplinary progress notes revealed a critical result communication dated 4/18/19 for positive MRSA of the nares. On 03/02/20 at 11:53 AM, the Certified Nursing Assistant (CNA) told the surveyor Resident #170 was on isolation. The CNA said staff were required to wear a gown and gloves to enter the resident's room and she wears a face mask when giving direct care to the resident. On 03/02/20 at 12:02 PM, the Unit Manager (UM) revealed Resident # 170 was on contact isolation for MRSA in the sputum and the nares. The UM said if a resident is on contact isolation, staff were required to put on a gown and gloves prior to entering the room and a mask when near the resident. The UM said if someone was on contact isolation, There is no reason not to wear personal protective equipment (PPE) prior to entering the room. The UM said the LPN should have put on PPE prior to entering Resident #170's room. On 03/02/20 at 02:38 PM, the DON if staff were touching an isolated resident or the resident's care items, they should wear isolation PPE. The DON confirmed the LPN should have worn PPE when working with Resident #170's nebulizer, because there was, A risk of coming into contact with secretions and or fluids. The policy entitled, Isolation- Categories of Transmission-Based Precautions, revealed a gown and gloves should be worn when entering a room of a resident on contact precautions. The policy further provided MRSA as an example of an infection that required contact precautions.