Based on observation, interview and record review it was determined that the facility failed to ensure a resident who required assistance with Activities of Daily Living (ADLs) had all necessary items maintained within reach of the resident. This deficient practice was identified for 1 of 1 resident (Resident #129) reviewed for accommodation of needs and was evidenced by the following: On 3/5/25 at 9:15 AM the resident was not available in their room, and at that time the surveyor reviewed the electronic medical record which revealed: a Progress Notes dated 3/4/25 timed 11:50 PM: Interdisciplinary Team Note. Note Text: Resident found on the floor at around 10:15 PM. According to the resident, the staff failed to place the bedside table within the resident's reach. While attempted to reach for the phone the resident fell on the floor, complaining of pain in their back. The resident was transferred to the Emergency Department for evaluation and returned to the facility on 3/5/25. X- Ray (digital image ) and CT-Scan (Computer Aided Tomography) performed at the hospital were negative for fracture and intracranial bleeding (brain bleed). The admission Record revealed Resident #129 was admitted to the facility with diagnoses which included, but were not limited to; Hemiplegia (paralysis that affects only one side of the body) and Hemiparesis (one sided muscle weakness) and ischemic cardiomyopathy. The admission Minimum Data Set (MDS), an assessment tool used to manage care dated 12/11/24, reflected that Resident #129 had intact cognition as evidenced by a 15 out of 15 score on the Brief Interview for Mental status (BIMS). Resident #129 was dependent on staff for most activity of daily living which included mobility, transfer and toileting. The Comprehensive undated care plan provided by the facility on 3/7/25 at 12:30 PM, reflected a Focus for falls related to weakness and Cerebro-Vascular Accident (damage to the brain from interruption of its blood supply). The goal was for Resident #129 not to sustain serious injury through the review date. The interventions were to anticipate and meet needs, Be sure call light is within reach, and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance. On 03/06/25 at 8:51 AM, the surveyor observed the resident was in bed and the resident informed the surveyor that they fell, and had reported pain on the back area. When asked to elaborate regarding the fall, Resident #129 stated in the presence of the Assistant Director of Nursing, that prior to providing care the Certified Nurse Aide (CNA) moved the bedside table away, and that was where the resident's phone was, and the CNA did not move the bedside table back where it was originally located, next to the bed. Resident #129 stated then the nurse came to administer medications, and walked away before they could asked to move the bedside table close to the bed. The resident's phone was ringing and ringing, they attempted to reach for the phone, and could not reach it and they fell out of the bed. Resident #129 added that was not the first time that the phone had been placed of their reach and they could not answer the phone. The resident further stated, I cannot walk, I felt helpless because the bedside table was placed near the door with the phone, and I could not reach the phone. On 03/07/25 at 11:00, during the exit conference held with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing (ADON), Regional Material Data Set Coordinator, and Regional Clinical Director. The ADON confirmed that staff who provided care should move items back within reach of the residents and the ADON confirmed that was not the first time that items have been left out of reach of Resdient #129. NJAC 8:39-27.1(a)

Based on interview and document review it was determined that the facility failed to complete and transmit the required Material Data Set (MDS) assessment for 1 of 1 system selected MDS assessments reviewed and was evidenced by the following: On 3/4/25 at 10:05 AM, the surveyor reviewed the medical record for Resident #83. The MDS record revealed that the Resident was discharged on 10/9/24 and the MDS record was identified as 132 days overdue. On 03/04/25 at 10:51 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RN/MDS) regarding the MDS process when a resident was discharged . The RN/MDS stated the facility must complete a discharge MDS, and she stated it is usually completed immediately. The surveyor asked the RN/MDS to review Resident #83's MDS in the presence of the surveyor. The RN/MDS reviewed the MDS and stated, I must have missed this one and the surveyor requested a Validation report for Resident #83's MDS. On 03/05/25 at 8:31 AM , the Licensed Nursing Home Administrator provided a copy of the Final Validation Report, dated 3/4/25, which revealed. Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). NJAC 8:39- 11.1

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individual comprehensive care plan (ICCP) for a resident who received intravenous (IV) therapy and had an IV catheter. The deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for IV therapy and was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 sitting in a wheelchair in their room. The surveyor observed the resident's right hand with a short IV line (a tube that administers fluid or medication into veins) between the thumb and first finger. Resident #38 stated that they had received medication through an IV weeks ago. On 2/28/25 at 9:56 AM, the surveyor again observed the short IV line inserted in Resident #38's right hand. On 2/28/25 at 12:00 PM, the surveyor reviewed the electronic medical record (EMR). A review of the admission Record (an admission summary) revealed Resident #38 had diagnoses which included, but were not limited to; pneumonia. A review of the admission Minimum Data Set (MDS) an assessment tool dated 2/7/25, included a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated intact cognition. A review of the Order Summary Report documented a physician order dated 2/10/25 for Sodium Chloride Solution 0.9% 80 milliliter (ml) per hour intravenously every shift for electrolyte imbalance for 3 days with an end date of 2/13/25. A review of the ICCP dated 2/1/25, including all resolved and canceled focus areas, failed to document the insertion and use of IV therapy including a focus area, goals, or interventions. On 3/4/25 at 9:00 AM, the Licensed Practical Nurse Unit Manager (LPN UM) reviewed the EMR and acknowledged there was no ICCP for the use of IV therapy. On 3/04/25 at 9:52 AM, the Director of Nursing (DON) stated that IV therapy should be in the care plan and when no longer in use, it would be marked as resolved. The DON further stated, I am educating the staff. A review of the facility provided policy, Comprehensive Care Plans revised 6/2023, included but was not limited to; to develop and implement a comprehensive person-centered care plan consistent with resident rights, includes measurable objectives and time frames to meet medical, nursing, and mental and psychosocial needs. The process will include an assessment of the resident's strengths and needs . The care plan will describe at a minimum . services to be furnished to attain or maintain the highest practicable physical well-being; any specialized services; specific interventions that reflect the needs and preferences of the resident; will include measurable objectives and timeframes . and interventions; and the staff responsible for carrying out interventions and the staff will be made aware when changes are made. NJAC 8:39-11.2(e)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure all residents were treated in a dignified manner by failing to ensure a) residents who were dependent on staff for care were provided with incontinence care prior to being served meals, and b) residents eating meals in the same dining room were served meals at the same time. This deficient practice occurred for 3 of 3 residents reviewed for dignity (Resident #31 and #42 and #129) and was evidenced by the following: On 2/27/25 at 10:16 AM, the surveyor observed Resident #129 in bed and the resident was partly covered and the incontinence brief could be observed bulging from the back. The resident informed the surveyor they were last provided with incontinence care at 5:00 AM. The resident informed the surveyor that they were unable to get out of the bed to use the bathroom, they could not walk, and staff would not answer the call light in a timely manner. On 2/27/25 at 10:59 AM, an incontinence observation performed with a random Certified Nursing Aide (CNA) revealed that Resident #129 was wearing an incontinence brief that was soaked with urine and soiled with feces. On 2/27/25 at 11:46 AM, the surveyor returned to Resident #129's room and the resident stated that they still had not been changed. The surveyor then observed that the resident had been served the lunch meal while not having been first provided with incontinence care. On 2/27/25 at 11:50 AM, the surveyor accompanied the Licensed Practical Nurse (LPN) to Resident #129's room and the resident informed the nurse that they had not been provided with incontinence care prior to the meal delivery. The LPN stated that the protocol was to check and change the residents prior to serving meals to the residents. On 2/27/25 at 12:00 PM, a review of the medical record revealed that Resident #129 was admitted to the facility with diagnoses that included, but were not limited to; Hemiplegia (paralysis that affects only one side of the body) and Hemiparesis (one sided muscle weakness) and ischemic cardiomyopathy. The admission Minimum Data Set (MDS), an assessment tool used to manage care dated 12/11/24, reflected that Resident #129 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental status (BIMS). The MDS also revealed Resident #129 was dependent on staff for most activity of daily living including mobility, transfer and toileting. The undated Care Plan provided by the facility on 3/5/25 at 10:30 AM, reflected a Focus for Self Care /Mobility Performance Deficit related to Cerebrovascular Accident (damage to the brain from interruption of its blood supply). The goal was for Resident #129 to improve current level of function in mobility, transfer and personal hygiene. The interventions were to document, report any changes, any potential for improvement reasons for self care deficit, expected course, declines in function . On 2/27/25 at 12:08 PM, during an interview at with the LPN, she stated, the CNA would document their care in the Point of Care (POC) system. The surveyor reviewed the POC with the LPN and there was no documentation regarding any care provided on 2/27/25 for Resident #129. On 2/27/29 at 12:15 PM, the surveyor interviewed the CNA who cared for Resident #129. The CNA stated that she served breakfast that morning to the resident and confirmed that she did not provide any care to the resident. She stated she was Agency Staff and was not informed of what was to be done for the resident. 2. On 2/28/29 at 11:40 AM, the surveyor observed the lunch meal pass on the 4th floor. The surveyor observed three residents seated in the right corner of the room that was adjacent to the nursing station. The surveyor observed a CNA set up the lunch tray for Resident #77. Resident #77 began eating their lunch meal while Resident #31 and #42 watched television and waited for their trays. The surveyor observed that both residents waited 25 minutes before they received their lunch meals. Resident #31 and #42 received their lunch meal at 12:05 PM. On 3/04/25 at 11:20 AM, the surveyor again observed the lunch meal on the 4th floor. The first lunch cart arrived on the floor at 11:24 AM. The surveyor observed 3 residents seated in the right corner of the room same as on 2/28/25. On 3/04/25 at 11:34 AM, the surveyor observed Resident #77 received their lunch meal. The CNA set-up the lunch meal for the resident and left the room. Resident #77 was eating their lunch and Resident #31 and #42 were actively watching Resident #77 eating while waiting for their trays. Resident #77 completed their meal at 11:45 AM. Resident #31 and #42 received their trays at 12:01 PM. On 3/4/25 at 12:50 AM, the surveyor interviewed the LPN assigned to the unit regarding the above observation. The LPN stated, The trays arrived at different times, and Residents should be fed at the same time while seated at the same table. The surveyor then asked the LPN if it was normal practice for residents to sit and observe other residents eating their meals. The LPN stated, I agreed with you, they should be served at the same time, it is what it is. The surveyor then reviewed Resident #31's medical record which revealed the resident was admitted to the facility with diagnoses that included, but was not limited to; unspecified Dementia with behavioral disturbances. According to the most recent MDS, dated [DATE], Resident #31 had severe cognitive impairment and required staff assistance with set-up for eating. Resident #31 scored 02 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a severe cognitive impairment. The surveyor reviewed Resident #42's medical record which revealed diagnoses which included, but were not limited to; hemiplegia, hemiparesis and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #42 was severely cognitively impaired. Resident #42 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS). On 3/05/25 at 10:16 AM, during an interview with the nurse educator regarding the above concern, she stated that the staff had since been in-serviced. On 3/6/25 at 1:30 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator (LNHA) who stated that the facility had been educated and the facility did not have a related policy for dining. NJAC 8:39 - 17.4(d)

Complaint # NJ 167926 Based on interview, record review and document review it was determined that the facility failed to report an allegations of abuse, and injury of unknown origin to the Department of Health (NJDOH) as required within two hours of the allegation being made. The deficient practice was evidenced for 2 of 4 resident reviewed for investigations (Resident #343 and #290) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343, sitting in the room in a wheelchair. The surveyor observed the right side of the resident's face with large area of discoloration and a bump around their right eyebrow. On 3/4/25 at 12:29 PM, Surveyor #1 reviewed the medical record for Resident #343. A review of the admission Record face sheet (an admission summary) reflected that Resident #343 was admitted to the facility with diagnoses which included but were not limited to; Heart Failure, Chronic kidney disease and history of falling. A review of an Annual Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 2/27/25, reflected that Resident #343 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognition. A review of the electronic Progress Notes (PN) dated 2/25/25 at 10:30 AM, reflected that the resident was noted with a bump on head. The PN reflected that the resident was assessed, vital signs were stable. Resident #343 was scheduled for dialysis treatment that day, left the facility for dialysis and returned at 4:57 PM. Upon return from the dialysis center, the Licensed Practical Nurse (LPN) who assessed the resident, indicated that the hematoma had increased in size (no measurement provided), the Registered Nurse/Unit Manager (RN/UM) was made aware. The Physician was notified and ordered to transfer the resident to the Emergency Department for evaluation and treatment. The Resident Representative was made aware of the transfer. A CT (computed tomography) scan (noninvasive imaging procedure that uses X-rays to create cross-sectional images of the body) performed at the hospital was negative for intracranial bleeding according to the facility. Resident #343 returned to the facility on 2/25/25 at 11:55 PM. On 3/5/25 the surveyor requested the investigation for review. On 3/5/25, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of the Reportable Event Record/Report dated 2/25/25. The incident was reported to the New Jersey Department of Health (NJDOH) on 2/28/25 at 4:30 PM (3 days later). On 3/7/25 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged to the survey team that she was made aware of the incident late in the evening, although the incident occurred at 10:00 AM that day. She informed the surveyor that the LNHA was in charge of the investigation and reported the incident to the NJDOH. She could not provide the rationale for reporting the incident 3 days later while the survey team was on site. 2. On 2/28/25 at 12:55 PM, upon an inquiry from Surveyor #2, the LNHA stated there were no investigations for Resident #290 related to care concerns, however, then provided Surveyor #1 with copies of progress notes beginning 9/15/23. On 3/04/25 at 9:06 AM, the LNHA stated she had an investigation regarding Resident #290, and then confirmed that nothing was reported the NJDOH. The surveyor reviewed the following: A Grievance/Concern Form revealed: Description of Concern: Resident reported to Registered Nurse Supervisor (RNS) on 11:00 AM on 9/16/23, that while in therapy the resident had a bowel movement in diaper and asked the therapist to bring them to their room to be changed. Resident #290 stated, three Certified Nurse Aides (CNAs) assisted them and I was aggressively and forcefully wheeled to the bathroom, as I was pleading to put back to bed to be changed because I am dizzy. Another Grievance/Concern Form revealed: Concern Reported To: IDC [Interdisciplinary Care Team] LNHA, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), Description of Concern: Resident #290 requested a meeting with the IDC team and was extremely infuriated due to many issues but the in particular the treatment they received from two CNAs last Friday 9/15/23. The resident claimed they defecated in diaper and needed to be changed. Resident #290 stated both CNAs were aggressive in the process and one CNA was taunting them, and the CNAs nails dug into them. On 3/07/25 at 8:50 AM, Surveyor #1 interviewed the LNHA in the presence of the survey team. The LNHA confirmed that Resident #290's documented allegations were allegations of abuse and confirmed they were not reported to the NJDOH. Surveyor #1 asked the LNHA if there was any reason the allegations were not reported to the NJDOH and the LNHA had no comment. The Abuse, Neglect and Exploitation policy, signed by the LNHA on 5/25/24 revealed: VII: Reporting/Response: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes: a. immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39- 9.4(f)

Complaint # NJ 167926 Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to complete a thorough investigation to rule out abuse or neglect for a resident who sustained an injury of unknown origin, for an allegation of abuse, and ensure a resident was protected from potential abuse while an investigation was completed. This deficient practice occurred for 2 of 4 residents reviewed for abuse (Resident #290 and Resident #343) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343 sitting in the wheelchair in their room. Surveyor #1 observed the right side of the resident's face with large area of discoloration, and a bump around their right eyebrow. On 03/04/25 at 12:29 PM, Surveyor #1 reviewed the Medical Record (MR) for Resident #343 which revealed the following: The admission Record revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (an infection that affects one or both lungs), Type 2 diabetes, and dependence on renal (kidney) dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/27/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score 14 out of 15 that indicated the resident had intact cognition. The Care Plan (CP) revealed a focus area initiated 2/25/25 that revealed Resident #343 had sustained an actual fall with skin discoloration to right forehead related to gait/balance problems. Interventions included neurological checks (assessment for head injury) for 24 hours. A review of the Nursing Progress Notes (PN) dated 2/25/25 at 10:30 AM revealed the following: RN #1 was called into resident's room by RN #2 and the Certified Nurse Aide (CNA) to show the bump on Resident #343's head. RN #1 asked the resident how it happened, and the resident stated that while in the chair, they were sliding from the chair. The CNA called for help and RN #2 and the CNA both assisted the resident back into the chair. The PN revealed that when RN #1 assessed the resident, the resident seemed okay and was alert. RN #1 checked resident's vital signs (VS/ blood pressure, pulse, respirations, temperature and pain). The Unit Manager (UM) was made aware of the incident after it occurred. On 3/5/25 at 8:31 AM, the surveyor requested any facility's incidents, investigations, reportable events that were sent to the New Jersey Department of Health (NJDOH) and any grievances for February 2025. On 3/5/25 at 10:07 AM, Surveyor #1 interviewed the RN/UM regarding the fall that occurred for Resident #343. The RN/UM stated she was made aware of the fall on 2/25/25 around 12:00 PM, which was after the morning meeting. At that time, the RN/UM stated she was unable to complete an assessment of the resident, as the resident had already left the building for dialysis treatment. The resident then returned from dialysis at 4:57 PM and the RN/UM was made aware by the Licensed Practical Nurse (LPN) on duty that the hematoma (an abnormal collection of blood outside of a blood vessel) was observed on the right forehead and had increased in size. On 3/5/25 at 11:32 AM, Surveyor #1 interviewed RN #1 regarding the fall. RN #1 stated she had asked the CNA to assist the resident to get the resident ready for dialysis on 2/25/25. RN #1 stated the resident was already sitting in the wheelchair and RN #1 had been passing medications on the opposite hallway. The CNA then exited out of Resident #343's room and called for help, and then RN #2 went to help and assisted the CNA to pull Resident #343 back into the wheelchair as the resident was sliding off. RN #1 then stated RN #2 informed her that he had observed the resident sitting on the edge of the wheelchair. RN #1 stated that RN #2 told her that they assisted the CNA to pull the resident back into the wheelchair and at that time had observed a small bump on the right side of Resident #343's forehead. RN #1 stated that RN #2 then asked them to check on the resident because of the observed forehead injury. RN #1 stated that she assessed Resident #343's vital signs and neurological status (assess an individual's neurological functions, motor and sensory response, and level of consciousness) and then the resident was sent out for dialysis at their scheduled time. RN #1 stated she contacted the RN/UM via text message. On 3/5/25 at 11:55 AM, Surveyor #1 reviewed the facility provided Investigation for the incident that occurred on 2/25/25 included the following statements: A statement signed by RN #1, dated 2/25/25 revealed . that called by other nurse on high side and the CNA who showed the bump on head . seemed fine . the unit manager was made aware after the incident . A statement completed by RN #2 dated 2/25/25 revealed . I was called by the CNA to assist with repositioning patient who was at the edge of the wheelchair after securing the patient back into the chair I observed a bump on the right side of the forehead when I asked if the patient had fallen she said no and notified the nurse the changes of the patient and to follow up. The patient left the unit at 11:00 AM for dialysis and returned at 4:00 PM with a more noticeable bump on forehead, the supervisor was informed . and [primary medical doctor] was informed .the patient will be transferred to the hospital for further evaluation and treatment. A statement from the CNA dated 2/25/25 revealed . at 9:45 AM the nurse informed me that the resident was going out at 10:00 AM to dialysis and wanted me to get the resident dressed . When got to the room the resident was already dressed and sitting in the wheelchair with back to the door. I asked if the resident was wet and needed to be changed and the resident responded, I am not sure if I am wet or not. I then made my way to the bathroom with the resident in wheelchair and as I approached the bathroom I noticed the resident started sliding down the chair and slid down to floor and was on [their] knees. I then went to get help from the nurse for a minute or so so the nurse can help me get the resident up to the chair. When the resident was back in the wheelchair I noticed [they] had a hematoma on [their] forehead, the nurse took a photo. I am not sure if the resident attempted to get up front her wheelchair on [their] own while I went to get help and hit [themselves] on the side or corner of [their] wheelchair because at that time there was nothing around her that [they] could use to harm [themselves] The RN/UM completed a statement dated 2/26/25 that revealed on 2/25/25, received a text from RN #1 that resident #343 had a bump on head on right side. I was in morning report at that time and I did not check my text messages. I got out of morning report at 12:05 PM and upon arrival RN #2 informed me of incident and resident was not at facility as left for dialysis. At 4:18 PM, I received a call from RN #2 that Resident #343 had returned and assessed patient. Called to notify [Medical Doctor] who gave order to send out resident for [Computer Aided Tomogrophy] of the head (multiple x-ray test to determine head injury) . A statement dated 2/26/25, signed by two social workers revealed they met with Resident #343 and documented: resident stated that fell from the chair in the bathroom on Tuesday around 8:00 AM. CNA was with the resident when fell and CNA called another person to help pick up . A Reportable Event Record submitted to the NJDOH on 2/28/25 at 4:30 PM, revealed an undated Summary of Investigation for the Date of Event: 2/25/25 revealed: On February 25, 2025 [no time indicated] the CNA brought Resident #343 to get ready for dialysis. While Resident #343 was being wheeled to the bathroom door, the resident began to slip from the wheelchair and fell on knees forward leaning more on right side, at this time the CNA decided to leave in that position to summon assistance in getting back to wheelchair. There investigation failed to identify a causal factor for the head injury, what initially led to the resident allegedly sliding out of the chair, how long the resident was left unattended on knees in the bathroom, and why the physician was not immediately notified of the identified injury prior to being transported to dialysis. On 3/6/25 at 8:36 AM, Surveyor #1 attempted to call RN #2 for an interview regarding the fall and RN #2 was not available for the interview. On 3/6/25 at 10:39 AM, Surveyor #1 completed a telephone interview with the CNA regarding the fall. The CNA stated she did not observe the fall, but the resident told her that they fell. On 3/6/25 at 11:00 AM, in the presence of the survey team, Surveyor #1 asked the the Director of Nursing (DON) if the investigation that was provided complete and the DON confirmed that the investigation that was provided to Surveyor #1 was complete. Surveyor #1 asked the DON about the facility's investigative process. The DON stated the supervisor would start the investigation and obtain statements from anyone involved with the resident care and also including the roommate, the resident and the supervisor would completed a summary. The DON stated usually they would go back 48 hours if the injury was identified as an injury of unknown origin. The DON then stated, not even close with the amount of statements that should have been received from staff regarding the investigation. The DON further stated she had interviewed the night supervisor from previous shift to inquire if there were any incident that happened during the night; however, the DON could not provide any statements collected from the night shift staff. The DON stated that the responsible party (RP) were present when the social workers interviewed the Resident and the RP stated the resident was not comprehending anything. When the DON was asked if she had been notified of the injury, she stated that she was made aware late in the afternoon after the resident had returned from dialysis and she did not know when the physician and RP's were notified. The surveyor asked why the staff did not follow-up after not receiving a response to the text, the DON stated, exactly, I don't know why. The surveyor asked the DON if the resident had fallen on the floor and the DON stated, don't know. On 3/6/25 at 12:23 PM, in the presence of the survey team, Surveyor #1 interviewed the Licensed Nursing Home Administrator (LNHA) who was in charge of the investigation. The LNHA stated the staff observed the resident in the morning prior to the dialysis treatment with a bruise and a bump on the forehead and stated the DON did not know when it happened. Upon return from the dialysis, RN #2 assessed the resident and reported that the hematoma had increased in size. The physician was then made aware and gave order to transfer the resident to the Emergency Department for evaluation and treatment. 2. On 2/28/25 12:41 PM, Surveyor #2 asked the Licensed Nursing Home Administrator (LNHA) about recalling Resident #290 during September 2023 and asked about any investigations completed while the resident was at the facility. The LNHA stated she recalled Resident #290, but there were no investigations at all, there were no grievances from the resident and there was nothing reported to the DOH regarding Resident #290. On 2/8/25 at 12:55 PM, the LNHA stated there were no investigations for Resident #290, however, then provided Surveyor #1 with copies of progress notes beginning 9/15/23. On 3/4/25 at 8:30 AM the surveyor reviewed the Electronic Medical Record for Resident #290 which revealed: the admission Record indicated the resident had diagnoses including, but were not limited to; Fracture of one Rib, Type 2 Diabetes, and Congestive Heart Failure, a Psychiatry Follow Up Note, dated 09/06/23 revealed the resident was admitted for Sub-Acute rehabilitation and presents calm and cooperative, pleasant reports, I feel a little bit better and I'm going to therapy but I still feel depressed and anxious, no signs and symptoms of mania or psychosis noted at that time. On 3/04/25 at 9:06 AM, the LNHA stated she had an investigation regarding Resident #290, and then confirmed that nothing had been reported the NJDOH. The surveyor reviewed the following: Grievance/Concern Form revealed: Description of Concern: Resident reported to Registered Nurse Supervisor (RNS) on 11:00 AM on 09/16/23, that while in therapy the resident had a bowel movement in diaper and asked the therapist to bring them to their room to be changed. Resident #290 stated, three Certified Nurse Aides (CNA #1, #2 and #3) assisted them and I was aggressively and forcefully wheeled to the bathroom, as I was pleading to be put back to bed to be changed because I am dizzy. The Actions taken to resolve the concern and the Results of the action taken part of the form were both left blank and the form was signed by the RNS and dated 9/16/23. The following attached employee statements revealed: Employee Name: CNA #1, Dated 9/18/23, Date incident occurred/found: 9/15/23. Description of the Incident/Accident: On Friday [9/15/23] I went to help CNA #2 with Resident #290 to put the resident on the toilet and after standing up, the resident said to change them in the bed and put them back to bed, and CNA #2 and #3 changed them; CNA #2, Dated 9/18/23, Date incident occurred/found: [left blank]. Description of the Incident/Accident: went with CNA #1 and #3 to put resident on toilet but couldn't do it and put in bed and changed diaper; CNA #3, Dated 9/18/23, Date/ shift assigned as caregiver: 9/15/23, Date incident occurred/found:9/15/23, 7:00 AM to 3:00 PM, Description of the Incident/Accident: Friday around 2:25 PM, Resident #290 called for help. I went to room, told me needed to have diaper changed. I called my coworkers to help to put on the toilet but resident could not do it and changed diaper. There was no statement from the resident included in the documents provided by the LNHA. Another document provided by the LNHA, dated October 5, 2023, was a grievance from Resident #290's Health Insurance Company (HIC). The document revealed Resident #290 alleges that was physically assaulted in the bathroom in room by the CNA. The resident alleged that they had an accident while at physical therapy and needed to be changed due to defecating in clothes, stated they were sitting when 3 aides [ Names redacted of CNA #1, #2 and #3] came to clean the resident and when they tried to pick the resident up from the chair, and when they realized that, [Resident #290] had an accident they slammed down in their chair then forcibly took them to the restroom in the resident's room. They were being extremely rough with the resident and forcing the resident to stand up on their own, also the resident stated that they were unable to stand on their own. Resident #290 alleged that the CNAs did not clean him/her well and the CNAs told him/her to stop faking it, and another CNA told him/her to stop crying once they got him/her on their bed. On 3/5/25 at 12:00 PM the LNHA provided Surveyor #2 with the requested CNA assignment sheets for 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/18/23, 9/19/23 and 9/20/23 which revealed: CNA #3 was assigned to Resident #290 on 9/14/23 [CNA #2 also worked on the same unit], 9/15/23 [CNA #1 and #2 also worked on the same unit]. On 9/18/23, two days after Resident #290 reported CNA #1, CNA #2 and CNA #3 forcibly and aggressively wheeled then back to bed to be changed because the resident was dizzy, CNA #3 was again assigned to Resident #290. On 3/07/25 at 8:50 AM, Surveyor #2 interviewed the LNHA in the presence of the survey team and the reviewed the allegations that Resident #290 made to the RNS on 9/16/23 and asked the LNHA if the allegations constituted abuse, and the LNHA confirmed that Resident #290's documented allegations were allegations of abuse. Surveyor #2 asked the LNHA what should immediately happen, per facility policy, after an allegation of abuse is made. The LNHA stated remove the CNA involved and the surveyor asked if that had occurred and the LNHA stated, I don't think so. Surveyor #2 asked again if it was an allegation of abuse and the LNHA responded, yes. There was no evidence that the CNAs were removed and did not have access to Resident #290. On 3/07/25 at 11:00, during the exit conference held with the LNHA, Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director, there was no additional information provided. The Abuse, Neglect and Exploitation policy, signed by the LNHA on 5/25/24 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident's property. V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI: Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, D. Room or staffing changes . A review of the facility's Unexplained injuries policy revised date 11/22, included that all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. NJAC 8:39- 4.1(a)12

Repeat Deficiency Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement a baseline individual comprehensive care plan (ICCP) to meet resident preferences and goals to address all medical and psychosocial needs within 48 hours of admission. This deficient practice was identified for 1 of 27 residents (Resident #131) reviewed for ICCP and was evidenced by the following: On 2/28/25 at 9:38 AM, the surveyor observed Resident #131 being escorted off the unit. When asked, the Licensed Practical Nurse Unit Manager (LPN UM) stated that the resident was anxious, and they wanted to provide the resident with activities. On 2/28/25 at 11:00 AM, the surveyor reviewed the admission Record (an admission summary) which reflected Resident #131 had diagnoses which included but were not limited to; altered mental status, unspecified psychosis, anxiety disorder, and Alzheimer's disease. A review of the most recent annual Minimum Data Set (MDS), an assessment tool, dated 12/25/24, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 06 out of 15 which indicated a severely impaired cognition. The MDS further documented that Resident #131 was administered high-risk antipsychotic medications. The MDS revealed Resident #131 had care areas which included cognitive loss and psychotic drug use. A review of the most recent psychiatric evaluation dated 2/12/25, included but was not limited to; the use of Aricept (used to treat dementia with Alzheimer's) 5 milligram (mg) at bedtime, Namenda (used to treat dementia) 5 mg twice a day, and Seroquel (used for psychosis) 25 mg at bedtime. The evaluation revealed a gradual dose reduction was not recommended, included potential side effects, and recommended bloodwork for monitoring. A review of the ICCP failed to document a focus area for the use of an antipsychotic medication, and medication for dementia; goals associated with the medications; or any interventions. On 3/06/25 at 9:04 AM, the direct care Certified Nurse Aide (CNA) #1 stated she was familiar with Resident #131. CNA #1 stated in the resident's mind, the resident wanted to go to work, take out the garbage, and perform normal daily tasks. CNA #1 stated the staff can sometimes provide clothes for the resident to fold to take their mind off of wanting to leave. On 3/06/25 at 10:33 AM, the Director of Nursing (DON) stated the process for developing a care plan would include when a resident was admitted , the supervisor on duty would be responsible to document a baseline care plan within 48 hours. The DON further stated that she expected antipsychotic medications to be included in the baseline care plan. The DON was then made aware of the missing information in the baseline care plan. On 3/7/25 at 11:00 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director. The facility acknowledged that Resident #131's use of antipsychotic medication use was not included in the baseline care plan. A review of the facility provided policy, Use of Psychotropic Drugs revised 9/2022, included but was not limited to; the use of psychotropic medication needed to be documented, monitored, and documented response to the medication. The indications for use will be documented . Residents who use psychotropic medications shall receive non-pharmacological interventions . A review of the facility provided policy, Baseline Care Plan revised 7/2023, included but was not limited to; . develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care . that meet standards of quality care. The baseline care plan will be developed within 48 hours of the resident's admission and include the minimum information necessary to care for the resident including but not limited to . initial goals . physician orders. The facility must provide . a summary of the baseline care plan that includes but not limited to; initial goals, summary of the medication instructions, services and treatments to be administered, and updated information as necessary. NJAC 8:39-11.2(d)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ # 169842 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care and bathing for 2 of 2 residents (Resident #73 and #104) reviewed for activities of daily living. This deficient practice was evidenced by the following: On 02/27/25 at 9:57 AM, the surveyor observed Resident #73 in bed. A Certified Nursing Aide (CNA) was at the bedside providing care and an interview conducted with the CNA revealed that the resident skin was intact. Per the surveyor request the CNA checked the resident for incontinence care. The surveyor observed that Resident #73 was wearing two incontinent briefs. One of the brief was folded and placed inside the first brief and secured in place with the liner of the first brief. The CNA informed the surveyor that the second brief was to catch the urine while the resident was in bed. On 2/27/25 at 10:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #73. The admission Record revealed with diagnoses that included, but were not limited to; Morbid (Severe) Obesity, unspecified Dementia and obstructive Pulmonary disease. The Minimum Data Set (MDS), an assessment tool, dated 02/04/25, reflected that Resident #73 was severely cognitively impaired and required extensive assistance with Activities of Daily Living (ADL). Resident #73 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a severe cognitive impairment. A review of Resident # 73's Care Plan (CP), with no revision date indicated that Resident #73 had impaired movement, weakness, and was totally dependent on staff for bathing, toilet use and personal hygiene. Resident #73 was frequently incontinent of bladder and bowel (B/B) functions and at risk for skin impairment. The CP interventions included but were not limited to: Provide frequent incontinence care every shift, turn and reposition every 2 hours. On 03/05/25 at 10:50 AM, the surveyor interviewed Resident #73 with an activity staff that was able to translate for the resident. Upon inquiry, Resident #73 stated they received a bed bath daily, and had not had a shower for 4 months. Resident #73 stated that they would like to get out of the bed for shower. The activity staff informed the Infection Preventionist (IP) of the interview with the resident. On 03/05/25 at 10:30 AM, the IP informed the surveyor that the facility had a large Gurney (wheeled bed or stretcher that is used to move patients who are sick or injured) on the 6th floor that could be used to transfer Resident #73 to the shower room. The surveyor went to the 6th floor with the IP and observed a Gurney that did not appear to accommodate a safe transfer out of the bed. The facility IP confirmed they had not used the Gurney before for a shower. The facility then confirmed that Resident #73 only received a bed bath daily, and could not verify when the resident last had a shower. The resident's CP did not indicate that staff would get the Gurney on the 6th floor to shower the resident on the day assigned for shower. A review of the shower log with the Unit Manager (UM) revealed 30 of the log dates for February 2025 for the 4th floor, were left blank and the UM could not indicate if the resident was bathed. On 3/6/25 at 9:30 AM, during an interview with the CNA who cared for Resident #73, she stated that she washed the resident in bed every day, and was not informed to get the Gurney from the 6th floor to transfer the resident for a shower. 2. On 2/27/25 at 10:01 AM during the initial tour, the surveyor observed Resident #104 was in bed. The Resident informed the surveyor that they were last provided with incontinence care at 6:00 AM that morning and would next get changed after lunch around 12:00 PM. The surveyor then asked the resident if they were soiled and the resident stated, yes. The surveyor left the room and observed a CNA in the hallway. The surveyor asked the CNA to assist with an observation. At 10:35 AM the CNA entered Resident's #104's room with the surveyor to perform an incontinence observation. The resident was observed wearing an incontinence brief that was soiled with large amount of feces and was soaked with urine. On 2/27/25 at 11:30 AM the surveyor reviewed the EMR for Resident #104. The admission Record revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; Parkinson's Disease, Anxiety disorder, need for assistance with personal care. The Quarterly MDS dated [DATE] revealed that Resident #104 had intact cognition. The MDS also revealed that Resident #104 was always incontinent. On 02/28/25 at 11:12 AM, the surveyor interviewed the nurse regarding incontinence care. The nurse stated that she was not aware of a policy that would dictate when incontinence care was to to be provided. The nurse went on to state that the residents were provided with incontinence care before breakfast and again after lunch. On 03/04/25 at 10:59 AM, the surveyor observed a CNA about to exit Resident #104's room. The surveyor asked the CNA to assist with an incontinence observation. The resident was observed soiled with urine and feces. An interview with the CNA at 11:05 AM, revealed that she provided care to the resident this morning, and would again change the resident after lunch. The above concerns were discussed with the LNHA and the Director of Nursing on 3/6/25 at 1:30 PM. On 3/7/25 at 11:17 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Clinical Director and the above concerns were mentioned. The DON stated, that was unacceptable regarding the rolled up incontinence brief inside of the incontinence brief, and stated that there should be no residents wearing double incontinence briefs. Upon reviewing the concerns regarding residents not receiving showers, the LNHA stated, I know there were holes you found regarding the bathing documentation. A review of the facility's policy titled, Activities of Daily Living, revised on 7/2023, indicated under Policy: The facility must provide necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such deterioration was unavoidable. The same policy under Procedure: 3 A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming personal and oral hygiene. NJAC 8:39-27.1(a)2(h)

Based on observation, interview, record review and review of facility provided documents, it was determined that the facility failed to care for, and remove an intravenous (IV) line for 1 of 1 resident (Resident #38) reviewed for IV therapy. This deficient practice was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 in their room with an IV connection line inserted in the right hand between the thumb and first finger. Resident #38 stated that the IV had been inserted weeks ago for medication and had never been removed. On 2/28/25 at 9:56 AM, the surveyor observed Resident #38 in their room with the IV connection line still in place. On 3/04/25 at 9:00 AM, the Licensed Practical Nurse Unit Manager (LPN UM) stated the IV line was inserted because the resident had been receiving an IV antibiotic which had been stopped on 2/10/25. The LPN UM and surveyor reviewed the electronic medical record (emr) and the LPN UM was unable to locate any orders for the IV line. The surveyor inquired about the orders for the care of the line and the insertion site. The LPN UM reviewed the emr and was unable to locate any orders to maintain the patency of the IV line or to care for the dressing over the insertion site or any documentation that the IV line was being flushed to maintain patency or the dressing was being changed by the nursing staff. The LPN UM stated there should be a physician's order for both. The LPN UM further stated she took the verbal orders from the Nurse Practioner (NP) but was unable to locate the orders. She stated she was waiting for the orders to remove the IV line, but the IV had been removed. The LPN UM and surveyor went to the resident's room. Resident #38 did not have the IV line and informed the surveyor and LPN UM that it was just removed. On 3/4/25 at 10:00 AM, the surveyor reviewed the emr. A review of the admission Record (an admission summary) included a diagnosis of pneumonia. A review of the admission Minimum Data Set (MDS) an assessment tool dated 2/7/25, included a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated intact cognition. A review of the Order Summary Report (OSR) revealed the following physician orders: dated 2/6/25, Sodium Chloride 0.9% 500 milliliters (ml) per hour (hr) intravenously one time only for hydration; dated 2/6/25, Sodium Chloride 0.9% 80 ml/hr intravenously every shift for 3 days; and dated 2/10/25 with an end date of 2/13/25, Sodium Chloride 0.9% 80 ml/hr intravenously every shift for 3 days. A review of a nursing note (nn) dated 2/13/25, documented the resident was on IV hydration until 2/13/25. The next nn dated 2/19/25, documented IV medications, but failed to document any care or orders for the IV line. A review of the Individual Comprehensive Care Plan (ICCP) including resolved and canceled focus areas date initiated 2/1/25, failed to include any focus area, goals, or interventions for the care and use of IV therapy. On 3/04/25 at 9:16 AM, the Director of Nursing (DON) stated if a resident completed IV therapy the IV should be removed. She further stated that if the IV was not being removed, it needed to be flushed (injecting ordered solution to keep the line patent) and that the orders and documentation that this was done should be documented in the treatment administration record (TAR). At 9:52 AM, the DON informed the surveyor that she had looked into this concern. She stated Resident #38 had 3 days of IV hydration that had been a verbal order. The DON added that the staff should have entered the orders in the emr to include a start date and end date and should be documented in the TAR. On 3/04/25 at 10:33 AM, during a telephone interview the NP stated she gave a verbal order to the LPN UM to administer the IV hydration for 3 days and to discontinue the IV after the order was completed. She was not sure the exact date the IV was to be removed. On 3/05/25 at 9:24 AM, the RN Infection Preventionist stated a resident with an IV would need to have monitoring every shift, change the IV site dressing once a week, and to flush the IV. She further stated she was familiar with Resident #38 who had a peripheral line but no IV line upon admission. The RN Infection Preventionist stated that she would focus on IV lines for antibiotic use and not for hydration. She stated that when a resident was finished with the IV use, the IV should be discontinued because it was a source of potential infection. A review of the facility policy, Intravenous Therapy revised 7/2023, included but was not limited to; IV tubing is changed every 96 hours or soon if the integrity of the system is compromised; all IV tubing is to be labeled with the date, time and initials; IV sites are checked ever 4 hours for signs and symptoms of infection and inflammation; IV documentation is recorded in the nurses' notes and/or medication administration record (MAR); and if the catheter is not being used for IV fluids or medications . will discontinue per the Practioner orders. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility provided position title, Certified Nurse Aide undated, included but was not limited to; performs duties in accordance with recognized standards; provides maximum resident care services; positions residents in correct body alignment . ; ensures that residents receive the highest quality of services; and assists with treatments. A review of the facility provided position title, Licensed Practical Nurse undated, included but was not limited to; takes an active role in resident assessment and care; administers medication and/or treatment and documentation of the same for the residents; responsible for clinical documentation; assists in developing and implementing care plans; communicates pertinent data to the charge nurse and/or physician; provides for the physical comfort and safety of the residents; supervises nursing personnel in providing direct resident care; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Registered Nurse undated, included but was not limited to; under the supervision of the DON, utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of care plans to ensure resident needs are met; formulates individualized nursing care plans; assesses residents daily and implements a change in action as needed; communicates resident information; maintains accurate resident care record and documents pertinent data; dispenses medication and performs treatments in accordance with policies and procedures; and ensures residents receive the highest quality of services. A review of the facility provided position title, Unit Manager undated, included but was not limited to; twenty-four hour responsibility for the continuity of nursing care and the management of the resident welfare; assesses the performance of nursing personnel as it relates to the standards of care and goals of the individual; encourages nursing staff to perform their jobs to the fullest of their potential; demonstrates, teaches and evaluates nursing skills utilized; concerns themselves with the safety of all facility residents; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Director of Nursing undated, included but was not limited to; evaluates work performance of all nursing personnel; performs rounds to observe residents and ensure needs are being met; and conducts observations of nursing care to ensure nursing staff is current in their knowledge and skills. On 3/6/25 at 12:53 PM, the above concern was presented to the facility administration team. The facility had no additional information to provide. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to consistently perform and document functional maintenance for 1 of 2 residents (Resident #51) reviewed for restorative care. This deficient practice was evidenced by the following: On 2/27/25 at 10:17 AM, the surveyor observed Resident #51 in bed and their left wrist and hand were bent backwards. On 2/27/25 at 1:23 PM, the surveyor reviewed the electronic medical record. The admission Record revealed diagnoses which included need for assistance with personal care. A review of the quarterly MDS dated [DATE], documented a BIMS of 02 out of 15 indicating severely impaired cognition, and that Resident #51 had ended both Occupational and Physical Therapy on 9/3/24. A review of the Order Summary Report revealed an order dated 10/17/24, Functional Maintenance Program (FMP) for daily Active Assist Range of Motion (AAROM) on Right Upper Extremities/Lower Extremities (UE/LE) and Passive Range of Motion Exercise (PROME) on Left UE/LE x 10 repetitions x 2 sets to all tolerable planes. A review of the ICCP included a focus area dated 1/3/25 at risk for joint stiffness, tightness and decline in functional mobility FMP to be implemented; a goal to participate in FMP to preserve current functional status and joint integrity; and interventions which included FMP for daily AAROM on Right UE/LE and PROME on Left UE/LE x 10 repetitions x 2 sets to all tolerable planes. On 2/28/25 at 10:02 AM, a Registered Nurse (RN) #5 stated Resident #51 would wear a splint provided by the rehabilitation department on the left wrist and hand from 2 PM to 4 PM. On 2/28/25 at 11:23 AM, the Occupational Therapist (OT) reviewed Resident #51's emr and stated the resident was not on therapy, but had been given orders for the nursing staff to perform the [NAME] and PROME and stated the documentation should be in the emr. On 2/28/25 at 11:29 AM, during a second interview, RN #5 reviewed the emr. She stated that the restorative care order would be administered by the Certified Nurse Aide (CNA). However, she was unable to access the documentation of the FMP being completed. On 2/28/25 at 11:35 AM, the Licensed Practial Nurse Unit Manager (LPN/UM) was unable to find any consistent documentation for the FMP being administered to Resident #51. She stated she was responsible to ensure the FMP was being completed and that it was important for the FMP to be completed so the resident would not be so stiff. The LPN/UM stated she would usually check for documentation at the end of the shift but has not been checking. On 2/28/25 at 11:51 AM, the DON stated that when therapy ordered restorative care it would be completed by the CNAs and the nurses should know about the order. She stated it would either be documented in a binder located on the Unit or in the emr. The DON stated the facility policy would allow for documentation in either area. On 2/28/25 at 12:25 PM, the DON returned and provided the October 2024 and November 2024 documentation with multiple missing dates of documentation. The DON provided the January and February 2025 documentation which revealed no documentation on the weekends. The DON acknowledged the missing documentation and stated that there should be no missing documentation as the order was for daily [NAME] and PROME. The missing documentation was as follows: February 2025, 9 of 28 days missing and no documented amount of repetitions or sets. January 2025, 8 of 21 days missing and no documented amount of repetitions or sets. December 2024, 8 of 31 days missing and no documented amount of repetitions or sets. November 2024, 4 of 30 days missing and no documented amount of repetitions or sets. October 2024, 3 of 31 days missing and no documented amount of repetitions or sets. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility provided position title, Certified Nurse Aide undated, included but was not limited to; performs duties in accordance with recognized standards; provides maximum resident care services; positions residents in correct body alignment . ; ensures that residents receive the highest quality of services; and assists with treatments. A review of the facility provided position title, Unit Manager undated, included but was not limited to; twenty-four hour responsibility for the continuity of nursing care and the management of the resident welfare; assesses the performance of nursing personnel as it relates to the standards of care and goals of the individual; encourages nursing staff to perform their jobs to the fullest of their potential; demonstrates, teaches and evaluates nursing skills utilized; concerns themselves with the safety of all facility residents; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Director of Nursing undated, included but was not limited to; evaluates work performance of all nursing personnel; performs rounds to observe residents and ensure needs are being met; and conducts observations of nursing care to ensure nursing staff is current in their knowledge and skills. On 3/6/25 at 12:53 PM, the above concern was presented to the facility administration team. The facility had no additional information to provide. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure controlled substances were properly disposed of and ensure adequate supervision was provided to a resident who had a history of falls. This deficient practice was identified for 1 of 1 resident (Resident #1) observed during the medication pass and 1 of 1 resident reviewed for accidents (Resident #110). The evidence is as follows: a) On 3/4/25 at 8:39 AM, the surveyor conducted a medication pass observation and observed the Licensed Practical Nurse (LPN) prepared medication for Resident #1. The LPN prepared the following medications: Klonopin (a Benzodiazepine scheduled IV controlled substance that has the potential for abuse) 0.5 milligram (mg)1 tablet (a medication used to treat anxiety); Eliquis (anticoagulant ) 2.5 mg 1 tab; Losartan Potassium 50 mg (milligram) medication used to treat high blood pressure; Propafenone 150 mg 1 tab medication (to treat heart rhythm); Senna 8.6 mg 1 tab medication used to treat constipation; Verapamil 240 mg 1 tab medication to treat high blood pressure; and Vitamin D3 50 mcg. (micrograms) Supplement. On 3/4/25 at 9:03 AM, the resident refused all of the medications and also threw one pill on the floor. The LPM retrieved the pill from the floor and then discarded all the medications, which included the Klonopin into the trash can attached to the medication cart. The nurse left the medication cart in the hallway next to the resident's room, and went to the nurse's station to call the physician. The surveyor remained in the hallway next to the medication cart. On 3/4/25 at 9:08 AM, a housekeeping staff approached the medication cart and removed the plastic bag which contained the discarded medications and placed the garbage bag in their trash basket. The surveyor approached the housekeeper and informed her not to dispose of the bag, and the staff could not understand and insisted on holding the bag. The surveyor then summoned the Assistant Director of Nursing (ADON) who was in the hallway. The surveyor explained the above concern to the ADON, and the ADON then removed the bag that contained the discarded medications from the housekeeping trash basket. The ADON opened the bag and was able to visualize the medications in the plastic bag. The ADON then gave the plastic bag to the Registered Nurse (RN) the Infection Preventionist (IP). The ADON informed the surveyor that all medications should be discarded in the drug buster (container to safely dispose of medication) located inside of each medication cart, and stated, controlled substances should be witnessed and discarded with two licensed staff. The ADON then opened the medication cart and there was no drug buster inside of the medication cart. On 3/4/25 at 9:15 AM, the surveyor interviewed the LPN who disposed of the medication into the trash can. The LPN informed the surveyor that she failed to dispose of the medications properly. On 3/4/25 at 9:50 AM, the IP approached the surveyor and showed the medications that she retrieved from the plastic bag, and the IP informed the surveyor that the nurse was educated on proper drug disposal. b. On 3/4/25 at 10:51 AM, the surveyor observed Resident #110 in the dayroom in a recliner chair. The resident was sleeping in the chair and there were ten other residents observed in the room. On 3/5/25 at 8:55 AM, the surveyor observed Resident #110 in the dayroom on the 2nd floor. The resident had their right leg over the chair and was sleeping. The activity staff in attendance was not in direct observation of the resident as she had her back turned and was preparing a drink for another resident. The surveyor asked the staff if she was alone. The Staff stated that the other activity staff went to the floor to transfer other residents. At that time, the surveyor requested any incident reports for Resident #110 from the facility. On 03/05/25 at 10:30 AM, the surveyor reviewed the facility provided Incident Reports which revealed: An Incident Report dated 07/06/23 timed 6:30 AM, the Report reflected that staff informed the Registered Nurse (RN) that Resident #110 was found on the floor in the dayroom at 6:30 AM. The staff indicated that she had to briefly leave the dayroom to attend to another resident. Resident #110 stood up, lost their balance and fell. The Certified Nurse Aide (CNA) did not inform the RN that the resident was left unsupervised in the room. Intervention added, reeducate staff not to leave the resident unattended. Provide Resident #110 with a wheelchair saddle to promote safety. Another fall occurred on 07/14/23 at 1:55 PM, in the activity room. According to the Incident Report, the activity staff turned their back to attend to another resident, Resident #110 stood up and fell on the floor. The intervention was to place Resident #110 in an area near the staff who are conducting the activities. On 8/8/23 at 5:35 AM the resident fell in the dayroom. The statement provided revealed that the Resident was trying to get out of the bed at 5:25 AM. The CNA brought the resident to the dayroom and left the resident unattended. The resident fell and was found on the floor at 5:35 AM. The resident sustained a laceration to the right eye which measured 1.5 centimeters x 0.1 cm. On 3/5/25 at 12:00 PM, the surveyor reviewed the residents medical record which revealed: The admission Face Sheet reflected that Resident #110 was admitted to the facility with diagnoses which included, but were not limited to; Altered mental status, unspecified sequelae of cerebral infarction. The Minimum Data Set (MDS) dated [DATE], reflected that Resident #110 had severe cognitive impairment. The resident undated comprehensive care plan provided by the facility on 3/6/25 at 11:30 AM, reflected that Resident #110 was at high risk for falls related to history of multiple falls, spontaneous and uncontrolled movement of both upper and lower extremities, communication deficit. The interventions on the care plan were to keep needed items within reach, place in supervised areas (dayroom/near nurses station) keep the bed against the wall and floor mat on the side. On 3/6/25 the surveyor discussed the above concerns with the Director of Nursing and the Licensed Nursing Home Administrator and asked to provide any additional information regarding the falls. On 3/7/25 at 11:30 AM the Regional Clinical Director informed the survey team that Resident #110 should not be left unsupervised in the dayroom and the staff had been educated. No additional information was provided. The policy for discarding and destroying medications last revised 03/2018, indicated the following: Medications that cannot be returned to the dispensing pharmacy ( e.g., non-unit dose medications, medications refused by the resident, and /or medications left by residents upon discharge) will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The policy for incidents/accidents revealed the following: A review of the facility's policy titled, Fall Prevention Program last revised 4/2023 revealed the following: Policy Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Procedure 1. The facility utilizes a standardized risk evaluation tool for determining a resident's fall risk. 3. Interventions will address resident's risk factors as identified by the risk assessment tool. Falls interventions will be documented on the resident's medical records e.g., baseline care plan. NJAC 8:39-294(i); 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to record and document the urinary output for residents with an indwelling urinary catheter per the Physician Order. This deficient practice was identified for 1 of 2 resident's reviewed for urinary catheter (Resident #122) and was evidenced by the following: On 3/4/25 at 9:48 AM, the surveyor observed Resident #122 resting in their bed. The resident's urinary drainage bag was in a blue colored bag (privacy bag) and secured to the bed frame on the right-hand side. On 3/4/25 at 10:38 AM, the surveyor reviewed the electronic medical record for Resident #122 which revealed the following: The resident was admitted to the facility with diagnoses that included but were not limited to, urinary tract infection (an infection in any part of the urinary system), malignant neoplasm of prostate (cancerous growth in prostate gland), and retention of urine (a condition where the bladder does not fully empty). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/29/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicative of moderately impaired cognition. Further review of the MDS reflected that Resident #122 had an indwelling catheter (thin hollow tube that is inserted into the bladder to drain urine ). Resident #122 was dependent on staff for toileting and hygiene. A review of the Comprehensive Care plan CP) included a focus area dated 1/22/25 which indicated that Resident #122 had an indwelling catheter related to: Obstructive uropathy (a condition when urine cannot flow), BPH (Benign Prostate Hypertrophy) a condition that causes prostate to grow larger than usual) with retention status post procedure. A review of the Physician Order Summary, (POS) revealed an order dated 1/22/25, to measure and record urine output every shift. The corresponding PO was transcribed into the electronic Treatment Administration Record (eTAR). Further review of the January 2025 - March 2025 eTARs for Resident #122 revealed the following date and time where the urine output was not recorded: Date: Shifts with no urine output documented: 1/24/25 Day shift (7 AM - 3 PM) 1/29/25 Evening shift (3 PM -11 PM) 2/4/25 Day shift (7 AM -3 PM) 2/5/25 Day shift (7 AM -3 PM) 2/9/25 Day shift (7 AM -3 PM) 2/12/25 Day shift (7 AM -3 PM) 2/16/25 Day shift (7 AM - 3 PM) 2/17/25 Evening shift (3 PM - 11 PM) 2/18/25 Day shift (7 AM - 3 PM) 2/28/25 Evening shift (3 PM - 11 PM) 3/1/25 Night shift (11 PM - 7 AM) 3/2/25 Evening shift (3 PM-11 PM) On 3/5/25 at 9:11 AM, during an interview with the surveyor, the Certified Nurse Aide (CNA #1) stated if she emptied the urinary drainage bag, she would measure the urine output and reported the amount to the nurse. She would also inform the nurse of any change in the urinary output. On 3/5/25 at 9:17 AM, during an interview with the surveyor, the Registered Nurse (RN) stated she would check the resident's urinary drainage bag at the beginning and at the end of her shift and measure the total output. The RN stated the CNA's were to empty the Foley catheter drainage and reported the amount to the nurses. The RN stated the nurses were responsible to record the urine output in the eTAR. The RN further stated if there was no urine output in the drainage bag then she would report it to the resident's Physician and the Unit Manager (UM) and document the changes in the progress notes. On 3/5/25 at 9:37 AM, during an interview with the surveyor, CNA #2 who worked the day shift stated she would report the urine output to the nurse at 2:00 PM before her shift ended. On 3/5/25 at 10:00 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager stated the urine output was recorded in the eTAR. The RN/UM explained the process. The CNA would empty the drainage bag, reported the output to the nurse, the nurse would document the amount in the eTAR. The RN/UM reviewed the eTAR with the surveyor and verified also the missing documentation. The RN/UM stated it was important to measure and record the urine output in the eTAR to ensure that the urinary catheter was patent and there was no infection. The RN/UM stated there were too many gaps in the eTAR, the staff needed to be educate to complete all their documentation in a timely manner. On 3/6/25 at 12:52 PM, the survey team met with the facility administrative staff, informed them of the above concerns and asked to provide any additional information on the next day. On 3/7/25 at 12:49 PM, during the exit conference, no additional information was provided. A review of the facility's Indwelling Catheter Justification and Removal undated policy included: It is the policy of the facility to ensure that the residents receive care and services to prevent the use of an indwelling catheter, unless clinically necessary and promotes urinary continence of its residents, in accordance with State and Federal Regulations. NJAC 8:39-19.4(a)5, 27.1(a)(b)

Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order and ensure oxygen equipment was stored properly. This deficient practice was identified for 1 of 1 resident (Resident #341) reviewed for respiratory care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/27/25 at 10:46 AM, the surveyor observed Resident #341 in their bed. The resident was receiving oxygen (O2) via nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower O2 levels). The oxygen concentrator was observed to be set at 4 liter per minutes (L/min). The surveyor observed a resident's wheelchair next to their bed with an O2 tank behind the wheelchair, connected to an undated NC which was wrapped around the handle of the O2 tank. The NC was not in any protective covering and was exposed to the environment. On 2/28/25 at 11:55 AM, the surveyor observed Resident #341 eating lunch in their room. The resident was receiving O2 at 3 L/min via NC, which was connected to the concentrator. The surveyor observed the wheelchair next to resident's bed with O2 tank behind the wheelchair and NC was connected. The NC was wrapped around the handle of the O2 tank and was not in any protective covering as on 2/27/25. On 2/28/25 at 12:28 PM, the surveyor reviewed the medical records of Resident #341 which revealed: A review of Resident #341's admission Record (an admission summary) reflected that Resident #341 was admitted to the facility with diagnosis that included but were not limited to; Asthma (a condition in which your airways narrow and swell and may produce extra mucus), hypotension (low blood pressure) and muscle weakness. A review of the Annual Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, dated 2/13/25, revealed the resident had a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Further review of the MDS indicated that Resident #341 received O2 therapy continuously. The February 2025 Order Summary Report (OSR) revealed a Physician Order with an initial date of 2/7/25 for Oxygen inhalation (via NC at 2 L/min) every shift for Asthma. On 2/28/25 at 12:38 PM, during an interview with the surveyor, the Registered Nurse (RN) stated that she would make rounds in the beginning of her shift to make sure the resident was receiving O2 as per the physician' order. The RN further stated that she would date and store the NC in a plastic bag when the O2 was not being used to prevent infection. The RN informed the surveyor that Resident #341 was receiving O2 at 3 L/min. In the presence of the surveyor, the RN reviewed the physician order and verified that the resident was to have the Oxygen titrated at 2 liter per minute. The surveyor accompanied the RN to the resident's room and observed resident's O2 was titrated at 3 L/min. The RN changed the O2 to 2 L/min. The RN discarded the NC attached to the portable Oxygen Cylinder and stated, the nasal cannula should be dated and stored in a plastic bag. On 2/28/25 at 1:27 PM, during an interview with the surveyor, the RN/unit manager (UM) stated that her expectation was that the nurses would make rounds in the beginning of their shift, and ensure that the physician orders for oxygen delivery was being followed. On 3/6/25 at 12:52 PM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing and informed them of the above concerns. The Director of Nursing (DON) acknowledged that the NC should be placed in a bag to prevent infections. A review of the facility policy Oxygen Administration with a revised date of 6/23 included: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Under Procedure: 5.e Keep delivery devices covered in plastic bag when not in use. A review of the facility policy Physician Orders Policy with a revised date of 5/23 included under procedure: 4. A licensed nurse or professional shall provide the care and services for a resident based on a physician order, when indicated. On 3/7/25 at 12:49 PM, during the exit conference, no additional information was provided. NJAC 8:39-11.2(b); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, it was determined that the facility failed to ensure that staff monitored, assessed and documented the care of a hemodialysis access site. This deficient practice was identified for 2 of 2 residents reviewed (Resident #2 and Unsampled Resident #1), and for 2 of 2 staff observed for dialysis access site care, and was evidenced by the following: On 2/27/25 at 1:26 PM, the surveyor observed Resident #2 in bed, and observed that Resident #2 had an Arterioventricular (AV) Fistula to the left arm (a procedure that connects an artery to a vein in preparation for dialysis). The resident's dominant language was Spanish and the resident was unable to communicate with the surveyor. At that time, a review of Resident #2's medical record revealed the following: The admission Record revealed diagnoses which included, but were not limited to; End Stage Renal Disease (ESRD) and Hemodialysis (a treatment that requires a machine to cleans the blood of impurities when the kidneys do not work). The Annual Minimum Data Set (MDS ) assessment dated [DATE], revealed that the resident received a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS) and was moderately cognitively impaired. The March 2025, Physician Order (PO) Sheet revealed a PO with an original date of 03/21/24, to check for Bruit and Thrill every shift. The surveyor reviewed the resident's current care plan, last revised 2/06/24. The Care Plan had a Focus for Hemodialysis related to ESRD with an intervention to monitor the left forearm AV Fistula for signs and symptoms of bleeding, infections and drainage. The surveyor reviewed the Treatment Administration Record (TAR) and observed that staff initialed the TAR for all 3 shifts (7 AM-3PM, 3 PM-11PM and 11 PM-7AM) indicating that the left forearm AV-Fistula (dialysis access site) was checked by the nurse for Bruit (an audible sound) and Thrill (a vibration that indicated a good blood flow). On 2/28/25 at 11:16 AM, the surveyor reviewed the dialysis communication book for Resident #2 with the Licensed Practical Nurse (LPN #1). LPN #1 verified the dialysis schedule, and confirmed that Resident #2 had a dialysis access site on the left forearm. The communication form was signed by the nurse and reflected that the nurse checked for Bruit and Thrill, documented the vital signs and checked the patency of the AV Fistula site prior to dialysis. That same day at 11:30 AM, the surveyor escorted the nurse to the room, the nurse showed the dialysis access site to the surveyor and informed the surveyor that the dialysis center provided care for the AV Fistula, and she was not responsible for anything else besides documenting the vital signs, and to assess the resident for pain. On 3/05/25 at 9:30 AM, the surveyor interviewed LPN #1 regarding care of the dialysis access site. LPN #1 confirmed that she did not have to do anything prior to the resident leaving for dialysis. The nurse accompanied the surveyor to the resident's room and showed the AV Fistula to the surveyor, she again stated clearly that she does not have to check for anything. She informed the resident of the dialysis treatment, monitored and documented the vital signs on the communication form and stated that the dialysis center cared for the dialysis access site. On 3/05/25 at 10:05 AM, the surveyor interviewed LPN #2 on the high side of the Unit regarding the care of the dialysis access site. LPN #2 accompanied the surveyor to another resident's (Unsampled Resident #1) room who also had an AV Fistula site on the left forearm. LPN #2 stated that the dressing should have been removed four hours after the dialysis treatment. LPN #2, then stated, in the presence of the Facility Nurse Educator confirmed that she checked the vital signs, informed the resident of the dialysis treatment, and would also assess the resident for pain. LPN #2 was not aware that she had to check the dialysis access site for patency prior to dialysis. The surveyor reviewed the dialysis policy with LPN #2, who stated, that she had not been aware of the policy to monitor the dialysis access site for patency. The surveyor reviewed the facility provided orientation packet and the yearly competency evaluation provided by the nurse educator on 3/5/25 at 11:25 AM. There was no competencies or education related to the care of the dialysis access site. During an interview on 03/06/25 at 01:30 PM, the surveyor brought the above concerns to the attention of the Licensed Nursing Home Administrator and Director of Nursing. Both confirmed that since the surveyor brought the concern to the attention of the facility, nursing staff had been provided with in-service education on the care of the dialysis access site. On 03/07/25 at 11:00, during the exit conference held with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director. The LNHA confirmed that both nurses were not aware to check the dialysis access site. The policy titled, Dialysis Policy revised 07/23, reflected the following: It is the policy of this facility to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy indicated to monitor for patency of dialysis access site. NJAC 8:39- 27.1(a)

Based on observation, interview and document review it was determined that the facility failed to ensure the proper rinse temperature was consistently maintained for the dish machine and dishware was appropriately dried to limit potential bacterial growth and the potential for food borne illness. The deficient practice was evidenced by the following: On 03/04/25 at 9:28 AM, the surveyor observed the dish machine in use cleaning the breakfast dishes. The surveyor observed, with staff, the final rinse temperature was 172 degrees Fahrenheit (F). Dietary Staff (DS #1) was also observed removing the plates from the dish machine with his bare hands and he proceeded to wipe the plates with a rag, and then placed them on a rack. The Food Service Director (FSD) was present and informed DS #1 to not wipe the dishes. The surveyor again observed DS #2 loading the dish machine with soiled items and then asked DS #2 what the temperatures for the wash and rinse should be. DS #2 stated, wash should be 160 F and rinse should be 180 F. The surveyor observed the rinse temperature which only reached 170 F as the items when through, when the surveyor asked the DS #2 why the temperature did not reach 180 F, DS #2 stated, sometimes it varies. DS #2 then placed a rack that contained soiled insulated tray lids into the machine and the rinse temperature reached 165 F. The surveyor asked the FSD what the temperature should be for the rinse and the FSD stated 180 F, and he then observed as items were placed in the dish machine that the temperature was 165 F for the rinse. The FSD stated he was going to check the hot water booster and shut the machine down. The FSD stated he checked it in the morning and it was working. The surveyor requested the dish machine policy and reviewed a temperature log affixed to the wall that indicated the rinse temperature was 186 F on 03/04/25. On 03/04/25 at 1:18 PM, the Liscened Nursing Home Administrator confirmed that the dish machine was not being used until the machine was fixed. On 03/05/25 at 9:41 AM, the surveyor interviewed the repairman for the dish machine via telephone. The repairman stated, the water pressure was too high and he adjusted it because when the pressure was too high the waster went through the machine too quickly and did not have enough time to heat up to the appropriate temperature. The surveyor asked if the facility should have been using the machine if the rinse temperature was not 180 F. The repairman stated, the rinse temperature should have been 180 F and the temperature was and obvious indication regarding the dish machine function. The Dishwashing Policy, undated, revealed #4: .Check temperature gauges before and during dishwashing to determine is wash and rinse temperatures being maintained. Wash temperatures should be 160- 175 degrees and final rinse temperature greater than 180 . Any deviations in temperatures will be reported to maintenance. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while transferring one of six residents (Resident) 6 reviewed on EBP. Specifically, facility staff failed to don personal protective equipment (PPE) (gown and gloves) when transferring R6 from his/her bed to his wheelchair. Additionally, two Certified Nurse Aides (CNAs) and one Licensed Practical Nurse (LPN) did not follow hand washing protocol during the lunch meal services. Findings include: Review of R6's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R6 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease. Review of R6's Physicians Order, located in the EMR under the Orders tab, dated 03/29/24 revealed, .on Enhanced Barrier Precautions [EBP] . During an observation on 02/10/25 at 11:55 PM on the COVID unit, EBP signage was posted at the entrance of R6's room. During this time, CNA2 entered R6's room carrying a meal tray, placed the tray on his bedside table, and preceded to transfer R6 from his bed to his wheelchair. CNA2 was not wearing PPE during the transfer. During an observation on 02/10/25 at 12:22 PM on the COVID unit, CNA3 removed a dirty meal tray from the dining room, placed the dirty tray in a food cart, and proceeded to another resident room to provide care. CNA3 did not use alcohol-based hand rub (ABHR) in between rooms/residents. During this same observation, CNA1 removed a dirty meal tray from the dining room, placed the dirty tray on the food cart, returned to the dining room, and assisted residents in the dining room. CNA1 did not use ABHR or wash her hands between tasks. During an interview on 02/10/25 at 12:19 PM, CNA2 confirmed she did not follow proper donning (process of putting on protective gear to protect you from infection) while transferring R6. CNA 2 confirmed she should have worn a gown and gloves. During an interview on 02/10/25 at 12:41 PM, CNA1 confirmed she did not follow the proper hand hygiene protocol while handling dirty meal trays and should have used ABHR between residents/tasks. During an interview on 02/10/25 at 12:47 PM, Licensed Practical Nurse (LPN)1 revealed that she, along with CNA1 and CNA3, did not follow the proper hand hygiene protocol. LPN1 continued to share that staff should have sanitized their hands by using ABHR before returning to the dining room area and in between residents to prevent the spread of infections. During an interview on 02/10/25 at 12:56 PM, the facility Infection Preventionist (IP) revealed staff should wash or sanitize their hands with ABHR between each resident when providing care or removing dirty meal trays. The IP continued to share this is her expectation of her staff to follow proper PPE and hand hygiene protocols. During an interview on 02/10/25 at 1:03 PM, the Director of Nursing (DON) revealed all staff were expected and should know to don a gown and gloves before entering an EBP room to provide care. The DON continued to share staff should wash or sanitize their hands between each resident. Review of the facility's policy titled, Enhanced Barrier Precautions, revised date August 2024 revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention used to reduce transmission of multidrug-resistant organisms . EBP is an extension of standard precautions utilized for residents . all staff must wear gloves and gown during high contact activities for residents . transferring . Review of the facility policy titled, Hand Hygiene dated July 2023, revealed, . It is the policy of this facility to ensure that facility staff performs proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . N.J.A.C. 8:39-19.4(a)

Based on observations, interviews and review of documentation, the facility failed to consistently maintain a functional Heating, Ventilation and Air Condition Unit (HVAC) in good repair on 1 of 3 nursing units ( 3rd floor) in order to maintain a comfortable environment for its residents, staff, and visitors . This deficient practice was evident by the following: On 08/29/24, at 10:30 am., the surveyor conducted a tour of an empty 3rd floor unit with the Administrator (ADM) and Maintenance Director (MD). According to the ADM, a decision was made to utilize the 3rd floor unit to accommodate isolation for 11 Coronavirus (COVID-19) positive residents and 9 residents presumed exposed. The 11 COVID positive residents and 9 presumed exposed were housed on this unit from 8/27/2024 to 8/28/2024. During the tour, the ADM stated that 3rd floor unit had been closed for over one year and the air conditioning units were not working. The decision was made to transfer the COVID positive residents to this floor on 8/27/2024. The MD stated that the 3rd floor was not on his daily maintenance rounds inspections. The surveyor observed there were no residents on the floor during the tour. The thermostat on the wall indicated 74 degrees Fahrenheit (F). The air conditioners in residents' rooms were still not functioning. According to the MD, prior to the transfer of residents from the other floors on 8/27/2024, he took a temperature on the 3rd floor unit at 2 PM ,which indicated 76 degrees Fahrenheit (F). (Normal temperature ranges is from 71 F-81 F degree). According to the Environmental Temperature Log (ETL) for the 3rd floor on 8/28/2024, the temperatures at 11 AM was documented at 76 degrees F and at 2 PM the temperature was documented at 78 degrees F. There were no specific locations correlated to each temperature taken on the ETL. The surveyor was also provided a copy of the Administrator's ETL for the 3rd floor. The ETL for the 3rd floor on 8/27/2024 at 2 PM and 5 PM temperatures were both documented at 76 degrees. On 8/28/2024, the following temperatures were documented : 11 AM 76 degrees F; 2 PM 78 degrees F and at 5 PM 79 degrees F. There were no specific locations correlated to each temperature taken on the ETL. Also, the Surveyor confirmed with the Administrator that there were no more temperatures taken after 5 PM on 8/27/24 and 8/28/2024 on the 3rd floor. On 8/28/2024, the MD was told by the Administrator that residents were complaining of being warm, so he deployed an additional 3 portable air conditioners and electric fans to residents' rooms and placed a Commercial electric fan in the hallway. On 08/29/24 at 12:15 PM, the Surveyor interviewed Resident #2 who stated, that he/she was placed on the 3rd floor and confirmed that the room air conditioner was not working and was proved a fan, but the room was still hot. The resident couldn't provide the surveyor with a time or date regarding the temperature. On 08/29/24 at 3:19 PM, the surveyor interviewed Resident #3's daughter who stated, air conditioner was not working in Resident #3 room, but an electric fan was provided. NJAC 8:39-31.2(e)

**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 issue the required Medicare Beneficiary Protection Notification for 1 of 3 residents (Resident #119) reviewed. This deficient practice was evidenced by: On 1/5/23 at 10:00 AM, the facility's Social Service Director (SSD) and Social Worker provided the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed one of the residents, Resident #119 listed who was discharged from a Medicare Part A coverage stay at the facility and was documented as having a discontinuation of their insurance payment. Review of facility medical records showed that Resident #119 was admitted to the facility on [DATE]. The last date documented for insurance coverage was from Medicare Part A service, 10/28/22. A review of the form titled, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) dated 10/25/22 documented, Family notified by phone regarding the residents last insurance coverage date. Further review of the form revealed that it did not include the family member's identity. There was no additional documentation about the communication of these forms to the resident or the resident's representative. On 1/9/23 at 10:44 AM, the surveyor interviewed the SSD. The SSD stated that the SNFABN and NOMNC forms should be issued at least 48 hours before the resident's last covered date. The SSD explained that if a resident had a Brief Interview for Mental Status (BIMS) score of less than 12 (considering the resident cognitively impaired), the service end date, possible cost, and right to appeal would be discussed with the resident's representative. The SSD added that Resident #119 had a BIMS 3 out of 15, which indicated that the resident had severely impaired cognition. The SSD stated that she notified the resident's daughter-in-law via phone on 10/25/22 to discuss the resident's last covered date of 10/28/22 and that the family member was not interested in paying for the therapy services. The SSD acknowledged that she did not have any electronic nor written documentation of the discussion on the SNFABN and NOMNC forms nor did she have the signed forms from the resident's representative. She stated that she was not aware that the forms were to be mailed to the resident's representative to be signed and returned to the facility. A review of facility policy and procedure titled, Notice of Medicare Non-Coverage with an original issue date of 1/10/23 indicated under Policy: Alaris Health at Castle Hill will provide a written and verbal notices to the resident and/or responsible party to indicate that the care is set to end. The facility policy further indicated under, Procedures: The resident's representative may receive and accept the written notice if the resident is unable to comprehend the notice being given. If the resident and/or representative are not available to receive the notice, a certified letter will be sent to the address listed on the face sheet. The policy provided by the facility did not address SNFABN notification. A review of Requirements of the SNF ABN CMS-10055 Form, indicated under pages 41 and 49-50, Obtain signed/dated SNF ABN with Option selected either in person (or return mail). Beneficiary retains patient copy-returns original. Telephone contacts should be followed immediately by either hand-delivered, mailed, emailed, or faxed notice. If beneficiary does not return signed copy, document initial contact and subsequent attempts to obtain signature in appropriate records or on notice itself. On 1/10/23 at 11:53 AM, the surveyor discussed the concern with the Director of Nursing and Licensed Nursing Home Administrator. No further information was provided. NJAC 8:39-4.1(a)(8)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #64 was admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy. On 1/4/23 at 1:50 PM, during a review of the Annual MDS, an assessment tool used to facilitate the management of care, dated 12/2/2022, indicated that the resident had a BIMS score of 5 out of 15, indicating that the resident had severe cognitive impairment. Continued review of the Annual MDS, the assessment further reflected under Section I Active Diagnoses, that the resident has Diabetes Mellitus (DM). A review of the electronic clinical physician orders (PO) for December 2022 presented an order with a start date of 3/31/22 for Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously (SQ) every 12 hours for DM. Review of the PO demonstrated another order with a start date of 11/15/2022 for Insulin Regular Human Solution 100 UNIT/ML Inject as per sliding scale (varies the dose of insulin based on blood glucose level): if 0-140 = 0 units; 141-200 = 2 units; 201-250 = 3 units; 251-300 = 4 units; 301-349 = 5 units; 350-400 = 6 units call MD if blood sugar (BS) greater than 400 and less than 70, SQ before meals and at bedtime for DM. Continuing the review of the PO evidenced another order for a DM medication with a start date of 10/31/2019 for Metformin HCl Tablet 1000 milligram (mg) 1 tablet by mouth two times a day for DM. A review of the resident's interdisciplinary person-centered comprehensive CP with a revision date of 12/22/2022 evidenced that the resident did not include a baseline CP for the Diagnosis of DM. A review of the resident's electronic medical record under the vitals section reflected that resident's blood sugars were the following: 1/4/2023 10:30 124.0 mg/deciliter (dL) 1/4/2023 06:12 162.0 mg/dL 1/3/2023 21:40 133.0 mg/dL 1/3/2023 17:44 190.0 mg/dL 1/3/2023 06:55 122.0 mg/dL 1/2/2023 20:33 263.0 mg/dL 1/2/2023 17:04 400.0 mg/dL 1/2/2023 05:40 127.0 mg/dL 1/1/2023 20:38 172.0 mg/dL 1/1/2023 16:09 218.0 mg/dL 12/31/2022 21:03 256.0 mg/dL 12/31/2022 18:03 243.0 mg/dL 12/31/2022 11:05 115.0 mg/dL On 1/5/23 at 11:04 AM, the surveyor interviewed the Licensed Practical Nurse (LPN4), who is the acting Unit manager for the fourth floor unit, who stated that Resident #64 should have a CP for DM. LPN #1 was unable to provide or explain why there was no CP for DM created for Resident #64 since admission. On 1/5/23 at 12:49 PM, the surveyor interviewed both LNHA and DON. During the interview the DON acknowledged that residents with a diagnosis of DM should have CP for DM. The LNHA on the other hand indicated, No, as long as those conditions are controlled like Diabetes or Hypertension, but if they're uncontrolled there should be a CP. The surveyor reviewed the documented blood sugars for the past five days on the Electronic Medical Record (eMAR) with the LNHA. The eMAR indicated eight instances of the blood sugars documented higher than 150 mg/dL. When the surveyor shared this information with the LNHA, she acknowledged that Resident #64 should have a CP for DM. Neither DON or LNHA could provide any further information as to why this resident did not have a CP for DM. On 1/12/23 at 11:35 AM, the LNHA provided the surveyor with a policy titled, Person Centered Care Planning Policy & Procedures last revised on 1/11/23. The Policy Statements states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation states; 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Areas of concern and medical Diagnosis/comorbidities that are identified during the resident assessment on admission and on an ongoing basis will be evaluated before interventions are added to the care plan. NJAC 8:39 - 27.1(a) Based on observation, interview and record review, it was determined that the facility failed to develop and implement a person-centered baseline care plan (CP) for facility residents within 48 hours of admission. This deficient practice was identified for 4 out of 28 residents reviewed, Resident #232, #83, #64 and #234 who had impaired communication, impaired vision and diagnosis of Diabetes Mellitus (DM). This deficient practice was evidenced as follows: 1. On 1/3/23 at 10:34 AM, during the initial tour, the 6th floor Licensed Practical Nurse/Unit Manager (LPN/UM6) informed the surveyor that one of the Spanish speaking residents on their unit was Resident #83. On 1/3/23 at 11:15 AM, the surveyor observed Resident #83 laying on the bed. The surveyor greeted the resident who responded in Spanish. On 1/3/23 at 11:20 AM, the surveyor interviewed the 6th floor Licensed Practical Nurse (LPN6) assigned to the resident who stated that Resident #83 speaks only Spanish. The LPN6 further stated that a translator and a communication board would be needed. The LPN6 with the aide of the surveyor, could not locate any communication board tool inside the resident's room. The surveyor reviewed Resident #83's medical record. Resident #83 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes Mellitus, Hypertension and Hypothyroidism. A review of the admission Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 10/12/22. The MDS reflected that Resident #83 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating that they had a moderately impaired cognition. The MDS assessment further reflected under Section A1100, Language that Resident #83 needed an interpreter and Spanish was their preferred language. A review of the resident's interdisciplinary person-centered comprehensive CP did not identify that the resident was Spanish speaking and required a communication board and an interpreter. 2. On 1/3/23 at 10:34 AM, during the initial tour, the LPN/UM6 informed the surveyor that one of the Spanish speaking residents on their unit was Resident #232. On 1/3/23 at 1:35 PM, the surveyor observed Resident #232 laying on the bed with eyes closed. The surveyor greeted the resident who responded in Spanish. The LPN6 assigned to the resident informed the surveyor that Resident #232 was blind, and could not see. The surveyor reviewed Resident #232's medical record. Resident #232 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Lumbar Degeneration, Blindness to both eyes and Acute Kidney Failure. A review of the A/MDS, an assessment tool used to facilitate the management of care, dated 12/25/22 reflected that the resident had a BIMS score of 10 out of 15, indicating that the resident had a moderately impaired cognition. The assessment further reflected under Section A1100, Language that Resident #232 needed an interpreter and Spanish was their preferred language. Review of the A/MDS, Section B1000 Vision, indicated severely impaired. A review of the resident's interdisciplinary person-centered comprehensive CP did not identify that the resident was Spanish speaking and blind, who required an interpreter. 3. On 1/3/23 at 2:00 PM, during the initial tour, Resident #234 was observed laying in bed with eyes closed. On 1/3/23 at 2:30 PM, the surveyor reviewed Resident #234's medical record. Resident #234 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Acute Embolism, Blindness to both eyes and Hyperlipidemia. A review of the A/MDS, dated [DATE] reflected that the resident had a BIMS score of 10 out of 15, indicating that the resident had a moderately impaired cognition. The assessment further reflected under Section A1100, Language that Resident #234 needed an interpreter and Spanish as preferred language. Continued review of the A/MDS Under Section B 1000 Vision, documented that the resident was severely impaired. A review of the resident's interdisciplinary person-centered comprehensive CP did not identify that the resident was Spanish speaking and blind, who required an interpreter. On 1/5/23 at 2:00 PM, the survey team met with the facility's Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and RN/MDS Coordinator and discussed the above concerns. The LNHA, DON and RN/MDS Coordinator acknowledged that the above residents did not have a baseline CP implemented to address visual impairment and impaired communication/language barrier.

**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 develop and implement a comprehensive, person-centered care plan (CP) for residents in the facility. This deficient practice was identified for 3 of 28 residents reviewed for comprehensive care plans (Resident #122 and #7) who had impaired communication related to a language barrier and (Resident #129) who had an advance directive and was evidenced by the following: 1. On [DATE] at 1:47 PM, the surveyor observed Resident #122 sitting in their wheelchair watching a Spanish T.V. show in the dayroom. The surveyor introduced herself to the resident who responded in Spanish. At around the same date and time, the surveyor interviewed the Licensed Practical Nurse/LPN and stated that Resident #122 speaks only Spanish. A review of Resident 122's medical record revealed the following: Resident #122 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Essential (Primary) Hypertension and Hypothyroidism. The quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating that the resident had a severely impaired cognition. The QMDS assessment further reflected under Section A1100, Language Spanish was the resident's preferred language. This was an indication that Resident #122 needed/wanted an interpreter to communicate with a doctor or healthcare staff member. A review of Resident #122's CP did not include that the resident was Spanish speaking and he/she required an interpreter. 2. On [DATE] at 2:06 PM, the surveyor observed Resident #7 sitting in her wheelchair in the dayroom for activities. The surveyor introduced herself to the resident who responded in Spanish. At around the same date and time, the surveyor interviewed the Recreation Aide who informed the surveyor that Resident #7 speaks only Spanish. A review of Resident #7's medical record revealed the following: Resident #7 was admitted to the facility on [DATE] with diagnoses that included but not limited to Angina Pectoris, Unspecified and Unspecified Asthma, Uncomplicated. The QMDS assessment dated [DATE], reflected that the resident had a BIMS score of 4 out of 15, indicating that the resident had severely impaired cognition. The QMDS assessment further reflected under Section A1100, Language Spanish was the resident's preferred language. This was an indication that Resident #7 needed and wanted an interpreter to communicate with a doctor or healthcare staff member. A review of Resident #7's CP did not include that the resident was Spanish speaking, requiring an interpreter. A review of the facility policy titled Person Centered Care Planning Policy & Procedures with a revised date of [DATE] revealed the following under Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Person Centered Care Planning Policy & Procedures further indicated under Policy Interpretation and Implementation, 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; j. Reflect the resident's expressed wishes regarding care and treatment goals; 12. The comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessments (MDS). On [DATE] at 12:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and MDS Coordinator. The surveyor discussed the above concern with the administrative team. The DON acknowledged that the above residents did not have a comprehensive CP developed and implemented to address their impaired communication/language barrier. The administrative team acknowledged that a CP for impaired communication and language barrier should be initiated for all residents that are Spanish speaking. On [DATE] at 9:32 AM, the DON and LNHA met with the survey team. The administrative team could not explain why there was no CP initiated and created for the residents reviewed. No further information was provided. 3. On [DATE] at 11:48 AM, the surveyor conducted a review of the hybrid medical record (electronic and paper) which indicated that Resident #129 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Review of Resident #129's Face Sheet (document that gives a patient's information at a quick glance) indicated that the resident's diagnosis included, but were not limited to: Pleural Effusion, Type 1 Diabetes Mellitus without complications, and Alzheimer's Disease. Further review of the resident's hybrid medical record revealed the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) which was signed on [DATE], indicating that the resident was listed as, Do not attempt resuscitation (DNR/DNAR) Allow Natural Death. A review of the resident's Physician Orders revealed that the code status of Resident #129 had changed from DNR to Full Code on [DATE]. A review of the resident's last Interdisciplinary Team (IDT) meeting note conducted on [DATE] revealed under code status that the resident was a Full Code. A review of the resident's baseline care revealed that there was no CP created to reflect the code status of Resident #129. On [DATE] at 11:24 AM, the surveyor conducted an interview with the DON and the LNHA. The LNHA stated that the code status of the resident should have its own CP, but neither the LHNA or DON could explain why the resident did not have any CP reflecting the code status. No further information was supplied to the surveyor regarding this issue. On [DATE] at 11:35 AM, the LNHA provided the surveyor with the facility policy titled, Person Centered Care Planning Policy & Procedures, which was last updated on [DATE]. The Policy Statement states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation, it states. 7. The care planning process will a. Facilitate resident and/or representative involvement; b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: c. Describe services that would otherwise be provided for those the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change, NJAC 8:39-11.2 (e)(2)

**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 a care plan (CP) to reflect changes to a resident's nutritional care for 2 of 28 residents (Resident #5 and #116) reviewed. The deficient practice was evidenced by the following: 1. On 1/3/23 at 10:30 AM, the surveyor observed Resident # 5 with eyes closed, laying on an air mattress. The resident was not able to be interviewed. A review of the admission Record for Resident #5 revealed that the resident was last admitted to the facility on [DATE] with diagnoses that included but were not limited to: Cerebrovascular disease, Vascular dementia, and Type 2 Diabetes without complications. A review of a Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/6/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident had severe cognitive impairment. The MDS further indicated that the resident had a Stage 3 pressure ulcer (A sore that gets worse and extends into the tissue beneath the skin, forming a small crater). A review of the resident's dietary CP dated from 12/15/22 to 12/21/22, revealed under the Focus section that the resident had a potential for altered nutrition related to skin impairment. Further review of the CP identified under the Interventions section, Provide supplements as ordered: Prostat SF 30 ml BID, Multivitamin with Minerals, Vitamin C & Zinc for wound healed with an initiation date on 9/6/2022. A review of resident's Electronic Medical Record under the Physician's Order for January 2023, revealed the resident did not have an order for the supplement Prostat SF (Sugar-Free). On 1/5/23 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident was not currently receiving Prostat SF. The LPN explained that the Prostat SF was ordered for the resident on 8/24/22 and was discontinued on 9/23/22 per the electronic medical record. The LPN indicated that the dietary CP had not been updated to show the discontinuation of the Prostat SF supplement. 2. On 1/3/23 at 10:30 AM, the surveyor observed Resident #116 in bed with eyes closed. The resident's breakfast tray was at bedside, partially eaten. The tray ticket indicated that the resident is on a Mechanical soft diet consistency. A Mechanical soft food diet refers to using equipment, such as a blender or processor to create foods that need less chewing. A review of the admission Record for Resident #116 revealed that they were initially admitted to the facility on [DATE] with diagnoses that included but were not limited to: Covid-19, Heart failure and unspecified dementia with behavioral disturbance. A review of Resident #116's Electronic Medical Record under the Physician's Order for January 2023 revealed the resident had a diet order for Regular diet, Mechanical Soft texture, Thin liquids, no straws for diet, with a start date of 7/15/2022. A review of the resident's dietary CP dated from 9/16/22 to 12/27/22, revealed under the Focus section that the resident, has a nutritional problem r/t: Texture modified diet: Pureed/thin, no straws. A pureed diet is defined as foods that require no chewing. On 1/6/23 at 9:32 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing home Administrator (LNHA). The LNHA stated that the dietary CP should be updated by the dietitians but neither the LHNA nor the DON could explain why the CP had not been updated for Resident #116. On 1/9/23 at 10:15 AM, the surveyor conducted a phone interview with the Registered Dietitian (RD). The RD could not explain why the resident's CP had not been updated. The RD acknowledged that it would be their responsibility to update a resident's CP. On 1/11/23 at 11:55 AM, the surveyor met with the LNHA and DON to further discuss the CP discrepancy. No further information was provided. On 1/12/23 at 11:30 AM, the LNHA provided the surveyor with a policy titled, Person Centered Care Planning Policy & Procedure, which was last revised on 12/21/21. Review of the policy revealed, 13. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to administer, and appropriately document resident's physician ordered medications. This deficient practice was identified for 3 of 5 residents reviewed and observed during medication administration, Resident #34, #109 and Resident #11. 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 1/5/23 at 8:14 AM, the State Surveyor along with the Federal Surveyor observed a Licensed Practical Nurse (LPN) on the 4th floor preparing for medication administration to Resident #34. The LPN signed the the electronic medication administration record (eMAR), documenting the administration of an eye drop without administering this eye drop to Resident #34 in the presence of the surveyors. When the LPN completed the medication administration for Resident #34, the LPN explained that she administered the eye drop to the resident this morning but did not sign for it in the eMAR. The State Surveyor requested the LPN to verify the eye drop medication administered to Resident #34. At that point the LPN could not locate the eye drop medication in the her medication cart. The LPN stated, I used the last one earlier today. Review of the January 2023 eMAR revealed an order for Xiidra Solution Eye Drops with directions of 1 drop in each eye twice daily for dry eyes. The start date for this physician's order (PO) was 9/26/22. On 1/5/23 at 11:46 AM, the State Surveyor called the Provider Pharmacy and spoke with the Registered Pharmacist (RPh) who indicated that a month's supply of Xiidra Solution (60 single use containers) were delivered to the facility for Resident #34 on 9/26/22, 10/23/22, 11/20/22, and 12/16/22. The RPh stated that Resident #34 should still have medication left until the end of January 2023. 2. On 1/5/23 at 8:25 AM, the State Surveyor along with the Federal Surveyor observed the LPN on the 4th floor preparing for medication administration to Resident #109. The LPN was observed signing for another medication in the eMAR, indicating administration of the medication prior to the preparation of medication to be administered to Resident #109. The LPN explained that she was signing for another eye drop, previously administered in the morning to Resident #109. This eye drop was not administering to Resident #109 in the presence of the surveyors. The surveyor reviewed the eMAR and noted that the LPN signed for in the eMAR was not an eye drop, but rather Strovite Multivitamin. The surveyors did not observe the LPN administer the Strovite Multivitamin to Resident #109. The LPN could not explain why she signed for the Strovite Multivitamin without administering the medication to Resident #109. Review of the eMAR revealed an order for Strovite Multiple Vitamins-Minerals 1 tablet daily as a supplement, documented as administered at the time of the observation. 3. On 1/5/23 at 8:39 AM, the State Surveyor along with the Federal Surveyor observed the 5th floor Registered Nurse (RN) approach Resident #11 to remove Lidocaine patches that were documented as placed on the resident during the night shift. The RN noted that the patches were not on Resident #11. Resident #11 informed the RN in Spanish, that she removed the patches and threw them in the garbage this morning. The surveyors observed the RN sign off on the eMAR, documenting that she removed the Lidocaine patches. The State Surveyor reviewed the January 2023 eMAR and noted 2 PO orders for Lidocaine Patch 4% apply to left shoulder topically at bedtime for Osteoarthritis. Apply for 12 hours and remove per schedule and the other order was for Lidocaine Patch 4% apply to right shoulder topically at bedtime for Osteoarthritis. Apply for 12 hours and remove per schedule. Both orders were to be signed for removal at 8:59 AM. The State Surveyor noted that the eMAR was signed as removed by the RN on 1/5/23, at the time of the surveyors observation. On 1/5/23 at 11:15 AM, the surveyor interviewed the RN who indicated that she signed for removing the Lidocaine 4% Patches, which she did not remove. The RN explained that she should have documented that she did not remove the patch and added a note to explain that the resident had removed it prior. Review of the Medication Administration Policy and Procedure revised on 11/16/22 documents, 12. The nurse administering the medication must electronically sign, date and time the resident's eMAR by selecting Y (yes) after giving each medication. The nurse will then select the Save button to finalize the administration of given medications before moving to the next resident. 15. If a medication is withheld or refused, the individual administering the medication shall select N (no) on the eMAR followed by selecting the appropriate reasoning and documentation. The nurse will then select the Save button to finalize the documentation. On 1/5/23 at 2:15 PM, the surveyor informed the Director of Nursing (DON), Licensed Nursing Administrator and Assistant DON of the deficient practice observed. No further information was provided. NJAC 8:39-11.2 (b); 29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide a communication device for a resident identified as having a language barrier. This deficient practice was identified for Resident #83, 1 of 4 residents reviewed for language and communication and was evidenced by the following: 1. On 1/3/23 at 10:34 AM, during the initial tour, the surveyor was informed by the Licensed Practical Nurse/Unit Manager (LPN/UM) that one of the Spanish speaking residents on their unit was Resident #83. On 1/3/23 at 11:15 AM, the surveyor observed Resident #83 laying on the bed. The surveyor introduced self to the resident who responded in Spanish. On 1/3/23 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident who stated that Resident #83 speaks only Spanish. The LPN further stated that a translator and a communication board would be needed. The surveyor could not locate any communication board tool inside the resident's room. The LPN acknowledged that there was no communication board inside the resident's room. The surveyor reviewed Resident #83's medical record. Resident #83 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes Mellitus, Hypertension and Hypothyroidism. A review of the admission Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 10/12/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating that the resident had moderately impaired cognition. The assessment further reflected under Section A1100, Language that Resident #83 needed an interpreter and Spanish as the preferred language. On 1/5/23 at 2:00 PM, the above concern was discussed with the facility's Licensed Nursing Home Administrator and DON who did not provide any further information and could not explain why Resident #83 did not have a communication board available in the resident's room. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that the oxygen (O2) therapy was administered to a resident in accordance with the current physician's orders (PO). This deficient practice was observed for 1 of 4 residents (Resident #56) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/3/23 at 1:26 PM, the surveyor observed Resident #56 laying in bed with O2 in use via a nasal cannula (NC) set at 2 liters per minute (LPM) attached to a humidified O2 concentrator (a medical device used for delivering O2). On 1/5/23 at 10:57 AM, the surveyor observed Resident #56 laying in bed with O2 in use via NC at 2 LPM attached to the humidified O2 concentrator. On 1/6/23 at 10:27 AM, the surveyor observed Resident #56 laying in bed with O2 in use via NC at 2 LPM attached to the humidified O2 concentrator. The surveyor reviewed Resident #56's medical records which revealed the following: The admission Record revealed that Resident #56 was admitted to the facility with diagnosis that included but was not limited to Sepsis, Unspecified Organism (an infection of the bloodstream). The Quarterly Minimum Data Set, dated [DATE], an assessment tool used to facilitate care management, revealed a Brief Mental Status (BIMS) score of 3 out of 15 indicating that the resident had a severely impaired cognition. The January 2023 Order Summary Report revealed that there was a PO with a start date of 8/11/22 for O2 at 3 LPM via nasal cannula every shift. On 1/6/23 at 10:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that Resident #56 was on O2 at 2 LPM as needed for shortness of breath. The surveyor brought the LPN to Resident #56's room to check the O2 rate that was administered to the resident. The LPN identified that the rate on the O2 concentrator for Resident #56 was set at 2 LPM. The LPN reviewed the PO and acknowledged that the PO was for the O2 to be administered at 3 LPM via nasal cannula every shift. A review of the facility policy titled Respiratory Care Policy & Procedures with a revised date of 7/1/22 under Procedure: Oxygen Concentrator-Set the flow rate as ordered by the physician. On 1/9/23 AT 2:10 PM, the surveyor expressed her concern to the Licensed Home Administrator (LNHA) and Director of Nursing. The LNHA agreed that the oxygen should have been administered in the right setting and that the nurses were expected to follow the physician's order. No further information was provided to explain why the O2 was set at 2 LPM. NJAC 8.39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for blood sugar monitoring checks performed at 3 AM for a resident with a diagnosis of Diabetes Mellitus (DM). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #27) and was evidenced by the following: On 1/4/23 at 2:00 PM, the surveyor observed Resident #27 seated in a wheelchair, eyes closed, with Oxygen in use via nasal cannula at 2 liters per minute attached to the humidified oxygen concentrator. A review of the resident's face sheet (an admission summary) reflected that Resident #27 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 DM, Acute Kidney Failure and Congestive Heart Failure. According to the Minimum Data Set, an assessment tool used to facilitate management of care dated, 12/8/22, Resident #27 was documented as having a Brief Interview for Mental Status score of 6 out of 15, indicating that the resident had a severely impaired cognition. A review of the January 2023 Electronic Medication Administration Report (eMAR) revealed a physician's order (PO) dated 12/30/22 for Accucheck at 3:00 AM without coverage in the morning. Accucheck is a blood glucose measuring system used for monitoring of glucose levels by sticking the finger with a lancing device. Further review of the January 2023 eMAR presented another physician order dated 12/3/22 for Novolog Solution 100 unit/ml (Insulin Aspart) inject as per sliding scale: If 151-200 = 2 units call MD if BS(blood sugar) less than 70; 201-250 = 4 units; 251- 300 = 6 units; 301-350 = 8 units; 351-400 = 10 units call MD if BS greater than 401, subcutaneously before meals and at bedtime for DM. The PO had administration times for 6:30AM, 11:30AM, 4:30PM and 9:00PM. On 1/13/23 at 11:02 AM, the surveyor interviewed the Nurse Practitioner (NP) taking care of Resident #27. The surveyor asked the NP for the rationale regarding the PO scheduled for 3:00 AM to check the blood sugar level of the resident when there was another blood sugar level check scheduled at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. The NP responded, checking the BS at 3:00 AM or around that time of the day will result in the most accurate level due to hormones changing. When requested, the NP could not provide any documented rationale evidencing the need for the 3 AM blood sugar monitoring. On 1/13/22 at 2:00 PM, the above concerns were discussed with the facility's Licensed Nursing Home Administrator and the Director of Nursing who did not provide any further information documenting the rationale for a 3:00 AM blood sugar monitoring order. NJAC 8:39-29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to maintain a medication rate error below 5%. The surveyor observed 4 nurses administer 28 doses of medication to 5 residents and there were 2 errors which resulted in a medication error rate of 7.14 %. The deficient practice was evidenced by the following: 1. On 1/5/22 at 8:14 AM, during the medication administration observation (medpass), the State Surveyor along with the Federal Surveyor observed the Licensed Practical Nurse (LPN) #1 preparing to administer medications to Resident #34 which included a Physician's order (PO) for Sennoside 8.6 mg 2 tablets twice daily for constipation. LPN#1 stated that the Sennoside 8.6 mg was unavailable. LPN#1 proceeded to administer Docusate Sodium 100 mg (1) soft gel (stool softener) in place of the Sennoside 8.6 mg. LPN#1 explained that she felt she had to give something to Resident #34 for constipation. During an interview right after medpass to Resident #34 with LPN#1, LPN#1 indicated that the physician gave her the right to substitute Docusate Sodium 100 mg when Sennoside 8.6 mg was not available. LPN#1 could not produce any documentation referring to the physician's order for Docusate Sodium 100 mg. 2. On 1/5/22 at 9:11 AM, during the med pass, the surveyor observed LPN#2 preparing to administer medications to Resident #107 which included a PO for Multiple Vitamins-Minerals tablet daily as a supplement. LPN#2 was observed preparing and administering Multiple Vitamins to Resident #107. During an interview with LPN#2, he informed the surveyor that he did not have any Multiple Vitamins-Minerals tablets available in his medication cart. Review of the Medication Administration Policy and Procedure, documented, 3. Medications must be administered in accordance with the orders, including any required time frame and 6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 1/5/22 at 2:00 PM, the surveyor brought these findings to the Licensed Nursing Home Administrator, the Director of Nursing (DON) and the Assistant DON. There was no further information provided. NJAC 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical records and other facility documentation, it was determined that the attending physician failed to document a discharge summary which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for 3 of 3 closed record's reviewed for discharge to community, expiration, and discharge to the hospital (Resident #128, #129, and #130). This deficient practice was evidenced by the following: 1. On [DATE] at 11:40 AM, the surveyor reviewed the closed medical record for Resident #130. The closed record revealed that the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the Minimum Data Set (MDS) Coordinator. 2. On [DATE] at 11:48 AM, the surveyor reviewed the closed medical record for Resident #129. The closed record revealed that the resident was admitted to the facility on [DATE] and had expired in the facility on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the MDS Coordinator. 3. On [DATE] at 12:01 PM, the surveyor reviewed the closed medical record for Resident #128. The closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the MDS Coordinator. On [DATE] at 1:24 PM, the surveyor conducted an interview with the Licensed Nursing Home Administrator (LNHA), who stated that the medical section of the discharge summary should be filled out by the doctor but could not explain why that section had been completed by the MDS Coordinator. On [DATE] at 1:32 PM, the surveyor interviewed the MDS Coordinator who has been working in this facility role for three years. The MDS Coordinator stated, they were told to fill out the medical section of the discharge summary by the Director of Nursing (DON). The MDS Coordinator added that they have not been in communication with the physician but only reading the physician's notes when filling out the medical section of the discharge summary. The MDS Coordinator stated that they were not aware that the physician was supposed to complete the medical section of the discharge summary. On [DATE] at 1:54 PM, the surveyor interviewed the DON, who stated that the previous Assistant Director of Nursing (ADON) filled out the Medical section of the discharge summary, but had recently asked the MDS Coordinator to complete the medical section of the discharge summary. The DON stated that she was not aware that the physician was responsible for filling out the medical section of the discharge summary. On [DATE] at 1:00 PM, the LNHA provided the surveyor with a policy titled, Policy/Procedure - Discharge Summary, dated, reviewed and signed by the LNHA on [DATE]. Under the Intent section, the policy states, It is the policy of the facility to assure that a discharge summary is completed in accordance to the State and Federal requirements. The Procedure section, states: 2. When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status to include items in paragraph (b) (1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). N.J.A.C. 8:39-35.2(d)(16)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of electronic medical records, it was determined that the facility failed to ensure that a fully Registered Dietitian sign/co-sign the nutrition assessment and nutrition re-assessments for 11 of 16 residents, Resident #286, #95, #59, #283, #284, #114, #287, #282, #93, #285 and #128. This deficient practice was evidence e by the following: (Rev. 207; Issued: 09-30-22; Effective: 09-30-22; Implementation: 10-01-22) §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who- (I) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a registered dietitian by the Commission on Dietetic Registration or its successor organization or meets the requirements of paragraphs (a)(1)(I) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016, or as required by state law On 1/6/23 at 10:14 AM, the surveyor interviewed the Registered Dietitian Eligible, (RDE) employed by the facility. The term Registered Dietitian Eligible is used by the Commission on Dietetic Registration (CDR) to identify individuals who have met didactic and supervised practice requirements and have established eligibility to take the registration examination. During the interview, the RDE informed the facility that they were employed by the facility as of December 13, 2022. The RDE explained that she had recently finished her Dietetic internship but had not yet taken the Registered Dietitian (RD) exam. The RDE verified that the facility did not have a RD in the building but had an RD who worked remotely. The RDE established that she had not been trained nor met the RD in person. The RDE explained that the basis of their communication was either text messaging or electronic mail. The RDE revealed that the RD does not sign any of her notes. 1. On 1/6/23 at 10:30 AM, the surveyor was reviewing the Electronic Medical Chart (EMC) for Resident #286. Resident #286 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Type 2 Diabetes with Hyperglycemia, Sepsis, Acute Kidney Failure and Urinary Tract Infection. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/28/22 and there was no evidence of an RD co-signing the information documented by the RDE. 2. On 1/6/23 at 10:35 AM, the surveyor was reviewing the EMC for Resident #95. Resident #95 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Gout, Anemia, Hyperlipidemia and Other Secondary Hypertension. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 1/4/22 and there was no evidence of an RD co-signing the information documented by the RDE. 3. On 1/6/23 at 10:40 AM, the surveyor was reviewing the EMC for Resident #59. Resident #59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Atrioventricular Block First Degree, Acute and Subacute Endocarditis and Presence of Cardiac Pacemaker. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/22/22 and there was no evidence of an RD co-signing the information documented by the RDE. 4. On 1/6/23 at 10:45 AM, the surveyor was reviewing the EMC for Resident #283. Resident #283 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Cellulitis of the Right Lower Limb, Cellulitis of the Left Lower Limb and Angina Pectoris. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/21/22 and there was no evidence of an RD co-signing the information documented by the RDE. 5. On 1/6/23 at 10:50 AM, the surveyor was reviewing the EMC for Resident #284. Resident #284 was admitted to the facility on [DATE] with diagnosis that included but were not limited to History of Falling, Acute Kidney Failure and Chronic Obstructive Pulmonary Disease. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/21/22 and there was no evidence of an RD co-signing the information documented by the RDE. 6. On 1/6/23 at 11:00 AM, the surveyor was reviewing the EMC for Resident #114. Resident #114 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, History of Falling and Type 2 Diabetes without Complications. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/19/22 and there was no evidence of an RD co-signing the information documented by the RDE. 7. On 1/6/23 at 11:05 AM, the surveyor was reviewing the EMC for Resident #287. Resident #287 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Alcoholic Cirrhosis of Liver with Ascites, Hepatic Encephalopathy and Acute Upper Respiratory Infection. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/28/22 and there was no evidence of an RD co-signing the information documented by the RDE. 8. On 1/6/23 at 11:10 AM, the surveyor was reviewing the EMC for Resident #282. Resident #282 was admitted to the facility on [DATE] and resubmitted on 12/27/22 with diagnosis that included but were not limited to Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease and Schizophrenia. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/22/22 and the re-admission nutrition note on 1/5/23. There was no evidence of an RD co-signing the information documented by the RDE for both dates. 9. On 1/6/23 at 11:15 AM, the surveyor was reviewing the EMC for Resident #93. Resident #93 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Hyperkalemia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Anemia. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/21/22 and there was no evidence of an RD co-signing the information documented by the RDE. 10. On 1/6/23 at 11:20 AM, the surveyor was reviewing the EMC for Resident #285. Resident #285 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Fracture of Unspecified Part of Neck of Left Femur, Hyperlipidemia and History of Falling. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/22/22 and there was no evidence of an RD co-signing the information documented by the RDE. 11. On 1/6/23 at 11:25 AM, the surveyor was reviewing the EMC for Resident #128. Resident #128 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Pneumonia, Sepsis and Chronic Obstructive Pulmonary Disease. During the review of the EMC what part, it was noted that the RDE completed the Initial Nutrition Note on 12/21/22 and there was no evidence of an RD co-signing the information documented by the RDE. On 1/6/23 at 12:53 PM, the Surveyor conducted an interview with the Director of nursing (DON) and Licensed Nursing Home Administrator (LNHA). The LNHA informed the surveyor that there are two dietitians on staff at the facility. The LNHA explained that one is an RDE, who will be taking their accreditation test in March, and another dietitian who is a RD works remotely. The LNHA explained, they are aware of the regulation and assumed that the RD was cosigning the RDE's notes. The LNHA revealed that she is a RD. Neither the LNHA nor the DON could explain why the RDE's notes were not being cosigned and no further information was provided. NJAC 8:39-17.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 1/3/23 at 10:15 AM, prior to the initial tour of the COVID 19 positive residents' unit, the DON who was also the acting Infection Preventionist informed the surveyor that when touring the 6th floor, all staff and visitors must wear a face protection (face shield or goggles) and a N95 mask. On 1/3/23 at 10:34 AM, during the initial tour, the surveyor interviewed the 6th floor Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated to the surveyor that the unit had 2 residents who were placed on contact and droplet precautions due to being tested positive for COVID 19. The rooms were located at the end of the hallway, Rooms 601 B and 602 P. The two rooms were across from one another. On 1/3/23 at 10:43 AM, while the surveyor was standing in the hallway between the rooms [ROOM NUMBERS], the resident's doors were observed to be open. The surveyor further observed a housekeeper sweeping the hallway floor who was not wearing eye protection or face shield and the N95 mask was not properly worn (only top elastic part of the mask was around the housekeeper's head). The surveyor interviewed the housekeeper who stated that the bottom elastic of her N95 mask was broken and acknowledged that she had no eye/face protection while at the COVID 19 side of the unit. 5. On 1/3/23 at 10:57 AM, the surveyor observed that the room where Resident #83 resided had a Personal Protective Equipment (PPE) cart at the entrance to the resident's room. The surveyor interviewed the Registered Nurse (RN) who was assigned to the resident who stated that Resident #83 was placed on contact and droplet precautions due to their exposure to another resident who tested positive for COVID 19. The RN further stated that Resident #83 will be under observation for the next 10 days. The surveyor wearing full PPE, went inside Resident #83's room and observed the resident's call bell was touching the floor. The surveyor showed the call bell to the RN who then picked it up and placed it on top of the resident's bedside table next to the resident's personal items. The surveyor observed the RN disinfecting the call bell and the wire connected to it then handed the call bell to the resident. The RN did not disinfect the contaminated bedside table where she initially placed the call bell (that was previously on the floor) next to the resident's personal items. The RN acknowledged that she did not disinfect the bedside table and agreed that she should have. 6. On 1/11/23 at 9:23 AM, the surveyor in the presence of a Federal Surveyor observed a wound treatment performed by a 6th floor Licensed Practical Nurse (LPN) assigned to Resident #233, who had a stage 2 pressure ulcer (skin breaks open of the sore, wears away, or forms an ulcer, which is usually tender and painful) to the sacral area. The surveyor observed the LPN remove the soiled dressing from Resident #233, that covered the pressure ulcer . The LPN then proceeded to remove her disposable gloves and perform handwashing. After putting on a clean pair of disposable gloves, the surveyor observed that the LPN cleansed the circular pressure ulcer wound using a gauze soaked in a normal saline solution. The LPN was observed to be cleaning the pressure ulcer using top to bottom strokes. After the wound treatment observation, the surveyor interviewed the LPN who stated that when she cleansed a pressure ulcer, she would utilize the top to bottom stroke. A review of the facility's policy titled; Wound Treatment did not indicate specifically on how to cleanse pressure ulcers. According to the National Pressure Ulcer Advisory, When cleansing a wound . The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles beginning in the center and working toward the outside. On 1/12/23 at 2:00 PM, the above concern was discussed with the LNHA, DON and MDS Coordinator who all agreed that the pressure ulcer should have been cleaned in an inner to outer stroke. No further information was provided. 7. On 1/10/23 at 1:24 PM, the surveyor in the presence of the Federal surveyor observed the facility's COVID 19 testing that was performed by the DON. The surveyor observed the DON open a BinaxNOW COVID 19 Ag testing card from the package then proceed to obtain the bottle of the Extraction Reagent. The surveyor then observed that the DON added 7 drops of the Extraction Reagent to the BinaxNOW COVID 19 Ag testing card. On 1/10/23 at 1:29 PM, the surveyor observed the DON swabbed the nostril of the facility's dietary staff. The surveyor noted that the DON did not swab the staff member's nostril in a circular motion or for at least 15 seconds. The DON then proceeded to insert the control swab inside the BinaxNOW COVID 19 Ag testing card. The DON informed the surveyor, after a few minutes, it will show one red line in the card if the staff is tested negative and two red lines if the staff will test positive. The surveyor asked the DON if she had documented the time when she swabbed the staff and the time when she inserted the swab in the card. The DON responded that she does not have the exact time. The DON explained that the timer that was on top of the table was broken. The DON identified that there was no other clock located around the testing area for her to monitor the testing time. On 1/10/23 at 1:31 PM, when the DON checked on the BinaxNOW COVID 19 Ag testing card, there were no lines noted and the strip of the card was observed to be soaked from the solution that appeared to be all white in color. The DON discarded the BinaxNOW COVID 19 Ag testing card. On 1/10/23 at 1:38 PM, the DON retested the same facility's dietary staff's nostril following the BinaxNOW COVID 19 Ag directions and adding 6 drops of liquid to the card receptacle area. The surveyor continued the observation and noted that the DON did not swab the staff member's nostril in a circular motion or for at least 15 seconds. On 1/10/23 at 1:45 PM, the DON showed the surveyor the BinaxNOW COVID 19 Ag testing card which revealed one red line on the top of the strip. This was less than 15 minutes. The DON stated to the surveyor that the staff was negative for COVID 19 since it only showed one red line then proceeded to discard the BinaxNOW card. The DON informed the surveyor that the wait time after the swab was inserted inside the BinaxNOW COVID 19 Ag testing card was 10 minutes. On 1/10/23 at 1:51 PM, another dietary staff was swabbed by the DON using the same technique as described above. The surveyor noted that the DON did not swab the staff member's nostril in a circular motion or for at least 15 seconds. The surveyor did observe the DON put 6 drops into the liquid receptacle area of the test card. The surveyor observed the DON insert the control swab sample inside the BinaxNOW COVID 19 Ag testing card at 1:52 PM. The DON informed the surveyor that the result would be due to be read by 2:07 PM (15 minutes). On 1/10/23 at 2:01 PM, the DON presented the BinaxNOW COVID 19 Ag testing card result, which revealed one red line on the top of the strip indicating that the staff tested negative for COVID 19. The DON did not wait the recommended time and read the result after 15 minutes. Review of the BinaxNOW COVID 19 Ag testing instruction packet demonstrates: Prepare for the test: Timing Device (not included) 1. Wash or sanitize your hands. Make sure they are dry before starting. 3. Put 6 drops into top hole. Do not touch card with tip. 5. Make at least 5 big circles. Do Not just spin the swab. Each nostril must be swabbed for about 15 seconds. 7. Turn swab to right 3 times to mix the swab with the drops 9. Wait 15 minutes. Read the result at 15 minutes. Do not read the result before 15 minutes or after 30 minutes. On 1/11/23 at 11:00 AM, the surveyor discussed the above concerns with the facility's LNHA and DON who could not explain why the BinaxNOW COVID 19 Ag instructions were not accurately followed during staff testing. No further information was provided. 8. On 1/10/23 at 10:41 AM, the surveyor in the presence of the Federal surveyor, Housekeeping Director (HD) and the Housekeeping Supervisor (HS) observed the two rooms where the clean linens were stored. The HD and HS informed the surveyors that clean linens were delivered from an outside laundry company to the facility and stored in room [ROOM NUMBER]. Upon entering room [ROOM NUMBER], where the clean linens were stored, the surveyors observed that there was a large black bin that contained garbage materials, once inspected. The surveyor also observed on the side of the wall right next to the door, that there were several items including 2 unused N95 masks on the floor, a fork, a broom, and a magazine. The HD and HS showed the surveyor another room, room [ROOM NUMBER] where the clean linens from room [ROOM NUMBER] were transferred, separated, and placed onto transport shelved bins that can be brought to the facility units for use. The surveyor observed the floor of room [ROOM NUMBER] to be dirty with several dried leaves and some disposable utensils on the floor. Further observation also revealed that there were cobwebs on the far corner of the room opposite to where the clean linens were stored on the shelved bins. The HD and HS stated to the surveyors that the items (2 unused N95 masks on the floor, a fork, a broom, and a magazine) found in linen room [ROOM NUMBER] should not be there, since clean linens were stored in the room. The HS and HD acknowledged that since clean linens are stored in room [ROOM NUMBER] as well, the room should be clean without evidence of cobwebs and a dirty floor. NJAC 8:39 - 19.4(a) Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 4 of 25 Residents observed (Resident #34, #109, #107, #233), 2 of 3 floors of the facility observed (4th floor and 6th floor), during the facility COVID testing process and with the storage of clean linens. This deficient practice was evidenced by the following: 1. On 1/5/23 at 8:14 AM, the State Surveyor in the presence of a Federal Surveyor observed medication administration (med pass) on the 4th floor performed by a Licensed Practical Nurse #1 (LPN#1). LPN#1 completed administering medication to Resident #34 and proceeded to wash her hands. The State Surveyor along with the Federal Surveyor observed LPN#1 scrub her hands with soap for a total of 2 seconds before placing her hands under water to rinse off the soap. 2. On 1/5/23 at 8:25 AM, the State Surveyor in the presence of a Federal Surveyor continued observation of medication administration on the 4th floor by LPN#1. LPN#1 prepared the medication and completed administering medication to Resident #109 without sanitizing or washing her hands that were not appropriately cleaned from med pass to Resident #34. LPN#1 only sanitized her hands at the end of the administration of medication to Resident #109 with an alcohol based hand sanitizer. 3. On 1/5/23 at 9:11 AM, the State Surveyor observed another med pass on the 4th floor by Licensed Practical Nurse #2 (LPN#2). LPN#2 completed administering medication to Resident #107 and proceeded to wash his hands. The State Surveyor observed LPN#2 scrub his hands with soap under water for 2 seconds while rinsing off the soap. On 1/5/23 at 9:27 AM, the State Surveyor interviewed LPN#2 who explained that he sings happy birthday while his hands are under the water. On 1/5/23 at 9:32 AM, the State Surveyor interviewed LPN#1 who explained that she scrubs her hands with soap away from the water for 60 seconds. LPN#1 further explained that she did not follow this process during the surveyor's observation, because I didn't touch the patient. If you don't touch the patient, you don't have to wash your hands. The State Surveyor reminded LPN#1 that her hands were contaminated by the medication cup and water cup that Resident #34 was holding during medication administration. LPN#1 responded, I guess I should have washed my hands properly. Review of Hand Washing/Hand Hygiene Policy and Procedure revised on 3/9/21 opened with, This facility considers handwashing /hand hygiene the primary means to prevent the spread of infections. Review of the Procedure portion of this policy under, 5. Rub all surfaces of hands, between fingers and wrist producing fiction for at least 15-20 seconds. 7. Rinse hands and wrist by holding them under running water with fingers downward the sink. The policy also adds, The CMS SOM (Centers for Medicaid & Medicare Services State Operations Manual) indicates that hand hygiene should be performed as follows: Before and after performing any nursing procedure. Review of the facility Medication Administration Policy and Procedure indicated, 14. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions etc.) when these apply to the administration of medications. On 1/5/22 at 2:00 PM, the surveyor met with the Director of Nursing (DON), Licensed Nursing Home Administrator and Assistant DON to discuss the breaches of infection control practices. No further information was provided during the survey to explain the deficient practice.