**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to installation of side rails, assessments were completed for the risk of entrapment prior to installation, and informed consent with explained risks and benefits was obtained prior to installation for one of one resident reviewed for side rails (Resident (R) 13) of 29 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include: Review of the facility's policy titled, Nursing Bed Rails, effective 10/2023, revealed The facility will use appropriate alternatives prior to installing a side or bed rail .Assess for risk of entrapment from bed rails prior to installation. Review of R13's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Diagnoses included vascular dementia, depression, bipolar disease, muscle weakness, and anxiety. Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/24 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R13's Care Plan, initiated 03/21/24, located under the Care Plan tab of the EMR revealed no care plan related to the resident having side rails. Review of R13's Order Summary Report located under the Orders tab of the EMR revealed an order, dated 03/21/24, for bilateral half side rails for positioning/enabler. Review of R13's EMR revealed no documented evidence of a side rail assessment, no documented evidence of any alternative measures prior to installation, and no documented evidence of obtained consent for side rail usage. During an observation and interview on 05/13/24 at 10:04 AM, R13 stated she used the side rails to help her get out of bed. She stated she did not need both of the side rails. There was a half side rail located on both sides of the resident's bed. During an interview on 05/14/24 at 2:33 PM, the Regional Registered Nurse (RRN) stated they did not have any side rail consents completed for this resident because the side rails were used for mobility. During an interview on 05/15/24 at 11:12 AM, the Director of Nursing (DON) stated they always checked to make sure the side rails fit properly, but did not have a completed assessment, documented alternatives used prior to installation, and did not have a completed consent related to side rails because they were used for positioning. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) complete a thorough investigation for a fall incident that was identified and documented on the Nurse's Notes (NN) from 9/24/21 through 9/25/21 for Resident#39 and b.) ensure that the physician and responsible party (RP) were notified and documented on 11/20/21 fall investigation for Resident#60. The deficient practice was evidenced for 2 of 3 residents reviewed for incident/accident. This deficient practice was evidenced by the following: 1. On 12/2/21 at 9:15 AM, during the tour, the surveyor observed Resident #39 sitting in a chair next to the South unit nursing station. A review of the admission Record for Resident #39 revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to: Intracerebral hemorrhage (a type of stroke) and hyperlipidemia (abnormally high concentration of fats or lipids in the blood). A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 9/16/21, indicated a Brief Interview for Mental Status (BIMS) scored at 3, which indicated that the resident had severely impaired cognition. A review of Resident #39's NN revealed the following: NN dated 9/24/21 at 10:30 PM, reflected that the nurse was notified by a Certified Nursing Assistant (CNA) that Resident #39 was observed sitting on the floor by the entrance of the Television Room. The NN revealed that the resident denied falling and that the CNA observed urine on the floor and the notes further reflected that the floor was cleaned and that upon assessment of the resident, they found no injuries. NN dated 9/24/21 at 11:15 PM, revealed that the nurse observed the resident getting out of their wheelchair and started ambulating. The nurse observed Resident #39 limping and leaning to the right side. The NN further revealed that the physician was notified, and the nurse received an order to send the resident to the emergency room (ER). NN dated 9/25/21 at midnight revealed that Resident #39 was transferred to the ER via stretcher by 911 emergency workers. NN dated 9/25/21 at 6:45 AM, revealed that Resident #39 returned from the ER with an x-ray result which indicated no fracture of the pelvis or right ankle. Resident #39 was diagnosed with a right ankle sprain. On 12/6/21 at 12:30 PM, the surveyor reviewed Resident #39's Incident Report (IR) dated 9/24/21 at 10:30 PM. The IR did not contain information that was documented in the NN on 9/24/21 and 9/25/21. The Incident Report had no information regarding Resident #39 limping and leaning to the right side. There was no documentation that the resident was transferred to the ER, had an x-Ray, or returned with a diagnosis of a right ankle sprain. On 12/07/21 at 1:25 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA acknowledged that Resident #39's Incident Report was incomplete and should have included all the information that was in the NN which included the nurse's observation of the resident limping and leaning to the right side, then transfer to the ER, the x-ray results and the resident's diagnosis of a right ankle sprain. 2. On 12/6/21 at 9:23 AM, the surveyor reviewed the last four months' Incident/Accident Committee Meeting and Incident Report's that were provided by the LNHA and revealed that 2 out of 4 IR's were not completed appropriately. On the 11/20/21 IR the physician and the responsible party (RP) were not notified of the fall incident. On the 10/30/21 IR the RP was notified but not the physician of the fall incident. On 12/6/21 at 9:26 AM, the surveyors interviewed the Regional MDS Nurse (RMDSN) and the MDS Nurse (MDSN). The MDSN informed the surveyors that as a facility practice, the assigned nurse would document and fill out the IR, the DON then will check and make sure that the form was filled out completely. The MDSN stated that the notification of physician and RP should have been documented in the IR. The surveyor informed the RMDSN and the MDSN of concerns regarding the IR's dated 10/30/21 and 11/20/21. On 12/6/21 at 9:46 AM, the surveyor informed the Registered Nurse/Unit Manager (RN/UM) about the 10/30/21 and 11/20/21 IR concerns. Both the surveyor and the RN/UM were not able to locate documentation about the 11/20/21 notification of RP and the physician in the Nurses Notes (NN). On 10/31/21 NN reflected that the POA (Power of Attorney) was notified of the fall incident and that the physician was called. The RN/UM informed the surveyor that it was the responsibility of the DON to check the completeness of the IR. On 12/6/21 at 9:51 AM, the surveyor asked the DON in the presence of the RN/UM about the 11/20/21 IR concerns. The DON informed the surveyor that it was her responsibility to check the completeness of the IR and it was an oversight on my part. She further stated that the nurses always notify the RP and the physician about any incident, and I don't know why it was not documented. On 12/6/21 at 11:36 AM, the surveyor called and spoke to the POA on the phone. The POA informed the surveyor that the facility staff had called regarding the 11/20/21 fall incident and that the facility was diligent when calling for any changes with the resident. On 12/6/21 at 11:38 AM, the surveyors met with Regional RN (RRN) #1, RRN#2, COO (Corporate Operation Officer), DON, and LNHA and were made aware of the above concerns. RRN#1 and the DON both stated that the physician was notified but not documented for the IR on 11/20/21, it should have been documented, and the IR should have been completed. A review of the facility's policy for Accidents and Incidents- Investigating and Reporting that was undated and was provided by the Regional Nurse indicated that The disposition of the injured ( i.e., transferred to hospital, put to bed, sent home, returned to work, etc.). NJAC 8:39-4.1 (a) (5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of other facility documents it was determined that the facility failed to a.) ensure residents identified as elopement risks were wearing a physician's ordered wander guard (a device that allows residents to have freedom within their facility while providing security by alarming to prevent the resident from exiting the building unattended) and b.) ensure that Elopement Assessment's and care plan's were done according to facility policy and procedure and standards of clinical practice. This was identified for 3 of 11 residents (Resident #51, #56, and #47). 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 12/1/21 at 10:40 AM, the surveyor observed Resident #51 self-propelling a wheelchair on the South nursing unit. On 12/2/21 at 12:15 PM, the surveyor was conducting a record review on the South nursing station and overheard a Licensed Practical Nurse (LPN) #1 ask a Certified Nursing Assistant (CNA) #1 where the wander guard was for Resident #51's. On 12/2/21 at 12:20 PM, the surveyor observed Resident #51 in the Center unit dining room waiting for lunch to be served. The surveyor observed no wander guard on the resident's chair or the resident's ankle. The Director of Nursing (DON) was unable to find the wander guard and she told the surveyor that she will find out what happened to the resident's wander guard. On 12/2/21 at 12:30 PM, the surveyor interviewed LPN #1 who stated that Resident #51 was not wearing a wander guard and they were unable to find the resident's wander guard. On 12/2/21 at 12:40 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding Resident #51 not having a wander guard and that LPN #1 was unable to locate the resident's wander guard. The LNHA stated that he sent a new wander guard to the unit and had it placed on the resident. On 12/2/21 at 12:45 PM, the surveyor observed Resident #51 eating lunch and the surveyor observed no wander guard on the resident. On 12/2/21 at 12:50 PM, the surveyor team went back to the Center unit dining room with the LNHA and observed Resident #51 with no wander guard. At that time, the LNHA had a facility nurse bring up a new wander guard and had it placed on Resident #51's ankle. A review of the resident's Face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included Schizophrenia (a mental disorder in which people interpret reality abnormally) and gait disorder. A review of the Quarterly Minimum Data Set (QMDS) dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated that the resident had moderately impaired cognition. In addition, it reflected that the resident used a wander/elopement alarm daily. A review of the resident's December 2021 Physician's Order Form (POF) revealed an order dated 10/25/18 for Wander guard to wheelchair every shift with a Diagnosis Elopement Risk. A review of the Treatment Record for December 2021 reflected the above physician's orders. The surveyor reviewed Resident #51's interdisciplinary care plan (IDCP) dated 11/5/20, under the Problem area which revealed that the resident was at risk for elopement due to a history of attempting to get out of the exit doors. The last Resident #51's evaluation revealed that the resident had no elopement episodes and to proceed with the care plan. 2. On 12/2/21 at 1:11 PM, in the presence of another surveyor, the surveyor requested a list of residents who required wander guards from the DON. Thereafter, three surveyors accompanied the DON to verify that those resident's wander guards were in place. In the presence of the DON, two surveyors observed Resident #56 seated in a wheelchair at a table in the Center unit dining room. The DON checked the resident for wander guard placement and acknowledged to the surveyors that Resident #56 did not have a wander guard in place. The DON further stated that there had been no incidents of elopement reported for the facility. A review of the resident's Face Sheet (an admission summary) reflected that Resident #56 was admitted with diagnoses that included but were not limited to: unsteady gait and dementia. A review of a QMDS dated [DATE], reflected that the resident had a BIMS score of 6, which indicated that the resident had severely impaired cognition. In addition, it reflected that the resident used a wander/elopement alarm daily. A review of the POF for December 2021 reflected an order for wanderguard to (R) ankle for elopement risk; check wanderguard function weekly on Fridays on (7-3) shift; check placement of wanderguard every shift, dated 11/12/20. A review of the Treatment Record for December 2021 reflected the above physician's orders. A review of the residents individualized Care Plan reflected a plan of care for dementia updated 2/18/21 which reflected that the resident should continue with wanderguard to R ankle. During review of the medical record, the surveyor could not find an Elopement Risk Assessment. 3. In the presence of the DON, two surveyors observed Resident #47 in the Center unit dining room able to ambulate independently. The DON checked the resident for wander guard placement and acknowledged to the surveyors that Resident #47 did not have a wander guard in place. The DON further stated that there had been no incidents of elopement reported for the facility. A review of the resident's Face Sheet (an admission summary) reflected that Resident #47 was admitted with diagnoses that included but were not limited to: Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and seizures (disorder of the brain). A review of the Comprehensive MDS dated [DATE] reflected that the resident had a BIMS score of 7, which indicated that the resident had severely impaired cognition. In addition, it reflected that used a wander/elopement alarm daily. A review of the POF for December 2021 reflected an order dated 9/4/21 for a wander guard to right ankle for elopement risk and to check placement every shift. A review of the Treatment Record for December 2021 reflected the above physician's orders. A review of Resident #47's Interdisciplinary Care Plan (IDCP) dated 9/4/21, under the Problem area which revealed that the resident was at risk for elopement due to anxiety and restlessness. Under Evaluations, dated 9/4/21 revealed that Resident #47 had periods of forgetfulness and can make his/her needs known. The resident was a high risk for elopement and has a wander-guard on the right ankle. The resident's behaviors will be monitored. During a review of the medical record, the surveyor could not find an Elopement Risk Assessment. On 12/2/21 at 2:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, and the Regional Nurse. At that time the LNHA, the DON and the Regional Nurse acknowledged that these residents did not have Elopement Risk Assessments. The Regional Nurse stated that the elopement assessment should be done upon admission to the facility for residents who were a high risk for elopement and then quarterly or in the event of a change. The DON was not aware of the Elopement Risk Assessment and was unaware of the assessment requirements. On 12/3/21 at 12:31 PM, the survey team met with the LNHA, the DON and two Regional Nurses. The administrative team again acknowledged that the three residents did not have Elopement Risk Assessments in their medical record. A review of the facility policy Resident Alarms? Used of Wander guard that was provided by the LNHA, with a review date of 11/21, reflected that each resident should be assessed for elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process. It also reflected that supervision should be provided to the resident in accordance with the residents' plan of care. When alarms are used additional monitoring should be provided such as verifying alarms are working properly. NJAC 8:39-11.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and other facility documents it was determined that the facility failed to follow through with the resident's Restorative Nursing Program (RNP) for 2 of 2 residents (Resident #19 and 24), according to the facility's policy and procedure and standards of clinical practice. This deficient practice was evidenced by the following: 1. On 12/1/21 at 10:56 AM, the surveyor observed Resident #19 lying on the bed eyes closed, with a right-hand limitation with no assistive device in use. A review of the Physician's Oder Form (POF) for December 2021 with a list of residents' diagnoses included Chronic obstructive pulmonary disease (COPD), cerebrovascular accident with right-sided weakness (stroke), and hypertension (elevated blood pressure). Further review of the November and December 2021 POF showed that there was no order for a right-hand assistive device or splint. A review of the 8/19/21, 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 10, which reflected that the resident's cognition was moderately impaired. The QMDS indicated that the resident had functional limitation in range of motion and impairment to one side of the body. A review of the Screen/Referral Form (S/RF) dated 11/19/21, for a Quarterly review showed a recommendation to continue the use of a right-hand roll as tolerated for chronic hand/wrist contracture. A review of the Interdisciplinary Team Care Plan Conference (ITCPC) for annual review dated 8/26/21, revealed that the resident remained alert with periods of forgetfulness and there were no significant changes or decline. A review of the personalized care plan showed that there was a care plan problem identified on 11/17/20 for a right-hand contracture with an intervention that included Skilled OT (Occupational Therapy) discharge on [DATE]. Patient to wear R (right) hand roll x 8 hours daily. A review of the Certified Nursing Aide (CNA) Accountability Form for November and December 2021 did not include accountability for a right-hand roll to be applied to the resident. On 12/7/21 at 10:19 AM, the surveyor observed the resident seated in a regular chair in the dining area with other residents with a cane beside the resident. The resident had no hand roll or splint in use. On 12/7/21 at 10:41 AM, the surveyor interviewed the Registered Nurse/Supervisor (RN/S) in the presence of the Staffing Coordinator. The RN/S informed the surveyor that as a facility practice when the resident was discharged (d/c) from rehab, the rehab staff will recommend if the resident was appropriate for splinting, ambulation, and ROM (range of motion) to be included in the restorative program. The RN/S stated that the nurse will then notify the physician with the recommendation, which the doctor will 100% agree with the therapist's recommendations, the order will be placed, transcribed to the TAR (Treatment Administration Record), to the CNAs accountability, and should be in the care plan as well. On that same date and time, the surveyor and the RN/S reviewed the 11/19/21 S/RF for recommendation to continue the use of the right-hand roll as tolerated for chronic hand/wrist contracture. The RN/S stated I don't know what happened why there was no order for a right-hand roll. She further stated that It should have been in the CNAs accountability and TAR for nurses to sign. On 12/7/21 at 11:08 AM, the Licensed Practical Nurse (LPN) informed the surveyor that CNA#1 assigned to the resident was not available for an interview. The LPN stated that there should be an order from the doctor concerning the right-hand roll of the resident, transcribed to the TAR, and it was missed. The LPN acknowledged that the resident had no right-hand roll when the surveyor observed the resident on 12/1/21 and 12/7/21. On 12/7/21 at 1:08 PM, the surveyors interviewed the Physical Therapist/Rehab Director (PT/RD). The PT/RD informed the surveyors that the facility had a functional maintenance program (FMP). The PT/RD stated that once the resident was d/c from therapy and remained in Long Term Care, the resident would be on FMP and an Alert Form would be given to nursing on the floor, and the Unit Manager would be given a copy that would be part of the resident's medical record. The PT/RD further stated that it was the responsibility of the nurse to call the doctor for recommendations and to obtain an order for a splint, ambulation, and ROM. The PT/RD indicated that there was no situation that the doctor did not agree upon our recommendations. 2.On 12/1/21 at 11:00 AM, the surveyor observed Resident#24 laying on a bed with a left arm hand limitation and told the surveyor I had a stroke, that was why the resident indicated that they can not fully open their left hand. The resident denied refusing a splint. On 12/3/21 at 11:18 AM, the surveyor observed the resident laying on a bed with no splint in use to their left hand. CNA#2 came out of the resident's room and informed the surveyor that Resident#24 was cognitively intact with some forgetfulness and required extensive assistance with activities of daily living (ADLs), set up with meals due to the left-hand limitation. CNA#2 stated that the resident had no splint to the left hand. She further stated that the left-hand limitation was not something new to the resident and the resident came with it. A review of the resident's Face sheet (an admission summary) disclosed that the resident had diagnoses that included CVA (cerebrovascular accident or stroke), diabetes mellitus, major depressive disorder, and congestive heart failure. A review of the Comprehensive Minimum Data Set (CMDS), dated [DATE], indicated a BIMS score of 14, indicating that the resident's cognition was intact. The CMDS further indicated that the resident had functional limitation in range of motion and impairment to one side of the body. A review of the December 2021 POF showed that there was no order for a left-hand splint. A review of the Initial ITCPC dated 8/27/21 showed that the resident was cognitively intact with a history of CVA, the Rehab/Therapy Resident's Rehabilitative status includes splinting to left hand/wrist drop. A review of the 9/16/21 OT Discharge Summary included pt (patient) will tolerate L (left) hand splint for wrist joints positioning and alignment. Baseline 8/16/21 L wrist drop, previous 9/16/21 L wrist drop, Discharge 9/16/21 L hand splint for 6 hrs (hours). A review of the personalized care plan did not include interventions for left-hand/wrist splint. A review of the CNA Accountability Form for November and December 2021 did not include accountability for a right-hand splint to be applied to the resident. On 12/7/21 at 10:41 AM, the surveyor interviewed the RN/S while both reviewing the resident's medical record. The RN/S stated I don't know why the OT Discharge summary dated [DATE] for a left-hand splint for 6 hrs was not ordered, not in the care plan, and was not ordered to reflect on the November and December 2021 TAR. She further stated that the left-hand splint should have been documented in the CNAs Accountability Form. On 12/7/21 at 11:08 AM, the LPN informed the surveyor that there should have been an order from the doctor about the resident's left-hand splint, transcribed to the TAR, and it was missed. The LPN acknowledged that the resident had no left-hand splint when the surveyor observed the resident on 12/1/21, 12/3/21, and 12/7/21. On 12/7/21 at 1:08 PM, the PT/RD informed the surveyor that the resident had no behavior of refusing a splint. The PT/RD further stated that the resident was admitted to the facility with a left-hand limitation, was not something new to the resident, and had no significant changes or decline. On 12/8/21 at 10:36 AM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Registered Nurse#1 and 2 (RRN#1 and 2), and Corporate Operation Officer (COO) and were made aware of the above concerns. The COO stated we spoke to rehab director and the rehab staff failed to notify the nursing department about the Rehab Alert, and the recommendation from the S/RF on 11/19/21 for Resident#19 and #24 on OT Discharge Summary on 9/16/21. The COO informed the surveyors that there was a communication problem, and that the therapist should have communicated the recommendations with nursing not just putting the paper in the chart, so that the nurse could have called the physician for an order. The COO further stated that there was no decline and harm to Resident #19 and 24. A review of the facility Restorative Nursing Programs with an effective date of 10/2018, that was provided by the LNHA included It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Policy Explanation and Compliance Guidelines: .5. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for such services. These services may include: a. Passive or active range of motion. b. Splint or brace assistance 6. Residents may receive Level II restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy .8. The discharging therapist, Restorative Coordinator, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan On 12/8/21 at 1:14 PM, the LNHA informed the surveyors that there was no additional information. NJAC 8:39-27.1 (a), 27.2 (m)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 3 medication carts and in 2 of 3 medication refrigerators inspected. This deficient practice was evidenced by the following: On 12/07/21 at 11:55 AM, the surveyor inspected the North unit medication refrigerator in the presence of a Licensed Practical Nurse (LPN) #1 which was in the North unit nursing station unlocked. The North unit medication refrigerator contained insulin, Purified Protein Derivative (PPD) and a narcotic lockbox (it was locked and affixed to the refrigerator) that contained Ativan topical gel and Ativan intramuscular vials. The surveyor interviewed LPN #1 who stated that the medication refrigerator should have been locked. On 12/07/21 at 12:15 PM, the surveyor inspected the South unit medication refrigerator in the presence of a Registered Nurse (RN) #1. The surveyor observed the South unit medication refrigerator thermometer at 26 degrees Farhenheit (F). The surveyor reviewed the South unit temperature log which had a temperature for 12/7/21 at 34 degrees F. The temperature log also revealed that the refrigerator temperature should be between 36 degrees and 46 degrees F. The surveyor interviewed RN #1 who stated that the temperature inside the South unit medication refrigerator was too cold and that the proper refrigerator temperature for medication should be between 36 to 46 degrees F. RN#1 also stated that she would call maintenance to check the refrigerator. A review of the November 2021 Consultant Pharmacist's Nursing Station Inspection Checklist revealed that the South unit medication refrigerator temperature was not between 36 to 46 degrees F. On 12/7/21 at 1:00 PM, the surveyor inspected the Center unit medication cart in the presence of LPN #2. The surveyor observed an opened Levemir insulin vial that was not dated. The surveyor interviewed LPN #2 who stated that an opened Levemir Insulin should have been dated. On 12/8/21 at 9:15 AM, the surveyor inspected the South unit medication refrigerator in the presence of RN #2. The surveyor observed the medication refrigerator thermometer with a temperature around 26 to 27 degrees F. The surveyor interviewed RN #2 who stated that the medication refrigerator was not working properly and that all the South unit refrigerated medications were moved to the North unit medication refrigerator. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Levemir Insulin vial once opened had an expiration date of 42-days. On 12/08/21 at 10:30 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON) and no further information was provided by the facility. A review of the facility's policy for Storing Medications that was undated and was provided by the DON indicated the following: Medications are to be stored at proper temperature. Medications requiring storage at room temperature are to be stored at a temperature of not less than 15 degrees Celsius (59 degrees Fahrenheit) or more that 30 degrees Celsius (86 degrees Fahrenheit). Medications requiring refrigeration are to be stored at a temperature not less than 2 degrees Celsius (36 degrees Fahrenheit) or more than 8 degrees Celsius (46 degrees Fahrenheit). A medication requiring storage in a cool place may be stored in the refrigerator unless otherwise specified on the label. A thermometer is kept in the refrigerator containing medications to measure proper temperatures. Medications are stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All medications and other drugs, including treatment items are stored in a locked cabinet or room inaccessible to the residents and visitors. A review of the facility's policy for Controlled Substances that was undated and was provided by the DON indicated the following: Storage of Controlled Substances indicated the following: All substances in schedules II, III, IV and V of the Controlled Dangerous Substances Act shall be stored separate from non-controlled under double lock. NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/06/21 at 10:30 AM, the surveyor interviewed Resident #63 who was in their room in a wheelchair. The resident denied any issues with going to dialysis and denied any transportation issues. A review of the paper chart showed that Resident #63 was admitted to the facility with medical diagnoses that included Cellulitis lower limbs (infection), cerebral vascular accident (stroke), end stage renal failure (kidney failure) and clotted AV shunt (dialysis access). A review of the Quarterly Minimum Data Set (QMDS), a quarterly assessment completed 10/2021, reflected that Resident #63 had a BIMS score of 15, which indictaed that the resident was cognitively intact. Section O, of the MDS, titled special procedures and treatments included dialysis. On 12/06/21 at 10:50 AM, the surveyor asked the residents nurse for the dialysis communication book. The Licensed Practical Nurse (LPN) gave the surveyor a binder with dialysis communication logs for Resident #63. The surveyor reviewed the logs for the month of November 2021 in the resident's communication book. During the month of November, the Resident #63 had gone to 13 dialysis treatments. Review of the communication book revealed that 9 of the 13 communication forms were not completed by the facility staff when the resident returned from dialysis. The section included changes in resident condition, vital signs, dialysis access site assessment and the signature of the receiving nurse. On 12/06/21 at 10:58 AM, the surveyor asked the LPN to explain how they are filled out and the nurse said, we fill out the top of the form before the resident leaves and include vital signs. The LPN then pointed to the middle of the form and said, the dialysis center fills out this section, and on the bottom gets filled out by us when the resident returns from dialysis. The surveyor asked why there were so many blank post dialysis sections and the LPN could not answer. A review of facility the policy titled, Care of the Resident Receiving Dialysis, the policy had a reviewed date of 11/2021. Under the section titled Policy Explanation and Procedures, it indicated the following: Dialysis communication form will be sent with the resident on each visit, upon return from dialysis the nurse will complete the post dialysis information located on the bottom of the dialysis communication record. NJAC 8:39-35.2 (d) (5) Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for 2 of 24 residents reviewed, Resident#12 and 63 and was evidenced by the following: 1. On 12/2/21 at 9:50 AM, the Director of Nursing (DON) in the presence of the Regional Registered Nurse (RRN) #1) informed the surveyor that Resident#12 was probably walking around that was why the resident was not in their room. The DON further stated that the resident had a diagnosis of Dementia. On that same date at 9:52 AM, the Certified Nursing Aide (CNA) informed the surveyor that the resident had forgetfulness, was able to walk independently without an assistive device and was on supervised smoking. On 12/2/21 at 9:56 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyors that Smoking Assessment was probably in the care plan, and it was the Minimum Data Set Nurse (MDSN) responsibility to do the Smoking Assessment. A review of the resident's Face sheet (an admission summary) disclosed that the resident had diagnoses that included Diabetes mellitus, seizures, altered mental status, and anxiety. A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate care management dated 5/7/21, indicated a Brief Interview for Mental Status (BIMS) score of 7, indicating that the resident's cognition was severely impaired. The CMDS further indicated that the resident was a smoker and with a wander guard. There was a smoking care plan that included an intervention for supervised smoking. A review of the medical records showed that the Resident Smoking Assessment was incomplete, the last assessment was done on 2/7/21, which was previously being done quarterly. Also, there was no Resident Smoking Assessment after 2/7/21 and there was no Elopement Risk Assessment. On 12/2/21 at 10:00 AM, the MDSN showed to the surveyors the Smoking Assessment from the resident's chart and the last assessment was completed on 2/7/21. The MDSN informed the surveyors that it was her responsibility to do a quarterly Smoking Assessment and it should be in the resident's chart. The MDSN stated, it's probably in my office because there were documents that are still in my office for filing. At that same time, the surveyors and the MDSN went to her office and she informed the surveyors that before the transition of the facility to a new company, she was also the acting Assistant Director of Nursing (ADON) when the previous ADON left. The MDSN showed to the surveyors a folder with documents for filing, which included a paper for Resident#12's Resident Smoking assessment dated [DATE] and 8/19/21. There was no Resident Smoking Assessment for November 2021 and the MDSN stated: it was missed. On 12/2/21 at 1:11 PM, the DON in the presence of RRN#2 provided the surveyors a list of residents with a wander guard that included Resident#12. On 12/2/21 at 2:29 PM, the surveyors met with RRN#1, DON, and the Licensed Nursing Administration (LNHA) and were made aware of the above concerns. Both the LNHA, DON, and RRN#1 acknowledged that there was no Elopement Assessment. RRN#1 informed the surveyors that the elopement assessment should be done upon admission on residents high risk for elopement when there is a change, or quarterly by law during quarterly and annual MDS. RRN#1 further stated that since the new company acquired the facility, they were in the process of checking the requirements with the assessment to comply with the regulations. RRN#1 indicated that the wander guard should be in the care plan. On 12/3/21 at 12:31 PM, the surveyors met with the LNHA, RRN#1 and 2, DON, and Regional Food Service Director (RFSD). Both the LNHA and RRN#1 acknowledged that yesterday on 12/2/21, there was no Elopement Assessment in the medical records of the resident. On 12/6/21 at 9:26 AM, the surveyors interviewed the Regional MDS Nurse (RMDSN) and the MDSN. The MDSN informed the surveyors that normally it was the Unit Manager (UM), me, and all department heads will initiate the care plan within 24-48 hours, then quarterly when there's a change according to the facility policy. The MDSN stated that the care plan for wander guard or elopement was in the chart of the resident, and the smoking assessment was in the care plan book. She further stated I'm not sure why it was not there at the time the DON and the surveyors checked it. Furthermore, the MDSN further stated that upon inspection of the medical records, which was five days after, the assessments were found in a different area of the chart. Both the MDSN and the RMDSN acknowledged that the medical records must be organized, readily available, complete, and accurate.

Based on observation, interview, and record review, it was determined that the facility failed to perform hand hygiene appropriately for 2 of 7 Staff observed after wound treatment and garbage disposal in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic handwash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis . Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient, . Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment, After contact with blood, body fluids or contaminated surfaces, Immediately after glove removal. Wash with Soap and Water: When hands are visibly soiled . Glove Use: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. 1. On 12/1/21 at 12:58 PM, the surveyor observed the Licensed Practical Nurse (LPN) #1 come out of Resident#42's room with a left-hand glove without performing hand hygiene. When LPN#1 was in the hallway, in front of Resident#42's room, LPN#1 removed her glove and disposed of it in the garbage bin that was in the medicine (med) cart which was parked outside the resident's room. Later on, LPN#1 walked toward the treatment cart that was parked across the resident's room and returned a box of dressing and a cleanser spray inside the treatment cart. Afterward, LPN#1 walked back to the med cart and performed hand hygiene with the use of the alcohol-based hand rub (ABHR). At that time, the surveyor interviewed LPN#1 regarding the above observation. LPN#1 informed the surveyor that I did the coccyx wound treatment of the resident. LPN#1 stated that I should have removed my gloves inside the resident's room and performed hand hygiene inside the room of the resident. I realized that I still have the glove on when I'm outside the room already. I was rushing. 2. On 12/1/21 at 1:04 PM, the surveyor observed the Housekeeper (HK) donn (applied) gloves and doff (removed) gloves when she picked up the garbage from the Center Unit medicine cart without performing hand hygiene. The surveyor observed the HK walk down in the hallway toward the clean utility room and dispose of the garbage that was picked up from the Center unit medicine cart. At that time, the surveyors interviewed the HK after the HK disposed of the garbage in the clean utility room about the above concerns with hand hygiene. The HK acknowledged that she did not perform hand hygiene before or after using gloves when she picked up the garbage from the medicine cart and stated I know, I should have used my ABHR from my pocket. She further stated that she was educated about hand hygiene by the Director of Nursing (DON). On 12/3/21 at 12:31 PM, the surveyors met with the Licensed Nursing Home Administration (LNHA), DON, Regional Registered Nurse (RRN) #1, RRN#2, all of which were made aware of the above concerns regarding hand hygiene of LPN#1. The DON informed the surveyors that LPN#1 is a new nurse and also an agency nurse. On 12/6/21 at 11:38 AM, the surveyors met with the LNHA, DON, RRN#1 and 2, Corporate Operation Officer (COO) and were made aware of the surveyors concern with the HK's hand hygiene. RRN#2 stated that it should be the wall hand sanitizer, not their hand sanitizer in the pocket to be used when performing hand hygiene. Both the LNHA, DON, COO, and Regional nurses acknowledged that HK should have performed hand hygiene before and after glove removal. On 12/8/21 at 1:14 PM, the LNHA informed the surveyors that there was no additional information. NJAC 8:39-19.4 (a) (1) (n)

Based on observation, interview, and facility-provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff in the laundry area according to facility policy and procedure. This deficient practice was evidenced by the following: On 12/8/21 at 9:24 AM, the surveyor toured the laundry area with the Director of Environmental Services (DES) who informed the surveyor that he's in charge of the laundry and the housekeeping department. There were 4 out of 6 hanging rack carts parked in the hallway near the laundry room with clean clothes which also had soiled bottom racks and used gloves. The DES informed the surveyor that probably it was the nurse from the unit who left the used gloves there. He further stated that it was the responsibility of the housekeeping department to check and make sure that the hanging rack carts were clean. At the same time, the surveyor observed another hanging cart with clothes that were not covered on the other side of the hallway. The DES stated, there were clean clothes without names and there should have a cover. The DES further stated, I don't know, probably a nurse came down here and removed the cover. Afterward, the surveyor and the DES entered the laundry room and observed used gloves on the floor next to the covered garbage bin. There was an assortment of debris including plastic, paper, a heavily soiled mop head, and heavy build-up of a black substance at the back of the two washing machines. Also, there was a white build-up accumulation on the surfaces of the two washing machines that extended to the concrete base and floor, on and underneath of the washing machine. In addition, there was a build-up of lint and dust around the laundry area floor and walls. There were two heel boots and a gown on the floor, and a ladder that were both covered with dust and lint. At that time, there was an exhaust fan that was not in use was covered with dry leaves. The DES had no answer why there was a build-up of dust and lint in the surrounding laundry room. Furthermore, the Laundry Staff (LS) informed the surveyor that she checks the laundry dryer for lint and logs it every two hours. The LS had no answer why there were dust, dirt, and lint in the laundry room. There was a log for checking the lint every two hours. There was no log for routine cleaning of the laundry area. Later on that same date and time, the surveyor and the LS went to the next room and observed the chute (a sloping channel or slide for conveying things to a lower level) for dirty clothes. The LS explained to the surveyor that the chute was connected to the second-floor nursing unit and that staff drop the soiled linens, gowns, towels, and blankets to the first-floor soiled laundry room. The soiled laundry room had multiple used gowns, towels, blankets, and linens that were observed directly on the floor. On 12/8/21 at 9:45 AM, the surveyors went to the laundry room, met with the Maintenance Director (MD) and Maintenance Staff (MS), and discussed the concern with dust, dirt, and lint surrounding the laundry room and the electric wiring. The MS informed the surveyors that there is no live electric current with that old telephone wirings. The MS stated that the laundry room should have been cleaned and there was no reason that the laundry room was not dusted off. The MD further stated that the exhaust fan was not being used at this time because it was wintertime and that the dried leaves should have been removed. On 12/8/21 at 10:00 AM, the LNHA informed the surveyors that the facility had identified the problem with the laundry area regarding the above concerns. The LNHA stated that the DES was not snap about it, that is why I'm putting the MD eventually to be in charge of the housekeeping and laundry department. On that same date and time, the COO stated to the surveyors that the bottom line, it is beyond their capabilities to clean. She further stated that I will have an outside vendor to do the general cleaning of the laundry. A review of the facility Departmental (Environmental Services)-Laundry and Linen Policy with a revised date of October 2010 that was provided by the LNHA included The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.In the Laundry 4. Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. 6. Reprocess any linen that is not visibly clean upon completion of the cycle or any linen that falls onto the floor. A review of the facility Cleaning and Disinfection of Environment Surfaces Policy with a revised date of October 2009 that was provided by the LNHA included Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: .9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. On 12/8/21 at 1:14 PM, the LNHA informed the surveyors that there was no additional information. NJAC 8:39-31.4 (a) (d) (f)

Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to a.) properly date, store and dispose of potentially hazardous and dry foods in a manner to prevent food borne illness and b.) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was observed and evidenced by the following: On 12/01/21 at 10:42 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. Five broken floor tiles and a missing tile in the dish machine area. 2. A white epoxy covered chipped and rust colored wall mounted wire rack. The rack was directly over the three compartment sinks for rinsing and sanitizing. The FSD acknowledged that there was a potential for cross contamination. 3. Two pieces of clear plastic used to tie the sanitizer solution tubing to the sink faucet. One of the plastic pieces had a heavy buildup of a black substance which was hanging directly over the sanitizing sink. The FSD acknowledged that there was a potential for cross contamination. 4. An air-drying rack which had sticky black debris on four shelves which the FSD was able to remove with a clean paper towel. The FSD acknowledged that the shelves wasn't clean but should be. In addition, there were three inverted muffin pans which had an unidentified white substance that the FSD was able to remove with his hand. There was also a 1/3 sized restaurant pan lid which had a sticky buildup on the underside . The FSD stated that it was not clean and should not have been on the rack. At 11:04 AM, in the presence of the FSD, the surveyor observed the following: 5. A [NAME] washed and rinsed a blender canister in the wash sink of the three-compartment sink; instead of washing, rinsing and properly sanitizing in three separate dedicated sinks. The FSD had previously stated that the three-compartment sink had been used to wash pots earlier that morning but was currently not set up for use. In the presence of the FSD, the surveyor interviewed the [NAME] who stated that he did not sanitize the blender canister and that the sanitizer should have been 70 parts per billion and I did not use a test strip. The [NAME] further stated that he had been employed for four weeks and was not educated on how to properly use the three-compartment sink. At 11:12 AM, in the presence of the FSD, the surveyor observed the following in the walk-in refrigerator: 6. An opened five-gallon bottle of BBQ sauce with no opened date and an opened five-gallon bottle of French dressing with a best if used by date of 2/5/21. 7. Seven opened packages of cheese with no opened date (one five-pound package of sliced Cheddar cheese, one five-pound package of shredded Cheddar cheese, four five-pound packages of sliced yellow American cheese and one five-pound package of sliced white American cheese). The FSD acknowledged there should have been opened dates on the packages to know if the cheeses could still be consumed. 8. Two fan covers with a heavy build up of a black fuzzy substance. The FSD acknowledged that the substance could dislodge from air blowing and go onto the food. 9. Ice buildup on the condenser. 10. Sticky white and black debris (which could be wiped off with a paper towel) on all of the wire racks in the refrigerator (four racks with five shelves each and one rack with four shelves). On continuation of the tour in the presence of the FSD, the surveyor observed the following: 11. A five well portable steam table used to serve resident meals which was not in use. There was a heavy buildup of food splatter and debris on the underside of the metal shelf which was directly over the food wells. 12. An opened bag of ziti pasta with no opened date and an opened bottle of gravy aide with no opened date on the spice rack. 13. A wall mounted knife rack which had a buildup of debris. 14. The hood over the cooking equipment which had seven baffles (a device used to restrain the flow of a fluid, gas, or loose material) that had a heavy sticky build up of what the FSD described as grease and dust. The substance was able to be wiped off with a paper towel. 15. In the dry storage area, there were five opened bags of pasta with no opened dates (one ziti, two elbow, one bowtie, and one fine noodles). A review of the facility policy Cleaning and Sanitizing, with a revised date of 4/30/20, reflected that all food contact surfaces need to be cleaned and sanitized to reduce the number of pathogens to a safe level. It also reflected that to clean and sanitize equipment, food should be scraped or removed from the equipment surfaces, washed and rinsed with clean water and then sanitized. It reflected that when storing clean and sanitized tableware and equipment they must be on a clean and sanitized shelf or rack. It further reflected that nonfood-contact surfaces should be cleaned regularly to prevent dust, dirt, food residue and other debris from building up. A review of the facility policy Three Compartment Sink, with a revised date of 7/1/20, reflected that the process is five step to clean and sanitize all kitchen wares which include washing, rinsing and sanitizing separately. In addition, it reflected that the sanitizer should be a Quaternary Ammonium solution with a measurement of 200-400 parts per million. A review of an undated facility Cleaning Schedule reflected that a 6:00-2:00 shift employee should date and label everything inside the walk-in refrigerator. NJAC 8:39-17.2 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to review and revise care plans over several quarters for 2 of 23 residents reviewed (Resident #56 and Resident #91). The deficient practice was evidenced by the following: 1. On 2/05/20 at 9:47 AM, the surveyor observed Resident #56 in bed, lying on an air mattress, padded 1/2 side rails with eyes closed. The surveyor reviewed Resident #56's medical records that revealed the following: According to the Face Sheet, Resident #56 was admitted to the facility with diagnoses that included Dementia. The Quarterly Minimum Data Set an assessment tool dated 12/19/19, indicated that the Resident #56 was unable to be interviewed by the facility for the Brief Interview of Mental Status Interview (BIMS) and the facility had assessed the resident as severely cognitive impaired. The February 2020 Physician's Order Form (POF) indicated that Resident #56 had an order for a puree diet with thin liquids. The diet order had been changed on 6/28/19 from nectar thick liquids (NTL) to thin liquids. Thickened liquids are needed for people with feeding and/or swallowing problems. Thickening the fluids makes swallowing safer. The Risk for Aspiration care plan was initiated on 2/27/19 and last updated on 5/29/19 that indicated the resident had a diet order of puree with NTL. There was a second care plan titled Risk for Aspiration that was initiated on 2/27/19 that indicated the resident had a diet order for puree with thin liquids and the last update was on 6/5/19 with a new diet order for puree with Nectar thick Liquids. The Weight Loss/Gain care plan initiated on 2/27/19 indicated the resident was on a puree diet with thin liquids and updated on 6/5/19 to reflect the diet change to puree with Nectar Thick Liquids. The last update on 6/18/19 indicated to continue the Nectar Thick Liquids. There was no documentation on the care plans that the Consultant Registered Dietitian (CRD) was involved in the development of the care plans. However, there was documentation in the Dietary Progress Notes (DPN) that the CRD documented the resident's progress quarterly. The CRD identified in the DPN dated 11/15/19 that Resident #56 was on a puree diet with thin liquids. The IDCP (Interdisciplinary Care Plan) Resident Summary sheets indicated that the Interdisciplinary Care Plan Team (ICPT) met to discuss Resident #56's plan of care on 5/29/19, 8/30/19 and 12/8/19. These meetings are done quarterly for all residents to discuss the residents plan of care, and to review and update the care plans, which would include adding or removing interventions that reflect the services provided to the resident. The IDCP Resident Summary sheet dated 12/8/19 indicated that Resident #56 was on a puree diet with NTL. This was not consistent with the physician's orders on the February 2020 Physician Order Form and the documentation made by the Consultant Registered Dietitian. The care plans mentioned above were not updated to reflect any documented changes with the resident or any change in the services provided. On 2/6/20 at 9:47 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #56 who stated that the resident was on a puree with thin liquid diet. At 9:59 AM, the surveyor interviewed the Licensed Practical Nurse assigned to Resident #56 who confirmed the resident was on a puree with thin liquid diet. 2. On 2/04/20 at 11:26 AM, the surveyor observed Resident #91 lying in bed with eyes open. The resident's padded side rails were in the up position. The resident was not verbal and the surveyor was informed by the nurse that the resident communicated by waving their arms and bangs on the side rails. The surveyor reviewed Resident #91's medical records that revealed the following: According to the Face Sheet, Resident #91 had diagnoses that included Cerebral Vascular Accident and Dysphagia (difficulty swallowing). The resident had a percutaneous gastrostomy tube (PEG tube) inserted into the abdomen to provide nutritional support through tube feedings. The Quarterly MDS dated [DATE], indicated that the resident was unable to be interviewed for the BIMS and the facility had assessed the resident as moderately cognitive impaired. The February 2020 Physician Order Form indicated that Resident #91 had a order for Jevity 1.5 one can (8 ounces) six times per day through the PEG tube and to provide puree pleasure foods with Nectar Thick Liquid. On 2/6/20 at 11:02 AM, the surveyor interviewed the CNA assigned to Resident #91 who stated that the resident doesn't always eat the pleasure foods well, but will eat what the family brings from home. At 11:05 AM, the surveyor interviewed the LPN assigned to the resident who stated that the resident often refuses tube feedings. The At Risk for Altered Nutrition Care Plan related to PEG-tube status initiated on 12/18/18 had no updates since 12/18/18. The Aspiration Precaution care plan was initiated on 3/10/17 and the last update was dated 12/27/18. There was no documentation on the care plans that the CRD was involved in the development of the care plans. However, there was documentation in the Dietary Progress Notes (DPN) by CRD regarding the resident's progress and slow downward trend with weight related to the resident's frequent refusal of the tube feedings. The Nurse's Notes revealed that Resident #56 frequently refused the tube feedings and has had occasions where the resident pulled out the PEG tube and would require hospitalization to have the tube replaced. The IDCP Resident Summary sheets available for review indicated that the ICPT met to discuss Resident #91's plan of care on 9/26/19 and 1/2/20. However, the care plans mentioned above were not updated to reflect any documented changes with the resident or any change in the services provided. On 2/6/20 at 11:00 AM, the surveyor interviewed the Consultant Registered Dietitian (CRD) who stated she comes to the facility once or twice a week, she does not develop nutrition care plans and that she would give her recommendations to nursing and the nurses write the care plans. The RD further stated she does not attend the ICPT meetings. The surveyor asked if she reviewed care plans for appropriate interventions and she replied no. On 2/6/20 at 11:30 AM, the surveyor interviewed the MDS Coordinator who was responsible to arrange the ICPT meetings for every resident. She stated that she doesn't bring the care plans to the ICPT meetings to be reviewed or updated. She stated she had a lot to keep track of and document. On 2/06/20 at 2:17 PM, the surveyor discussed with the Administrator, Director of Nursing (DON) and the Corporate Registered Nurse the above care plan concerns and that this was a repeat deficiency from the previous survey, A review of the Consultant Dietitian Contract dated October 21, 2019 under #1 and #3 indicated that the CRD reviews the resident's medical history and CRD would meet with the DON, MDS Coordinator or Nursing Supervisor prior to leaving the facility and provide a summary of residents evaluated and recommended interventions. There was no mention in the contract for the Consultant Dietitian to attend the ICPT meetings. A review of the facility's policy Resident Care Plan Policy and Procedure dated 12/2019 indicated under Updating Care Plans the following: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals and 2. The care plan will be updated and/or revised for the following reasons: a. Significant change in the resident's condition. b. A change in planned interventions. c. Goals are obtained and new goals established to meet current resident needs and/or goals. d. New diagnosis, new medication, etc NJAC 8:39-4.1,3

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of clinical practice by not transcribing and initiating a physician's order (PO) for antibiotic treatment (ABT) in a timely manner for 1 of 23 residents (Resident #5) reviewed. 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 well being, 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 2/5/20 at 9:21 AM, the surveyor observed Resident #5 walking down the hallway using a cane. The surveyor reviewed Resident #5's medical record that revealed the following: According to the Face Sheet, Resident #5 was admitted to the facility with diagnoses that included Diabetes Mellitus and Diverticulosis. The Quarterly Minimum Data Set, an assessment tool dated 1/16/20, revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status which indicated that Resident #5 was cognitively intact. On the Physician's Order form dated 1/24/20, revealed a new order that was written by the Nurse Practitioner (NP) for the antibiotic Keflex 500 mg by mouth to be administered twice daily for seven days. The Nurse Practitioner documented on the Progress Note dated 1/24/20 under Assessment the following note: Rash and Cellulitis (a bacterial infection underneath the skin surface characterized by redness, warmth, swelling and pain) and under Plan: Keflex 500 mg twice daily for seven days. The January 2020 Medication Administration Record (MAR) revealed that Resident #5 received the first dose of Keflex on 1/25/20 at 5:00 PM. The surveyor requested a list of back up medications from the RN Supervisor #1. The RN Supervisor #1 provided the facility's back up medication binder titled Utilization Declining Inventory. There was a form that indicated Keflex 250 mg was available in the back up box. Under the section titled Quantity and Medication, it had indicated that on the evening of 1/24/20 and the morning of 1/25/20 there were six Keflex 250 mg capsules available in the back up box if needed. On 2/7/20 at 10:50 AM, the surveyor interviewed the RN Supervisor #1 on duty. After reviewing the physician order for Keflex written on 1/24/20 and the January 2020 MAR, RN Supervisor #1 stated that the Keflex should have been given to the resident on 1/24/20 during the evening shift and on 1/25/20 at 8:00 AM. The RN Supervisor #1 further stated We have this medication in the back up box. On 2/7/20 at 11:00 AM, the surveyor interviewed Resident #5 concerning the time of the Nurse Practitioner's visit. Resident #5 stated it was evening when the NP told the resident they had an infection and needed to be treated with antibiotics. The resident informed the surveyor that the resident received the first dose of antibiotics at 5:00 PM the next day. On 2/7/20 11:10 AM, the surveyor interviewed the NP, who stated she wrote the Keflex order for Resident #5 between 8:00 PM and 8:30 PM on 1/24/20 and she informed one of the nurses about the order, but could not recall which nurse she had spoken to. The NP further stated that whenever she writes orders she flags the chart and informs the nurse on duty. There was no documentation in the Nurses Notes on 1/24/20 that the NP had visited and ordered an antibiotic. On 2/7/20 at 11:15 AM, the surveyor interviewed the 11-7 Registered Nurse (RN #1) assigned to Resident #5 on the 1/24/20 night shift. RN #1 stated that when she was completing her 24-hour chart checks (review of all resident's charts to ensure all new PO's received in the last 24 hours were carried out and transcribed) she saw that Resident #5 had had a new order dated 1/24/20 for the antibiotic Keflex. RN #1 then stated she reviewed Resident 5's January 2020 MAR and noted that the Keflex order had not been transcribed. RN #1 stated she wrote the new order for Keflex ABT onto the MAR and scheduled the medication for 8:00 AM and 5:00 PM. RN #1 furthur stated that during morning report on 1/25/20 she told the day nurse about the new order for the Keflex and also wrote it on the 24 hr report. The 1/24/20 24 hour report titled Daily Report form under the section titled 3:00 PM to 11:00 PM Shift revealed that the Licensed Practical Nurse (LPN #1) had not documented next to Resident #5's name that the resident had been seen by the NP who had ordered ABT. Further review of the form under the section titled 11:00 PM to 7:00 AM it was documented under Resident #5's name by the RN #1 Keflex coming tonight. On 2/7/20 at 11:40 AM, the surveyor interviewed via telephone LPN #1 assigned to Resident #5 on 1/24/20 evening shift. LPN #1 stated he did not remember receiving an order for Keflex for the resident on 1/24/20. On 2/7/20 11:50 AM, surveyor interviewed via telephone the evening RN Supervisor #2, who worked on 1/24/19 evening shift . The RN Supervisor #2 stated he did not remember receiving a PO for Keflex for Resident #5 on 1/24/20. On 2/7/20 12:00 PM, the surveyor attempted to interview via telephone LPN #2 assigned to Resident #5 on 1/25/20 day shift concerning why she did not administer the 1/25/19 8:00 AM dose of Keflex. LPN #2 could not be reached. A review of the facility's policy titled Back Up Box indicated under Procedure #2: Back up medications shall only be used under circumstances where due to the condition of the resident it would be beneficial to initiate prompt administration of a medication (prior to the pharmacy delivery). A review of the facility's policy titled Transcribing Medication Orders Onto The Medication Administration Record did not include any information on transcribing and initiating PO's in a timely matter. On 2/7/20 at 1:15 PM, the surveyor met with the Administrator, Director of Nursing (DON) and Corporate RN about the above concerns. The DON stated that LPN #2 no longer worked at the facility. No further information was provided. NJAC 8:39-11.2(b).

Based on observation, interview, and record review, it was determined that the facility failed to: a) apply floor mats in accordance with the physician's order and b) collaborate with hospice for the development and implementation of the plan of care and to ensure that the residents needs are met according to the facility's policy. This deficient practice was identified for 1 of 1 resident (Resident #30) reviewed for hospice services and was evidenced by the following: On 2/4/20 at 11:25 AM and 2/5/20 at 9:32 AM, the surveyor observed Resident #30 lying in bed with eyes closed. There were two floor mats folded up and leaning up against the resident's nightstand. The surveyor reviewed Resident #30's medical record which revealed the following: According to the Face Sheet, Resident #30 was admitted to the facility with diagnoses that included: Weakness, Dementia, and Edema of Bilateral Lower Extremities. The February 2020 Physician's Order Form indicated that Resident #30 had a physician's order dated 2/2/19 for floor mats to both sides of bed while in bed every shift. The Certified Nursing Assistants (CNA) refer to the Resident Care Card for the resident's plan of care daily. The Resident Care Card dated 2/11/19 listed interventions that included floor mats to both sides of bed while in bed every shift. Resident #30's care plan titled [the resident] is at risk for falls R/T (related to) unsteady gait, weakness, impaired cognitive function initiated on 1/23/19 had interventions that included 2/2/19 floor mat to both sides of bed. The Initial Physician Orders and Certification form completed by hospice listed a start of care date of 1/29/20. The form, under Equipment, did not include any orders for floor mats. There were two Hospice Aide Care Plan's dated 1/29/20 and 1/30/20 that did not include floor mats. The Nurse's Notes from 1/29/20 through 2/5/19 had no documentation that the facility had discussed the residents plan of care, to include floor mats, with the hospice provider. On 2/5/20 at 9:35 AM, the surveyor interviewed the CNA assigned to the resident. The surveyor asked the CNA about the folded up floor mats that were leaning against Resident #30's night stand. The CNA stated that the floor mats should be on the floor on both sides of the bed at all times when the resident was in bed. The CNA stated that when she came in at 7:00 AM she checked Resident #30 and the floor mats were in place as ordered and that the hospice aide came in at 8:00 AM and must have not replaced them before she left. The CNA further stated that she speaks with the hospice aide regularly. However, had never discussed that the resident's need for floor mats when the resident was in bed. On 2/5/20 at 9:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident who stated that the resident required floor mats. When asked about the folded up floor mats that were leaning against Resident #30's night stand the LPN stated that the hospice aide must have removed the mats when she was doing care and must not have put them back. The LPN also reported that she had noticed on 2/4/20 that the hospice aide did not put the floor mats down before she left. She stated she did not call hospice provider or talk to the hospice aide about the floor mats the next time she was in the facility. On 2/5/20 at 9:48 AM, the surveyor interviewed the Registered Nurse Supervisor (RN) who stated that all staff should reference the Resident Care Card and plan of care before providing care to the resident. The RN was unsure if the hospice aide had access to the plan of care or the Resident Care Care, but stated staff should be giving the hospice aide verbal report daily. The RN could not recall giving the hospice aide verbal report related to the floor mats and was unsure why the floor mats were not listed on the Hospice Aide Care Plan. The RN further stated that she had not discussed the plan of care with the hospice provider and was not aware of any plan of care from the hospice provider. On 2/5/19 at 10:02 AM, the surveyor interviewed the Minimum Data Set (MDS) Coordinator responsible for scheduling and arranging care conference meetings. The MDS Coordinator stated no meeting was held to discuss the residents plan of care with the hospice provider. She stated that the hospice care plan was separate from the facility care plan and the facility has not reached out to the hospice to formulate a collaborative plan of care for this resident and had not discussed floor mats with the hospice provider. On 2/7/20 at 12:15 PM, the Director of Nursing (DON) looked through the chart in the presence of the surveyor and confirmed that there was no plan of care from hospice in the chart and was unsure why it was not there. The DON stated that she knows that hospice should have one and it should be in the resident's chart. On 2/7/20 DON provided an Interdisciplinary Care Plan (ICP) that had been faxed to the facility from the hospice provider. The ICP printed on 2/7/20, titled Risk for falls/injury did not include floor mats as an intervention. On 2/10/20 at 10:55 AM, the surveyor interviewed the hospice Team Leader (TL) assigned to the resident who stated that the hospice care plan is developed within 48 hours of admission to hospice and should have been sent to the facility. The TL was unsure why it was not sent to the facility. The TL also stated that when a resident is admitted to hospice, they make immediate recommendations. However, they do not collaborate with the facility to create the plan of care. On 2/10/20 at 11:01 AM, the surveyor interviewed the hospice RN Case Manager (RNCM) assigned to the resident. The RNCM stated that she did not know that the resident required floor mats and had not been made aware of this prior to 2/5/20. The RNCM also stated that the hospice aide only references the Hospice Aide Care Plan when they come into the facility to provide care for the resident. The RNCM reported that she had not reviewed the facility care plans nor discussed the plan of care with facility staff. A review of the facility's policy titled Hospice Policy and Procedures under policy Interpretation and Implementation #10 revealed the following: 10. In general, it is the responsibility of the facility to meet the residents' personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: . d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. NJAC 8:39-27.1 (a)

Based on observation, interview and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness; b.) failed to sanitize and air dry pans in manner to prevent cross contamination of microbial growth. This deficient practice was evidenced by the following: On 2/4/20 at 9:32 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. On top of the steam table there was a stack of 5 pans, in circulation for use, that were observed to have water in between them. The FSD stated that pans were clean and ready for use and that the staff should have ensured the pans were completely dry before stacking. 2. In the dry storage area, the surveyor observed dented cans which were in rotation for use as follows: - a 100 fluid ounce can of whole potatoes with a one inch dent to the body of the can and a one inch to the upper lip. - two six pound (lb) 10 ounce (oz) cans of diced peaches with a one inch dents to the upper lip and a one inch dent to the lower lip. - two six lb 10 oz cans of diced peaches with quarter inch dents to the upper rim. - a six lb eight oz can of apple sauce with a one and a half inch dent to the top. - three six lb four oz cans of cut sweet potatoes in light syrup with one inch dents to the body. - a three lb 14 oz can of mushrooms with a quarter inch dent to the upper rim. FSD stated the cans were in circulation for use. The FSD also stated that the cans should have been removed and put in the dented can section by the staff member who received the delivery. On 2/4/20 at 1:21 PM, the surveyor discussed with the Administrator and Director of Nursing of the above findings. The surveyor reviewed an undated facility policy titled, Dented cans. The policy revealed that all cans must be removed from the box and inspected before they are stored on the shelves, if any of the cans are dented they are to be isolated in the designated dented can area to be returned to the vendor. The surveyor reviewed an undated facility policy titled, Nesting water. The policy revealed that all dishes, pots and pans have to be free of the nesting of water. The policy also revealed that after pots, pans and dishes are washed they are to be stored on a rack to air dry. NJAC 8:39-17.2(g)