Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 2 of 5 newly hired licensed staff reviewed (Staff Member #2 and #4). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the employee files of six randomly selected new hire employees for which five of the selected were licensed staff. The surveyor reviewed the facility provided files for the five licensed staff. There was no license verification printout from the corresponding licensing entity to verify the staff license was active prior to or upon their date of hire (doh). However, 3 of the 5 licensed staff had a criminal background check (CBC) that contained a license verification. The following two staff had a CBC but the CBC did not contain information that their license was active prior to or upon their doh: Staff Member #2 (SM #2), a Licensed Practical Nurse/Infection Preventionist, with a doh of 2/7/25, did not have documented evidence that a license verification was performed prior to their doh. Staff Member #4 (SM#4), a Certified Nurses Aide, with a doh 10/22/24, did not have documented evidence that a license verification was performed prior to their doh. On 4/8/25 at 11:07 AM, the surveyor interviewed the Scheduling & Payroll Manager (SPM) regarding the process for new hires and license verification. The SPM stated that she would do a license check and background check. She added that she would get a copy of the license and check it on the website. She would then keep the copy of the license until the criminal background check came back then shred it. She stated that the background check was done prior to the start date. The SPM stated that she verified the licenses but that she did not print it out and keep it in their file. On 4/9/25 at 10:12 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for new hires and license verification. The DON stated that the Human Resources department performed a background check and license verification prior to being hired. She added that the license was checked on the website and it would be printed out for proof and placed in their employee file and that it was done to make sure their license was active and to make sure there was not anything on their license that would be a flag. The surveyor showed the DON the two employee files that did not have evidence of license verification. The DON confirmed that there was no documented evidence that SM #2 and #4's licenses were verified. The facility did not provide any documented evidence that SM #2 and #4's licenses were verified prior to their doh. On 4/9/25 at 12:59 PM, the surveyor notified the LNHA, DON, Clinical Lead of New Jersey (CLoNJ) and Regulatory Compliance Advisor (RCA) the concern that SM #2 and #4 did not have their licenses verified prior to their doh. On 4/10/25 at 11:23 AM, in the presence of DON, CLoNJ and RCA, the LNHA stated that an audit was done with license verification and that the SPM was educated. The LNHA did not provide any additional information. A review of the facility's Abuse Prohibition Policy, with a revised date of 10/24/22, included the following: 3. The Center will screen potential employees for a history of abuse .and checking with the appropriate licensing boards and registries. A review of the facility's HR200 Hiring Policy, with a review date of 7/1/22, included the following: Process 3. Post-Offer, Pre-Hire: 3.1 Internal candidate: 3.1.1 Verify all hiring requirements were obtained, current and appropriate for the new position . 3.2 External candidate: 3.2.1 Verify credentials, licenses, certificates, or other documents required for the position . N.J.A.C. 8:39-43.15(a)

Based on observation, interview, and record review, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman (LTCO) for 1of 1 resident reviewed for hospitalization, Resident #18. This deficient practice was evidenced by the following: On 4/6/25 at 10:43 AM, the surveyor observed the Resident #18 sitting on the wheelchair in the day room, and the resident stated that they were hospitalized before. 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; type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral, complete traumatic amputation of left great toe, subsequent encounter, essential (primary) hypertension. A review of the Quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 9/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. A review of the resident's medical record revealed the resident was transferred to the hospital twice on October 2024 for left toe gangrene and for hypotension (low blood pressure). Further review of the medical records revealed that there was no documented evidence that the LTCO was notified of the resident's transfers to the hospital. On 4/7/25 at 1:29 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), the binder for acute transfer and bed hold policy, and LTCO notifications for 2024. On 4/9/25 at 9:00 AM, the LNHA stated that she spoke to the Social Worker (SW), who stated that she did not know she had to do notifications in 2024, however, she started them in 2025. The binder for the LTCO notification of transfers for 2025 was provided. The facility staff could not provide any documentation to show that the LTCO had been notified of the resident's transfers to the hospital in October of 2024. On 4/9/25 at 9:43 AM, the surveyor interviewed the Director of SW (DSW), who had been working in facility since October 2023. The DSW stated, I will be honest, I do not have the emergency transfer notification, bed hold, bed rates and Ombudsman notifications for 2024, and that the DSW was unaware about the logs until this year. The DSW further stated that If I knew that, I would have done it. On 4/9/25 at 10:40 AM, the surveyor interviewed the Director of Nursing (DON), and the DON stated, In my knowledge, we notify family of transfer, as far as bed hold and rates, the SW does that in my knowledge of it. The DON further stated that LNHA did make us aware either last Sunday or Monday that the bed hold and LTCO notifications for 2024, were not done. The DON also stated that I am aware of the regulations. On 4/9/25 at 1:10 PM, the surveyor notified the LNHA, DON, Regulatory Compliance Advisor, and Clinical Lead of New Jersey regarding above concerns. On 4/10/25 at 8:25 AM, the LNHA confirmed that there was no documented evidence that the LTCO was notified of the resident's acute transfer to hospital on October 2024. A review of the facility's Discharge and Transfer Policy, dated 3/24/25, reflected that the written notice must also be provided to the Ombudsman .using the Notice of Hospital Transfer . NJAC 8:39-4.1(a)31

Based on observation, interview, record review, and policy review, it was determined that the facility failed to notify the resident and/or the resident's representative in writing of the reason for transfer or discharge for 1 of 1 resident transferred to the hospital, Resident #18. This deficient practice was evidenced by the following: On 4/6/25 at 10:43 AM, the surveyor observed the Resident #18 sitting on the wheelchair in the day room. 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; type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral, complete traumatic amputation of left great toe, subsequent encounter, essential (primary) hypertension. A review of the Quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 9/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. A review of the resident's medical record revealed the resident was transferred to the hospital twice on October 2024 for left toe gangrene (It happens when the blood flow to an area of tissue is cut off) and for hypotension (low blood pressure). Further review of the medical records revealed that there was no documented evidence that the bed hold notifications for October 2024 for Resident #18 was done when the resident was transferred to hospital. On 4/7/25 at 1:29 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), the binder for acute transfer and bed hold policy, and notifications for 2024. On 4/9/25 at 9:43 AM, the surveyor interviewed the Director of SW (DSW), who had been working in facility since October 2023. The DSW stated, I will be honest, I do not have the emergency transfer notification, bed hold, bed rates and Ombudsman notifications for 2024, and that the DSW was unaware about the logs until this year. The DSW further stated that If I knew that, I would have done it. On 4/9/25 at 10:01 AM, the surveyor interviewed the [NAME] Wing Unit Manager (UM), who stated that the Director of Nursing (DON), Responsible Party (RP), and the Doctor were notified verbally of the resident's transfer to hospital, and if they were not in the facility, a phone call will be made. The surveyor asked the UM if nursing was giving the written bed hold policy and pay rate to the resident or RP, and the UM responded No, and I do not know anything about that. On 4/9/25 at 10:40 AM, the surveyor interviewed the DON, and the DON stated, In my knowledge, we notify family of transfer, as far as bed hold and rates, the Social Worker does that in my knowledge of it. The DON further stated that LNHA did make us aware either last Sunday or Monday that the bed hold notifications for 2024, were not done. The DON also stated that I am aware of the regulations. On 4/9/25 at 1:10 PM, the surveyor notified the LNHA, DON, Regulatory Compliance Advisor, and Clinical Lead of New Jersey regarding above concerns. The LNHA stated that the Business Office Manager (BOM) was responsible in completing the transfer notifications and bed holds. On 4/9/25 at 1:22 PM, in the presence of the LNHA and Scheduling/Payroll Manager who called the BOM via phone, and the BOM stated, Once the person goes out, I see their insurance, Medicaid is a bed hold, Medicare I discharge out of the system because of their policy. I update the census to where they went. The bed hold notification would be provided if person is private pay, and then scanned in the system in their chart. The surveyor asked what about the other residents with other insurances, and BOM replied, They do not have bed hold days, I believe I am aware of the regulation. The surveyor asked if she knew where Resident #18's bed hold notifications were and she replied that it should be in the resident's medical record. On 4/10/25 at 8:25 AM, the LNHA confirmed that there was no documented evidence that the bed hold notifications and policy was provided in written form to the resident and/or RP on October 2024. The LNHA further stated, Education will be done that notifications will be given regardless of payer. On 4/10/25 at 10:26 AM, the LNHA stated, I will educate the BOM upon her return, regarding bed hold policy for all residents regardless of payer. A review of the facility's Bed-Holds Policy, dated 1/16/23, reflected that when a resident is transferred out .the designee will provide the resident and their representative .with the written Bed Hold Policy Notice and Authorization form regardless of payer. NJAC 8:39-4.1(a)31

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) ensure that the physician orders were followed and orders for blood work was transcribed and followed for 1 of 20 residents, (Resident #59), and b.) adhere to appropriate disposal of unused medication for 1 out of 3 residents, (Resident #65), observed during the medication pass, according to the standard of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 4/6/25 at 9:40 AM, Surveyor #1 (S#1) observed Resident #59 lying on bed with eyes closed. S#1 reviewed the medical records of Resident #59 and revealed: A review of the admission Record (AR, an admission summary) or face sheet reflected that the resident was admitted with diagnoses that included but were not limited to; chronic systolic (congestive) heart failure, type 2 diabetes mellitus with other ophthalmic complication, anemia (low red blood cells count) in chronic kidney disease, and end stage renal disease (a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/5/25, revealed in Section C Cognitive Patterns, a brief interview for mental status (BIMS) score of 14 of 15, which reflected that the resident's cognitive status was intact. A review of the active Physician's Orders (PO) revealed: -start date 7/1/23, Retacrit (generic name epoetin alfa-epbx, medication used to treat anemia) injection solution 10000 unit/ml (milliliters) inject 10000 unit subcutaneously in the evening every Saturday for anemia. CBC (complete blood count, is a commonly ordered blood test used to evaluate one's overall health and detect a wide range of disorders, including anemia and infection) and BMP (basic metabolic panel is a helpful and common test that measures several important aspects of blood, like electrolytes and blood sugar) weekly on Thursday mornings prior to administration of epoetin and please fax results to pharmacy, hold for hgb (hemoglobin, is a protein in red blood cells that carries oxygen. The hgb test measures how much hgb is in the blood. Normal results; Male: 13. 8 to 17. 2 grams per deciliter (g/dL) or 138 to 172 grams per liter (g/L) Female: 12. 1 to 15. 1 g/dL or 121 to 151 g/L Low hgb level may be due to: Anemia) over 10. -start date 10/19/23, A1C (An A1C test measures the average amount of sugar in blood over the past few months) one time a day every three months starting on the 19th for one day for medication (med) regime. -start date 8/21/24, CBC and CMP (comprehensive metabolic panel is a blood test that measures proteins, enzymes, electrolytes, minerals and other substances in the body. A healthcare provider can use the results to diagnose, screen for or monitor health conditions or side effects of medications) every two weeks. 11-7, check for lab (laboratory) slip. 7-3, follow up with result. Every shift every 14 days for anemia. The above PO were plotted in the electronic Medication Administration Record (eMAR) and revealed: -A review of the October 2024 eMAR reflected that on 10/19/24, the order for A1C was left blank. There was no documented evidence that the PO for A1C was followed. -A review of the January 2025 eMAR reflected that on dates 1/4/25, 1/11/25, and 1/18/25, there were check marks and electronically signed by nurses. -A review of the chart codes/follow up codes in the January 2025 eMAR revealed that a check mark meant administered. A review of the Lab Reports revealed that on 12/26/24 collection date, hgb result was 10.3 g/dl and on 1/13/25 collection date, the hgb result was 10.5 g/dl. Further review of the Lab Reports revealed that there was no A1C blood work was done on 10/19/24. On 4/7/25 at 12:18 PM, S#1 interviewed Registered Nurse #1 (RN#1) about the above findings and concerns regarding the order for blood work and epoetin. RN#1 confirmed by checking the lab book that there was no lab done for 10/19/24 for A1C. At that same time, RN#1 reviewed the eMAR for January 2025, and the lab results for CBC specifically for hgb. RN#1 stated that the 1/4/25, 1/11/25, and 1/18/25 epoetin order should have been followed and med should not been administered because the results for hgb were above 10. RN#1 confirmed that the nurses should have held the med. He also confirmed that the check mark on those dates meant that the epoetin was administered. On 4/8/25 at 12:12 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ). S#1 discussed the above concerns for Resident #59. On 4/9/25 at 12:37 PM, the survey team met with the LNHA, DON, CLoNJ and the Regulatory Compliance Advisor (RCA). The LNHA stated that regarding the med epoetin and lab reports, I am going to have a meeting with lab Representative to put a process with routine lab and to see if they can send preprinted routine lab and put them in lab book. The LNHA also stated that an audit will be done. On 4/10/25 at 11:43 AM, the CLoNJ stated that the survey team could proceed with decision making and that there was no additional information. A review of the facility's Lab and Radiology Integration Clinical System Process, dated 6/2024, that was provided by the LNHA, revealed under Guidance/Expectations for Lab/Radiology Order Entry: Lab/Radiology orders will be entered in the electronic medical record . Centers can order one time only labs/rad (radiology) or recurring lab/rad orders (standing orders). Centers must print the lab/rad requisition prior to the lab/rad date and maintain in a folder for the lab/rad practice . A review of the facility's Physician/Advanced Practice Provider (APP) Orders, with a review/revision date of 2/24/25, that was provided by the LNHA, revealed under Policy: Orders will be accepted only from authorized, credentialed physicians/APP or from order authorized credentialed practitioners in accordance with state regulations regarding prescriptive privileges . Purpose: To ensure all physician orders are received from a credentialed practitioner before implementing . On 4/10/25 at 12:02 PM, the survey team met with the LNHA, DON, CLoNJ and RCA for an exit conference, and there was no additional information provided by the LNHA and her team. 2. On 4/8/25 at 9:15 AM, during the medication (med) pass, Surveyor #2 (S#2) observed Registered Nurse #2 (RN#2) assigned to the med cart (med-cart) located on the [NAME] Wing Unit Low side prepare and administer medications (meds) to Resident #65. S#2 observed RN#2 remove a tablet (tab) of Amlodipine (a med used to control blood pressure) 2.5 mg (milligram) from the packaging and dropped it on the surface of the med-cart. RN#2 then stated that they could not give that to the resident as it was contaminated. RN#2 then proceeded to dispose of the tab into the open topped trash receptacle mounted on the side of the med-cart. S#2 asked RN#2 if that was the usual way to dispose of meds, and RN#2 stated, yes, contaminated meds are thrown in the garbage and not given to the resident. S#2 then observed RN#2 prepare another tab for administration to the resident. S#2 completed the med-pass observation of RN#2. S#2 reviewed the medical records for Resident #65 which revealed the following: A review of Order Summary Report (OSR) and an eMAR that reflected a PO for Amlodipine 2.5 mg to be given at 9:00 AM. A review of AR reflected that Resident #65 was admitted with diagnoses of, but not limited to, essential hypertension (high blood pressure) and type 2 diabetes (a chronic condition when the body cannot use insulin effectively). A review of Resident #65's quarterly MDS, with an ARD of 3/13/25, reflected, in Section C, that the resident had a BIMS score of 15 out of 15, which indicated that Resident #65 was cognitively intact. On 4/8/25 at 12:14 PM, the survey team met with the DON, LNHA, and CLoNJ to discuss the above concerns with med disposal. S#2 asked if it was common practice to dispose of meds that were not taken by a resident in the open trash container mounted on the side of the cart. The DON and CLoNJ both stated, no, they should be disposed in the (name redacted) (drug disposal system). S#2 asked if meds placed in the open trash could potentially be accessed by another resident or other unauthorized person. The DON stated yes, it could be possible. On 4/9/25 at 10:18 AM, S#2 interviewed the facility Consultant Pharmacist (CP) by telephone. S#2 discussed the concerns with the med pass observation including disposal of unused meds. S#2 asked the CP if any education was done for the nursing staff on med pass, specifically med disposal, and the CP stated that any education was usually done one on one with staff at the med-cart, none done as a class, and nothing referencing disposal of unused med. The CP also stated that it was standard practice to use a self-contained drug disposal system (name redacted) to safely dispose of meds. On 4/9/25 at 12:38 PM, the survey team met with the LNHA, DON and CLoNJ, and the DON stated that (name redacted) approved self-contained drug disposal systems were placed in all med-carts and staff education was conducted for proper disposal of meds. A review of the facility's Disposal of Medications Policy, dated 1/24, reflected, under POLICY, 3. Methods of disposition of pharmaceutical hazardous and non-hazardous waste are consistent with applicable state and federal requirements, local ordinances, and standards of practice. Under PROCEDURES, 1.b. Authorized personnel who have access to meds should deposit pharmaceutical waste in the appropriately labeled container. The facility did not provide any further pertinent information on med disposal. NJAC 8:39-11.2(b); 27.1(a); 29.2(a)(d); 29.4(g)(h)(i)

Complaint NJ #184234 Based on interview, observation, and record review, it was determined the facility failed to; a.) update a resident's discharge goals based on the resident's representative (RR) wishes, b.) hold an interdisciplinary care plan meeting to collaborate with the RR on an updated discharge planning process, c.) and document in the electronic medical record , for 1 of 2 residents, (Resident #9), reviewed for discharge planning. This deficient practice was evidenced by the following: On 4/7/25 at 9:25 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #9. A review of the admission Record (or face sheet, an admission summary) documented that the resident had diagnoses that included but were not limited to, dementia, and adult failure to thrive (a decline in overall health and well-being in older adults). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/13/25, revealed a Brief Interview for Mental Status (BIMS) score of 99, which reflected the resident was unable to complete the interview. A review of the physician's progress note (PN) dated 3/27/25, by the primary physician indicated the RR wanted the resident to be transferred to an assisted living facility. A review of other PN and assessments including care plan (CP) meeting notes from January to April 2025, revealed, no additional documentation of the RR's desire for Resident #9 to be referred for discharge (d/c) to another facility. On 4/7/25 at 9:42 AM, the surveyor spoke with Resident #9's RR over the phone, who stated they wanted the resident to be referred to another facility for transfer since February 2025. The RR stated there was paperwork that needed to be completed by the facility which was not done until recently. The RR stated they came to the facility and spoke with the Admissions Director (AD) on several occasions for the required paperwork to be completed. The RR stated that they had not discussed with any other facility staff and only dealt with the AD. The RR further explained that a representative from the referred facility attempted to contact the facility for requested paperwork and received no response. On 4/7/25 at 11:49 AM, the surveyor observed Resident #9 sitting in a chair in the day room for an activity. The resident was alert, verbally responsive, and pleasantly conversant with the recreational aide. On 4/8/25 at 11:26 AM, the surveyor interviewed the AD who stated the Social Worker (SW) was responsible for following up on a resident and/or RR request to be referred to another facility. The AD stated it would be expected for the facility to follow up as soon as they were notified of a resident and/or RR request for referral to another facility. At that same time, the surveyor asked the AD about Resident #9. The AD stated that they recently submitted via fax requested paperwork for Resident #9 to another facility as requested by the RR. The AD provided the faxed documentation which was dated 4/4/25. The AD stated he could not recall when the RR first verbalized their wishes for the resident to be referred for transfer to another facility and stated the SW would have additional information. On 4/8/25 at 11:34 AM, the surveyor interviewed the SW who stated the RR spoke with the AD when visiting the facility and did not come to her. The SW stated she was first made aware by the AD that the RR was requesting Resident #9 to be referred for d/c to another facility in mid-March 2025, and that was when she approached the RR. The SW stated at the time that RR verbalized their wish to refer the resident to be transferred to another facility and specified an assisted living facility they were interested in. The SW stated she was not aware of when the RR had previously verbalized their wish for the resident to be referred for transfer to another facility. On that same date and time, the surveyor asked the SW after she spoke with the RR if she followed up with their wishes for a referral to another facility. The SW stated that she did not follow up. The SW stated that Resident #9 required a higher level of care than what could be provided at an assisted living facility and did not think the resident would be approved. The SW stated a representative for the other facility did come to the facility, she cannot recall when, she spoke with them, and they did not request any paperwork. The SW stated she believed the resident would not be accepted into the facility. The SW stated she did not document in the EMR when she spoke with the RR in mid-March 2025, and there was no documentation regarding their verbalized wishes for Resident #9 to be referred for transfer. The SW acknowledged that she did not follow up regarding the RR's wishes and an interdisciplinary (IDT) CP meeting was not held with the RR to further discuss a d/c plan of care for Resident #9. On 4/8/25 at 12:14 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Clinical Lead of New Jersey (CLoNJ) about the concern for Resident #9's RR requesting for the resident to be referred to another facility with no documentation or follow up. The surveyor asked what the facility's protocol was for when a RR requested for a resident to be referred to another facility. The DON stated that once a RR expressed and decided on a facility for a resident to be referred, the SW would follow up with the other facility and collaborate with that facility to provide the needed paperwork. On 4/9/25 at 12:37 PM, the LNHA, the DON, the CLoNJ, and the Regulatory Compliance Advisor (RCA) met with the survey team. There was no additional information provided by the facility. The surveyor asked what the process for d/c was if a resident requested to be transferred to another facility. The LNHA stated the physician, the SW, the business office, and the IDT would be notified to work with the resident/RR and the referred facility. The LNHA acknowledged it would also be expected for it to be documented in the EMR regarding a resident and/or RR wishes and update the plan of care. A review of the facility's Person-Centered Care Plan Policy, with a last revised date of 10/24/22, under Purpose revealed: .To promote positive communication between patient, patient representative, and team to obtain the patient's and RR input into the plan of care, ensure effective communication, and optimize clinical outcomes . A review of the facility's Discharge Planning Process Policy, with a last revised date of 11/15/22, under Policy revealed: The Center's d/c planning process must be consistent with the patient's discharge rights. Under Process of the policy revealed: . 1. The interprofessional care team will use the d/c planning process to: 1.1 Identify d/c needs and develop a d/c plan to meet those needs . 1.4 Involve the patient and RR to establish goals of care and treatment preferences . 1.7 Provide ongoing support, encouragement, and education to patients and patient representatives, and families from admission through d/c from the Center . 1.8.2 If the patient indicates an interest in returning to the community, the Center must document any referrals to local contact agencies or other appropriate entities made for this purpose . 1.8.4 If d/c to the community is determined to not be feasible, the Center must document who made the determination and why . NJAC 8:39-4.1; 27.1 (a); 46.6 (b)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents by following the physician orders and b.) verify the duplicate order for one 1 of 1 resident, (Resident #39), reviewed for respiratory care, in accordance with professional standards of practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 4/6/25 at 9:45 AM, the surveyor observed Resident #39 lying on bed, with head of bed elevated, on oxygen (O2) 2 LPM (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) via concentrator (a device that supply an O2) with tubing dated 3/31/25. A review of the admission Record (an admission summary) or face sheet revealed diagnoses which included but not limited to; encephalopathy (refers to brain disease, damage, or malfunction) unspecified, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/18/25, revealed in Section C Cognitive Patterns the cognitive skills for daily decision making was coded 3, which reflected that the resident's cognition was severely impaired. A review of the April 2025 electronic Medication Administration Record (eMAR) revealed the following active Physician's Orders (PO): -start date 3/21/25, O2 PRN (as needed) at 1 LPM via N/C to maintain sats (saturation is a measure of how much O2 is in the blood. For healthy adults, a normal O2 sats level is between 95% and 100%), if sats are less than 92% PRN post treatment (tx): evaluate heart rate (HR), respiratory rate (RR), pulse oximetry, skin color, and breath sounds. -start date 3/21/25, O2 PRN at 1 LPM via N/C to maintain sats if sats are less than 92% every shift. Further review of the above April 2025 eMAR revealed that there were duplicate PO for O2 PRN. The above PO for O2 PRN that included monitoring of HR, RR, pulse oximetry, skin color, and breath sounds were blank. Furthermore, the above PO for O2 PRN every shift monitoring was not followed as evidenced by the following O2 sats and O2 at 1 LPM was administered: On 4/1, 4/2, 4/3, 4/5, and 4/6/25, Day Shift (7:00 AM - 3:00 PM) O2 sats were above 92%. On 4/1, 4/2, 4/3, 4/4, 4/5, and 4/6/25, Evening Shift (3:00 PM - 11:00 PM) sats were above 92%. On 4/1, 4/2, 4/3, 4/4, 4/5, and 4/6/25, Night Shift (11:00 PM - 7:00 AM) sats were above 92%. A review of the medical records revealed that there was no documented evidence as to why the PRN O2 was administered beyond the parameters and did not follow the PO. On 4/7/25 at 12:08 PM, both the surveyor and the Registered Nurse (RN) observed the resident seated in a wheelchair with other residents in the dayroom with no O2 in use. Afterward, both the surveyor and the RN went to resident's room, and the RN informed the surveyor that the resident's O2 was a PRN order. The RN stated that nurses had to check O2 sats every shift and verify the order when to administer the O2. He further stated, usually when O2 sats was low, it should be documented in the eMAR. On 4/7/25 at 12:26 PM, the surveyor notified the RN of the above findings and concerns with regard to the duplicate order for O2 PRN and not following the PO for PRN O2. The surveyor also notified the RN of the observation that the resident was on 2 LPM during the 1st day of tour on 4/6/25. The RN stated that the nurse should have been followed the order for 1 LPM and that the order to document if the resident's 02 was below 92% prior to administering the O2. He further stated that the blanks should have been filled out with O2 saturation. The RN stated that the PO should have been followed and the nurse should clarify the duplicate orders. On 4/8/25 at 12:12 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ), and the surveyor discussed above concerns and findings with Resident #39's PRN O2 duplicate orders and not following the PO. On 4/9/25 at 12:37 PM, the survey team met with the LNHA, DON, CLoNJ, and Regulatory Compliance Advisor (RCA). The LNHA stated, we started an audit to ensure the O2 was matching the eMAR. The CLoNJ stated we did an audit on PRN O2 orders. At that same time, the surveyor asked about the concerns with double entry for PO PRN O2 and as to why the PO was not followed, the LNHA and the DON did not respond. On 4/10/25 at 11:43 AM, the CLoNJ stated that the survey team could proceed with decision making and that there was no additional information. A review of the facility's Oxygen: High Pressure Cylinders Policy, with a review/revision date of 12/16/24, that was provided by the LNHA, revealed under policy that high pressure cylinders are set up a licensed nurse, respiratory therapist, or rehabilitation therapist with a physician's/advanced practice provider's order . On 4/10/25 at 12:02 PM, the survey team met with the LNHA, DON, CLoNJ and RCA for an exit conference, and there was no additional information provided by the LNHA and her team. NJAC 8:39-27(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report was accurately posted and in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: On 4/6/25 at 9:00 AM, the surveyor entered the facility. The surveyor observed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted on the table across from the receptionist desk was dated 4/3/25, day shift. The NHRCSR was not up to date. On 4/8/25 at 12:31 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Clinical Lead of New Jersey(CLoNJ) the concern that the staffing report that was posted and observed on 4/6/25 was dated 4/3/25, and was not up to date. The LNHA stated that it should be posted every day. On 4/9/25 at 9:44 AM, the surveyor interviewed the Scheduling & Payroll Manager (SPM) regarding posting of the NHRCSR. The SPM stated that she would print out the NHRCSR and post it in the morning. She added that the later shifts were behind the day shift. The surveyor asked who was responsible for posting it when she was not at the facility. The SPM stated that prior to the new LNHA starting she posted it on the weekend but that now she only worked Monday through Friday and did not know who posted it on the days she was not at the facility. On 4/9/25 at 12:55 PM, in the presence of the DON, CLoNJ, and Regulatory Compliance Advisor, the LNHA stated that the Receptionist would post the report on the weekend and that staff were educated. The LNHA did not provide any additional information. A review of the facility's Posting Staffing Policy, with a review date of 8/7/23, included the following: Policy In accordance with federal and state regulations, Centers will post the census, shift hours, number of staff and total actual hours worked by licensed and unlicensed nursing staff who are directly responsible for patient care for each shift and on a daily basis. Process 1. The DON or designee will post the number of staff and actual hours worked of nursing staff directly responsible for the care of patients 2. The posting should include the: 2.1 Center name; 2.2 Current date; 2.3 Patient census at the beginning of each shift; 2.4 Center specific shifts . 3. The posting should be: . 3.3 Completed on a daily basis at the beginning of each shift; . N.J.A.C. 8:39-41.2 (a)(b)(c)

NJ#176708 Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate accountability of controlled substances, have sufficient secure procedures in place to prevent further diversion of controlled substances, and to educate all staff on accountability procedures for controlled substances. This deficient practice was identified for 1 of 2 years of controlled substances accountability reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/7/25 at 11:42 AM, the surveyor reviewed the contents of the facility provided binder containing completed DEA 222 forms (forms from the Drug Enforcement Agency that are used to order Schedule II controlled substances from the provider pharmacy). The binder revealed completed DEA 222 forms with the most recent date of 5/30/24. On 4/9/25 at 10:18 AM, the surveyor interviewed the facility Consultant Pharmacist (CP) by telephone. The CP stated that they have been servicing the facility since 2022. The surveyor asked the CP what procedures they do regarding controlled substance accountability. The CP stated that they do monthly audits at the medication carts (med-cart) and compare the count of controlled substance medications present in the cart to the count sheet (a form that tracks each time a dose was removed from the med-cart), to check for discrepancies. The surveyor asked if the CP audits the DEA 222 forms. The CP stated no, not unless they are asked to. On that same date and time, the surveyor asked the CP if they knew that there were no records of DEA 222 forms since 5/30/24, and if that was of any concern. The CP stated that they were not aware and that it was unusual. The surveyor asked the CP if they were aware of a controlled substance diversion issue that was discovered on April 2024, and the CP stated yes, they were aware that something occurred with a nurse removing controlled substances. The surveyor asked the CP if they were aware of or assisted in any plans or procedures put in place to prevent diversion of controlled substances. The CP stated, no, they were not aware of any other plans or procedure put in place. On 4/9/25 at 10:49 AM, the surveyor interviewed the Director of Nursing (DON) regarding the requested 4/2/24 documents regarding the facility reported incident of drug diversion and what the facility implemented to prevent recurrence of the incident. The DON stated that she was not fully familiar with what occurred as she only started at the facility February 2025, but will find out. The surveyor asked if there were any further records of DEA 222 forms after 5/30/24 and if there were any records of 4/2/24 pertaining to the controlled substance diversion including, but not limited to, investigations, reports, inventories, interventions, plans of correction, education, or policies and procedures. On 4/9/25 at 11:30 AM, the DON stated to the surveyor that they were unable to provide any further DEA 222 forms for the period after 5/30/24, and she was in process of obtaining more for the facility. The DON also stated that they would look for any other investigative documents for the diversion and it there were any corrective plans put in place. On 4/9/25 at 12:30 PM, the DON provided copies of an educational in-service sign in sheet and Action Plan (AP) from 4/3/24, referencing the incident. The DON also provided copies of investigations and employee statements that were previously provided with the original Facility Reported Event (FRE) on 4/2/24. The surveyor reviewed the documents provided by the DON. The AP did not reflect any conclusions or preventive actions put in place. The in-service sign in sheet reflected the names of ten employees of the nursing department. The surveyor reviewed the investigative documents for the FRE. The documents revealed that the initial investigation was performed and appropriate reporting to the required agencies was done. The documents included a statement from the employee involved that reflected a statement of apology for a mistake and unprofessionalism. On 4/9/25 at 1:53 PM, the survey team met with the DON to discuss concerns with controlled substance accountability. The surveyor asked the DON what the process was for current controlled substances (CDS) when they were discontinued or the resident was discharged (d/c), The DON stated that if the CDS was completed, the count sheet was placed in the resident's hard copy chart for medical records. If the CDS was discontinued or resident d/c, the CDS will be destroyed by the DON and another nurse and there will be a log to document it. The DON stated she was not sure what the previous process was. On the same date and time, the surveyor interviewed the Unit Manager (UM) who was present at the time of the FRE. The surveyor asked the UM what the process was for removing CDS. The UM stated that the DON and floor nurse would reconcile the amount of CDS from the count sheet and then destroy the remaining CDS. The UM also confirmed that the not all nurses signed the in service sign in sheets. The UM acknowledged that all nurses should have been signed the in service sign in sheets for drug diversion. On 4/9/25 at 2:15 PM, the DON provided CDS count sheets showing signatures indicating removal and destruction. The surveyor reviewed the sheets which reflected only the years 2022 and 2023. The DON confirmed there were no count sheets available for 2024. The DON also confirmed, based on the education sign in sheet that not all the nurses were educated on correct disposal of CDS. On 4/10/25 at 11:24 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, The Clinical Lead of New Jersey (CLoNJ), and Regulatory Advisor (RA) to discuss the above concerns with the lack of staff education on CDS diversion prevention and lack of a specific plan to prevent further diversion prior to surveyor's inquiry. A review of the facility's Controlled Drugs: Management of Policy, with a revision date of 1/31/25, reflected, Centers will upload Controlled Substance Declining Inventory Sheets to the patient medical record upon discontinuing of the medication, d/c, or completion. The facility did not provide any further pertinent information. NJAC 8:39-29.7(c)

Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 3 residents, (Resident #62), during the medication pass observation. This deficient practice was evidenced by the following: On 4/8/25 at 9:31 AM, the surveyor observed the Licensed Practical Nurse (LPN) assigned to the medication cart (med-cart) located on the East Wing Unit, High Side, prepare and administer due medications (meds) to Resident #62. The surveyor observed the LPN prepare and administer Linzess (a medication (med) used to treat irritable bowel syndrome with constipation). The med was scheduled to be given at 9:00 AM per the physician's orders (PO) and the LPN was within the accepted time based on the order. The surveyor observed on the Linzess med container labeling that reflected to take on an empty stomach. The surveyor asked the LPN about the labeling. The LPN stated they noticed it and was going to call the physician to ask about it. The surveyor concluded the med-pass. The surveyor reviewed the electronic medical record for Resident #62. A review of Resident #62's admission Record (or facesheet, an admission summary) reflected that the resident was re-admitted to the facility with diagnoses of, but not limited to, essential hypertension (high blood pressure) and type 2 diabetes (a chronic condition when the body cannot use insulin effectively). A review of Resident #62's comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/11/25, reflected, in Section C Cognitive Patterns, that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #62 was cognitively intact. Section H Bowel and Bladder, revealed that the resident was occasionally incontinent of bowel and did not have constipation. A review of the resident's Order Summary Report (OSR, a listing of the resident's active meds and other orders) revealed the following: An order for Linzess Oral Capsule 145 mcg (microgram) Give 1 capsule by mouth one time a day for chronic constipation, with a start date of 10/22/24. A review of the resident's electronic medication administration record (eMAR) revealed that the order for Linzess was scheduled for administration at the 9:00 AM administration period. A review of the CP report, revealed that the CP did document that the resident's chart was reviewed for the period of October 2024 through present, and did not reflect any irregularities with the Linzess orders or the time Linzess was scheduled. On 4/8/25 at 12:14 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Clinical Lead of New Jersey (CLoNJ) to provide concerns observed during the med-pass, specifically the timing of Linzess and the lack of documentation of this irregularity by the CP. On 4/9/25 at 10:18 AM, the surveyor interviewed the CP by telephone. The surveyor asked the CP if they were familiar with Linzess. The CP stated, yes, they were. The surveyor asked the CP if they were familiar with the administration of Linzess regarding timing and food. The CP stated that it should be given in the morning, but they would have to check the information regarding food. On 4/9/25 at 12:38 PM the survey team met with the LNHA, DON, CLoNJ and Regulatory Compliance Advisor (RCA). The LNHA stated that the administration time for the Linzess was changed to be given at least 30 minutes before breakfast and the staff was educated on administration of meds according to manufacturer guidelines. A review of the facility's Disposal of Medications Policy, dated 1/24, reflected under Procedures: 1. The DON and the CP will monitor for compliance with federal and state laws regarding the disposal of meds. A review of the facility's Medication Administration Policy, dated 1/25, reflected under Policy: Meds are administered as prescribed in accordance with manufacturers' specifications, . Procedures, Medication Administration: 3. Med administration timing parameters include the following: a. Meds to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. A review of the manufacturer package insert for Linzess, reflected under 2 DOSAGE AND ADMINISTRATION, 2.2 Preparation and Administration Instructions, Take LINZESS on an empty stomach, at least 30 minutes prior to a meal, at approximately the same time each day. The facility did not provide any further pertinent information for this concern. NJAC 8:39-29.3(a)(1)

Based on interview and record review, it was determined that the facility failed to a.) assure that the required staff attended the quarterly Quality Assurance (QA) meetings for 2 of 4 quarterly QA meetings and b.) ensure there was a scheduled frequency of meetings and reporting according to the regulation and facility's policy. This deficient practice was evidenced by the following: On 4/8/25 at 3:09 PM, the surveyor reviewed the QAPI (Quality Assurance Performance Improvement) Plan, dated 1/1/25, and the Center Quality Assurance Performance Improvement Process Policy that was provided by Licensed Nursing Home Administrator #1 (LNHA#1) on 4/7/25 at 8:20 AM, and revealed that the facility QAPI members will meet at least quarterly. The LNHA also provided the QAPI sign in sheets and revealed: 7/24/24=10 attendees signed and did not include their titles. 8/22/24=nine attendees signed and did not include their titles. 9/25/24=12 attendees signed and did not include their titles. 10/29/24=11 attendees signed and did not include their titles. 11/26/24=11 attendees signed and did not include their titles except for LNHA#2. 12/12/24=12 attendees signed and did not include their titles except for the LNHA#2. 2/28/25=11 attendees signed and did not include their titles except for LNHA#1, Director of Nursing (DON), Infection Preventionist (IP), Social Services (SS), and Minimum Data Set Coordinator (MDSC). 3/26/25=six attendees signed and did not include their titles except for LNHA#1, DON, Medical Director (MD), IP, Unit Manager (UM), and Clinical Lead of New Jersey (CLoNJ). Further review of the above sign in sheets for QAPI revealed that there was no QAPI sign in sheet for January 2025 and that on all meetings the MD was present. On 4/9/25 at 11:19 AM, the surveyor interviewed the CLoNJ regarding the QAPI sign in sheets. The CLoNJ confirmed after reviewing the sign in sheets that on 10/29/24, 11/26/24, and 12/12/24, QAPI sign in sheets, there was no DON present. The CLoNJ stated that the IP was the covering DON at that time, and the CLoNJ was the covering IP. The CLoNJ acknowledged that she did not sign on 10/29/24 and 11/26/24 QAPI sign in sheets. On that same date and time, the surveyor asked the CLoNJ if she was aware of the regulation that the IP must physically work onsite in the facility, cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility, and the CLoNJ responded that she was unaware of that. The surveyor notified the CLoNJ of the concern that the facility had no January 2025 QAPI sign in sheets. On 4/10/25 at 8:50 AM, the surveyor asked LNHA#1 why the only provided QAPI Meeting Schedule was for 2025 when the surveyor asked for the planned QAPI Meeting Schedules for 2023, 2024, and 2025, and LNHA#1 responded that she did not find any schedule for 2023 and 2024. She further stated that the 2023 and 2024 quarterly schedule should be the same with 2025 schedule provided to the surveyor. LNHA#1 also stated that there was no January 2025 quarterly QAPI schedule because she was not the Administrator at that time. A review of the provided 2025 QAPI Meeting Schedule for 2025 revealed: All Meetings start at 9:30 AM January 2025 (no schedule provided) 4/22/25 (Quarterly) 7/17/25 (Quarterly) 10/16/25 (Quarterly) On 4/10/25 at 9:39 AM, the surveyor met with LNHA#1 for QAPI meeting, and the surveyor notified LNHA#1 of the above findings and concerns. LNHA#1 stated that the 2025 QAPI Meeting Schedule should be the same schedule that the facility should follow as scheduled for January, April, July, and October respectively for a quarterly meetings. She also acknowledged that there should be a planned quarterly QAPI meeting schedule. A review of the undated facility's Center Quality Assurance Performance Improvement Process Policy, that was provided by LNHA#1, revealed: Process: 1. The Administrator, along with the DON, directs the development and documentation of the Center QAPI Plan .and effectively Quality Assessment and Assurance (QAA) Committee. 2. The QAA Committee: 2.1 Functions under the authority of the Administrator and the Governing Body and is composed of: 2.1.1 Administrator, 2.1.2 DON, 2.1.3 MD, 2.1.4 IP, or designee, 2.1.5 Consultant Pharmacist (recommended), 2.1.6 Patient and/or family representatives (if appropriate), 2.1.7 Three additional staff representatives including, but not limited to, department heads, certified nursing assistants, rehabilitation services, hospice, home health, etc. 2.2 Meets at least quarterly. On 4/10/25 at 12:02 PM, the survey team met with the LNHA, DON, CLoNJ and Regulatory Compliance Advisor for an exit conference, and there was no additional information provided by the LNHA and her team. N.J.A.C. 8:39-33.1(a)(b)

Based on observation, interview, and record review, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 3/11/25, indicated a Brief Interview for Mental Status (BIMS) test was not completed as the resident was documented as being rarely/never understood. Section O of the MDS indicated the resident's pneumococcal vaccination was up to date. A review of the immunizations listed in the EMR revealed documentation for a pneumovax dose which indicated the resident refused. Additional review revealed the refusal was documented on 4/23/24. On 4/9/25 at 11:36 AM, the surveyor reviewed the hard copy chart of Resident #57, which revealed there was no documentation of administration or declination for the pneumococcal vaccine. On 4/9/25 at 11:46 AM, the surveyor interviewed the Infection Preventionist (IP), who stated she was responsible for assessing and reviewing the residents' immunizations. The IP explained she would review the state online database for resident's vaccination records and asked residents and/or the resident's representative (RR) about vaccination status upon admission. The IP stated vaccines would be offered to residents if they wished to receive them. An informed consent form would be signed if the resident desired or declined a vaccine. The IP stated immunizations would be documented under the immunizations section of the EMR. The surveyor asked the IP about Resident #57's pneumococcal vaccination documentation and history. The IP stated Resident #57 was newly admitted to the facility in March 2025, and had previous stays at the facility. The IP stated it was previously documented in the EMR that the pneumococcal vaccine had been previously refused. The IP confirmed the documentation was from the resident's previous stay in 2024. The IP stated that she did not discuss with the resident and/or RR to offer the pneumococcal vaccine upon admission. The IP was not sure if it was part of the facility policy to offer a vaccine to every resident upon a new admission, even if they had documentation from a previous stay at the facility. The IP stated she would have to follow up about the process and that if it's something she should be doing, then she would. On 4/9/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Clinical Lead of New Jersey (CLoNJ), and the Regulatory Compliance Advisor (RCA). The surveyor asked if it would be expected for staff to assess a resident who were newly admitted for immunizations and for them to be offered an opportunity to receive a vaccine, whether they had a previous stay or not. The DON replied Yes. The surveyor notified the facility's management of the concern that the resident was not offered a pneumococcal vaccine. On 4/10/25 at 11:22 AM, the LNHA, the DON, the CLoNJ, and the RCA met with the survey team. The DON stated that the IP was doing an audit on all resident to review immunizations and ensure up to date documentation of their refusal or consent for vaccination. There was no additional information provided by the facility. A review of the facility's Pneumococcal Vaccine Policy, with a last revised date of 9/13/24, under Process revealed: . 1. Upon admission, obtain the pneumococcal vaccination history of all patients . 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule . N.J.A.C. 8:39-19.4 (i)

Based on interview and record review, it was determined that the facility failed to offer a resident a coronavirus-19 (COVID-19) vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 3/11/25, indicated a Brief Interview for Mental Status (BIMS) test was not completed as the resident was documented as being rarely/never understood. Section O of the MDS did not indicate if the resident was up to date or not with the COVID-19 vaccine. A review of the immunizations listed in the EMR revealed documentation for a COVID-19 booster 2023-2024, dose which indicated the resident refused. Additional review revealed the refusal was dated 4/23/24. On 4/9/25 at 11:36 AM, the surveyor reviewed the hard copy chart which revealed there was no documentation of administration or declination for the COVID-19 booster vaccine. On 4/9/25 at 11:46 AM, the surveyor interviewed the Infection Preventionist (IP), who stated she was responsible for assessing and reviewing the residents' immunizations. The IP explained she would review the state online database for resident's vaccination records and asked residents and/or the resident's representative (RR) about vaccination status upon admission. The IP stated vaccines would be offered to residents if they wished to receive them. An informed consent form would be signed if the resident desired or declined a vaccine. The IP stated immunizations would be documented under the immunizations section of the EMR. The surveyor asked the IP about Resident #57's COVID-19 vaccination documentation and history. The IP stated Resident #57 was newly admitted to the facility in March 2025 and had previous stays at the facility. The IP stated Resident #57 was newly admitted to the facility in March 2025 and had previous stays at the facility. The IP stated it was previously documented in the EMR that the COVID-19 booster vaccine had been previously refused. The IP confirmed the documentation was from the resident's previous stay in 2024. The IP stated that she did not discuss with the resident and/or RR to offer the COVID-19 booster vaccine upon admission. The IP was not sure if it was part of the facility policy to offer a vaccine to every resident upon a new admission, even if they had documentation from a previous stay at the facility. The IP stated she would have to follow up about the process and that if it's something she should be doing, then she would. On 4/9/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Clinical Lead of New Jersey (CLoNJ), and the Regulatory Compliance Advisor (RCA). The surveyor asked if it would be expected for staff to assess a resident who were newly admitted for immunizations and to be offered an opportunity to receive a vaccine, whether they had a previous stay or not. The DON replied Yes. The surveyor informed the facility's management of the concern that the resident was not offered a COVID-19 booster vaccine. On 4/10/25 at 11:22 AM, the LNHA, the DON, the CLoNJ, and the RCA met with the survey team. The DON stated that the IP was doing an audit on all residents to review immunizations and ensure up to date documentation of their refusal or consent for vaccination. There was no additional information provided by the facility. A review of the undated facility's COVID-19 Vaccination Policy, under Policy revealed: . 1. The facility will offer the COVID-19 Vaccine to our healthcare workers and the residents as soon as it becomes available . 2. Consents for vaccination must be obtained, If the vaccine is refused, a declination must be signed . The policy did not further address offering of COVID-19 booster doses. N.J.A.C. 8:39-5.1(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that included effective communications for 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire. On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript Report for the five CNAs with the date range of April 9, 2024 to April 8, 2025. The reports were not based on the annual year from each CNAs date of hire (doh). A review of the facility provide Transcripts included the following: CNA #1, with a doh of 2/18/19, did not have effective communications training. CNA #4, with a doh of 2/5/24, did not have effective communications training. CNA #5, with a doh of 11/26/25, did not have effective communications training. On 4/8/25 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process for education. The DON stated that the company had a process for yearly mandatory education and a calendar provided and followed. The DON stated that some education was done in the electronic system, skills fair and inservices. She added that the tracking was in the electronic system. On 4/9/25 at 11:01 AM, the IP/E/LPN and Clinical Lead of New Jersey (CLoNJ) confirmed that they could not locate any additional inservice sign in sheets that the CNAs may have attended that were not entered into the electronic system. On 4/9/25 at 1:03 PM, the surveyor notified the LNHA, DON, CLoNJ and Regulatory Compliance Advisor (RCA) the concern that CNA #1, #4, and #5 did not have effective communications training. On 4/10/25 at 11:25 AM, in the presence of DON, CLoNJ, and RCA, the LNHA stated that the IP/E/LPN received education to ensure that CNAs receive annual education which included the mandatory topics. The LNHA did not provide any additional information. A review of the facility's In-service Training Policy, with a review date of 7/1/22, included the following: Policy .[Facility] will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. In-service training programs are planned and conducted to develop and improve the skills of all personnel in accordance with federal and state law, in accordance with the facility assessment, and consistent with the staff members' expected roles. All mandatory in-service training content is located on the learning management system and is supported by various policies and procedures. Employee's training completion will be tracked via a transcript which is located within the learning management system. Other in-service training and competency results completed outside of the learning management system will be stored in the employee's personnel file. Process .2. Training topics include, but are not limited to, the following: 2.1 Effective communication; N.J.A.C. 8:39-13.4

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that included rights of the resident and the responsibilities of a facility to properly care for its residents for 2 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript Report for the five CNAs with the date range of April 9, 2024 to April 8, 2025. The reports were not based on the annual year from each CNAs doh. A review of the facility provide Transcripts included the following: CNA #4, with a doh of 2/5/24, did not have resident's rights training. CNA #5, with a doh of 11/26/25, did not have resident's rights training. On 4/8/25 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process for education. The DON stated that the company had a process for yearly mandatory education and a calendar provided and followed. The DON stated that some education was done in the electronic system, skills fair and inservices. She added that the tracking was in the electronic system. On 4/9/25 at 11:01 AM, the IP/E/LPN and Clinical Lead of New Jersey (CLoNJ) confirmed that they could not locate any additional inservice sign in sheets that the CNAs may have attended that were not entered into the electronic system. On 4/9/25 at 1:03 PM, the surveyor notified the LNHA, DON, CLoNJ and Regulatory Compliance Advisor (RCA) the concern that CNA #4 and #5 did not have resident's rights training. On 4/10/25 at 11:25 AM, in the presence of DON, CLoNJ and RCA, the LNHA stated that the IP/E/LPN received education to ensure that CNAs receive annual education which included the mandatory topics. A review of the facility's In-service Training Policy, with a review date of 7/1/22, included the following: Policy .[Facility] will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. In-service training programs are planned and conducted to develop and improve the skills of all personnel in accordance with federal and state law, in accordance with the facility assessment, and consistent with the staff members' expected roles. All mandatory in-service training content is located on the learning management system and is supported by various policies and procedures. Employee's training completion will be tracked via a transcript which is located within the learning management system. Other in-service training and competency results completed outside of the learning management system will be stored in the employee's personnel file. Process .2. Training topics include, but are not limited to, the following: . 2.2 Resident's rights and facility responsibility for proper care of residents; . N.J.A.C. 8:39-13.4 (c)3

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript Report for the five CNAs with the date range of April 9, 2024 to April 8, 2025. The reports were not based on the annual year from each CNAs doh. A review of the facility provide Transcripts included the following: CNA #1, with a doh of 2/18/19, did not have QAPI training. CNA #4, with a doh of 2/5/24, did not have QAPI training. CNA #5, with a doh of 11/26/25, did not have QAPI training. On 4/8/25 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process for education. The DON stated that the company had a process for yearly mandatory education and a calendar provided and followed. The DON stated that some education was done in the electronic system, skills fair and inservices. She added that the tracking was in the electronic system. On 4/9/25 at 11:01 AM, the IP/E/LPN and Clinical Lead of New Jersey (CLoNJ) confirmed that they could not locate any additional inservice sign in sheets that the CNAs may have attended that were not entered into the electronic system. On 4/9/25 at 1:03 PM, the surveyor notified the LNHA, DON, CLoNJ and Regulatory Compliance Advisor (RCA) the concern that CNA #1, #4, and #5 did not have QAPI training. On 4/10/25 at 11:25 AM, in the presence of DON, CLoNJ and RCA, the LNHA stated that the IP/E/LPN received education to ensure that CNAs receive annual education which included the mandatory topics. The LNHA did not provide any additional information. A review of the facility's In-service Training Policy, with a review date of 7/1/22, included the following: Policy .[Facility] will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. In-service training programs are planned and conducted to develop and improve the skills of all personnel in accordance with federal and state law, in accordance with the facility assessment, and consistent with the staff members' expected roles. All mandatory in-service training content is located on the learning management system and is supported by various policies and procedures. Employee's training completion will be tracked via a transcript which is located within the learning management system. Other in-service training and competency results completed outside of the learning management system will be stored in the employee's personnel file. Process .2. Training topics include, but are not limited to, the following: . 2.4 Quality assurance and performance improvement (QAPI) training on the elements and goals of the QAPI program; N.J.A.C. 8:39-33.1

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nurses Aides (CNA) received 12 hours of mandatory annual in-service training for 1 of 5 CNAs reviewed (CNA #4); b) CNA education included resident abuse prevention training for 1 of 5 CNAs reviewed (CNA #4); and c) dementia management training for 2 of 5 CNAs reviewed (CNA #4 and CNA #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. She added that all of the education was in the electronic system since the in person educations were entered into the electronic system. On 4/8/25 at 12:45 PM, the IP/E/LPN provided the Student and Group Transcript Report for the 5 CNAs with the date range of April 9, 2024 to April 8, 2025. The reports were not based on the annual year from each CNAs doh. A review of the facility provide Transcripts included the following: CNA #4, with a doh of 2/5/24, had three hand hygiene modules which were all dated 1/14/25, and listed as administrator entered and totaled 21 minutes and 1 abuse, and neglect module which was dated 4/8/25, which was done after surveyor's inquiry, and listed as administrator entered which was six minutes. CNA #4 did not have 12 hours of education. CNA #4 did not have resident abuse prevention training prior to the surveyor requesting the information. CNA #4 did not have dementia management training. CNA #5, with a doh of 11/26/25, did not have dementia management training. On 4/8/25 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding the process for education. The DON stated that the company had a process for yearly mandatory education and a calendar provided and followed. The DON stated that some education was done in the electronic system, skills fair and inservices. She added that the tracking was in the electronic system. On 4/9/25 at 11:01 AM, the IP/E/LPN and Clinical Lead of New Jersey (CLoNJ) confirmed that they could not locate any additional inservice sign in sheets that the CNAs may have attended that were not entered into the electronic system. On 4/9/25 at 1:03 PM, the surveyor notified the LNHA, DON, CLoNJ, and Regulatory Compliance Advisor (RCA) the concern that CNA #4 did not have 12 hours of annual education and did not have resident abuse prevention and dementia training and CNA #5 did not have dementia management training. On 4/10/25 at 11:25 AM, in the presence of DON, CLoNJ, and RCA, the LNHA stated that the IP/E/LPN received education to ensure that CNAs receive 12 hours annual education which included the mandatory topics. The LNHA did not provide any additional information. A review of the facility's In-service Training Policy, with a review date of 7/1/22, included the following: Policy .[Facility] will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. In-service training programs are planned and conducted to develop and improve the skills of all personnel in accordance with federal and state law, in accordance with the facility assessment, and consistent with the staff members' expected roles. All mandatory in-service training content is located on the learning management system and is supported by various policies and procedures. Employee's training completion will be tracked via a transcript which is located within the learning management system. Other in-service training and competency results completed outside of the learning management system will be stored in the employee's personnel file. Process .2. Training topics include, but are not limited to, the following: . 2.3 Abuse, neglect, and exploitation to include; 2.3.1 Activities constituting abuse, neglect, exploitation, and misappropriation of resident property; 2.3.2 Procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property; and 2.3.3 Dementia management and resident abuse prevention; 3. In addition, there are requirements regarding in-service training for nurse aides . 3.1 Ensure continuing competence for no less than 12 hours per year; 3.2 Dementia management and resident abuse prevention; N.J.A.C. 8:39-13.4 (c)2, (c)4; 43.17 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#171811 and #175736 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to ensure that residents received timely and appropriate incontinence care. This deficient practice was identified for 7 of 20 residents, (Residents #9, #18, #30, #39, #58, #59, and #276), reviewed. This deficient practice was evidenced by the following: 1. On 4/6/25 at 9:40 AM, the surveyor observed Resident #59 inside room [ROOM NUMBER], lying on bed with eyes closed. On 4/6/25 at 9:58 AM, the surveyor asked the assigned Licensed Practical Nurse (LPN) to accompany the surveyor in Resident #59's room. Inside the resident's room, the surveyor observed the resident was awake and allowed the LPN to check resident's incontinence brief. The surveyor observed the LPN performed handwashing, donned (put on) gloves, and repositioned the resident. Both surveyor and LPN observed resident with double incontinence brief. During an interview, the LPN informed the surveyor that the resident was cognitively impaired and incontinent of bladder and bowel (B & B) elimination. The LPN further stated that the resident should not have a double incontinence brief. The surveyor reviewed the medical records of Resident #59 and revealed: A review of the admission Record or face sheet (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; chronic systolic (congestive) heart failure, type 2 diabetes mellitus with other ophthalmic complication, anemia (low red blood cells count) in chronic kidney disease, and end stage renal disease (a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels). A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 2/5/25, revealed in Section C Cognitive Patterns, a brief interview for mental status (BIMS) score of 14 of 15, which reflected that the resident's cognitive status was intact. The cMDS also included that the resident was coded #3 for B & B continence, which reflected that the resident was always incontinent. A review of the personalized care plan (CP) revealed that there was no documented evidence that the resident should have a double incontinence brief as a plan of care. Further review of the medical records revealed that there was no documented evidence as to why the resident should have a double incontinence brief. On 4/8/25 at 8:50 AM, the surveyor interviewed assigned Certified Nursing Aide #1 (CNA#1) of Resident # 59. CNA#1 informed the surveyor that most of the time she had 17 residents in her assignment. CNA#1 stated it was hard to finish with residents' incontinence care if she had 17 residents, but she ensures that she would finish even if she had to leave the facility late at 3:30 PM. She further stated that her time starts 7:00 AM. The CNA confirmed that on her assignments, rooms #2, #4, #8, #10, and #12 were all incontinent of B & B. She further stated that Resident #59 was incontinent of both B & B elimination. On that same date and time, the surveyor asked CNA#1 if she noticed at any given time the resident with double incontinence brief or any other resident with double incontinence brief. CNA#1 stated yes, a few times and it was not right. CNA#1 further stated it was 11-7 CNA who does that because of short staff. She also stated that at times there were only one or two CNAs in the whole unit to take care of the resident and the aides did not want the bed to get wet that was why the CNA put double incontinence brief. The CNA confirmed that she was aware of the New Jersey staffing law for 7-3 shift should be 1 CNA to 8 residents. On 4/8/25 at 9:51 AM, the surveyor interviewed CNA#2 via phone conference. CNA#2 informed the surveyor that he was a per diem CNA who works three times per week and usually on a weekend. CNA#2 confirmed that he worked this weekend Saturday going to Sunday morning, (4/5/25), for 11-7 shift with 17 residents. CNA#2 confirmed Resident #59 was on his assignment and that he put double incontinence brief to the resident. CNA#2 stated also that the resident was incontinent. 2. On 4/6/25 at 9:45 AM, the surveyor observed Resident #39 lying on bed inside room [ROOM NUMBER], with head of bed elevated, on oxygen (O2) 2 LPM (liters per minute) via nasal cannula (a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose). A review of the AR revealed diagnoses which included but not limited to; encephalopathy (refers to brain disease, damage, or malfunction) unspecified, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent cMDS, with an ARD of 2/18/25, revealed in Section C, the cognitive skills for daily decision making was coded 3, which reflected that the resident's cognition was severely impaired. The cMDS also revealed that the resident was coded #3 (always incontinent of both B & B elimination). A review of the personalized CP revealed that there was no documented evidence that the resident should have a double incontinence brief as a plan of care. Further review of the medical records revealed that there was no documented evidence as to why the resident should have a double incontinence brief. On 4/8/25 at 8:50 AM, CNA#1 confirmed that Resident #39 was incontinent of both B & B elimination. On 4/8/25 at 9:55 AM, CNA#2 confirmed that he was the aide of Resident #39, and that the resident was incontinent. He further stated that the resident had double incontinence brief and he did not notify the nurse about it. 3. On 4/8/25 at 10:37 AM, the surveyor met with four residents during the resident council meeting. Four of four residents, included Residents #18 and #30, both stated that short staff especially on weekends, affected care by responding to the toileting needs of residents. On that same date and time, Resident #30 stated that one time the CNA put a double incontinence brief on them, and on that same day, when the resident refused, it then stopped and did not happen again. The resident unable to state the name of the CNA and what shift. At that same time, Resident #18 confirmed that they experienced double incontinence brief a few times in 3-11 shift. Resident #18 unable to state the name of the CNA. Resident #18 also stated that the issue was that there was no enough staff that was why aide was putting double incontinence brief to residents. On 4/8/25 at 12:12 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ). The surveyor discussed the above concerns and findings with Residents #39, #59, and Resident Council Meeting concerns with double incontinence brief. On 4/9/25 at 12:37 PM, the survey team met with the LNHA, DON, CLoNJ, and the Regulatory Compliance Advisor (RCA). The DON stated for double incontinence brief we did start an in service and I did rounds at 4:30 AM to check the residents to make sure no double incontinence brief. On 4/10/25 at 11:43 AM, the CLoNJ stated that the survey team could proceed with decision making and that there was no additional information. A review of the facility's Continence Management Policy, with a review/revision date of 6/15/22, that was provided by the LNHA, revealed under Policy that patients will be assessed for the need for continence management as part of the nursing assessment process . Purpose: -To provide appropriate treatment and services for patients with urinary incontinence to minimize urinary tract infections and restore continence to the extent possible. -To provide appropriate treatment and services for patients incontinent of bowel to restore continence to the extent possible. Practice Standards: 6. Provide routine incontinence care . On 4/10/25 at 12:02 PM, the survey team met with the LNHA, DON, CLoNJ and RCA for an exit conference, and there was no additional information provided by the LNHA and her team. 4. On 4/6/25 at 10:39 AM, the surveyor observed Resident #9 lying on bed with eyes closed. On 4/6/25 at 10:49 AM, the surveyor proceeded to the nurse's station and asked for a nurse to accompany the surveyor to Resident #9's room. The LPN accompanied the surveyor to Resident #9's room. Inside the resident's room, the surveyor observed the resident was awake and allowed the LPN to check resident's incontinence brief. After donning gloves, the LPN opened Resident #9's incontinent brief and both the surveyor and LPN observed the resident had a white absorbent pad with elastic on both sides of the pad inside the incontinent brief. The resident had double incontinent brief. The LPN stated that the white absorbent pad looked like a sanitary pad. She added that she did not work on this side of the unit and was not sure why the resident would have a sanitary pad. The surveyor reviewed the medical record of Resident #9 and which revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), hypothyroidism (abnormally low activity of the thyroid gland, resulting in metabolic changes in adults), and anemia. A review of the most recent quarterly MDS (qMDS), with an ARD of 3/13/25, revealed in Section C, the resident's cognitive skills for daily decision making was severely impaired. The qMDS also included that the resident was coded #3 for Bladder & Bowel continence, which reflected that the resident was always incontinent. Further review of the medical record revealed that there was no documented evidence as to why the resident should have a double incontinence brief or an additional absorbent pad. 5. On 4/6/25 at 10:39 AM, the surveyor observed Resident #58 lying on bed with eyes closed. On 4/6/25 at 10:57 AM, the surveyor asked the LPN to accompany the surveyor to observe Resident #58's incontinence brief. Inside the resident's room, the surveyor observed the resident was awake and allowed the LPN to check resident's incontinence brief. After donning gloves, the LPN opened Resident #58's incontinence brief and the both the surveyor and LPN observed the resident had a white absorbent pad with elastic on both sides of the pad inside the incontinence brief. The resident had a double incontinence brief. The surveyor asked the LPN if that was considered double incontinence briefing. The LPN stated that she did not know and that she had never seen that before. She added that it looked like a sanitary pad. The surveyor reviewed the medical record of Resident #58 which revealed: A review of the AR, reflected that the resident was admitted with diagnoses that included but were not limited to; dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), hypertension (high blood pressure) and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). A review of the most recent qMDS, with an ARD of 3/17/25, revealed in Section C, the resident's cognitive skills for daily decision making was moderately impaired. The qMDS also included that the resident was coded #3 for Bladder & Bowel continence. Further review of the medical record revealed that there was no documented evidence as to why the resident should have a double incontinence brief or an additional absorbent pad. On 4/7/25 at 11:32 AM, the surveyor interviewed the Central Supply Staff (CSS) regarding the observation of the absorbent pad that had elastic on both sides. The CSS stated that the facility had a sanitary pad but that it did not have elastic on the sides. On 4/8/25 at 12:34 PM, the surveyor notified the LNHA, DON, and CLoNJ the concern that Resident #9 and #58 had a double incontinence brief applied. A review of the facility's provided policy titled Staffing/Center Plan, with a review date of 8/7/23, included the following: Policy Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. Purpose To assure that appropriate staffing levels are scheduled and maintained. Process 1. The Center meets or exceeds the staffing levels mandated by state and federal staffing requirements. 2. Staffing levels are reviewed on an ongoing basis by Center staff to evaluate compliance and provide appropriate levels of care by qualified employees . 4. The Center maintains appropriate staffing levels, with qualified personnel, 24 hours/day, seven days/week on each shift to assure that patients are safe and their needs are met . NJAC 8:39-25.2(b)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received an annual performance review for 5 of 5 CNA files reviewed. This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the performance reviews for five randomly selected CNAs. On 4/8/25 at 1:40 PM, the Director of Nursing (DON) notified the surveyor that she could not locate the performance reviews for the five CNAs. On 4/9/25 at 1:06 PM, the surveyor notified the LNHA, DON, Clinical Lead of New Jersey (CLoNJ), and Regulatory Compliance Advisor (RCA) the concern that the performance reviews were not done. On 4/9/25 at 1:26 PM, in the presence of the CLoNJ, the DON confirmed that they did not have performance reviews for the five CNAs. On 4/10/25 at 11:25 AM, in the presence of the LNHA, CLoNJ and RCA, the DON stated she was auditing the nursing staff to see when their last annual performance evaluation was done and would get them completed. The LNHA did not provide any additional information. A review of the facility, Performance Appraisal Policy, with a review date of 7/1/22, included the following: Managers will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews. N.J.A.C. 8:39-43.17 (b)

5. On 4/6/25 at 9:46 AM, Surveyor #3 (S#3) observed Resident #21 asleep in bed. A review of Resident #21's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; psychotic disorder with delusions (a type of mental illness where a person experiences persistent, false beliefs (delusions) that they firmly hold despite evidence to the contrary), bipolar disorder (a mental illness characterized by extreme and persistent shifts in mood, energy, and activity levels), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). A review of Resident #21's qMDS, with an ARD of 1/31/25, reflected that the resident had a BIMS score of 3 out of 15, which indicated that the resident's cognition was severely impaired. The qMDS also included that the resident received an antipsychotic (a mood altering medications specifically used to manage psychosis, a mental disorder characterized by a disconnection from reality) med. A review of Resident #21's April 2025 eMAR included the following PO: -Seroquel Oral Tab 50 mg, give 1 tab by mouth at HS for Delusional disorder. Monitor Behavior While Resident is Taking Seroquel every shift. [There was not a target behavior listed to monitor for the Seroquel] There was an additional order, Behavior documentation for exit seeking and wandering on 3-11 and 11-7 shifts every evening and night shift. This was not the behavior that the Seroquel was ordered for. On 4/7/25 at 11:38 AM, S#3 interviewed the RN regarding the process for behavior monitoring and Resident #21. The RN stated that there was an order in the eMAR every shift and if there was a behavior would write y (yes) and write a note that went to the progress note section [in the electronic record]. S#3 asked what Resident #21's target behaviors were that were monitored. The RN stated that had not seen the resident have any behaviors since March. She added that the resident had a wandergard but that she did not see the resident wandering. S#3 asked the reason why Resident #21 was receiving Seroquel. The RN stated can find out. On 4/7/25 at 11:58 AM, the RN stated that Resident #21 was on Seroquel mostly for wandering on 3-11 or 11-7 shift. On 4/7/25 at 12:01 PM, S#3 interviewed the LPN/UM regarding behavior monitoring. The LPN/UM stated that the resident was seen by the PNP and that the PNP would tell us what behavior to monitor or it was based on our interaction with the resident. The LPN/UM stated that Resident #21 wandered and hallucinated and would look for the resident's brother in the afternoon. She further stated that based on the resident's notes, the resident had behavior monitoring for exit seeking and wandering. On 4/8/25 at 9:54 AM, S#3 showed the LPN/UM Resident #21's eMAR with the two orders for behavior monitoring. The LPN/UM stated that the resident was monitored for exit seeking and confirmed that the order for monitoring for Seroquel did not have the target behavior that should be monitored. She further stated that the Seroquel was ordered for delusional disorder and that the target behavior should be delusions. The LPN/UM confirmed that the target behavior of delusions should have been in the order. On 4/8/25 at 12:36 PM, S#3 notified the LNHA, DON and CLoNJ the concern that Resident #21's behavior monitoring order did not include a target behavior for the antipsychotic med. On 4/9/25 at 12:52 PM, in the presence of the LNHA, CLoNJ, and RCA, the DON stated that she started an audit of residents' orders for psychotropic meds updated the order for behavior monitoring. The LNHA did not provide any additional information. NJAC 8:39-27.1(a) 4. On 4/6/25 at 10:15 AM, Surveyor #2 (S#2) observed Resident #57's door closed. The resident's privacy curtain was closed, and the resident was being assisted by staff with morning care. On 4/8/25 at 10:15 AM, S#2 reviewed the paper medical records and the electronic medical record (EMR) of Resident #57. The AR documented that the resident was newly admitted to the facility and had diagnoses that included but were not limited to; dementia, drug induced subacute dyskinesia (a movement disorder that develops within days to weeks after initiating or increasing the dose of certain medications), chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). A review of the cMDS, with an ARD of 3/11/25, indicated a BIMS test was not completed as the resident was documented as being rarely/never understood. A review of the PO revealed: -dated 3/8/25, indicated to obtain dental, ophthalmology, podiatry, physiatry, psych[psychiatry], and wound consults as needed/indicated and treatment for patient health and comfort. -dated 3/13/25, indicated benztropine mesylate (a med used to help with tremors, improve muscle control and reduce stiffness) oral tab 0.5 mg, give 1 tab by mouth BID. The med order had an indicated diagnosis of depression. -dated 3/13/25, indicated Depakote (a med used to treat types of seizures and used to treat certain mood episodes in adults) oral tab delayed release 500 mg, give 1 tab by mouth BID for depression. -dated 3/8/25, indicated lorazepam (a med used to treat anxiety disorders) oral tab 0.5 mg, give 1 tab by mouth in the evening for anxiety. -dated 3/13/25 indicated olanzapine (an antipsychotic meds used to treat mental health conditions such as schizophrenia and bipolar disorder) oral tab 15 mg, give 1 tab by mouth at bedtime for depression. -dated 3/8/25, indicated Sertraline (an antidepressant med) oral tab 100 mg give 1 tab by mouth one time a day for depression. There were no PO for monitoring of target behaviors and adverse effects for psychotropic med. A review of the CP for Resident #57, included a focus area for complications r/t the use of psychotropic meds of olanzapine, lorazepam, and sertraline, dated 3/18/25. Interventions of the CP included: -Complete behavior monitoring flow sheet; date initiated 3/18/25. -Gradual dose reduction as ordered; date initiated 3/18/25. - Monitor for continued need of med r/t behavior and mood; date initiated 3/18/25. - Monitor for side effects and consult physician and/or pharmacist as needed; date initiated 3/18/25. - Obtain psych evaluation as ordered; date initiated 3/18/25. A review of the March 2025 and April 2025 eMAR and electronic Treatment Administration Record (eTAR) revealed there were no entries for monitoring of target behaviors and side effects of psychotropic meds. A review of the EMR revealed there was no documentation of the resident's target behaviors. On 4/8/25 at 11:00 AM, S#2 interviewed the Licensed Practical Nurse (LPN), who was assigned to care for Resident #57. The LPN stated residents who received psychotropic meds were monitored for behaviors which were documented in the EMR. The LPN further explained that behavior monitoring was documented in the eMAR and there should be a separate order from the meds for behavior monitoring. LPN#1 stated that monthly psychotropic summaries would also be completed in the EMR. At that same time, S#2 asked the LPN about psychiatric consults for residents, the LPN replied that residents with psychotropic meds ordered would have a routine psychiatric consult and/or psychology consult. The LPN stated the psychiatric consultant visited the facility at least once a week to see residents. S#2 asked the LPN if Resident #57 had a psychiatry consult. The LPN stated she was not sure as it was the first time she was assigned to the resident and would have to look in the EMR. On 4/8/25 at 11:20 AM, S#2 interviewed the LPN/UM about Resident #57 and their psychotropic meds. The LPN/UM stated the resident had not really exhibited behaviors since their admission and had not had any outbursts. She further explained Resident #57 had a history of being resistive to care and outbursts. S#2 asked about management for psychotropic med use. The LPN/UM stated that residents who had psychotropic med ordered would have routine psychiatric consults. The LPN/UM stated Resident #57 should have one. The LPN/UM reviewed with S#2 the EMR and confirmed there was no documentation that the resident had a psychiatric consult. The LPN/UM checked the list of residents referred to the psychiatric consultant since March 2025 and found Resident #57 was not on the list. The LPN/UM could not speak to what happened and stated she did not know how it was missed. On that same date and time, S#2 asked the LPN/UM about the indicated diagnoses for the resident's olanzapine, depakote, and benztropine mesylate. The LPN/UM reviewed the med orders and stated that they were not typical indications for the med and would have to review with the physician to clarify. At that time, S#2 asked the LPN/UM about behavior monitoring, and she explained that it was documented for residents with antipsychotic and antianxiety med orders. The LPN/UM stated that a PO for behavior monitoring would be documented in the EMR, and it was a separate entry order from the psychotropic med. S#2 also asked about monthly psychotropic summaries as mentioned by the LPN. The LPN/UM replied that before they were being completed and that she was not sure now if it was still part of the facility's process. The LPN/UM stated she would have to follow up with the DON. On 4/8/25 at 12:14 PM, S#2 notified the LNHA, the DON, and the CLoNJ of the concerns for the diagnosis of the resident's psychotropic meds, there was no psychiatry consult as per the facility's protocol, no behavior monitoring, and no adverse effect monitoring. On 4/9/25 at 12:37 PM, the LNHA, the DON, the CLoNJ, and the RCA met with the survey team. The DON stated that they reviewed the hospital records which only documented diagnoses of depression and stated they would have to reach out the resident's sending facility to further determine the resident's history and specific target behaviors. Additionally, a psychiatric consultant would be in to visit with the resident, and all residents on psychotropic meds were audited. There was no additional information provided by the facility. A review of the facility's Behaviors: Management of Symptoms Policy, with a last revised date of 7/1/24, under Purpose it documented: To identify, prevent, and manage behavioral symptoms by .Monitoring outcomes of CP interventions. Under Practice Standards it detailed: . 2. Staff will monitor for and document in the medical records any exhibited behavioral symptoms . 3. Identify, to the extent possible, potential underlying causes of behavioral symptoms (e.g., pain, delirium, environmental factors, etc.) . 5. The Center will ensure that necessary behavioral health services are person-centered and reflect the patient's goals of care, while maximizing the patient's dignity, autonomy, privacy, socialization, independence, choice, and safety . 6. When med is ordered for behavioral symptoms . 6.2 Complete the Psychotropic/Therapeutic Med Use Evaluation when a patient is newly prescribed a psychotherapeutic med and then quarterly . 6.3 Complete the Abnormal Involuntary Movement Scale (AIMS) per nursing schedule for patients receiving anti-psychotic meds . Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behaviors for the use of a psychotropic (affecting the brain and nervous system, altering mood, thoughts, perception, and behavior) medications for 5 of 5 residents, (Residents #12, #21, #24, #49, and #57), reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 4/6/25 at 10:29 AM, Surveyor #1 (S#1) observed Resident #12 walking all around the room, alert, and well groomed. S#1 reviewed Resident #12's medical record which revealed the following: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; metabolic encephalopathy (brain dysfunction from metabolic imbalances), unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, adjustment disorder with anxiety, and depression unspecified. A review of the quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 4/2/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete interview-rarely understood), and a staff assessment reflected severely impaired cognitive status. The MDS indicated that the resident did not exhibit behavior symptoms within the look-back period and had received in the last seven days an antipsychotic medication (med) daily. A review of the resident's individualized care plan (CP), dated 3/20/25, reflected the resident received psychotropic drugs due to behavioral episodes of verbal aggression towards staff, physical aggression towards staff, and episodes of resistance with care, history of violent behaviors. A review of the physician's order (PO) indicated the resident was prescribed the antipsychotic medications (meds): -Quetiapine Fumarate (Seroquel) oral Tablet (tab) 25 mg (milligram) give 1 tab by mouth at bedtime (HS) for psychosis ordered 6/28/24, and discontinued (d/c) on 11/20/24. -Seroquel oral tab 25 mg (Quetiapine Fumarate) give 25 mg by mouth at HS every other day for Psychosis, ordered on 11/20/24. -Monitor and document behaviors every shift ordered on 7/17/24. There was no target behaviors indicated. On 4/7/25 at 12:19 PM, S#1 interviewed the Registered Nurse (RN) regarding psychotropic meds. The RN stated, sometimes the resident might be aggressive, will tap you really hard on the arm to get attention. The RN further stated that the resident was on Seroquel at HS, usually they just tell you to monitor their behavior. S#1 asked if there should be a target behavior listed on the order with Seroquel and the RN stated, Yes, I will try to find out. The antipsychotic should have behaviors listed. On 4/7/25 at 12:29 PM, S#1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the [NAME] Wing Unit. The LPN/UM stated the Psychiatric doctor will send the LPN/UM recommended orders, then the LPN/UM will call the primary medical doctor (PMD), and if the PMD agreed with the recommended orders, the order will be be in. The LPN/UM further stated that the new orders were for increase behavior and mood changes, some people had different behavior monitoring, for antipsychotics, there should be a target behaviors. At that time, S#1 reviewed with the LPN/UM the orders in the electronic Medication Administration Record (eMAR), and both S#1 and the LPN/UM did not see target behaviors. The LPN/UM stated, I honestly do not know why it was not there, and that the she I will speak to the Psychiatric Nurse Practitioner (PNP) from the Psychiatric consulting group to determine what appropriate target behaviors should be monitored. She further stated that the changes in mood was not enough to describe target behavior. On 4/7/25 at 12:30 PM, S#1 reviewed the Psychiatric Consult Notes (PCN) dated 4/4/25, completed by the PNP which revealed, Pt (patient) is a poor historian. Information received from pt, staff, and medical chart No evidence of hallucinations No manic or psychotic behaviors reported. 2. On 4/6/25 at 10:21 AM, S#1 observed Resident #24 lying in bed and alert. The resident stated, My doctor said sleep is important. S#1 reviewed Resident #24's medical record which revealed the following: A review of the AR reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; adjustment disorder with anxiety, other symptoms and signs involving emotional state, hallucinations, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, unspecified, adjustment disorder with mixed anxiety and depressed mood, and unspecified dementia, unspecified severity, with psychotic disturbance. A review of the most recent comprehensive MDS (cMDS), with an ARD of 3/11/25, revealed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The cMDS did not reflect that the resident had behaviors exhibited. A review of the resident's individualized CP initiated 6/25/24, reflected the resident at risk for complications related to (r/t) the use of psychotropic drugs. A review of the PO revealed the resident was prescribed the antipsychotic med, Quetiapine Fumarate oral tab 25 mg, give 0.5 tab by mouth two times a day (BID) for psychosis (0.5 tab=12.5 mg), ordered on 12/5/2. There was no target behaviors indicated. A review of the PCN dated 4/4/25, completed by the PNP which revealed, Pt reports feeling, okay. No recent mood changes reported. No current evidence of hallucinations or delusions noted this visit. No recent mood changes reported. On 4/7/25 at 12:41 PM, S#1 interviewed the LPN/UM, who confirmed no target behaviors listed in the eMARS, and stated, Yes, these psychotropic orders should have target behaviors listed as well. 3. On 4/6/25 at 10:47 AM, S#1 observed the Resident #49 in the room lying in bed, bed lowest to the floor, screaming intermittently, and the resident stated, I'm fine. S#1 reviewed Resident #49's medical record which revealed the following: A review of the AR reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; unspecified psychosis not due to a substance or known physiological condition, generalized anxiety disorder; depression, unspecified, Alzheimer's disease with early onset, dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, other Alzheimer's disease, and traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, subsequent encounter. A review of the qMDS, with an ARD of 1/8/25, revealed the resident unable to complete interview, was coded as rarely understood, and a staff assessment reflected severely impaired cognitive status. A review of the resident's individualized CP initiated 10/5/2020, reflected the resident exhibits distressed/fluctuating mood and behavioral symptoms r/t Psychiatric Disorder Dementia with yelling out in the hallway and periods of sadness. A review of the PO revealed the resident was prescribed the antipsychotic meds: -Risperidone oral tab 0.5 mg, give 0.5 mg by mouth two times a day for Unspecified Psychosis ordered 1/23/24, d/c on 3/3/25. -Risperidone oral tab 0.5 mg, give 0.5 mg by mouth two times a day for Psychosis, monitor for increase in behaviors and changes in mood ordered 3/3/25. -Monitor behavior while resident is taking Risperidone every shift 2/26/24. There was no target behaviors listed. A review of the PCN dated 3/28/2, completed by the PNP which revealed, No evidence of hallucinations. No manic or psychotic behaviors reported . Continue to monitor for mood and behavioral changes: agitation, aggressiveness, hallucinations or delusions. On 4/8/25 at 12:13 PM, the survey team met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ), and S#1 notified them of the above concerns regarding anti-psychotic meds. On 4/9/25 at 10:40 AM, S#1 interviewed the DON, and the DON stated, I am aware of the psychotropic behavior monitoring, and target behaviors not being done. On 4/9/25 at 12:38 PM, the survey team met with the Regulatory Compliance Advisor, LNHA, and CLoNJ, and the DON stated, I started the house wide audit of all residents, reached out to the psychiatrist to do monthly meeting and each week I will audit for behavior monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews on 4/8/2025 and 4/9/2025 in the presence of the Senior Maintenance Director (SMD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning. This deficient practice had the potential to affect 40 residents and was evidenced by the following: An observation at 11:19 AM revealed that when testing the call bell system for resident room [ROOM NUMBER], there was no audible notification of the call bell activation at the nurse's station. In an interview at the time, there were three staff members at the nurse's station. The surveyor asked the staff members if they can hear anything. The three staff members stated no. The surveyor notified them they were testing the call bell system for resident room [ROOM NUMBER]. The staff members then stated that something must be wrong because they can usually hear audible notification of call bell activations at the nurse's station. An observation at 11:20 AM revealed that when testing the call bell system for resident room [ROOM NUMBER], there was no audible notification of the call bell activation at the nurse's station. An observation at 11:30 AM revealed that when testing the call bell system for resident room [ROOM NUMBER], there was no audible notification of the call bell activation at the nurse's station. In an interview at the time, the SMD confirmed that there was no audible notification of the call bell activation and stated that the entire East wing (21 resident rooms) was served by the call bell system. The facility's Administrator was notified of the deficient practices at the Life Safety Code exit conference on 4/9/2025 at 2:00 PM. N.J.A.C 8:30-31.2 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#171811 REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 2 units, and was evidenced by the following: 1. On 4/6/25 at 9:40 AM, Surveyor #1 (S#1) observed Resident #59 inside room [ROOM NUMBER], lying on bed with eyes closed. The nightstand table bottom door had no cover, and the cover piece was on the side of the table. The bottom part of the nightstand table had multiple personal items that include two bedpans, papers, and plastics. The regular chair inside the room had multiple blackish and brownish stains. The adjoining toilet room (with room [ROOM NUMBER]) vent had accumulation of grayish substances, and the tissue paper holder was broken. The two tissue paper rolls were on top of the toilet bowl. The closet door was broken and uneven. Outside the room, in the hallway, S#1 observed multiple vents with accumulation of grayish substances. On 4/6/25 at 10:08 AM, during the Entrance Conference meeting with S#1 with the Licensed Nursing Home Administrator (LNHA), the LNHA informed the surveyor that there were two units in the facility. The LNHA further stated that the East Wing Unit which was the rooms with even numbers and the [NAME] Wing Unit which was the odd room numbers. On 4/7/25 at 12:13 PM, S#1 asked Registered Nurse #1 (RN#1) to accompany the surveyor to Resident #59's room. Inside the resident's room, both S#1 and RN#1 observed the regular chair with brownish and blackish stains. RN#1 unable to identify what were those stains and stated that it should have been cleaned. S#1 and RN#1 also observed the curtains in the window with scattered brownish stains and RN#1 stated that it should have been cleaned. RN#1 also confirmed that the aircon had an accumulation of dust, and RN#1 stated that it should have been cleaned. On that same date and time, S#1 asked RN#1 confirmed that the nightstand table bottom door should have been fixed. Prior to leaving the room the surveyor asked RN#1 who had the closet on the right side was and why the door was uneven. RN#1 opened the closet on the right side, RN#1 confirmed it was uneven and stated that it should have been fixed by the Maintenance Person (MP). RN#1 also confirmed that the closet belong to Resident #59. Outside the resident's room, in the hallway both S#1 and RN#1 observed accumulation of grayish substance on the multiple vents, and RN#1 stated that should have been cleaned by Maintenance department. RN#1 also confirmed that the grayish substances were accumulation of dust. 2. On 4/6/25 at 9:45 AM, S#1 observed Resident #39 inside room [ROOM NUMBER], lying on bed, with head of bed elevated, with oxygen in use. Inside the resident's room, the surveyor observed the window curtains were stained with brownish discoloration and ripped. The adjoined toilet room (with room [ROOM NUMBER]) tissue paper holder was broken and the vent with accumulation of grayish substances. On 4/7/25 at 12:08 PM, S#1 was accompanied by RN#1 inside Resident #39's room. Both S#1 and RN#1 observed the ripped curtains, the adjoined toilet room with broken tissue holder, and RN#1 confirmed that the vent inside the toilet room with accumulation of dust. RN#1 also confirmed the ripped curtains with unknown brown stain should have been fixed by the MP, and the curtains should have been cleaned. 3. On 4/7/25 at 10:54 AM, S#1 reviewed the last three months Resident Council Minutes that was provided by the LNHA and revealed: -4/2/25 minutes included that nine residents attended the meeting that included Residents #4, #11, #18, and #30. The staff who attended were the Director of Recreation, Food Services Director, and Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP informed the residents that the facility currently did not have a Maintenance Director. On 4/8/25 at 10:51 AM, during the Resident Council Meeting, Residents #11 and #18 both stated that they were unaware if facility had new MP because the regular MP was out for medical reason. On 4/8/25 at 12:12 PM, the survey team met with the LNHA, Director of Nursing (DON), and the Clinical Lead of New Jersey (CLoNJ). S#1 discussed the environment concerns with rooms [ROOM NUMBERS] in East unit, vents in the hallway, and the Resident Council Meeting concerns. On 4/9/25 at 12:37 PM, the survey team met with the LNHA, DON, CLoNJ, and the Regulatory Compliance Advisor (RCA). The LNHA informed S#1 that rooms [ROOM NUMBERS] tissue holder was replaced, aircon was cleaned, the closet door was fixed, vent was cleaned, and the vendor was asked for a quote for the whole building curtain replacements. The LNHA had no response with regard to Resident #59's nightstand table and further stated that she had to go back to check the nightstand table of Resident #59. On 4/10/25 at 9:39 AM, S#1 met with the LNHA for Quality Assurance Performance Improvement (QAPI) meeting. The LNHA stated that there were multiple areas of concerns surveyors identified that were not identified by the facility team during the most recent QAPI meeting, and that included issues with vents and homelike environment. On 4/10/25 at 11:43 AM, the CLoNJ stated that team could proceed with decision making and that there was no additional information. 4. On 4/6/25 at 10:10 AM, Surveyor#2 (S#2) toured the East Wing Unit Bath/Shower room and observed the following: -Next to the toilet, there was a used towel folded in half on the floor. -On sink #1, there was an open tube of toothpaste and on the other side of the sink there were two toothbrushes which were used and saturated with dried toothpaste. - On sink #2, there was a pile of towels on one side and a blue colored pajama set on the other side. A chair in front of the sink had a tied clear plastic bag with towels in it. On 4/6/25 at 10:14 AM, S#2 interviewed Certified Nurse Aide (CNA) #1 who stated that nursing staff checked the bath/shower room after it was used by a resident to clean up, dispose of used linen, and make sure nothing was left by the resident. CNA #1 was not sure of how often housekeeping cleaned the bath/shower room. CNA#1 accompanied the surveyor to check the bath/shower room and confirmed the above observations. CNA #1 was not sure who used the bath/shower room last and stated it was probably a resident who was independent and had frequently left their belongings in the bath/shower room. On 4/6/25 at 11:05 AM, S#2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated it was expected for the shower room to be cleaned as soon as the resident was done using it. The LPN/UM further explained the staff would return a resident to their room, then would go to bath/shower room to remove any linens and belongings left by the resident. The LPN/UM stated for independent residents, it was expected for staff to check the bathroom after it was used. S#2 discussed with the LPN/UM the observed concerns in the bath/shower room. On 4/6/25 at 11:12 AM, S#2 accompanied by the LPN/UM toured the bath/shower room. The LPN/UM confirmed the observed concerns as the bath/shower room had not been cleaned from S#2's previous observation. The LPN/UM donned gloves and started cleaning up the items left in the bathroom. On 4/8/25 at 12:14 PM, S#2 notified the DON, the LNHA, and the CLoNJ of the above concerns. On 4/10/25 at 11:22 AM, the survey team met with the LNHA, the DON, the CLoNJ, and the RCA, and the LNHA stated the East unit bath/shower room was deep cleaned and education was provided to nursing staff. The LNHA further stated that the LPN/UM and the ADON/IP would do daily rounds. 5. On 4/6/25 at 8:55 AM, the survey team entered the facility, walking from the back of the building parking lot to the front of the building, Surveyor #3 (S#3) observed residents' rooms from the outside, with ripped curtains on the East Wing Unit. On 4/10/25 at 8:20 AM, S#3 observed in the East Wing Unit, Rooms #12, #28 and #34 with window curtains ripped and facility management were made aware. 6. On 4/6/25 at 9:45 AM, S#3 observed the Resident #64 sitting on the wheelchair in the day room, with family members also in the dayroom visiting the resident. On 4/6/25 at 9:55 AM, S#3 observed in the [NAME] Wing Unit, room [ROOM NUMBER]-B (Resident #64) and room [ROOM NUMBER] doorways with peeling wood on the bottom, and sharp wood exposed in room [ROOM NUMBER] doorway. On 4/6/25 at 10:05 AM, S#3 interviewed RN#2, who had been working in the facility since September 2024. RN#2 confirmed the peeled wood was sharp to touch and had been like that, since RN#2 had been working at the facility. S#3 asked if the wood should be that way and RN#2 responded, No, and that MP do rounds in the morning and we notify the MP verbally what needed to be done or fix. On 4/8/25 at 11:15 AM, S#3 interviewed the Director of Maintenance (DoM) from another facility regarding S#3's concerns above. The surveyor also notified the DoM regarding the ripped curtains in the residents' rooms observed upon entrance, and DoM was unaware of the ripped window curtains. 7. On 4/6/25 at 10:21 AM, S#3 observed Resident #24 in room [ROOM NUMBER]-B, lying in bed. S#3 observed the edges of the window curtains torn. The resident stated, The curtains have been like that for three months. On 4/6/25 at 10:36 AM, S#3 interviewed CNA#2, who stated she had been working in the facility for two months, and confirmed the curtains were ripped. CNA#2 further stated that the curtains were ripped since she started working at the facility. CNA#2 further stated that she told the nurses about it, and I do not know what was next. On 4/8/25 at 12:13 PM, S#3 notified the LNHA, DON and the CLoNJ regarding the above concerns of peeled wood and ripped curtains. 8. On 4/7/25 at 12:04 PM, while observing the facility East Wing Unit, S#4 observed broken molding near the floor in a doorway between a janitor closet and the nurses' station. On the same date and time, S#4 observed air circulation vents located in the ceiling of the East Wing Unit. The vent covers were observed to have an accumulation of gray substance both inside and outside of the vent cover. At 12:56 PM, S#4 observed the air circulation vents located on the [NAME] Wing Unit of the facility. S#4 observed the same accumulation of a gray substance on the vents located on the [NAME] Wing Unit. The vents observed with the accumulation of gray substance included but not limited to: East Wing Unit: Small vent outside room [ROOM NUMBER]. Large vent at the end of the high side hall. Small vent in the hall outside the beauty parlor. Small vent in the hall outside the nursing station. Large vent at the end of low side hall. Small vent outside room [ROOM NUMBER]. Large vent near the doorway to the low side hall. Small vent in hall outside the admissions office. West Wing Unit: Large vent at the end of the high side hall. Small vent in the hall outside room [ROOM NUMBER]. Large vent at the entrance to the high side hall. Small vent in the hall outside the clean utility room. Small vent in the hall outside room [ROOM NUMBER]. On 4/8/25 at 12:12 PM, the survey team met with the LNHA, DON, and the CLoNJ to discuss the above concerns with the air circulation vents located on both wings of the building and the broken molding on the East Wing Unit. On 4/9/25 at 12:37 PM, the survey team met with the RCA, DON, LNHA, and CLoNJ, and the LNHA stated, Regarding the ripped window curtains, we notified the vendor to replace curtains and the doorways with wood issues have been fixed. The LNHA further stated that a new cleaning schedule was initiated after surveyor's inquiry. A review of the facility's Accommodation of Needs Policy, with a review/revision date of 2/1/23, that was provided by the DON, revealed that the resident/patient has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely . Under Process of the policy revealed: .1. The center must provide .1.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Reasonable accommodations of individual needs and preferences means the facility's efforts to individualize the patient's physical environment. This includes the physical environment of the patient's bedroom and bathroom, as well as individualizing as much as feasible the facility's common living areas. The facility's physical environment and staff behaviors should be directed toward assisting the patient in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible in accordance with the patient's own needs and preferences . On 4/10/25 at 12:02 PM, the survey team met with the LNHA, DON, CLoNJ and RCA for an exit conference, and there was no additional information provided by the LNHA and her team. NJAC 8:39-31.2(e), 31.4(a)(f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/6/25 at 9:21 AM, the surveyor, in the presence of the Cook, observed the following during the kitchen tour: 1. In the juice refrigerator, there was an unlabeled and undated glass bottle containing an orange-colored sauce. The [NAME] stated that it was a staff member's food item and not an item for the residents. The [NAME] acknowledged it should not have been in the refrigerator and removed the bottle. 2. On a food prep countertop, there was a compact blender. The blender cup was sealed on to the machine and was observed wet inside. The [NAME] checked and confirmed the blender cup was wet inside. The [NAME] stated that items after washing were supposed to be left to air dry as it prevented bacteria growth. The [NAME] removed the blender cup and placed it to be re-washed. On 4/7/25 at 9:13 AM, the surveyor notified the Dietary Manager (DM) and the Regional District Manager (RDM) of the above concerns observed during the kitchen tour on the previous day. The DM acknowledged staff food items should not be stored in the kitchen and equipment after washing should be air-dried prior to storing. On 4/8/25 at 12:14 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Clinical Lead of New Jersey (CLoNJ) of the above concerns observed in the kitchen. On 4/9/25 at 9:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) about the nutrition refrigerators on the units. The LPN/UM stated the refrigerators stored outside food belonging to residents and snacks provided by the kitchen. The LPN/UM explained the nurses and the certified nurse aides (CNAs) were responsible for ensuring items placed in the refrigerators were dated and labeled with the resident's name. The LPN/UM stated food items were disposed after 72 hours as indicated by signage on the refrigerator. The surveyor inspected the [NAME] unit nutrition refrigerator with the LPN/UM and observed the following: 3. In the refrigerator, there was an undated and unlabeled box which consisted fast-food restaurant chicken. The LPN/UM confirmed the box was unlabeled and undated. 4. In the refrigerator, there was a black plastic bag containing three food containers filled with food items. The items were unlabeled and undated. The LPN/UM disposed of the bag in the garbage bin. 5. In the refrigerator, there was a black bag with a carton of eggs which was less than half full. The bag and the carton were unlabeled and undated. The LPN/UM confirmed the items were unlabeled and undated. 6. In the refrigerator, there were two bottles of water, with a first name written on their labels. The LPN/UM stated that it was a staff member's name, and it should not have been stored in the nutrition refrigerator. 7. In the freezer, there was a frozen half full 20 ounces soda bottle which was undated and unlabeled. 8. In the freezer, there was an uncovered Styrofoam cup with a clear colored frozen item. The cup was undated and unlabeled. 9. In the freezer, there was a sandwich bag with grapes, which was undated and unlabeled. The LPN/UM stated she could not say who the items belonged to. She acknowledged the food items should have been labeled with the resident's name and dated when placed in the refrigerator. The LPN/UM stated the items would be removed and disposed. On 4/9/25 at 9:54 AM, the surveyor inspected the East unit nutrition refrigerator with the LPN/UM and observed the following: 10. In the refrigerator, there were two take-out food containers, which were undated and unlabeled. The LPN/UM stated the items would be disposed. The LPN/UM stated that the dietary staff would stock the refrigerator with snacks, and they usually checked the refrigerators for outdated items. She acknowledged it would be expected for outside food items to be labeled with a resident's name and dated when it was stored in the refrigerator by staff. 11. In the freezer, the bottom floor of the freezer was soiled with dark in color marks and there was a crumpled paper label. The LPN/UM was unsure of who was responsible for cleaning the nutrition refrigerators and would have to find out from the DON. On 4/9/25 at 12:37 PM, the LNHA, the DON, the CLoNJ, and the Regulatory Compliance Advisor (RCA) met with the survey team. The LNHA stated the item found in the kitchen refrigerator was hot sauce that belonged to one of the kitchen staff, which was removed, and the staff were in-serviced. The blender cup was re-washed and airdried. Additionally, in-service education was provided to dietary staff. On 4/9/25 at 12:59 PM, the surveyor notified the LNHA, the DON, the CLoNJ, and the RCA of the concerns observed in the nutrition refrigerators. The surveyor asked who was responsible for ensuring items were dated and labeled. The LNHA replied that it was the nurses' responsibility. The surveyor asked who was responsible for cleaning the refrigerators and if there was a routine cleaning schedule. The LNHA stated the process going forward would be for housekeeping to clean the outside of the refrigerator and dietary staff would clean the inside of the refrigerator. The LNHA who started at the facility approximately two weeks ago, could not speak to who was previously responsible for cleaning the refrigerators and for when the refrigerators were last cleaned. On 4/10/25 at 9:57 AM, the surveyor interviewed the DM and RDM about the dietary department's responsibility for nutrition refrigerators. The DM stated dietary staff checked refrigerator temperatures and any food items belonging to the kitchen were stocked and removed as needed. The DM stated the dietary staff were not responsible for cleaning the nutrition refrigerators or checking that outside food items were stored appropriately. The RDM stated dietary staff cleaned out the refrigerators yesterday after the surveyor informed the facility's management of the concerns observed. The RDM further explained that the staff storing food items in the nutrition refrigerator were responsible for ensuring the items were dated and labeled. The DM was not sure who was responsible for cleaning the refrigerators prior to surveyor's inquiry and that it was not part of the dietary staff's responsibility. On 4/10/25 at 11:22 AM, the LNHA, the DON, the CLoNJ, and the RCA met with the survey team. The DON stated the refrigerators were deep cleaned after surveyor's inquiry. There was no additional information provided. A review of the facility's Warewashing Policy, with a last revised date of February 2023, under the Policy Statement revealed, All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Under Procedures revealed: . 4. All dishware will be air dried and properly stored . A review of the facility's Food Storage: Cold Foods Policy, with a last revised date of February 2023, under the Procedures revealed, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the facility's Food Brought in for Patients/Residents Policy, with a last revised date of 1/26/24, under Process revealed: . 1.2. Food items that require refrigeration must be labeled with the resident's name and date the food was brought in . 1.3 Food items must be stored in a closed container to prevent contamination . 1.5 Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to resident . NJAC 8:39-17.2(g)

Refer to F584 and S0560 Based on observations, interviews, and record review, it was determined that the facility failed to ensure the staff, as well as herself, the Licensed Nursing Home Administrator (LNHA), implemented the facility's policies and procedures including the promotion of a homelike environment and sufficient staffing in order to provide the appropriate needs of residents. This failure had the potential to affect all 71 residents who currently live in the facility. The evidence was as follows: On 5/21/25 at 9:00 AM, during revisit #1, to standard of 4/10/25, the survey team entered the facility and observed the posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 5/21/25-Day Shift, current census was 71, shift hours of 7:00 AM-3:00 PM (7-3), and the staff to resident ratio of 1 Certified Nurse Aide (CNA):10.1 Residents. On that same date at 9:14 AM, Surveyor #1 (S#1) met with the LNHA for a brief entrance conference with regard to the revisit, and the LNHA acknowledged that the completion date for the submitted plan of correction (POC), the reason for the revisit, was on 5/20/25. S#1 asked the LNHA for the facility's POCs, and she stated that she would get back to the surveyor with their binder for POCs. At 10:11 AM, S#1 interviewed the Scheduling and Payroll Manager (SPM) who confirmed that today's census was 71 with one bed hold, and that the ratio was 1CNA:10 Residents. The SPM further stated that she was aware of the New Jersey (NJ) Mandated law for staffing, 1CNA:8 Residents for 7-3 shift, 1CNA:10 Residents in the evening (3:00 PM-11:00 PM), and 1CNA:14 Residents at night (11:00 PM-7:00 AM). The SPM acknowledged that the facility's CNA were mostly per diem, and at times not meeting the required staffing. The SPM also acknowledged that the facility follows the NJ Mandated law for staffing as part of their policy and procedure for staffing the facility. At 10:32 AM, S#1 interviewed the Director of Nursing (DON), who informed the surveyor that it was since yesterday (5/20/25) in the afternoon that they were aware that there will be a short staffing problem for today (5/21/25), for 7-3 shift for CNA due to a call out. The DON further stated that she was unable to communicate to the LNHA about the short staff and the need of an agency CNA. The DON also stated that it was only the LNHA who had access to post the need of the facility for CNA. At that same time, the DON informed S#1 that the facility had issues with acquiring the curtains as part of the facility's POC. The DON stated that the facility ordered the curtains and were delivered maybe two weeks ago. The DON further stated that if they were delivered, the expectation was, the damaged curtains should have been replaced. The DON acknowledged the concerns of the surveyors that the concerns from the standard survey on 4/10/25, for curtains were not corrected, and that the facility should provide a homelike environment to residents as facility's policy and protocol. Furthermore, the DON stated that she acknowledged the concerns of the surveyors about environment concerns that included housekeeping and maintenance issues. She further stated that the Maintenance and Housekeeping Departments were working on it, and the expectation was it should have been done by the completion date. The DON also stated that the facility shared a Maintenance Director from another sister facility. Surveyor #2 (S#2) asked the DON why the facility had no full time Maintenance Director, and the DON responded that she would get back to the surveyors why the facility had no full time Maintenance Director, if it was in their facility assessment, and policy. At 11:22 AM, S#1 interviewed the LNHA. The LNHA confirmed that she was the one who can post the need of the facility with regard to CNA in order to have agency fills up their need. The LNHA also stated that the facility can contact her at anytime for that need. The LNHA confirmed that she was not notified yesterday that a CNA called out and for her to be able to find a replacement and post the need of a CNA. At that same time, the LNHA confirmed that she was aware of the facility's policy and procedure with regard to sufficient staffing and homelike environment, and as an administrator, it was her responsibility to ensure that policy and procedures were implemented and followed. The LNHA also stated that she was aware of the completion date on 5/20/25, and that the curtains should have been addressed as well as the other environment concerns, and staffing. Furthermore, Surveyor #3 (S#3) notified the LNHA of the concerns with East wing unit shower room was dirty, molding not fixed near the nursing station. S#2 asked the LNHA why the provided audit tool/forms were signed by the LNHA as checked and no concerns if she was aware that they were not fixed. The LNHA stated that it was the Department heads who visually check the units for environmental tours and the LNHA received the verbal confirmation that they were fixed and no problem. A review of the Position Title: Administrator signed by the LNHA on 7/15/24, revealed: position summary; the administrator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The administrator administers, directs, and coordinates all activities of the center (facility) to assure that the highest degree of quality of care is consistently provided to residents. Essential Functions: 4. Assures all aspects of the center physical plant and environment are maintained at a high level . 6. Follows company administrative policies . Clinical Excellence: 3. Assures that staffing levels in all departments are appropriate to meet the needs of all patients and residents . Center Risk Manager Activities: 1. Responsible for implementation and oversight of the facility's risk management and quality assurance program and committee. Job Skills: 4. Thorough knowledge of administrative management techniques, supervisory practices, procedures and principles. A review of the Facility Assessment, last activity 8/20/24, revealed that the facility's Core Staffing & Personnel Audit, required one Maintenance Staff. A review of the facility's Accommodation of Needs Policy, with a revised date of 2/1/23, revealed: the resident/patient .has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely . Under Process of the policy revealed: .1. The center must provide .1.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . On 5/21/25 at 12:58 PM, the survey team met with the LNHA, DON, and Market Clinical Head, and the Regional Senior Maintenance Director for an exit conference. S#1 notified the facility management of the above findings and concerns. NJAC 8:39-9.2(a); 14.2

Based on interview, record review, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for 3 of 18 residents (Resident #49, #36, #8) reviewed. This deficient practice was evidenced by the following: 1. On 11/28/23 at 11:51 AM, the surveyor observed Resident #49 sitting in a wheelchair in their room. The resident was alert, pleasant, and verbalized no concerns. A review of Resident #49's hybrid (electronic and paper) medical records revealed the following: According to the admission Record (an admission summary) the resident was admitted with diagnoses that included but were not limited to, Dementia, Anxiety Disorder, and Schizophrenia. A physician's order, dated 11/15/2021 read, DO NOT RESUSCITATE (DNR). A physician's order dated 11/15/2021 read, DO NOT INTUBATE (DNI). The resident's paper chart included: an Advance Directives acknowledgement form dated 11/3/21 and signed by the resident's representative, a completed 'PROXY DIRECTIVE- (Durable Power of Attorney for Health Care) form, dated 11/12/2021, and a DNR form, dated 11/1/21. The Social Services Assessment and Documentation, dated 11/9/23, 8/10/23, 5/9/23, 2/8/23, 11/10/22, 8/10/22, and 11/5/21, documented Resident #49 did not have an advance directive and had a full code status. On 11/29/23 at 1:16 PM, the surveyor interviewed the Director of Social Services (DSS) who started two months ago at the facility. The DSS stated upon admission, on a quarterly basis and as needed, advance directives would be reviewed with residents and/or resident representatives. The DSS further explained it would be documented in the Social Services Documentation and Assessment (SSDA) in the electronic health record. The surveyor discussed the concern of the SSDA differing from the resident's advance directives and code status. The DSS documented the SSDA dated 11/9/23. The DSS stated she would review and provide further information. On 11/30/23 at 12:36 PM, the DSS informed the surveyor she followed up and the SSDA was incorrect. The DSS explained she may have documented for the incorrect resident. The DSS was asked about the other SSDA for the resident that also differed from the resident's advance directives. The DSS stated she should have noticed that and stated she could not speak to why the SSDA were not documented accurately. On 12/4/23 at 1:30 PM, the surveyor informed the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the regional nurse of the concerns regarding the accuracy of the assessment, documentation, and review of the identified residents' advance directives. On 12/5/23 at 9:57 AM, the LNHA and the DON met with the surveyors and acknowledged the social workers' documentation were incorrect in comparison to the resident's advance directives and code status. A review of the facility provided policy titled, OPS117 Health Care Decision Making with a revised dated of 3/1/22 read under Practice Standards: .2. Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and/or portable medical orders and determine whether the patient wishes to change or continue these instructions . 3. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The admission record reflected that Resident #8 was admitted to the facility with medical diagnoses which included but not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. A review of the form titled New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) (a written medical order from physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated and signed by the physician on 8/11/23 indicated that Resident #8 wishes to be Full Code (patient wasn't resuscitation and all life saving measures during a medical emergency). On 12/2/23 at 11:09 AM, the surveyor reviewed Resident #8's comprehensive care plan (CCP) with a date revised on 3/14/23 titled, [Resident #8] has an established advanced directive as DNR. (Do Not Resuscitate) which did not reflect the resident's current wishes. On 12/4/23 at 1:24 PM, the surveyor spoke to the Administrator and the Director of Nursing (DON) who verified that Resident #8 was on full code status. There was no further information provided. N.J.A.C. 8:39-9.6 2. On 11/28/23 at 11:51 AM, the surveyor observed Resident #36 in bed with eyes closed. The resident was not alert, or oriented. A review of Resident #36's hybrid (electronic and paper) medical records revealed the following: According to the admission Record (an admission summary) the resident was admitted with diagnoses that included but were not limited to Schizoaffective Disorder, Bipolar Type, Dysphagia, Vascular Dementia, Chronic Kidney Disease, Type 2 Diabetes, Major Depressive Disorder, and anxiety disorder. A physician's order, dated 3/28/23 read, DO NOT RESUSCITATE (DNR). A physician's order dated 3/28/23 read, DO NOT INTUBATE (DNI). A physician's order dated 3/28/23 read, DO NOT HOSPITALIZE (DNH). The resident's paper chart included: POLST (New Jersey Practitioner Orders for Life-Sustaining Treatment) dated 3/28/23 and signed by the resident's surrogate, and the Physician. The Social Services Assessment and Documentation located in the electronic medical record, dated 12/22/22, 3/14/23, and 6/21/23 documented Resident #36 did not have a separate Healthcare order (POST-Physician Order for Scope of Treatment, POLST-Physician Orders for Life Sustaining Treatment, MOLST-Medical Order for Life Sustaining Treatment, etc.) completed.

2. On 12/4/23 at 12:08 PM, the surveyor observed Resident #67 sitting up in a reclining chair in their room being set up by staff for lunch. The surveyor observed a window in the resident's room. The window screen facing the interior of the resident's room was observed with the top area of the screen bent and pulled back from the window. On 12/5/23 at 8:58 AM, the surveyor interviewed the Maintenance Director about the process for addressing maintenance issues in resident areas. The Maintenance Director stated that staff would inform him of any issues, he would assess the problem and fix it. If he was not able to fix the issue, then he would hire someone/vendor to fix the issue. The Maintenance Director stated there was an electronic logging system in which maintenance requests were to be put in by staff for maintenance to address. The surveyor requested the electronic logging system report for 2023. On 12/5/23 at 9:34 AM, the Maintenance Director provided the electronic logging system report for 2023. The Maintenance Director stated he did not do formal rounds on resident's rooms, but when walking around in the facility would note any maintenance concerns. A review of the report revealed there were no entries related to the window screen in Resident #67's room and no entries for the ripped curtain in Resident #54's room. On 12/5/23 at 2:32 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the regional nurse about the concerns for the window screen in Resident #67's room. The LNHA, DON and regional nurse stated they were not aware of the damaged window screen. On 12/6/23 at 9:20 AM, the survey team met with the LNHA, DON and former DON. No additional information was provided. A review of the facility provided policy titled Accommodation of Needs with a revised date of 2/1/23 which read under Policy: The resident/patient (hereinafter patient) has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Under Process it read: .1. The center must provide .1.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . N.J.A.C. 8:39-4.1 (a)11; 31.4 (a), (b); 31.8 (e) Complaint #: NJ00162688, NJ00161423 Based on observation, interview, and record review, it was determined that the facility failed to maintain resident's equipment and living areas in a clean and home like manner. This deficient practice was identified for 2 of 20 residents (Resident #54 and Resident # 67) and was evidenced by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. According to Resident #54's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/27/23, the Brief Interview for Mental Status (BIMS) was not conducted due to resident's cognitive status which revealed that the resident had memory problem with both short-term and long- term memory. The surveyor toured the resident's room on 11/30/23 at 11:18 AM and observed Resident #8's curtain lining ripped and was hanging on the floor. On 12/5/23 at 2:48 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON informed the surveyor that during a room cleaning, the condition of the room is also checked. The DON further stated that the facility had no specific policy on regards to room cleaning. There was no further information provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00162321 Based on observation, interview, and record review it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 4 of 20 residents reviewed, Resident #18, #69, #8, and #170. This deficient practice was evidenced by the following: 1. On 11/28/2023 at 11:59 AM, the surveyor observed Resident #18 in bed with eyes closed. The surveyor observed the resident with a wander guard (wander guard is an electronic device made for the purpose of keeping elderly people or people with dementia from wandering as well as alerting the caregiver whenever his or her patient breaches a perimeter or strays too far) worn on their right ankle. The surveyor reviewed Resident #18's electronic medical record (EMR). Review of Resident #18's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease and Repeated Falls. A review of the November 2023 Physician's order (PO) form for Resident #18 revealed an order for Wander Guard/Wander Elopement Device due to poor safety awareness dated 4/1/2022. Review of Resident #18's Quarterly MDS (QMDS), dated [DATE] reflected under Section P (used to assess physical restraints and alarms used during a seven-day look-back period), under the section Alarms and Restraints. P0200. Alarms - Wander/elopement alarm, was listed as 0. Not used. On 11/28/2023 at 12:15 PM, the surveyor interviewed the East Wing Unit Manager (UM), who stated Resident #18 has a Wander Guard due to the resident wandering throughout the unit and their risk for elopement. On 12/01/2023 at 10:45 AM, the surveyor interviewed the Registered Nurse (RN#1), who completes the MDS assessment. RN#1 stated they had miscoded Resident #18's wander guard. 2. On 12/01/2023 at 11:38 AM, the surveyor reviewed the closed medical record for Resident #69, who was MDS coded for an unplanned discharge. The surveyor reviewed the Discharge Plan Documentation (DPD) created on 10/5/2023 by the Licensed Practical Nurse (LPN). The DPD indicated Resident #69's discharge was a planned discharge. A review of the 10/9/2023 Nursing Progress Note (PN), indicated that Resident #69 Resident is being discharged to home. Medication list and discharge instruction have been given to resident and wife. Vitals are within normal range. Review of the A section of the 10/9/23 MDS for Resident #69 revealed that section A0310 - G. Type of Discharge, documented, 02. Unplanned. There was another option 01. Planned which identified the correct discharge for Resident #69 which was not specified. The surveyor reviewed Resident #69's Discharge MDS on 10/9/2023, under section A, Type of Discharge. Resident # 69 was coded as unplanned discharge. On 12/01/2023 at 11:55 AM, the surveyor interviewed RN#1. RN#1 stated that the discharge was miscoded and should have been coded as planned. The surveyor reviewed the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual updated October 2019. The manual included, A physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The manual instructed for section P to identify all physical restraints that were used at any time (day or night) during the 7-day look-back period and code the frequency of use; Code 0, not used; Code 1, used less than daily; and Code 2, used daily. The steps for assessment and determining physical restraint use included to review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look back period. It further included that any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. On 12/1/2023 at 10:55 AM, the Director of Nursing (DON) provided the surveyor with the two facility policies titled, Patient Security Bracelet with a revision date of 6/1/2021 and Genesis, SNF Clinical System Process - MDS 3.0 with an effective date of 11/29/2021. The Patient Security Bracelet policy states under the policy section, Resident/Patient security bracelets (e.g., Wander guard) will be inspected .the expiration date, placement checks, and function inspections of the bracelet will be documented in the medical record. The Genesis, SNF Clinical System Process - MDS 3.0 states, Best practices: CRC/MDS Coordinator/Designee, Section C. Coordinating with Social Services, Recreation Director, Nutrition Services. 3. Communicates Assessment Record Date (ARD) for patients being discharged . On 12/4/2023 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to review concerns. The DON stated the MDS for Resident #18 and #69 should have been coded correctly and those errors will be corrected. No further information provided. 3. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The FS reflected that Resident #8 was admitted to the facility with medical diagnoses which included but were not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the Q/MDS under Section J1900 for number of falls since admission/entry or reentry to the facility revealed that Resident #8 had one fall with no injury and another fall with major injury. The surveyor interviewed the facility's Registered Nurse/MDS Coordinator (RN/MDS-C) who stated that the MDS section for falls was coded in error. The RN/MDS-C further stated that Resident #8 only had a fall with no injury. The RN/MDS-C clarified the coding error and informed the surveyor that Resident #8 did not have any falls with major injury. 4. On 12/5/23 at 10:43 AM, the surveyor reviewed a closed record. Resident #170 was admitted to the facility on [DATE] and was discharged to another facility on 2/8/23. The surveyor reviewed Resident #170's hybrid medical records. The resident was admitted to the facility with diagnosis that included but were not limited to Quadriplegia secondary to motor vehicle accident, Neurogenic Bladder, Hypertension, Spinal Stenosis and Depression. The surveyor reviewed the discharge MDS assessment dated [DATE] under Section A0310G indicated 2. Unplanned. A review of the progress notes dated 11/1/22 documented by the resident's Nurse Practitioner (NP) which indicated that the NP had a discussion with the resident's daughter regarding a recommendation for the resident to be transferred to the psychiatric hospital for medication management due to increase in behaviors. Further review of the progress notes dated 11/3/23 documented that Resident #170 was transferred to the psychiatric hospital for behavior modification. On 12/4/23 at 1:10 PM, the surveyor interviewed the MDS Coordinator who stated that the resident's discharge was considered unplanned. She did not provide any further information. On 12/4/23 at 1:24 PM, the surveyor discussed the above concern to the facility's LNHA and DON. The surveyor questioned if the resident's discharge was considered planned since it was discussed by the NP and the family member 2 days before Resident #170 was transferred to the psychiatric hospital. No further information was provided. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . For unplanned discharge includes, for example: Acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acute-care admission is required based on emergency department evaluation; or Resident unexpectedly leaving the facility against medical advice; or Resident unexpectedly deciding to go home or to another setting (e.g., due to the resident deciding to complete treatment in an alternate setting.) NJAC 8:39-11.1, 11.2(e)(1)

Complaint #NJ00158121 Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 1 of 20 residents reviewed for comprehensive care plans (Resident #270). This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #270 which revealed the following: The admission Minimum Data Set (MDS), an assessment tool to facilitate care, dated 7/29/22, indicated the resident had diagnoses that included but were not limited to, heart failure, hypertension, Diabetes Mellitus, and End Stage Renal Disease. The facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored an 8 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS documented the resident was totally dependent with eating, bathing, and locomotion. Resident #270 also required extensive assistance with transfers and bed mobility. A review of the resident's care plan (CP) revealed a care plan, dated 7/29/22 related to the resident's daily routine which read, While in the facility resident/patient states it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. There was no goal indicated in the CP. The interventions were not completed, with blank areas and individualized to Resident #270 and included the following: .I like to snack between meals and prefer __________ .It is important for me to have reading materials such as _____ .I keep up with the news by discussions with another person, group discussions, listening to the radio, reading magazines, reading the newspaper, using the computer, watching TV, and/or ____. (Delete all that do not apply) .I like to participate in ______ (specify leisure options) with groups of people .I like to use a computer, do crosswords/puzzles/games, listen to music, look out the window, lay down/rest, meditate, pray, read, think, watch TV/movies, and/or other _______. (Delete location information if initial assessment.) .It is important for me to go outside when the weather is good and enjoy eating/drinking, playing games or sports, gardening, napping, sitting, smoking, talking/visiting, tanning, walking, bird watching/wildlife observing, working, and/or ______. (Delete all that do not apply) .I would benefit from accommodation for physical limitations by using demonstration, adaptive materials/equipment, physical prompts and/or others _____. (Delete all that do not apply) . On 12/6/23 at 11:45 AM, the surveyor interviewed the Director of Nursing (DON) about the concerns for Resident #270's CP not being resident centered omitting any of the resident's preferences. The DON acknowledged the CP was not complete or resident centered as the noted intervention entries were blank. On 12/6/23 at 1:00 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the DON, the previous DON and the regional nurse were informed of the concerns for Resident #270's CP not being comprehensive, and resident centered. No further information was provided by the facility. A review of the facility's provided facility titled, Person-Centered Care Plan with a revised date of 10/24/22, which under Purpose read: .To attain or maintain the patient's highest practicable physical, mental and psychological wellbeing .To promote positive communication between patient, patient representative, and team to obtain the patient's and resident representative input into the plan of care, ensure effective communication, and optimize clinical outcomes . NJAC 8:39- 11.2 (d); 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan for 2 of 20 residents reviewed, Resident #54 and Resident #8. This deficient practice was identified by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but was not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. According to Resident #54's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/27/23, the Brief Interview for Mental Status was not conducted due to the resident's cognitive status which revealed that the resident had memory problems with both short-term and long- term memory. Further review of the Q/MDS under Section J1800 for any falls since admission/entry or reentry to the facility revealed that Resident #54 had two or more falls with no injuries while a resident at the facility. The facility's Director of Nursing (DON) provided a copy of the fall incident report to the surveyor. A review of the form revealed that Resident #54 had a fall incident on 8/7/23 and 12/1/23. The surveyor reviewed the residents comprehensive care plan (CP) which reflected a CP for Resident #54 titled, [Resident's name] is at risk for falls: related to cognitive loss, lack of safety awareness, impaired mobility. with a revision date of 2/28/21. A review of the list of interventions did not reflect that the CP was revised on any of the fall dates (8/7/23 and 12/1/23) nor updated after each fall incident. 2. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The AR reflected that Resident #8 was admitted to the facility with medical diagnoses which included but was not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the Q/MDS under Section J1900 for number of falls since admission/entry or reentry to the facility revealed that Resident #8 had one fall with no injury while the resident was at the facility. The facility's DON provided a copy of the fall incident report to the surveyor. A review of the form revealed that Resident #8 had a fall incident on 9/6/23. The surveyor reviewed the resident's comprehensive CP which reflected a CP for Resident #8 titled, [Resident's name] is at risk for falls r/t impaired mobility, above knee amputation, History of falls with a revision date of 5/11/23. A review of the list of interventions did not reflect that the CP was revised nor updated after the fall incident (9/6/23). A review of the facility's policy and procedure titled, Falls Management under Practice Standards #1. All patients will be assessed for risk of falls upon admission, with reassessments routinely (e.g., quarterly, post-fall) performed to determine ongoing need for fall prevention precautions. #2. 2.1 Adjust and document individualized intervention strategies as patient condition changes. The surveyor interviewed the DON who stated that whenever a resident had a fall incident, the facility will hold a care conference to discuss what new interventions should be put in place to prevent further falls. The surveyor requested for a documentation from the care conference for both fall incident of Resident #54. This was not provided by the facility. On 12/5/23 at 9:56 AM, the surveyor met with the facility's Licensed Nursing Home Administrator and the DON regarding the above concerns. There was no additional information provided. NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The AR reflected that Resident #8 was admitted to the facility with medical diagnoses which included but not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. A review of the form titled, Consultant Pharmacist's Medication Regimen Review dated 8/8/23 and 10/11/23 indicated No recent fasting lipid panel can be found in the record. Please consider monitoring a fasting lipid panel next lab day and then once yearly thereafter if WNLs. (Within normal limits) A review of the Order Summary Report revealed a physician's order dated 10/16/23 with a start date of 10/19/23 for Fasting Lipid Panel one time a day every 12 month (s) starting on the 19th Further review of Resident #8's medical records did not reveal any laboratory results that the ordered test was done according to physician's order. On 12/4/23 at 1:24 PM, the surveyor discussed the above concern to the facility's Licensed Nursing Home Administrator and Director of Nursing. The DON stated that the blood work was not according to physician's order. There was no further information provided. NJAC 8:39-27.1 (a) NJAC 8:39-29.2 (a) NJAC 8:39-11.2 (b); 29.2(d) Complaint #: NJ00162986 Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to: accurately documenting the administration of medication for 4 out of 20 residents, Resident #24, #36, and #58 as well as transcribing a physician's order for blood work for 1 out of 20 residents reviewed, Resident #8. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 11/30/23, the surveyor reviewed the use of Tramadol 50 mg for Resident #24. The surveyor reviewed the Controlled Medication Utilization Record (CMUR), a medication declining sheet for Resident #24's Tramadol 50mg (pain medication), delivered by the provider pharmacy on 4/16/23. The surveyor reviewed Resident #24's hybrid medical records. The admission Record (AR) (an admission summary) reflected that Resident #24 was admitted to the facility with medical diagnoses which included but was not limited to Disorder of Circulatory, Colostomy, Embolism and Thrombosis, Hyperlipidemia, Acquired Absence of Right Upper Limb Below Elbow. According to Resident #24's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 12/22/23, the Brief Interview for Mental Status (BIMS) was not conducted due to the resident's cognitive status which revealed that the resident had memory problems with both short-term and long- term memory. When comparing the dates documenting on the CMUR and the electronic medication administration record (eMAR) for May 2023 and July 2023 discrepancies were noted. When reviewing the CMUR, the surveyor noted an entry for 1 tablet of Tramadol 50 mg removed from stock for administration to Resident #24 on 5/16/23. Review of the May 2023 eMAR fails to document the administration of the medication to Resident #24 for 5/16/23. When reviewing the CMUR, the surveyor noted an entry for 1 tablet of Tramadol 50 mg removed from stock for administration to Resident #24 on 7/2/23. Review of the July 2023 eMAR fails to document the administration of the medication to Resident #24 for 7/2/23. 2. On 11/30/23, the surveyor reviewed the use of Lorazepam 0.5mg for Resident #36. The surveyor reviewed the CMUR sheet for Resident #36's Lorazepam 0.5mg (anxiolytic), delivered by the provider pharmacy on 1/14/23. The surveyor reviewed Resident #36's hybrid medical records. The AR reflected that Resident #36 was admitted to the facility with medical diagnoses which included but was not limited to Schizoaffective Disorder, Dysphagia, Vascular Dementia, Chronic Kidney Disease, and Generalized Anxiety Disorder. According to Resident #36's Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 9/21/23, the BIMS was not conducted due to the resident's cognitive status which revealed that the resident had a severely impaired cognition. When comparing the dates documenting on the CMUR and the electronic medication administration record (eMAR) for February 2023 discrepancies were noted. When reviewing the CMUR, the surveyor noted an entry for 1 tablet of Lorazepam 0.5mg removed from stock for administration to Resident #36 on 2/10/23, 2/11/23 and 2/16/23. Review of the February 2023 eMAR fails to document the administration of the medication to Resident #36 for 2/10/23, 2/11/23 and 2/16/23. 3. On 11/30/23, the surveyor reviewed the use of Alprazolam 0.25mg for Resident #58. The surveyor reviewed the CMUR sheet for Resident #358's Alprazolam 0.25 mg (anxiolytic), delivered by the provider pharmacy on 9/8/23. When comparing the dates documenting on the CMUR and the electronic medication administration record (eMAR) for October2023 discrepancies were noted. When reviewing the CMUR, the surveyor noted an entry for 1 tablet of Alprazolam 0.25mg removed from stock for administration to Resident #58 on 10/2/23, 10/7/23 and 10/29/23. Review of the October 2023 eMAR fails to document the administration of the medication to Resident #36 for 10/2/23, 10/7/23 and 10/29/23. The surveyor reviewed Resident #58's hybrid medical records. The AR reflected that Resident #58 was admitted to the facility with medical diagnoses which included but was not limited to Traumatic Subdural Hemorrhage with loss of Consciousness, Unspecified Fracture of Shaft of Humerus, Left Arm, Unspecified Severe Protein-Calorie Malnutrition, Dysphagia, and History of Malignant Neoplasm of Thyroid and Stomach. According to Resident #58's A/MDS) dated [DATE], the BIMS was not conducted due to the resident's cognitive status which revealed that the resident is rarely/never understood. On 11/30/23 at 12:40 PM, the surveyor interviewed the DON who stated that all controlled substances removed from stock should be signed as removed on the declining CMUR sheet and then signed in the eMAR as administered to the resident. On 12/6/23 at 10:14 AM, the surveyor interviewed the Consultant Pharmacist (CPHARMD) who stated that she randomly picks CMUR sheets to audit for accuracy of inventory. She explained that she does not compare the documentation on the CMUR with the documentation of the administration on the eMAR to make sure that both are aligned.

2. On 11/28/23 at 11:39 AM, the surveyor observed Resident #1 lying in bed with their eyes closed and non-verbal. The surveyor reviewed Resident #1's hybrid medical records which revealed the following: According to the AR the resident was admitted to the facility with diagnoses which included but were not limited to, Alzheimer's Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Hypertension. A review of the Physician Progress Notes revealed that Resident #1's primary physician last documented that he had visited and examined the resident on 10/21/23 and 3/21/23. There was no documentation between March 2023 and October 2023 that the primary physician conducted alternating face to face visits with Resident #1 while working in collaboration with the nurse practitioner (NP) visits. On 12/6/23 at 11:47 AM, the surveyor interviewed the physician via a telephone call who acknowledged that he did not document physician's progress notes at least every 60 days. On 12/6/23 at 1:00 PM, the surveyor discussed the above concerns with the facility's Licensed Nursing Home Administrator and Director of Nursing. No further information was provided by the facility. N.J.A.C 8:39-23.2(d) Based on interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 2 of 20 (Resident #8 and Resident #1) reviewed for physician visits and was evidenced by the following: 1. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The admission Record (AR) (an admission summary) reflected that Resident #8 was admitted to the facility with medical diagnoses which included but were not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 10/14/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. A review of the Physician's progress notes reflected the following: 6/23/23 Physician progress notes completed by Advanced Practice Nurse (APN). 7/7/23 Physician progress notes completed by APN. 7/31/23 Physician progress notes completed by APN. 8/30/23 Physician progress notes completed by APN. 9/26/23 Physician progress notes completed by APN. There was no documented evidence that the physician visited and examined Resident #8 at least every 60 days. On 12/4/23 at 1:24 PM, the surveyor discussed the above concerns to the facility's Licensed Nursing Home Administrator and Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 11/30/23 at 9:40 AM, the surveyor observed LPN#1 administer medication to Resident #53. Resident #53 was due to receive the medication Probiotic Oral Capsule 250 MG (Saccharomyces boulardii). LPN#1 stated it was not in the medication cart and that it was not an available back up medication in the facility. LPN#1 stated she would re-order from the pharmacy and signed the medication on the electronic Medication Administration Record (eMAR) as not given. The Surveyor reviewed the electronic medical record of Resident #53 which revealed the following: A physician's order, dated 11/24/23 read, Probiotic Oral Capsule 250 MG (Saccharomyces boulardii) Give 1 capsule by mouth two times a day for prophylaxis for 8 Days. A review of the November 2023 eMAR documented the Probiotic Oral Capsule 250 MG (Saccharomyces boulardii) was signed by the nurses as administered to the resident. On 11/30/23 at 11:09 AM, the surveyor interviewed LPN#1 who stated she re-ordered medication from pharmacy and confirmed the medication was not part of the facility's house stock. LPN#1 stated she could not speak to the previous entries being signed as administered and directed the surveyor to the unit manager for further information. On 11/30/23 at 11:37 AM, the surveyor interviewed a pharmacist (RPh) at the facility's provider pharmacy about the Probiotic medication order and delivery. The RPh stated the order was placed to the pharmacy for the medication and was cancelled by the pharmacy as it was an over the counter medication not covered by the pharmacy. She further stated the pharmacy's billing dept faxed to the facility on [DATE] a form explaining that the medication was not covered. There was not further requests by the facility related to the medication documented by the pharmacy. On 11/30/23 at 12:55 PM, the surveyor asked the regional nurse to provide further information for the probiotic medication ordered on 11/24/23 that was not available. On 12/4/23 at 1:30 PM, the surveyor informed the DON, Licensed Nursing Home Administer (LNHA), and the regional nurse of the concerns for the probiotic medication, that was not delivered and not available in the medication cart. On 12/6/23 9:17 AM, the survey team met with the DON, LNHA, and previous DON. The previous DON stated they have acidophilus (an alternative probiotic) in stock in the facility and the nurses had been giving that medication. The DON and previous DON acknowledged the acidophilus was different from the ordered entered on 11/24/23. The previous DON stated the nurse did not select the appropriate probiotic order when entering it into the electronic medical record. The previous DON stated the order was clarified on 11/30/23 after the surveyor's inquiry. A review of the facility provided policy titled, 6.0 General Dose Preparation and Medication Administration with a revised date of 1/1/22, under Procedure it read, .3.7 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration order .4.1 Facility staff should: .4.1.2 Confirm that the MAR reflects the most recent medication order . NJAC 8:39-29.2; 29.7 Complaint #: NJ00162986 Based on observation, interview, and record review, it was determined that the, monitored, and reviewed. This deficient practice was identified for 2 of 2 units reviewed during unit inspections. This deficient practice was evidence by the following: 1. On 11/28/23 at 10:00 AM, the surveyor proceeded to perform unit inspections of the facility. While on the [NAME] Unit, the surveyor examined the declining Controlled Medication Utilization Record (CMUR) sheet for Oxycontin 10 mg belonging to Resident #2. The medication was delivered by the provider pharmacy to the facility on 8/18/23. The CMUR documented that on 9/2/23 there were no more tablets left. The CMUR then had an additional line signed with a date of 9/18/23 that there was 1 tablet left in the inventory. The surveyor interviewed the Licensed Practical Nurse (LPN) #1 who was utilizing the medication cart and asked to see the medication. When LPN#1 inspected the locked control substance area, she could not find the one tablet of Oxycontin 1mg and could not explain why the sheet had one tablet documented in the inventory. The surveyor informed the Director of Nursing (DON) of this discrepancy. On 11/29/23 at 12:45 PM, the surveyor discussed the matter with the DON who informed the surveyor that the Oxycontin was signed off on CMUR sheets for the date of 9/18/23 at 9:00 AM. The sheet dated with a delivery date of 8/18/23, did not have 1 left even though the 1 was documented after the sheet already showed 0 was left. The DON presented another CMUR sheet dated with a provider delivery date of 9/14/23 showed that 1 was removed from this sheet on 9/18/23 at 9:00 AM duplicating the documentation on the 8/18/23 sheet. The DON stated that the CMUR sheet with the provider pharmacy delivery date of 8/18/23 should have been removed from the active book. The DON could not explain why this CMUR with one tablet listed in the inventory, was still active even though the medication was no longer there. 2. During the facility annual survey, the surveyor investigated a facility reportable that related to the possible loss of a controlled substance, Lorazepam 0.5 mg belonging to Resident #36. On 11/28/23 at 12:40 PM, the surveyor discussed a reportable event that was sent to the New Jersey Department of Health (NJDOH) on 2/10/23 at 2:30 PM with the DON. The reportable event related to a medication cart narcotic audit completed by the Consultant Pharmacist (CPharmD) who found that the actual count of the Lorazepam 0.5mg was 14 yet the CMUR for Resident #36 showed 15 tablets left. The DON presented the facility investigation of the incident to the surveyor. The DON explained that the conclusion of the investigation was that the nurse on duty had forgotten to document the removal of the Lorazepam 0.5mg in the CMUR, as well as not documenting the administration of the Lorazepam 0.5mg in the electronic medication administration record (eMAR). During the interview with the DON, the DON revealed that the Licensed Practical Nurse signed the CMUR for the removal of the Lorazepam 0.5 mg at 4:30 PM and documented in the eMAR at 4:55 PM, both after the nurse's shift had ended. Review of the Consultant Pharmacist Med Room and Med Cart Audit, Spot check of 3 controlled items for count. Does inventory count match? N. Review of the documentation under, Comments: Lorazepam card with 14, count down sheet indicated 15. DON aware. On 12/5/23 at 1:19 PM, the surveyor interviewed the Consultant Pharmacist (CPHARMD) who recapped the discrepancy. The CPHARMD explained that she picks 3 random controlled substance medication to audit monthly on each unit. The CPHARMD stated, This should not be happening with narcotics. 3. On 11/28/23 at 12:40 PM, the surveyor reviewed the CMUR sheet for Tramadol 50 mg belonging to Resident #24. The CMUR sheet was noted having 3 tablets Wasted on 7/11/23, 8/17/23 and 9/24/23. Review of the three dates revealed that 7/11/23 and 8/17/23 both had 2 signatures with one of the signatures being a witness to the destruction. The 9/24/23 destruction only had one signature of a nurse. On 11/29/23 at 12:45 PM, the surveyor discussed the matter with the DON who informed the surveyor that she never noticed that the 9/24/23 Wasted did not have a witnessed signature. The DON explained that the nurse who signed the Wasted was no longer employed by the facility. The surveyor reviewed the CMUR sheet with the DON for clarification why the nurses Wasted Tramadol 50mg on three different occasions and if she was aware of the reason. The DON could not explain why Tramadol was wasted on three different dates. On 12/6/23 at 10:14 AM, the surveyor interviewed the CPHARMD who stated that she did not notice the missing second signature for the Wasted Tramadol 50mg on 9/24/23. If I had noticed, I definitely would have pointed that out to the DON. Review of the Routine Reconciliation of Controlled Substances under Procedure 2. The reconciliation should be performed by two licensed nurses or a nurse and authorized and licensed healthcare professional. Under 8. Before destruction or disposal of controlled substances the assigned nurse and witness should count the number of doses to be destroyed to each declining inventory sheet and document the doses to be destroyed as correct. Review of Controlled Drugs: Management of Destruction: Two licensed professionals are required to destroy and document destruction of controlled substances per state regulation.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices of appropriately performing hand hygiene and disinfection of a blood pressure cuff used during medication administration for 1 of 4 nursing staff members observed during medication passage on 1 of 2 units observed. This deficient practice was evidenced by the following: On 11/30/23 at 9:02 AM, the surveyor observed Registered Nurse # 1(RN#1) administer medication to Resident #41. RN#1 sanitized his hands with alcohol-based hand rub (ABHR) appropriately before entering the room to check the resident's blood pressure. RN#1 did not disinfect the blood pressure machine prior to entering the room and checking Resident #41's blood pressure. Prior to exiting Resident #41's room, RN#1 went to wash his hands at the resident's sink. RN#1 placed paper towels on the side of the sink and turned on the water faucet. He applied soap, wet his hands with water, lathered his hands for 6 seconds outside the running water prior to rinsing, dried his hands with a paper towel that was on the side of the sink, and used another paper towel to turn off the faucet. RN #1 proceeded to exit the room to prepare Resident #41's medication. On 11/30/23 at 9:19 AM, the surveyor observed RN#1 prepare the medication and wash his hands upon reentering the resident's room to administer the medication. RN#1 turned on the faucet, wet his hands with water from the sink, applied soap, lathered his hands for 3 seconds outside the running water prior to rinsing, dried his hands with a paper towel from the dispenser on the wall and used another of the paper towels to turn off the faucet. On 11/30/23 at 9:25 AM, the surveyor observed RN#1 administer the resident's medication and went to get Resident #41 another cup of water from the medication cart. Prior to exiting the room, RN#1 went to wash his hands at the sink. RN#1 turned on the faucet, wet his hands with water from the sink, applied soap, lathered his hands for 8 seconds outside the running water prior to rinsing, dried his hands with a paper towel from the dispenser on the wall and used another of the paper towels to turn off the faucet. On 11/30/23 at 9:28 AM, the surveyor observed RN#1, upon completing medication passage to Resident #41 and prior to exiting the room wash his hands at the sink. RN#1 turned on the faucet, wet his hands with water from the sink, applied soap, lathered his hands for 3 seconds outside the running water prior to rinsing, dried his hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet. RN#1 was observed signing the electronic medication administration record (eMAR) (indicating medication administration to Resident #41 was completed). RN #1 was not observed disinfecting the blood pressure machine after utilizing the blood pressure cuff on Resident #41. On 11/30/23 at 11:15 AM, the surveyor interviewed RN#1 regarding handwashing and disinfecting reusable medical equipment. RN#1 explained that hands should be washed at least 30 seconds and was able to explain to the surveyor the correct steps of handwashing. In addition, RN#1 explained that all reusable medical equipment, such as a blood pressure machine should be disinfected before and after use with residents. The surveyor shared the observations of washing his hands for less than 20 seconds and not disinfecting the blood pressure cuff with RN#1. RN#1 explained he did not realize his hand washing time was so short and acknowledged the blood pressure machine should have been disinfected. On 12/4/23 at 1:30 PM, the surveyor informed the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) and previous DON of concerns related to RN#1 observations of handwashing for less than 20 seconds and lack of disinfecting the reusable blood pressure machine. No verbal response by the facility was noted at this time. On 12/5/23 at 10:33 AM, the DON provided the hand hygiene policy. The surveyor interviewed the DON who stated that all staff should wash their hands for at least 20 seconds. A review of the facility provided policy titled IC203 Hand Hygiene, last revised on 9/29/2020, read under Perform Hand hygiene: Before and after resident care .After contact with the resident's environment. Under Hand Hygiene Techniques, it read: .Rub hands vigorously outside the stream of water for 15-20 seconds covering all surfaces of the hands and finger . A review of the facility provided policy titled IC201 Cleaning and Disinfecting, last revised on 10/24/22, read under Purpose: .To ensure reusable medical equipment is cleaned and disinfected appropriately . Under Practice Standards it read: .5.3 multi-patient equipment must also be cleaned/disinfected between patients . On 12/6/23 at 9:17 AM the surveyor met with the LNHA, DON and previous DON for any further information. No further information was provided by the facility. N.J.A.C. 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documents it was determined that the facility failed to provide documented evidence that a resident was notified in advance and in writing of two room changes with rationales for the changes. This was evidenced for 1 out of 1 resident reviewed for room changes (Resident # 26). This deficient practice was evidenced by the following: On 2/28/22 at 12:02 PM, the surveyor observed Resident #26 in bed, alert and willing to be interviewed. Resident #26 stated that he/she was previously in room [ROOM NUMBER]P which was a private room. The resident further stated that after returning from a doctor's appointment he/she was not returned back to room [ROOM NUMBER]P and was transferred to a semi-private room [ROOM NUMBER]B. The resident stated that there was no prior notification of the room change and the reason for the transfer. Resident #26 stated that he/she was satisfied with the current room status and roommate. The resident also stated that he/she was in contact with the State Ombudsman representative about the room changes. A review of the Significant Change Minimum Data Set (MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 14 which reflected an intact cognition. A review of Resident #26's census and room status tracking, reflected that the resident was in room [ROOM NUMBER]P, a private room on the [NAME] wing as of 9/8/21 until 2/7/22. The resident was moved to room [ROOM NUMBER]A, a semi-private room on the [NAME] wing on 2/7/22 until 2/9/22. The resident was moved to room [ROOM NUMBER]B, a semi-private room on the East wing on 2/9/22. A review of Progress Notes for the month of September 2021 and February 2022 did not reflect documented evidence of room changes for Resident #26. A review of the Care Plan did not reflect documented evidence for room changes for Resident #26. On 3/02/22 at 9:48 AM, the surveyor interviewed the East wing Licensed Practical Nurse (LPN) who stated that Resident #26 has resided on the East wing for approximately the last two weeks. The LPN stated that the resident was previously in room [ROOM NUMBER] on the [NAME] wing. She stated that she worked on the [NAME] wing the day Resident #26 was moved. The LPN stated that the resident requested the move due to conflict with the roommate. She further stated that the resident was taken to see the room before being transferred and was agreeable. The LPN stated that this should have been documented and acknowledged that there was no documented evidence in the progress notes. On 3/07/22 at 11:35 AM, the surveyor interviewed the State Ombudsman Representative ([NAME]) who stated that she was at the facility to investigate a complaint for Resident #26 related to a report of a room change that was made without notifying the resident. The [NAME] also stated that the resident had stated that he/she was happy with the current room at this time. On 3/07/22 at 12:50 PM, the surveyor interviewed the Licensed Nursing Home Administrator/Center Executive Director (CED) in the presence of the survey team, the Clinical Lead Specialist Registered Nurse (CLSRN), and the Director and Assistant Director of Nursing from a sister facility. The CED stated that we have been informing the resident about a room change since the summer and I didn't get that involved with the case. The CLSRN requested time to investigate. On 3/09/22 at 11:05 AM, the surveyor interviewed the CLSRN. She stated that she reviewed the medical record for Resident #26 and found no documented evidence regarding room changes. She stated that the resident should have been notified in advance and in writing of the room change as well as the reason for the room change. The CLSRN stated that the facility policy included a form used for notification and provided this to the surveyor. She further stated that this should have been documented, and a copy of the form should be part of the medical record. The CLSRN also stated that the resident should have been shown the room as well as meet the roommate prior to the move. She stated that if the resident was not in agreement that there should have been a team meeting with the resident to come to a resolution. The CLSRN stated that the social worker would typically be involved with this process, however, a nurse could as well. She also stated that there had been no investigations on this matter. A review of the facility policy Room Transfers, with a review/revision date of 3/9/20 reflected the following processes: 5. If the Center has a need to move a patient, the patient's needs are to be met in a different room and the patient agrees to transfer: 5.1 Give the patient/resident representative as much notice as possible including the reason for the move. 5.2 Give patient/resident representative a copy of the Room Transfer/New Roommate Change Form.; 5.2 Offer a choice of rooms, if possible. 5.4 Provide an opportunity for the patient/resident representative to see the new location and meet the new roommate. 5.5 If patient/resident representative refuses to transfer, document refusal on the Room Transfer/New Roommate Change Form. 11. Maintain the Room Transfer/New Roommate Change Form (electronic or non-electronic) .in the medical record. A review of the facility policy Resident Rights Under Federal Law, with a review/revision date of 3/1/22 reflected the purposes as follows: To treat each resident with respect and dignity and care for each resident in a manner and in and environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the resident's goals , preferences, and choices into care. To recognize each resident's individuality as well as honor and value his/her input. To protect and promote the rights of the resident. NJAC 8:39-4.1 (a)(13)

Based on resident and facility staff interviews it was determined the facility failed to allow for open visitation which included children under the age of 18 for Resident #18, 1 of 4 residents interviewed for visitation and was evidenced by the following: On 03/02/22 at 10:00 AM, the surveyor conducted a resident council meeting. Resident #18 told the surveyor that their grandson had not been allowed to visit since the pandemic. Resident #18 stated the facility said no visitor under the age of 18. Resident #18 told the surveyor, The administrator does not like children. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 8/23/21, Section I, titled medical diagnoses showed the resident had medical diagnoses which included Diabetes, Heart failure, and High blood pressure, with a Brief Interview of Mental Status score of 14, meaning the resident was cognitively intact. On 03/02/22 at 11:03 AM, the surveyor interviewed the facility receptionist regarding visitation. The receptionist was responsible for letting people in the building and doing the covid screening which included temperature checks at the time of entry. The receptionist stated that open visitation was occurring at the facility. The surveyor questioned if children were allowed to visit residents and the receptionist said, the administrator (Center Executive Director/CED) said no children under the age of 18 are allowed to visit. On that same date and time, the receptionist then directed the surveyor to the CED. At the same time the surveyor interviewed the CED who told the surveyor that any age can visit unless they are symptomatic. But the CED did not speak to the denial of Resident #18 grandson being restricted. On 03/08/22 at 11:28 AM, the surveyor interviewed the Clinical Lead Specialist Registered Nurse (CLSRN) regarding visitation and restricting children. The regional nurse told the surveyor, Visitation should have been open to include children under 18, I don't know why children weren't allowed, probably lack of education. On 03/09/22 at 3:03 PM, the surveyor reviewed the policy titled, Visitation: Universal Guidance, dated 11/23/21. The policy stated that with few limitations, visitation is now allowed for all residents at all times, while continuing to follow all core principles of COVID-19 infection. The policy read that if the facility was in an outbreak visitors must still be allowed in the facility. The policy did not address any age restrictions for visitors. NJAC 8:39-4.1 (23)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of medical records, and other pertinent facility documents, it was determined that the facility failed to notify the representative of the New Jersey Long Term Care Ombudsman about the resident's transfer to the hospital. The deficient practice was identified for 2 of 2 residents reviewed for notifications during hospitalization, Residents #43 and #36. The deficient practice was evidenced by the following: 1. A review of resident's admission Record face sheet indicated that Resident #43 had diagnoses which included but were not limited to: End stage renal disease, Hypertension and Pulmonary fibrosis. A review of the Significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/15/21 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. A review of the nurse's notes (NN) dated 11/8/21 at 07:37 PM revealed that Resident #43 was admitted to the hospital with a diagnosis of left hip fracture and the family was notified of the hospitalization. The resident returned to the facility on [DATE]. Further review of the NN dated 12/22/21 at 11:27 PM revealed that the resident was admitted for abnormal lab results and the family was notified of the hospitalization. The resident returned to facility on 12/31/21. The resident was hospitalized again on 1/22/22 with a diagnosis of hyperkalemia and urinary retention, and family was notified of hospitalization. The resident returned to facility on 2/7/22. Further review of medical records revealed that there was no documentation that the Ombudsman was notified of the unplanned hospitalizations. On 3/2/22 at 11:15, the surveyor interviewed the Registered Nurse (RN) who stated that nurses notify the family of hospitalizations, and the social worker notifies the Ombudsman, but they have not had a social worker since December 2021. On 3/2/22 at 1:00 PM, the surveyor met with the Clinical Lead Specialist Registered Nurse (CLSRN) and asked for the Ombudsman's notification of residents who were discharged for the past 3 months. The CLSRN stated that there was no notification and would not be able to provide documentation of Ombudsman notification for the past 3 months. She acknowledged that the facility did not notify the Ombudsman of Resident #43's unplanned hospitalizations. On 03/07/22 at 12:50 PM, during the followo up interview of the surveyor, the CLSRN stated that it was the Business Office Manager's (BOM) responsibility to notify the Ombudsman office of resident's hospitalization. On 3/8/22 at 09:25 AM, the surveyor interviewed the BOM in the presence of another surveyor who stated that she only found out on 3/4/22 that the Ombudsman notification was her responsibility. She further stated that she would update the monthly discharge tracking list daily and e-fax it the next business day after the end of each month. The BOM sent the January and February 2022 discharge lists to the Ombudsman via e-fax on 3/7/22 and the surveyors received a copy of the lists with the e-fax confirmation. 2. A review of the admission Record reflected that Resident #36 was admitted in the facility had diagnoses which included but not limited to Heart failure, Gastrostomy status, and Type 2 Diabetes mellitus without complications. A review of the 12/15/21, Quarterly Minimum Data Set (QMDS), indicated a BIMS score of 8, which reflected that the resident's cognition was moderately impaired. A review of the NN dated 2/3/22 revealed that Resident #36 was discharged to the hospital from the facility for peg tube replacement and family was notified of the hospitalization. The resident returned to the facility on 2/17/22. A review of the resident's physician notes dated 2/18/22 indicated that the resident was readmitted to the facility after acute hospitalization for peg dislodgement. Further review of medical records revealed that the Ombudsman was not notified of the unplanned hospitalization. On 3/8/22 at 9:25 AM, the surveyors met with the BOM and asked her on who was responsible of notifying the ombudsman of residents' hospital transfer and she stated, I am. She also informed the surveyors that she was made aware of the responsibility by the CLSRN on 3/4/22. The BOM stated that she had been working in the facility for 2 years and she was not aware that she was responsible for notifying the ombudsman of residents' discharge to hospital until another surveyor's inquiry. She informed the surveyor that she did not notify the ombudsman of Resident #36 discharge to the hospital and could not provide a receipt of notification to the surveyors. A review of policy titled Discharge and Transfer under 5. For Patients Transferred to a Hospital bullet 5.1.1 indicated that copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such in a list of patients on a monthly basis or per state requirements. No additional documentation was provided to the survey team during the survey. NJAC 8:39-4.1 (a)31

Based on interview and record review, it was determined that the facility failed to provide written notification of the facility's policy for bed hold to the resident/resident's representative at the time of transfer from the facility to the hospital. This deficient practice occurred to 1 of 1 resident reviewed, Resident#36 for hospitalization and was evidenced by the following: A review of the admission Record (an admission summary) reflected that Resident #36 was admitted in the facility with diagnoses which included but not limited to Heart failure, Gastrostomy status, and Type 2 Diabetes mellitus without complications. It was also indicated that the resident had family listed on contact list. A review of the 12/15/21, Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 8, which reflected that the resident's cognition was moderately impaired. A review of nurse's notes dated 2/3/22 reflected that the resident was discharged to the hospital from the facility for peg tube replacement. The resident returned to the facility on 2/17/22. The surveyor could not find documented evidence that the facility had provided its bed hold policy to the resident's representative at the time of transfer, or in cases of emergency transfer, within 24 hours. On 3/7/22 at 12:35PM, the survey team met with the facility Licensed Nursing Home Administrator/Center Executive Director (CED), Director of Nursing (DON) and Assistant Director of Nursing (ADON) from another facility, and Clinical Lead Specialist Registered Nurse (CLSRN). The CED stated that it was the facility Business Office Manager's (BOM's) responsibility to notify the resident's representative of the bed hold policy. On 3/8/22 at 9:25 AM, the surveyor met with the facility BOM in the presence of another surveyor, who stated that she was responsible for providing written notice of the bed hold policy to the resident or resident's representative(s) upon resident's discharge to the hospital via email, fax, or hard copy by mail within 24 hours. At that same date and time, the BOM could not provide documentation that the Bed Hold Policy Notice and Authorization form was given to the resident's representative and stated, I don't have it, I probably skipped it. On 3/8/22 at 11:27 AM, the admission Director from another facility stated to the surveyor that there were no notices related to bed hold policies given in advance to the resident or resident's representative(s) of any transfer such as information provided in the admission packet. On 3/9/22 at 10:40AM, the CLSRN met with the survey team. She was made aware that the facility could not provide evidence that the facility provided the resident's representative the written notices related to bed-hold policies. No further information provided prior to survey team's exit. A review of facility policy titled AR102 Bed Holds, reviewed date 5/20/21, reflected its purpose To provide written notice of the bed hold policy to the resident/resident representative at the time of transfer out of the service location- this applies to all payers. It indicated that providing written notice to all residents at the time of transfer, If the resident representative is not present to receive the written notice upon transfer, the notice may be delivered via e-mail, fax, or hard copy by mail within 24 hours. It also specified in the policy to maintain a copy in the medical record. NJAC 8:39-4.1(a)(32)

Based on observation, interview, and record review it was determined the facility failed to complete weekly wound measurements and wound assessments per facility policy for 1 of 1 resident, Resident#16 reviewed for skin conditions and was evidenced by the following: On 02/28/22 at10:36 AM, during the initial tour of the facility Resident #16 told the surveyor that they had venous wounds on the left foot and the facility wound doctor had not been in to see the resident since January. Resident #16 told surveyor Before January, the wound doctor would see me every week. A review of the resident's medical records included diagnosis of Peripheral vascular disease, hypertension, absence of right leg above knee and cellulitis of left lower limb. A review of the Annual Minimum Data Set, an assessment tool used to facilitate care dated 11/23/21, indicated the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 03/01/22 at 09:46 AM, the surveyor reviewed the active physician order with a start date of 2/13/22 which included the following wound care order: Cleanse with normal saline solution, pat dry, Apply Xeroform Petrolatum dressing (a medicated dressing) to left lower ankle, cover with dry dressing and wrap until seen by wound doctor. At the same time the surveyor reviewed the Treatment Administration Record (TAR) which indicated the wound care was completed daily by the nursing staff from the 13th of February to the 1st of March. On 03/03/22 at 09:50 AM, the surveyor reviewed medical records and showed that there was an order for wound consult apointment dated 3/2/22. The order for wound consult appointment was placed after surveyor's inquiry regarding wound care physician visits. On 03/03/22 at 10:10 AM, with the resident's permission the surveyor observed wound care with unit Licensed Practical Nurse (LPN). Prior to the wound care, the resident again told the surveyor he/she hadn't seen a wound care doctor since the beginning of January. On 03/03/22 at 10:15 AM, the surveyor interviewed the LPN regarding wound measurements. The LPN told the surveyor that the Director of Nursing (DON) was measuring the wounds after the wound doctor stopped coming to the facility in January, but then the DON went on a medical leave. The surveyor asked who was responsible for measuring wounds since the DON was not available and the LPN told surveyor, I don't know who measures the wounds now. On 03/03/22 at 10:40 AM, the surveyor reviewed the wound measurements in the Electronic Medical Record (EMR). The only measurement in the residents' EMR for February was on 2/1/22. Further review indicated there was one measurement completed in January and three measurements were completed in December. On 3/8/22 at 11:10 AM, the surveyor again reviewed the February wound measurements which then showed measurements for 2/1/22 and 2/8/22. The 2/8/22 measurement appeared after the surveyor's inquiry on 3/3/22 and had a computer lock in date of 3/7/22. On 03/09/22 at 10:40AM, the Clinical Lead Specialist Registered Nurse (CLSRN) met with the survey team and informed the team regarding resident's wound assessments, evaluations, and measurements. The RRN stated wound care staff was definitely a slip. She also stated, I'm always transparent, it is, what it is. Right now, everything is black and white. On 03/10/22 at 09:47 AM the surveyor reviewed the policy titled, Skin Integrity Management, the policy had a revision date of 06/01/21. Under the section of the policy titled Practice Standards 3.3 it indicated the facilities policy was to perform wound observation, measurements and complete a Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline in a wound. NJAC 8:39-27.1

Based on observation, interview, record review, and other pertinent facility documents, it was determined that the facility failed to appropriately monitored and assessed wound for 1 of 1 resident, Resident#59's reviewed according to facility policy for pressure ulcer. This deficient practice was identified and was evidenced by the following: On 3/1/22 at 11:59 AM, the surveyor observed Resident#59 in the room lying in bed, awake, alert and verbally responsive. A review of the admission Record (an admission summary) reflected that Resident#59 was admitted in the facility on 10/21/21 and had diagnoses which included but not limited to Multiple sclerosis (MS), a chronic disease affecting the brain and spinal cord, and can cause problems with vision, balance, and muscle control and Pressure ulcer of sacral region stage 4. A review of the 1/27/22, Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 14, which reflected that the resident's cognition was intact. It also reflected that the resident was provided from extensive assistance to total dependence on staff members for all activities of daily living. The QMDS reflected that the resident was at risk for developing pressure ulcer, and as having two unhealed pressure ulcers. A review of a wound Advanced Practical Nurse (APN) progress notes dated 1/18/22 reflected that the resident had Stage 3 pressure ulcer to right lower sacrum and Stage 4 pressure ulcer to sacral region. On 3/2/22 at 12:31 PM, a review of electronic medical records for wound evaluations conducted by a NURSE titled [name redacted] Skin Integrity Report for February 2022 reflected that the last wound assessments done for the resident was 2/1/22. The Licensed Practice Nurse (LPN) and the surveyor could not find further wound assessments documented for the resident. The LPN informed the surveyor that she did not do wound assessments and stated, I'm only LPN and I cannot do assessments. The LPN stated that the wound Advance Practice Nurse (APN) performed weekly wound assessments for the resident and stated that the wound APN left and no longer worked for the facility. She also stated, the last time the wound nurse was in the facility was 1/18/22. Furthermore, the LPN stated that there were no weekly wound assessments done for the resident and that there should have been a Registered Nurse (RN) performed weekly wound assessments after the APN wound nurse left. The LPN informed the surveyor that there wouldn't be further wound assessments for the resident since the facility had no one to do it. The LPN indicated that the resident's wound were healing and no negative outcome to the resident because nurses were doing the wound treatment as ordered. On the same day at 12:52 PM, the Registered Nurse/MDS Clinical Reimbursement Coordinator (RN/MDS CRC) informed the surveyor that she used for MDS coding included APN wound notes and [name redacted] Skin Integrity Report. She also stated that the wound APN was the one measuring residents' wounds and the last time APN wound nurse made wound assessments and measured resident #59's wounds was 1/18/22. She also stated that the facility wound protocol was wound measurement should be done weekly. She acknowledged to the surveyor that the last wound assessment done for the resident was on 2/1/22 as documented in resident's electronic medical records [name redacted] Skin Integrity Report for February 2022. She could not state to the surveyor that the staff evaluated the resident's wound on 2/1/22. She also stated that there were no weekly wound assessments done for the resident afterwards. On 3/3/22 at 9:15 AM, the LPN informed the surveyor that there was a survey team came to see the resident earlier today and performed wound assessments for the resident. She also stated that today was the first time a wound team came and did wound assessment on the patient since the wound nurse left, and after surveyor's inquiry. On 3/7/22 at 9:00 AM, the surveyor observed that the wound assessments in [name redacted] Skin Integrity Report for February 2022 were modified and updated after the surveyor's inquiry to LPN and CRC on 3/2/22. On 3/7/22 at 12:35 PM, the survey team met with the facility Licensed Nursing Home Administrator/Center Executive Director (CED) Director of Nursing (DON) and Assistant Director of Nursing (ADON) from other facility, and Clinical Lead Specialist Registered Nurse (CLSRN). The surveyor discussed to the administrative team concerning the resident's weekly wound assessments and its revisions after the surveyor's staff inquiry on 3/2/22. The CLSRN stated that the licensed nurses were responsible for weekly wound assessments and evaluations. She informed the survey team that the facility had an external wound tracking portal that was linked to an electronic medical record, which enabled the staff get access to the residents' wound assessments. She also stated that she would investigate and would get back to the surveyor. On 3/8/22 at 2:09 PM, the CLSRN called the facility DON on the phone in the presence of the survey team. The surveyor team interviewed the DON in the presence of the CLSRN. The DON confirmed to the surveyors that Resident#59 was last seen by the APN wound nurse on 1/18/22. On that same date and time, the DON stated that she then started calling the nurses on the phone from home to obtain resident's wound assessments and measurements after surveyor's inquiry. The surveyor asked who were the nurses that provided her the resident's wound assessments, but the DON could not provide the information. The CLSRN opened the facility external wound tracking portal and showed it to the surveyors. A review of the facility's external wound tracking portal for the resident in the presence of the CLSRN reflected that the wound assessments were initiated, modified, and locked on 3/3/22 by the DON. The documentation reflected that the entries were completed on 3/3/22 after the surveyor made an inquiry on 3/2/22. The CLSRN stated that the initiated date was the actual date of entry. On 3/9/22 at 10:40 AM, the CLSRN met with the survey team and informed the team regarding resident's wound assessments and stated, wound care staff was definitely a slip. She also stated, I'm always transparent and confirmed to the survey team that the wound tracking portal was revised on 3/3/22 after the surveyors' inquiry on 3/2/22. She stated It is, what it is. Right now, everything is black and white. A review of facility policy titled NSG236 Skin Integrity Management, revised 6/1/21 reflected Perform wound observations and measurements and complete Skin Integrity Report (Forms ON Demand (FOD) #[name redacted]-692R) upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound). On 3/9/22 at 11:30 AM, there was no further information provided prior to survey team's exit. NJAC 8:39-27.1 (b)(e)

Based on observation, interview, and record review it was determined that, the facility failed to post the nurse staffing information on 2 of 3 areas of the facility in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 2/28/22 at 9:00 AM, upon entry into the facility the surveyors did not observe that there was a Nurse Staffing Report (NSR) displayed in the facility lobby. On 2/28/22 at 9:30 AM, the surveyor toured the [NAME] wing nursing unit, the surveyor was unable to observe the facility daily NSR and schedule. The Licensed Nursing Home Administrator/Center Executive Director (CED) informed the survey team that there were two nursing units, the East and [NAME] wing. On 3/3/22 at 8:59 AM, the surveyor team interviewed the facility Staffing Coordinator (SC). The SC informed the survey team that part of her job is to post the daily NSR in the lobby area and Ns schedule at the East wing unit. She stated that she will post the daily Ns on the East Wing in a display cabinet next to the time clock. She acknowledges that she doesn't post the Ns schedule in the [NAME] wing for four days and was also unaware that the daily NSR should be displayed in the lobby in a visible area for family and visitors. The SC was unaware of the facility's policy for displaying the daily NSR. The SC confirmed that she did not post the NSR the last 4 days. The surveyor observed the lobby area on the following days: 2/28/22, 3/1/22, 3/2/22 and 3/3/22 with no NSR posted. There was no Nurse staffing (Ns) schedule posted on the [NAME] wing on the following days: 2/28/22, 3/1/22, 3/2/22, and 3/3/22. On 3/7/22 at 12:35 PM, the surveyor met with the CED, Clinical Lead Specialist Registered Nurse (CLSRN), Director of Nursing (DON) and the ADON from another facility and they were made awere of the above concerns. A review of the facility's policy titled Staffing/Center Plan dated 7/16/19 that was provided by the CLSRN indicated the following: A written staffing plan is prepared for each department. Time schedules are maintained and posted on the unit. NJAC 8:39-41.2 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Infection Preventionist (IP) has completed specialized training in infection prevention and control and qualified by certification for 1 of 1 staff in accordance with the facility policy and Center for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 20-26 for a LTCF (Long Term Care Facility) included iii. The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPC program On 2/28/22 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator/Center Executive Director (CED) during the entrance conference and informed the surveyor that he had been working in the facility for 8 months and that the Director of Nursing (DON) for at least a year. The CED stated that the DON was not at the facility for two weeks now. The surveyor asked the CED for a copy of the facility's Infection Preventionist (IP) certification and documentation that the IP was qualified to the position, and he stated that he will get back to the surveyor. On 2/28/22 at 11:15 AM, the Clinical Lead Specialist Registered Nurse (CLSRN) informed the survey team that the facility was aware of the regulation about having an Infection Preventionist (IP). The CED stated I know we're getting the deficiency and that the facility was not in compliance with the requirement of an IP. On 3/1/22 at 9:40 AM the CLSRN informed the surveyor that I just want to get back to you regarding your question about our IP status in the facility. We're not in compliance with the state regulation for not having an infectious disease doctor and requirement for an infection preventionist nurse. The CLSRN acknowledged that there was a federal IP requirement that the facility was not in compliance and she stated that she forwarded the concerns with their legal team and looked out for these concerns. The CLSRN further stated that the facility's IP was the DON. A review of the CED's schedule that was provided by the CED revealed that the CED was on Exempt Vacation from 2/14/22 to 2/18/22. A review of the employee file of the DON showed that was provided by the Workforce Center Manager (WCM) revealed that the DON was on workers compensation effective 1/7/22 up to present date. On 3/2/22 at 9:05 AM, the survey team interviewed the WCM who informed the surveyors that the DON was out for workers comp (compensation) since January 2022. The WCM further stated that the DON was not working because staff can not work while on workers comp. On 3/8/22 at 11:12 AM, the CLSRN met with the survey team and informed the surveyors that the DON who was the facility's IP should have completed the certification for IP. The surveyor asked the CLSRN why the DON did not complete the certification requirement and the CLSRN had no answer. According to the facility's Infection Prevention and Control Program (IPCP) Description with a revision date of 6/7/21 that was provided by the CLSRN included The Infection Preventionist develops, implements, monitors and maintains the IPCP and fulfills the basic requirements for the role. According to the facility's Infection Preventionist Job Description with a revision date of 11/3/17 that was provided by the WCM included Specific Educational/Vocational Requirements: 3. Must complete specialized training in infection prevention and control 7. Must work at least part-time at the center. On 3/9/22 at 10:29 AM, the survey team met with the CLSRN. The CLSRN informed the surveyors that the CED will not be at the facility until further notice. The CLSRN stated that obviously system was not in place. The surveyor asked the CLSRN if there will be additional information and she stated that there was no additional information. NJAC 8:39-19.1(b)

Based on observation and interview it was determined that the facility failed to allow Residents #14, #17, #18, and #28 the right to dine in the facility main dining room meals. This was identified in 4 of 4 residents interviewed for dining and was evidenced by the following: On 02/28/22 at 12:25 PM, during lunch observation on the East wing of the facility, the residents were observed in their rooms having lunch. The residents who required staff assistance were having lunch in the day room on the unit. On 02/28/22 at 12:40 PM, the surveyor observed the facility's main dining room located off the main lobby between the East and [NAME] wings. The main dining room was dark and empty. On 03/02/22 at 10 AM, the surveyor conducted Resident Council meeting in the main dining room with four residents, Resident#14, #17, #18, and #28 . Four of the four residents voiced that they wanted to eat in dining room, and it had been missed. All residents told the surveyor they didn't understand why they weren't allowed as they were fully vaccinated. On 03/03/22 at 10:54 AM, a surveyor interviewed the Food Service Director (FSD) and the Corporate District Manager of Healthcare services dining. The FSD stated when he first started working at the facility, the facility just restarted using the main dining room. The FSD stated that two and a half weeks prior the Licensed Nursing Home Administrator/Center Executive Director (CED) came to him to restart using the dining room, however he stated, a few days before the state arrived he was told by the CED to close the dining room again because of a covid-19 case. Since that time the FSD had not been told to restart using the dining room. The FSD stated the facility had enough staff to accommodate both lunch and dinner services in the dining room. On 03/08/22 at 11:15 AM, the surveyor interviewed East wing Certified Nursing Aide (CNA) regarding utilizing the main dining room. The CNA told the surveyor she started employment on 2/18/22 and the dining room had not been open since her start date of 2/18/22. The surveyor then interviewed a unit Licensed Practical Nurse (LPN) regarding the dining room. The LPN who had been employed at the facility for six years told the surveyor that the dining room hasn't been used in about two months due to a Covid positive resident. On 03/08/22 at 11:18 AM. the Clinical Lead Specialist Registered Nurse (CLSRN)told the surveyor, To confirm, dining is supposed to be open. On 03/08/22 at 12:30 PM, the surveyor observed the main dining room and lunch was not being served. On 03/09/22 at 2:25 PM, the surveyor reviewed the policy titled, Facilitating Community Life During Covid. The policy was dated 2/9/22. The policy stated that residents who are up to date (vaccines) may dine and participate in activities without facemasks or social distancing if all participating residents are up to date (vaccines). NJAC 8:39-4.1 (24, 28)

Based on observation, interview, and a review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS). The deficient practice was observed for 1 of 1 on the automatic medication dispensing system located in the facility's Nursing office and was evidenced by the following: On 3/1/22 at 11:30 AM, the surveyor requested the controlled substances count sheet (CSC) for the facility AMDS for the month of February 2022 from the covering Director of Nursing (DON). On 3/2/22 at 9:45 AM, the surveyor asked the covering DON if she was able to locate the CSC sheets from February 2022. She provided the surveyor with the CSC sheet from 3/1/22. The covering DON informed the surveyor that she was still looking for the February 2022 CSC sheet. She stated that the AMDS controlled substance counts are done once a day and two nurses must sign off that the counts were accurate. On 3/3/22 at 9:30 AM, the surveyor requested the CSC sheet for the facility AMDS for the month of February 2022 from the Clinical Lead Specialist Registered Nurse (CLSRN). On 3/3/22 at 10:00 AM, the CLSRN provided the surveyor with the AMDS Controlled Substance (CS) book which contained count down sheets for all controlled substances that are contained within the AMDS. The back sectioned of the CS book contained the CSC sheets. The CLSRN stated that according to the CSC sheets that the last time the controlled substances and narcotics were counted in the AMDS was on 11/29/21. On 3/3/22 at 10:30 AM, the surveyor requested the CLSRN to run the controlled substances counts for all the controlled substances within the AMDS. The surveyor compared the AMDS controlled substance print out numbers with the count down sheets from the CS book. The surveyor found no discrepancies with the controlled substance counts. Upon review of the above document, the surveyor observed the following dates that there was no nurse signatures from 11/29/21 until 3/1/22 to ensure the controlled medications were counted. On 3/7/22 at 11:10 AM, the surveyor interviewed the Minimum Data Set (MDS) Coordinator/Registered Nurse (MDSC/RN). The MDSC/RN told the surveyor that it was never her responsibility to check the controlled substance counts for the AMDS. She noted that the counts were done during shift change between the 7-3 and 3-11 shift and the counts were conducted by the DON and a Nursing Supervisor. On 3/7/22 at 11:15 AM, the surveyor interviewed a Registered Nurse (RN) on the [NAME] unit. RN#1 stated that checking the controlled substance counts used to be her responsibility. She stated that she used to be the 7-3 nursing supervisor and she used to check the controlled substance count in the AMDS during shift change with the 3-11 nursing supervisor. She further stated that due to staffing shortages that both her and the 3-11 supervisor had to pass medications and it was no longer their responsibility to check the controlled substance counts. Furthermore, RN#1 informed the surveyor that the AMDS controlled substance counts were being done by the DON and another nursing supervisor. RN#1 stated that they were two nursing supervisors who have recently left the company and when the DON went on disability, that nobody was given the responsibility to check the AMDS controlled substance counts. She further stated that as of 3/1/22, that medication nurses are now responsible to check the AMDS controlled substance counts and the counts are conducted during shift change at 3 PM. On 3/8/22 at 11:40 AM, the surveyor interviewed the CLSRN who stated that she doesn't know why the facility were not checking the AMDS controlled substance counts. A review of the facility's policy titled Controlled Drugs: Management dated 6/1/21 and was provided by the CLSRN indicated the following: Ongoing Inventory: A complete count of all Schedule II-IV controlled drugs is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one license nursing staff to another. The count must be performed by two licensed nurses .Ongoing Inventory of Controlled Drugs (Shift count): 5.1.3 Both licensed nursing staff participating in the count must: 1. Confirm that the Inventory page reflects the quantity of drugs present in the container, and that the integrity of each container is intact. 2. Verify the amount remaining as noted in the Amount Left column on each inventory page. 3. Both licensed nursing staff sign the Shift Count page in the Controlled Substances Book to acknowledge completion of the shift count. NJAC 8:39-29.4(n)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) notify the Local Health Department (LHD) of the facility's COVID-19 outbreak for 2 of 2 ocassions on 2/14/22 and 2/15/22, b.) ensure that the facility staff was educated about infection control and other infection control mandates, and c.) ensure that the residents were monitored for COVID-19 for 9 of 9 residents reviewed (Resident#50, 14, 36, 11, 32, 24, 21, 16, and 41) according to facility policy and in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, included Educate residents, HCP, and visitors about SARS-CoV-2, current precautions being taken in the facility, and actions they should take to protect themselves. Regularly review CDC's Interim Infection Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic for current information and ensure staff and residents are updated when this guidance changes .Notify HCP, Residents, and Families about Outbreaks, and Report SARS-CoV-2 Infections, Facility Staffing, Testing, and Supply Information to Public Health Authorities Notify the health department promptly about of the following: one or more residents of HCP with suspected or confirmed SARS-CoV-2 infection Respond to a newly identified SARS-CoV-2 infected HCP or Resident Because of the risk of unrnecognized infectioin among residents, a single new case of SARS-CoV-2 infection in any HCP of a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak .Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms . According to the New Jersey Executive Directive No. 20-026 dated 1/26/21 Required Core Practices for Infection Prevention and Control included i. Facilities must educate residents, staff, and visitors about COVID-19, current precautions being taken in the facility, and protective actions. 1. On 2/28/22 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator/Center Executive Director (CED) during the entrance conference and informed the surveyor that he had been working in the facility for 8 months and that the Director of Nursing (DON) for at least a year. The CED stated that the DON was not at the facility for two weeks now. He further stated that there were no residents on TBP (transmission-based-precaution) for COVID and non-COVID-19 in the facility. On that same date and time, the CED informed the surveyor that two residents tested positive for COVID-19 in the facility's most recent outbreak. He stated that both Resident#41 and Resident#50 tested positive for COVID-19 on 2/14/22, both recovered, and none were hospitalized . At that time, the surveyor asked the CED if the LHD was notified about the COVID-19 outbreak and to provide documentation. The CED stated yes, and stated that he will get back to the surveyor. On 3/3/22 at 10:25 AM, the survey team met with the Clinical Lead Specialist Registered Nurse (CLSRN). The surveyor followed up with the CLSRN the documentation that the LHD was notified of the 2/14/22 COVID-19 outbreak, and asked who was responsible for reporting the outbreak. The CLSRN stated that it was the CED's responsibility to report the outbreak and we're skin and bone here. On 3/3/22 at 10:59 AM, the survey team met with the CED and the CLSRN. The CLSRN informed the surveyors that the LHD was not notified when there was an outbreak on 2/14/22 according to their facility policy and CDC guidelines. The CLSRN stated to the surveyors that it was the CED's responsibility to notify the LHD of positive COVID-19 in the building. The CLSRN further stated that the notification was not done because the CED was on vacation at that time. A review of the CED's schedule that was provided by the CED revealed that the CED was on Exempt Vacation from 2/14/22 to 2/18/22. A review of the employee file of the DON showed that was provided by the Workforce Center Manager (WCM) revealed that the DON was on workers compensation effective 1/7/22 up to present date. On 3/7/22 at 12:36 PM, the survey team met with the CED, DON, and ADON (Assistant Director of Nursing). The DON and ADON were from another facility. The facility team acknowledged and clarified that Resident#41 was tested positive on 2/14/22, was hospitalized , and recovered. Also, the facility team stated that Resident#50 was tested positive for COVID-19 on 2/15/22, was not hospitalized , and recovered. At that same time, the DON from another facility (DONfaf) stated that CED should have been notified according to the facility policy and CDC guidance. The surveyor asked the facility management why they were not notified. The facility team had no response. 2. On 3/2/22 at 3:01 PM, the survey team interviewed Certified Nursing Aide#1 (CNA#1). CNA#1 informed the surveyors that she was not aware of the regulation about the COVID-19 vaccine and the deadline when staff should comply not until the surveyors were at the facility on 2/28/22. CNA#1 stated that no one told us here. On 3/3/22 at 10:25 AM, the survey team met with the CLSRN and made them aware of the above concerns. The CLSRN informed the surveyors that there should be a center meeting in the facility about the updates and memos that were provided by the corporate office from CMS, CDC, and NJDOH guidelines including mandates that should be disseminated to the facility staff as a form of education. The surveyor asked the CLSRN for a copy of the education provided to the staff and the CLSRN stated that she will get back to the surveyor. On 3/8/22 at 9:23 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding staff education. The LPN informed the surveyor that to be honest, there's no organization here lately because no one is here, we don't have a DON, we don't have a Social Worker, and we used to have ADON who provides us education here but now no one. At that same date and time, the LPN stated that the last time we had in-service here was last year and I can't even remember what month because it was too long since they provided us education here regarding CDC updates. On 3/8/22 at 9:36 AM, the surveyor interviewed CNA#2 who informed the surveyor that she's been working in the facility for 30 years. CNA#2 stated that the last time she received in-service was a long time ago and I can't even remember when because there was no one here to provide education. She further stated that she wanted to have an education about changes in the infection control mandates to understand why the COVID testing was changed to staff. On 3/8/22 at 11:12 AM, the CLSRN met with the survey team and stated that there was no education provided to the staff after March 2021 and I don't know why it was not relayed to all staff about education/in-service regarding infection control and other mandatory updates with regard to COVID-19 when information was disseminated via email to all management personnel. 3. On 3/2/22 at 11:40 AM, the survey team met with the LNHA, Clinical Reimbursement Coordinator (CRC), and the CLSRN. The CLSRN stated that the facility was on a COVID-19 outbreak starting 2/14/22 and 2/15/22 when there were two residents tested positive for COVID-19. She further stated that the facility should be on outbreak monitoring until 3/14/22. A review of the electronic medical records titled COVID-19 Screening in the assessment tab revealed that the following residents were not monitored accordingly from 2/14/22 through 3/1/22: Resident#50 did not have a COVID-19 screening from 2/16/22 to 2/23/22. The resident was not screened or monitored for COVID-19 every shift from 2/14/22 to 2/15/22 and from 2/24/22 to 3/1/22. Resident#14 did not have a COVID-19 screening on 2/19/22. The resident was not screened or monitored for COVID-19 every shift from 2/14/22 to 3/1/22. Resident#36 did not have a COVID-19 screening from 2/17/22 to 2/23/22 and 2/25/22 to 2/27/22. The resident was not screened or monitored for COVID-19 every shift on 2/24/22 and from 2/28/22 to 3/1/22. Resident#11 was not screened or monitored for COVID-19 every shift from 2/14/22 to 3/1/22. Resident#32 did not have a COVID-19 screening on 2/14/22 and 2/19/22. The resident was not screened or monitored for COVID-19 every shift from 2/15/22 to 3/1/22. Resident#24 did not have a COVID-19 screening on 2/14/22 and 2/20/22. The resident was not screened or monitored for COVID-19 every shift from 2/21/22 to 3/1/22. Resident#21 did not have a COVID-19 screening on 2/14/22 to 2/18/22, and 2/20/22. The resident was not screened or monitored for COVID-19 every shift on 2/19/22, and from 2/21/22 to 3/1/22. Resident#16 was not screened or monitored for COVID-19 every shift from 2/14/22 to 3/1/22. Resident#41 did not have a COVID-19 screening on 3/1/22. The resident was not screened or monitored for COVID-19 every shift from 2/24/22 to 2/28/22. On 3/3/22 at 10:25 AM, the survey team met with the CLSRN and made her aware of the above concerns. On 3/7/22 at 8:58 AM, the survey team met with the CED and the DONfaf. The surveyor asked the CED and DONfaf how often the residents should be monitored for COVID-19 during an outbreak and who were the residents that should be monitored. The CED stated and the DONfaf acknowledged that all residents should be monitored every shift during an outbreak. The CED and the DONfaf acknowledged and confirmed that it was facility policy to monitor all residents every shift during an outbreak. The DONfaf further stated that all residents should be monitored daily and that nurses should have changed the UDA (user-defined assessment or a scheduler in the electronic medical record) from daily to every shift monitoring. On 3/8/22 at 9:23 AM, the surveyor asked the Licensed Practical Nurse (LPN) why the residents were not being monitored or screened during an outbreak that started on 2/14/22 and the LPN had no answer. On 3/8/22 at 11:12 AM, the CLSRN met with the survey team and informed the surveyors that there was a lack of communication and just got missed, which was why residents were not monitored every shift during an outbreak that started on 2/14/22. The CLSRN stated that it was an Interdisciplinary Team affair, I don't know what had happened but probably staff forgot to change the UDA from daily to every shift during an outbreak. According to the facility COVID-19 Testing and Management of: Symptomatic Persons, Close Contacts and Outbreaks Policy dated 2/9/22 that was provided by the CRC included, Initiating Outbreak Response: Because of the risk of unrecognized infection among patients, a single new case of SARS-CoV-2 infection in any HCP or a nursing home onset SARS-CoV-2 infection in a patient should be investigated as an outbreak .Notifications: .Notify Local Department of Health (DOH) .Monitoring: Increase monitoring of all patients from daily to every shift, to more rapidly detect those with new symptoms. Utilize Outbreak COVID-19 Screen in pcc . On 3/9/22 at 10:29 AM, the survey team met with the CLSRN. The CLSRN informed the surveyors that the CED will not be at the facility until further notice. The CLSRN stated that obviously system was not in place. The surveyor asked the CLSRN if there will be additional information and she stated that there was no additional information and that everything is black and white at this time. NJAC 8:39-19.4 (a)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to implement a procedure for staff testing for COVID-19 for 15 of 36 staff and further testing in accordance with nationally accepted guidelines for infection prevention and control of COVID-19 and facility policy. This deficient was evidenced by the following: According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, included New Infection in Healthcare Personnel or Residents .All HCP who have a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested as described in the testing section If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued .A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. If the outbreak investigation is broadened to either a facility-wide or unit-based approach, follow recommendations below for alternative approaches to individual contact tracing. Alternative, broad-based approach: If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g. unit, floor, or other specific area(s) of the facility). Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later. On 2/28/22 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator/Center Executive Director (CED) during the entrance conference. The CED informed the surveyor that the Director of Nursing (DON) was responsible for COVID-19 testing in the facility. The CED stated that the DON was not at the facility for two weeks now. On that same date and time, the CED informed the surveyor that two residents tested positive for COVID-19 in the facility's most recent outbreak. He stated that both Resident#41 and Resident#50 tested positive for COVID-19 on 2/14/22, both recovered, and none were hospitalized . At that time, the surveyor asked the CED about COVID-19 testing of facility staff and he stated that staff was being tested two times a week every Tuesday and Thursday, and the last testing was done on 1/24/22 with the use of a rapid test. He further stated that it was facility policy to test staff twice a week. The surveyor asked for a copy of the staff testing log and he stated that he will get back to the surveyor. A review of the Employee COVID 19 POC (Point of Care) Testing Log (ECTL) showed that it was on 2/11/22 that employees were tested. A review of the electronic printed Antigen Test results dated 2/15/22 showed that the scope of testing was the whole house, tested were 21 employees and 100% negative for COVID-19 test. A review of the submitted Daily Staffing Sheet for 2/15/22 revealed that 36 nursing staff were working at the facility and out of 36 staff, 21 employees were tested and 15 were not tested. Further review of the ECTL and electronic printed Antigen Test results provided by the Clinical Lead Specialist Registered Nurse (CLSRN) showed that there was no further staff testing that was done after 2/15/22. On 3/2/22 at 11:30 AM the surveyor informed the CED and the CLSRN of the above concerns. The CLSRN stated that as per facility policy and practice, all staff should have been tested on the day of 2/14/22 when the residents were determined to have a positive COVID-19, then within 48 hours, on the 7th day then weekly until the 28th day. On 3/2/22 at 11:40 AM, the CED, Clinical Reimbursement Coordinator (CRC), and the CLSRN met with the survey team. The CLSRN stated that there were two weeks that the facility missed the testing for all staff and that we will make sure to test everyone today. She further stated that the facility should be on an outbreak monitoring until 3/14/22 and testing should be continued up to that time. On 3/7/22 at 12:36 PM, the survey team met with the CED, DON, and ADON (Assistant Director of Nursing). The DON and ADON were from another facility. The facility team acknowledged and clarified that Resident#41 was tested positive on 2/14/22, was hospitalized , and recovered. Also, the facility team stated that Resident#50 was tested positive for COVID-19 on 2/15/22, was not hospitalized , and recovered. On 3/8/22 at 9:23 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding staff testing. The LPN informed the surveyor that the last time she was tested for COVID-19 was around the end of January or beginning of February 2022. The LPN was not sure how often the staff should be tested, I believe we should be tested at least once every two weeks. I know there was a positive in the facility when I returned on 2/15/22, I was off 2/14/22 and I was not tested on [DATE]. The surveyor asked the LPN why she was not tested on [DATE] and the LPN had no answer. On 3/8/22 at 9:36 AM, the surveyor interviewed Certified Nursing Aide (CNA) who informed the surveyor that she's been working in the facility for 30 years. The CNA stated that the last time she was tested for COVID-19 was around January 2022, and I can't remember the exact date and there's no specific person who does the testing since the DON was out. She further stated that the facility started testing staff again when the survey team came to the facility and she can't remember when the exact date was. On 3/8/22 at 11:12 AM, the survey team met with the CLSRN. The CLSRN stated that testing was not done and we're not in compliance with our policy, CDC, and CMS guidelines about testing. She further stated that the 15 staff out of 36 on 2/15/22 should have been tested for COVID-19. The CLSRN informed the surveyors that testing resumed on 3/2/22 upon the surveyor's inquiry and all staff was negative for COVID-19. According to the facility COVID-19 Testing and Management of: Symptomatic Persons, Close Contacts and Outbreaks Policy dated 2/9/22 that was provided by the CRC included, Outbreaks: .Perform testing for all patients and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later Testing Documentation: Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other patients and staff are tested, the dates that staff and patients who tested negative are retested, and the results of all tests. If additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE use until there are no new cases for 14 days. On 3/9/22 at 10:29 AM, the survey team met with the CLSRN. The CLSRN informed the surveyors that the CED will not be at the facility until further notice. The CLSRN stated that obviously system was not in place. The surveyor asked the CLSRN if there will be additional information and she stated that there was no additional information and that everything is black and white at this time. NJAC 8:39-19.4 (a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) 4 of 4 Certified Nursing Aides (CNA) received their annual performance reviews and any necessary education based on the performance reviews, and b.) 2 of 4 CNA staff were educated on abuse prevention and Dementia care in accordance with requirements. This deficient practice affects all residents in the facility and was evidenced by the following: On 3/8/22, the surveyor reviewed four random CNA files for mandatory in-service education and their performance evaluation. There were 4 of 4 CNAs that did not meet the required 12 hours mandatory annual education requirements. There were 2 of 4 CNAs did not receive education on abuse prevention and Dementia care. There were no evidence of annual performance review for 4 of 4 CNA. On 3/8/22 at 1:35 PM, the surveyor interviewed the Clinical Lead Specialist Registered Nurse (CLSRN) who stated that the Director of Nursing (DON) or a designee was responsible for conducting annual performance review and the Nurse Educator (NE) with DON oversight was responsible for CNA annual education. The CLSRN informed the surveyor that there was no NE, and the facility has recently posted the position. On that same date and time, the CLSRN acknowledged that the annual employee performance review for the 4 CNAs was not completed. She further stated that she could not provide additional documentation for CNAs mandatory in-service education, and that her team will be going in to start working on the missing education over the next few weeks. A review of policy titled HR224 In-service Training under Policy indicated that the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. All mandatory in-service training content is located on the learning management system and is supported by various policies and procedures. Employee's training completion will be tracked via a transcript which is located within the learning management system. A review of policy titled HR616 Performance Appraisal under Policy indicated that managers will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal or have a performance-based conversation. In-service education will be provided based on the outcome of these reviews. No additional documentation was provided to the survey team during the survey. NJAC 8:39-43.17(b)

REFER to F730, F867, and F880 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) also known as the Center Executive Director failed to ensure that the facility policies were implemented, the Centers for Medicare and Medicaid Services (CMS) requirements and the US Centers for Disease Control and Prevention (CDC) guidance were followed to ensure residents rights were observed and a quality of care was provided to the facility residents in accordance with regulatory standards. This deficient practice has the potential to affect all 68 of 68 residents on their facility-wide census. The evidence was as follows: 1. On 3/07/22 at 12:50 PM, the surveyor interviewed the Center Executive Director (CED), CED in the presence of the survey team, the Clinical Lead Specialist Registered Nurse (CLSRN), and the Director and Assistant Director of Nursing from a sister facility. The CED stated that we have been informing Resident#26 about a room change since the summer and I didn't get that involved with the case. The CLSRN requested time to investigate. On 3/09/22 at 11:05 AM, the surveyor interviewed the CLSRN. She stated that she reviewed the medical record for Resident #26 and found no documented evidence regarding room changes. She stated that the resident should have been notified in advance and in writing of the room change as well as the reason for the room change. The CLSRN stated that the facility policy included a form used for notification and provided this to the surveyor. She further stated that this should have been documented, and a copy of the form should be part of the medical record. Furthermore, the CLSRN also stated that the resident should have been shown the room as well as meet the roommate prior to the move. She stated that if the resident was not in agreement that there should have been a team meeting with the resident to come to a resolution. The CLSRN stated that the social worker would typically be involved with this process, however, a nurse could as well. She also stated that there had been no investigations on this matter. 2. On 3/8/22, the surveyor reviewed four randomly selected Certified Nursing Aide (CNA) files for their mandatory in-service education and their performance evaluation. There were 4 of 4 CNAs that did not meet the required 12 hours mandatory annual education requirements. There were 2 of 4 CNAs who did not receive education on abuse prevention and Dementia care. There were no evidence of annual performance review for the 4 of 4 CNA's. On 3/8/22 at 1:35 PM, the surveyor interviewed the CLSRN who stated that the Director of Nursing (DON) or a designee was responsible for conducting annual performance review and the Nurse Educator (NE) with DON oversight was responsible for CNA annual education. The CLSRN informed the surveyor that there was no NE, and the facility has recently posted the position. The CSLRN indicated that the CED was aware that there were no DON and NE at the facility. On that same date and time, the CLSRN acknowledged that the annual employee performance review for the 4 CNAs was not completed. She further stated that she could not provide additional documentation for CNAs mandatory in-service education, and that her team will be going in to start working on the missing education over the next few weeks. The CED was not able to interview at this time and the CSLRN informed the surveyor that the CED will not be at the facility until further investigation. 3. On 3/03/22 at 12:48 PM, in the presence of the CLSRN, the Regional CED, and the Director of Nursing (DON) from a corporate sister facility, the CED stated that I can't find the binder for QAPI, and that he could not provide the last three-quarters of sign-In sheets for QAPI meetings. After the surveyor inquiry, the CED also stated that he did not have copies of the QAPI information saved anywhere on a computer. On 3/07/22 at 9:40 AM, the CED provided a copy of the last three-quarters of sign-in sheets for QAPI meetings allegedly held on and dated 7/13/21, 10/11/22, and 1/4/22. The surveyor reviewed the sign-in sheet and observed that there were no signatures for some key department heads. The surveyor asked why the Social Worker had not signed for attendance the last two quarters even though the Social Worker was a full-time employee and the CED had no response. The surveyor also inquired why the 7/13/2021 QAPI meeting sign-in sheet only had five participants (CED, DON, Rehab Director, Business Office Manager, and the Medical Director). The surveyor further inquired if various department heads were involved in the QAPI meetings and process and if vendors participate; the CED had no response. On 3/08/22 at 12:17 PM, the CLSRN requested that the surveyor/Team Coordinator (TC) of the survey team meet with her and the [NAME] President for Operations (VPO) about concerns with QAPI processes. The TC and an additional surveyor met with the CLSRN and VPO. The VPO informed the surveyors that the CED would not be at the facility today. He further stated that the corporate office was investigating how the CED provided the last three-quarters of sign-in sheets for QAPI meetings when he previously stated the QAPI binder was missing. The VPO stated that upon investigation, the staff informed them that the CED had requested staff to sign the attendance accountability sheets the day before providing them to the surveyor. The VPO requested a copy of the sign-in sheets the CED provided to the TC to confirm legitimacy. On 3/08/22 at 1:30 PM, in the presence of the survey team, the CLSRN confirmed the sign-in sheets were not legitimate. She also confirmed that there was no QAPI plan. She stated that she would provide a copy of the QAPI Policy. There was no documented evidence provided to the survey team of the required QAPI topics covered, including how the facility would self-identify issues, create measurable goals/benchmarks, and how they would implement a process for implementation and evaluation of performance improvement. 4. On 3/3/22 at 10:25 AM, the survey team met with the CLSRN. The surveyor followed up with the CLSRN the documentation that the LHD was notified of the 2/14/22 COVID-19 outbreak, and asked who was responsible for reporting the outbreak. The CLSRN stated that it was the CED's responsibility to report the outbreak and we're skin and bone here. On 3/3/22 at 10:59 AM, the survey team met with the CED and the CLSRN. The CLSRN informed the surveyors that the LHD was not notified when there was an outbreak on 2/14/22 according to their facility policy and CDC guidelines. The CLSRN stated to the surveyors that it was the CED's responsibility to notify the LHD of positive COVID-19 in the building. The CLSRN further stated that the notification was not done because the CED was on vacation at that time. A review of the CED's schedule that was provided by the CED revealed that the CED was on Exempt Vacation from 2/14/22 to 2/18/22. A review of the employee file of the DON showed that was provided by the Workforce Center Manager (WCM) revealed that the DON was on workers compensation effective 1/7/22 up to the present date. On 3/8/22 at 9:23 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding staff education. The LPN informed the surveyor that to be honest, there's no organization here lately because no one is here, we don't have a DON, we don't have a Social Worker, and we used to have ADON who provides us education here but now no one. At that same date and time, the LPN stated that the last time we had in-service here was last year and I can't even remember what month because it was too long since they provided us education here regarding CDC updates. On 3/7/22 at 8:58 AM, the survey team met with the CED and the DON. The surveyor asked the CED and DON how often the residents should be monitored for COVID-19 during an outbreak and who were the residents that should be monitored. The CED stated and the DON acknowledged that all residents should be monitored every shift during an outbreak. The CED and the DON acknowledged and confirmed that it was facility policy to monitor all residents every shift during an outbreak. The DON further stated that all residents should be monitored daily and that nurses should have changed the UDA (user-defined assessment or a scheduler in the electronic medical record) from daily to every shift monitoring. On 3/09/22 at 10:29 AM, the survey team met with the CLSRN who stated that the CED was responsible for the day-to-day operation of the facility and that he was aware that there were concerns with manpower, infection control education and protocols, and above mentioned issues identified. She stated that the CED should have attended to all the concerns including what the survey team had identified with staffing, education of staff, notifying families/representatives, and ombudsman, infection control, wounds, posting of schedule and other concerns with residents. The CLSRN informed the surveyors that the CED will not be at the facility until further notice. The CLSRN stated that obviously system was not in place. The surveyor asked the CLSRN if there will be additional information and she stated that there was no additional information and that everything is black and white at this time. The CLSRN also stated that the Senior CED called the CED multiple times and had communication with the CED about concerns in the facility and the corporate office was aware. She stated that the Senior CED offered help which the CED declined. She stated systems were not in place and that there was a plan to implement improvement plans however the survey team arrived before they could implement changes. The CLSRN stated at that time they were unable to provide any additional information related to the concerns of the survey team. On 3/09/22 at 5:32 PM via email, the CLSRN provided the surveyor with a statement from Senior CED regarding interaction and communication with the CED as follows: 3/9/2022 Regarding: [name redacted] Support System As the assigned Senior Center Executive Director for [name redacted]. I helped [name redacted] with mostly financial's, other reports, and any other areas that he asks for. I usually reached out to [name redacted] on a regular basis, sometimes weekly, sometimes few days in a week and or every other week; when I don't find him, I leave messages. There were times I even offered my support on the weekends. However, [name redacted] does not seek for help, he never asked me to help with anything at the center level except financial and other reports to be submitted; when I ask him if I can come to the center to help or to review any of his reports, sometimes he would say that he is busy or not today. Furthermore, when I ask how I can help or if he needs help, he would say, he got it. Somehow, I did not think he liked me to come to the building. When he was on vacation in February, I offered to come to the building and he said just to call the building and follow up with [name redacted]. I did call the building twice that week and asked if there is any issue and there were no concerns or issues brought to my attention at that time and I visited the center one day that week with no issues reported as well. [name redacted] Center Executive Director A review of the facility job description for the CED, effective date 4/4/19 and signed by the CED on 10/1/21, did not reflect responsibilities related to resident care, quality of life or regulatory compliance. NJAC 8:39-5.1(a) NJAC 8:39-9.2(a) NJAC 8:39-27.1(a) NJAC 8:39-33.1 (a),(b),(c),(d),(e) NJAC 8:39-33.2 (a),(b),(c)(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13),(d) NJAC 8:39-33.3 NJAC 8:39-39.4(a)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) identify, develop and implement a Quality Assurance Performance Improvement Plan as a means to self-identify and correct deficient practices, and b.) provide accurate accountability and evidence of quarterly Quality Assurance and Performance Improvement meetings for 3 of 3 quarters reviewed (July 2021, October 2021, and January 2022). This deficient practice was evidenced by the following: On 2/28/22 at 10:04 AM, during the entrance conference meeting of the surveyor and the Licensed Nursing Home Administrator/Center Executive Director (CED). The surveyor requested a copy of the Quality Assurance Performance Improvement (QAPI) Plan, the QAPI Policy and the last three quarters QAPI meeting sign-in sheets for attendance accountability. The CED stated that he will get back to the surveyor. On 3/02/22 at 9:30 AM, the surveyor still had not received the documents requested from entranc and asked the CED again for the QAPI Plan, the QAPI Policy and the last three quarters of sign-in sheets for attendance accountability. The Center Executive Director (CED) stated, I'm still looking for it. On 3/03/22 at 12:48 PM, in the presence of the Clinical Lead Specialist Registered Nurse (CLSRN), the Regional CED and the Director of Nursing (DON) from a corporate sister facility, the CED stated that I can't find the binder for QAPI, and that he could not provide the last three quarters of sign-In sheets for QAPI meetings. After surveyor inquiry, the CED also stated that he did not have copies of the QAPI information saved anywhere on a computer. On 3/07/22 at 9:40 AM, the CED provided a copy of the last three quarters of sign-in sheets for QAPI meetings allegedly held on and dated 7/13/21, 10/11/22, and 1/4/22. The surveyor reviewed the sign-in sheet and observed that there were no signatures for some key department heads. The surveyor asked why the Social Worker had not signed for attendance the last two quarters even though the Social Worker was a full-time employee and the CED had no response. The surveyor also inquired why the 7/13/2021 QAPI meeting sign-in sheet only had five participants (CED, DON, Rehab Director, Business Office Manager, and the Medical Director). The surveyor further inquired if various department heads were involved in the QAPI meetings and process, and if vendors participate; the CED had no response. On 3/07/22 at 12:56 PM, in the presence of the survey team and the CED, the CLSRN acknowledged that there was no documented evidence of QAPI meeting minutes, or a written QAPI Plan for surveyor to review. On 3/08/22 at 12:17 PM, the CLSRN requested that the surveyor/Team Coordinator (TC) of the survey team meet with her and the [NAME] President for Operations (VPO) with regard to concerns with QAPI processes. The TC and an additional surveyor met with the CLSRN and VPO. The VPO informed the surveyors that the CED would not be at the facility today. He further stated that the corporate office was investigating how the CED provided the last three quarters sign-in sheets for QAPI meetings when he previously stated the QAPI binder was missing. The VPO stated that upon investigation, staff informed them that the CED had requested staff to sign the attendance accountability sheets the day prior to providing it to the surveyor. The VPO requested a copy of the sign-in sheets the CED provided to the TC to confirm legitimacy. On 3/08/22 at 1:30 PM, in the presence of the survey team, the CLSRN confirmed the sign-in sheets were not legitimate. She also confirmed that there was no QAPI plan. She stated that she would provide a copy of the QAPI Policy. On 3/08/22 at 1:55 PM, the surveyor attempted to call the Medical Director twice. The surveyor was unable to leave a voicemail or message. On 3/09/22 at 11:24 AM, the surveyor attempted to call the Medical Director again and spoke to the office manager who informed the surveyor that the Physician/Medical Director was not available, that he was with a patient and would have to call the surveyor back. The surveyor provided the phone number to call. On 3/09/22 at 12:08 PM, the Medical Director (MD) returned the phone call to the surveyor. He informed the surveyor that routine quarterly QAPI meetings were not being conducted. The MD stated that I think a monthly meeting about falls and diet where done with the CED, DON, and managers. The MD further stated that the last meeting was held in December 2021. He stated none had been held since the DON was not there. The MD could not recall sign-in sheets being used for attendance accountability. There was no documented evidence provided to the survey team of the required QAPI topics covered, including how the facility would self-identify issues, create measurable goals/benchmarks, and how they would implement a process for implementation and evaluation of performance improvement. The surveyor reviewed the deficiencies cited from the last standard survey dated 11/1/19, which included a citation that the facility failed to ensure evidence that all sampled CNA's had received their in-service education requirements. The survey team identified the same deficient practice (Refer to F730), and there was no documented evidence of a QAPI to ensure sustainability that the deficient practice would not recur for this current survey. The facility was still unable to provide evidence that a sample of CNA's had met the minimum education requirement. A review of the facility's policy Quality Assurance Performance Improvement (QAPI) Process, with a review/revision date of 12/1/21 included the following: The QAPI program is ongoing, integrated, data driven, and comprehensive, addressing all aspects of care, quality of life, and patient centered rights and choice. The Center Executive Director (CED) leads the Center's QAPI processes The CED directs the development and documentation of the Center QAPI Plan, including an Annual QAPI Calendar, and is responsible for development, maintenance and ongoing evaluation of an active end effective QAPI Committee (QAPIC). The QAPIC meets at least 10 times annually, preferably monthly, to monitor quality within the Center, identify issues, and develop and implement appropriate plans of action to correct identified quality issues; and records highlights in the QAPI Improvement Log (available in Center's Google Drive). QAPI meeting minutes are filed by month for a period of one year in the QAPI Binder. Documentation for each meeting must include: Agenda, sign-in sheet, minutes, and an updated improvement log. (This policy did not satisfy the requirement for the facility to have a written QAPI Plan). NJAC 8:39-33.1 (a),(b),(c),(d),(e) NJAC 8:39-33.2 (a),(b),(c)(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13),(d) NJAC 8:39-33.3