**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident's updated advance directive was implemented in a timely manner in accordance with the resident's wishes and the facility's policy. This deficient practice was identified for 1 of 2 residents (Resident #280) reviewed for Advance Directives and was evidenced by the following: On [DATE] at 10:51 AM, during the initial tour of the facility, the surveyor observed Resident #280 seated in a chair in his/her room. The resident stated that he/she was recently admitted to the facility. The surveyor reviewed the medical record for Resident #280. A review of the the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: altered mental status, major depressive disorder, and frontotemporal neurocognitive disorder (occurs when nerve cells in the frontal and temporal lobes of the brain degenerate, causing the lobes to shrink). A review of the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, was in progress and was not able to be viewed. A review of the resident's Baseline Care Plan (BCP), identified the resident's Code Status as a Full Code [the healthcare provider will implement all available medical interventions, including CPR (cardiopulmonary resuscitation), to try and revive a patient if their heart stops beating or if they stop breathing]. A review of the Order Summary Report (OSR), included the following physician order (PO): A PO, dated [DATE], for Full Code. A review of the Progress Notes (PN) included a Social Services Note (Late Entry) with an effective date of [DATE], that the family completed a POLST (Practitioner Orders for Life-Sustaining Treatment) form and it was in the chart for doctor to sign. On [DATE] at 12:00 PM, the surveyor reviewed the resident's paper chart and noted New Jersey POLST form, undated, which indicated the following: Do Not Attempt Resuscitation (DNAR), Allow Natural Death, and Do Not Intubate (DNI - intubate: insert a tube into the trachea (windpipe) for ventilation); Use oxygen (O2), manual treatment to relieve airway obstruction, medications for comfort. The POLST was signed by the resident, the resident's healthcare representative (surrogate), and the facility Nurse Practitioner. On [DATE] at 12:06 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 who stated that if a resident were a Full Code they would have a heart sticker on the spine of their paper chart. LPN #4 viewed Resident #280's paper chart and stated the resident did not have a heart sticker on their chart to indicate that he/she was a Full Code. LPN #4 then proceeded to review the resident's EHR (electronic health record) and stated that the resident's dashboard specified that the resident was a Full Code and the resident also had an order for a Full Code. LPN #4 then reviewed the resident's POLST form within the paper chart and stated that the POLST indicated that the resident was a Do Not Resuscitate/Do Not Intubate (DNR/DNI). LPN #4 stated that the POLST was usually completed upon admission and both the POLST and the code status order should have matched. LPN #4 stated that she would review the resident's paper chart in an emergency in order to determine the resident's code status. On [DATE] at 12:11 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that in an emergency, the nurses would review the POLST and honor the POLST. LPN/UM #1 stated that the POLST should have been dated because the resident's code status could change. LPN/UM #1 stated the POLST, physician's order, and care plan should all match. On [DATE] at 11:47 AM, the surveyor interviewed the Director of Nursing (DON) who stated that for new admissions, the nurses looked at the transfer form to determine the code status, unless there was a POLST form that stated otherwise. The DON stated that the resident was a Full Code until the POLST was signed by the physician or until confirmed by the family. The DON stated that a resident's code status order of Full Code and POLST form for DNR/DNI was something that needed to be flagged and addressed with the doctor immediately once identified. The DON further stated the POLST, physician's order, and care plan should all coincide. On [DATE] at 9:37 AM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team the DON stated that the resident would remain a Full Code until the doctor came in and signed both the orders and the POLST form. A review of the facility's Code Status policy, dated [DATE], included: In the absence of an Advance Directive, POLST, or further direction from the physician, the default direction will be Full Code. A review of the facility's Practitioner Orders for Life-Sustaining Treatment (POLST) policy, updated [DATE], included: If the individual does not have a POLST form at the time of admission, the facility will introduce POLST. The Social Services, attending physician or advance practice nurse will complete the POLST with the individual or the legally recognized health care decision maker, after discussing options of care. If the POLST conflicts with the patient's previously-expressed health care instructions or advance directive, then, to the extent of the conflict, the most recent expressions of the patient's wishes governs. NJAC 8:39-4.1(a)4; 9.6(b)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to obtain a physician's order for 1 of 1 resident (Resident #173) reviewed for positioning and mobility. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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 5/27/2025 at 9:39 AM, the surveyor observed Resident #173 in a wheelchair in the hallway wearing a sling on his/her right arm. On 5/28/2025 at 10:53 AM, the surveyor observed Resident #173 wearing a sling on his/her right arm. The resident stated, My arm doesn't work too well. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: flaccid (a muscle or tissue that is weak) hemiplegia (paralysis or severe weakness on one side of the body) and cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/25/25, included that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had an impairment to the upper and lower parts of one side of the body. A review of the individual comprehensive care plan (ICCP) did not include the use of the sling to the resident's right arm. A review of the physician's orders did not include the sling to the resident's right arm. On 5/28/2025 at 10:55 AM, the surveyor interviewed Licensed Practical Nurse/ Unit Manager (LPN/UM) #4 who confirmed that there was no physician's order for the sling and stated that there should be one. On 5/28/2025 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated that a physician's order should have been obtained for the sling. On 5/29/2025 at 11:38 AM, the surveyor interviewed the Nurse Practitioner (NP) who stated that the use of a sling required a physician's order. He further stated that a new order was entered today (5/29/25) after the surveyor's inquiry. A review of the facility's Physician Orders, policy, updated April 2024, included, Medications, diets, therapy, or any other treatment may not be administered to the residents without the written approval from the attending physician. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #: 185447 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 5 residents (Residents #127 and #150) reviewed for pressure ulcers and was evidenced by the following: 1.) On 5/28/25 10:50 AM, the surveyor observed Resident #127 lying in bed on an air mattress and the resident stated that he/she was in pain. At that time, the Licensed Practical Nurse (LPN) #2 entered the room to answer the call light. The surveyor observed the air mattress pump was attached to the foot board and was set between 280 and 320 pounds (lbs). On 5/28/25 at 10:52 AM, the surveyor interviewed LPN #2 who stated the air mattress should be set according to the resident's weight, but the setting could also be a combination of things. At that time, LPN #2 changed the setting to 280 lbs. When asked what the purpose of the air was mattress was, LPN #2 stated it was to prevent pressure ulcers and to ensure the residents were properly cushioned. On 5/28/25 at 10:55 AM, the surveyor reviewed the medical record for Resident #127. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, a personal history of venous thrombosis and embolism (blood clot) and polyneuropathy (a condition where multiple peripheral nerves are damaged, affecting different parts of the body). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/27/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the assessment revealed that the resident was at risk for developing pressure ulcers/injuries and that the resident had a pressure reducing device for the bed. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 4/11/23, for a potential for pressure/injury development. Interventions included: Resident has specialty air mattress. Check to be sure pump/mattress is functioning correctly with care. A review of the Weights Summary revealed that the resident's weights were as follows: On 5/9/25 the resident weighed 151.6 lbs. On 4/8/25, the resident weighed 152.8 lbs. On 3/10/25, the resident weighed 153.6 lbs. 2.) On 5/27/25 at 11:00 AM, the surveyor observed Resident #150 lying in bed receiving incontinence care. On 5/27/25 at 11:15 AM, the surveyor reviewed the medical record for Resident #150. A review of the admission Record, revealed the resident had diagnoses which included, but were not limited to, adult failure to thrive, cerebral infarction (stroke), and type two diabetes mellitus. A review of the comprehensive MDS, dated [DATE], included the resident's cognition was severely impaired. Further review of the assessment revealed that the resident had a stage four pressure ulcer that was present on admission, two unstageable deep tissue injuries that were present on admission, and that the resident had a pressure reducing device for the bed. A review of the ICCP included a focus area, dated 2/25/25, for a potential for pressure/injury development. Interventions included: Resident has specialty air mattress. Check to be sure pump/mattress is functioning correctly with care. A review of the Order Summary Report (OSR), for May 2025, included a physician's order (PO), dated 4/18/25, for alternating air pressure to prevent further skin breakdown every shift for preventative and monitor for functioning. A review of the May 2025 Treatment Administration Record (TAR) for the above-mentioned PO was signed out as completed on day, evening, and night shifts. A review of the Weights Summary revealed that the resident's weights as follows: On 5/9/25 the resident weighed 108.0 lbs. On 4/25/25 the resident weighed 105.0 lbs. On 4/10/25 the resident weighed 112.6 lbs. On 3/10/25 the resident weighed 104.8 lbs. On 5/28/25 at 10:32 AM, the surveyor interviewed LPN #3 who stated that Resident #150 had wounds on his/her sacrum (a large, triangular bone at the base of the spine), inner thighs, and bilateral heels. On 5/28/25 at 10:53 AM, the surveyor and LPN #3 entered Resident #150's room and observed the resident lying in bed with their eyes closed. At that time, LPN #3 confirmed the air mattress setting was firm and was set between 320 and 350 lbs. LPN #3 stated the purpose of the air mattress was to keep the wound from being pressed on and to prevent pressure ulcers. The LPN stated when she checked the air mattress, she just checked to ensure it was inflated. LPN #3 further stated she was unsure it was supposed to be set to the resident's weight. On 5/28/25 at 10:56 AM, LPN #3 stated that she found out that the air mattress should have been set based on the resident's weight. On 5/28/25 at 11:01 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that an air mattress was used to prevent pressure ulcers and to alternate pressure and relieve pressure. She stated that if a resident was 100 lbs and it was set to 300 lbs that would be too much. When asked if the air mattress should be set to the resident's weight, LPN/UM #2 stated she was unsure. She then stated that the wound care nurse typically checked the air mattress settings, but that the nurses should ensure the air mattress was working properly. On 5/28/25 at 11:09 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated the purpose of the air mattress was to prevent skin breakdown. She stated that it was typically set based on the resident's weight. The ADON stated that if the settings were too high or too low it could be uncomfortable for the resident. The ADON then stated that the nurses were responsible for checking the air mattress and that it should be checked each shift. On 5/28/25 at 11:40 AM, the Director of Nursing (DON), in the presence of the survey team, stated the purpose of the air mattress was to offload pressure for the resident. She stated that the setting was based on the resident's weight. She further stated that if it was not set to the resident's weight if could cause injuries, and if the resident already had a pressure ulcer it could worsen. The DON stated the nursing staff was responsible for checking the air mattress to ensure it was set appropriately. On 5/30/25 at 9:38 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged the air mattresses were set incorrectly and that they should have been set based on the resident's weight. A review of the [name redacted] manufacture's guidelines for the specialty air mattress included, Step 6 determine the patient's weight and set the control knob to that weight setting on the control unit. A review of the [name redacted] manufacture's guidelines for the low air mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) included, Pressure adjust knob adjustable by patient's weight. Turn the pressure adjust knob to set a comfortable level by using the weight scale as a guide. A review of the facility's Pressure Ulcers/Skin Breakdown -Clinical Protocol policy, updated March 2025, included, Treatment/Management: the physician or consultant will order pertinent wound treatments, including pressure reduction surfaces. A review of the facility's Low Air Loss Mattress Usage policy updated February 2025, included, Low air loss mattresses will be utilized in accordance with the manufacture guidelines. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. This deficient practice was identified for 1 of 3 residents (Resident #139) reviewed for respiratory care and was evidenced by the following: On 5/22/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #139 lying in bed with a tracheostomy tube [a surgical opening in the neck directly into the trachea (windpipe)]. The resident did not respond to the surveyor when spoken to and the resident's oxygen concentrator (a medical device that extracts and concentrates oxygen from ambient air) was set at six liters. On 5/23/25 at 9:06 AM, the surveyor reviewed the medical record for Resident #139. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, chronic respiratory failure with hypoxia (oxygen deficient), and chronic obstructive pulmonary disease (lung condition characterized by airflow obstruction). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/5/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated that the resident cognition was severely impaired. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, dated 5/24/24, to give humidified oxygen as prescribed at four liters/35% humidification. A review of the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 1/24/25, for oxygen inhalation, four liters per minute of oxygen blended in via trach collar (a device placed over a tracheostomy to deliver oxygen) at 35% every shift for hypoxia and shortness of breath. A review of the Treatment Administration Record (TAR) revealed that the above PO for oxygen inhalation was signed out as administered on 5/22/25 for the day shift. On 5/23/25 at 11:56 AM, the surveyor observed Resident #139 lying in bed with their eyes opened, but the resident was non-verbal. The oxygen concentrator was set to deliver six liters of oxygen (instead of four liters as ordered.) On 5/27/25 at 12:17 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she had already performed trach care for the resident that day. LPN #1 stated that the resident's concentrator was supposed to be set at four liters with 35% humidification. The surveyor asked LPN #1 to view the concentrator to confirm the setting and LPN #1 confirmed that it was set at six liters, but it should have been set at four liters. LPN #1 then proceeded to turn the concentrator dial down from six liters to four liters. LPN #1 stated that she was going to check the oxygen concentrator setting after she completed the medication pass, but she had not noted the discrepancy yet. LPN #1 added that it was important to follow the physician's order to make sure the resident received the right amount of oxygen. On 5/28/25 at 9:54 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that there were physician orders for oxygen and the nurses were expected to check the concentrator each shift to ensure that the resident's concentrator was at the correct setting. LPN/UM #1 stated that the resident needed to receive the correct amount of oxygen to remain stable in accordance with the physician orders. On 5/28/25 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing should have assessed the oxygen concentrator and ensured that it was set to the correct setting as determined by the physician's order. The DON stated that it was important to make sure that the resident was oxygenating properly to avoid further injury. The DON stated that when the order for oxygen was signed out by the nurse on the TAR, it indicated that the nurse had looked at the concentrator and confirmed that the concentrator was set to the correct setting. On 5/29/25 at 12:24 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns that were identified with the resident's oxygen concentrator settings. A review of the facility's undated Oxygen Administration policy, included: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure palatable temperature of food for lunch meals served on 1 of 5 units (E-Unit). This deficient practice was evidenced by the following: On 5/23/2025 at 10:21 AM, the surveyor conducted a resident council meeting. During that meeting, 4 out of 5 residents (Resident #58, #71, #118, and #129) stated that their food was not served hot. On 5/27/2025 at 11:23 AM, the surveyor visited the kitchen to observe the food service distribution line: At 11:45 AM, the FSD calibrated (process used to make sure the instrument is taking an accurate temperature reading) the thermometer to 31.7 F (degrees Fahrenheit) and then proceeded to obtain the food temperatures from the food items on the steam table. At 11:55 AM, the surveyor observed the first food cart (Food Cart #1) leave the kitchen. The food cart was uncovered. At 11:56 AM, Food Cart #1 arrived on the E-Wing and staff immediately started to distribute the lunch trays. At 12:01 PM, the last meal tray was passed and the surveyor observed the FSD obtain the food temperatures with the previously calibrated thermometer. The temperatures included, but were not limited to, the following: Milk #1 - 44.0 F Milk #2 - 42.1 F Regular pork chop - 109.9 F At that time, the surveyor interviewed the FSD, who stated that the milk should be kept at less than 41 F and the pork chop at 135 F or higher. On 5/30/2025 at 9:23 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, who stated that the cold beverages should be kept below 41 degrees Fahrenheit and he was unaware of the temperature that the pork chop should have been maintained at. A review of the facility's Record of Food Temperatures undated policy, included: 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. NJAC 8:39-17.4(a)(2)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. This deficient practice was identified for 2 of 2 courtyards and on 2 of 5 units (A-Unit and B-Unit) and was evidenced by the following: 1.) On 5/22/25 at 10:00 AM, during the initial tour of the facility, the surveyor observed a courtyard with a large gazebo which had very tall weeds. On 5/23/25 at 11:40 AM, the surveyor observed the courtyard with a large gazebo which had very tall weeds. On 5/27/25 at 11:32 AM, the surveyor interviewed Resident #118 who stated that the courtyard with the large gazebo had both rusted furniture, weeds, and the lawn decor was broken and in disrepair. The resident complained about the lack of maintenance and his/her inability to bring visitors out to there due to the condition of the area. On 5/28/25 at 9:58 AM, the surveyor observed the courtyard with the large gazebo which revealed the following: One black metal table that had a reddish-orange substance on it's upper surface and two black metal chairs. Two white wicker chairs that appeared faded and weathered. One of the wicker chairs had a very faded orange cushion on it. A broken wind chime, a broken bird feeder, and a lawn ornament that laid on the ground face down beneath the tree that faced the window in the connecting hallway where residents were observed working with physical therapy throughout the day. Both the grass and the weeds had appeared to have been cut. 2.) On 5/23/25 at 10:34 AM, the surveyor interviewed Resident #58 who stated that the aluminum roof over the smoking area leaked when it rained. The resident further stated that the facility Licensed Nursing Home Administrator (LNHA) kept saying that they were going to fix it. On 5/28/25 at 10:05 AM, the surveyor observed the smoking area while it rained and the patio flooring was very wet despite the area being covered. Two unsampled residents were observed seated side-by-side in their wheelchairs in the center of the patio next to the ashtray in order to remain dry. The remainder of the flooring outside of the very center of the patio was saturated with rain water. On 5/28/25 at 12:43 PM, the surveyor interviewed the Director of Maintenance (DM), who stated that he was responsible for caring for the courtyard where the wooden gazebo was. The DM stated that the landscaping company was behind schedule due to all of the rain, but that they did come in and had completed the weed whacking. The DM stated he had not seen the metal table and chairs with any rust or discoloration on them. The DM added that all of the stuff that was broken and on the ground would be removed during the next planned project. The DM further stated that there was a family member who went out to the courtyard every once in a while, but it was rare. At that time, the DM stated that the roof in the covered smoking area did leak, but that it was just a simple car port and the whole thing would have to be pulled apart to prevent leakage. The DM stated that residents had complained about the leaking roof in the smoking area and that it was more of an issue for administration. The DM stated that it was not a home like environment for the weeds to be tall and the weeds should have be maintained. On 5/29/25 at 12:20 PM, the surveyor interviewed the LNHA who stated that the facility contracted a landscaping company, but he was unsure how often they came to the facility to cut the grass in the courtyard. The LNHA stated that it was up to DM to reach out to the contractor to ensure the grass was cut. The LNHA further stated that Maintenance and Housekeeping were responsible for ensuring that the gazebo area was maintained. At that time, the LNHA stated that the residents may have complained about the smoking area roof leaking during rain and that rain was coming in on the sides. The LNHA further stated that the residents had not voiced that only two residents could be out there at time to remain dry while smoking due to the leaking roof. On 5/30/25 at 9:24 AM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) who stated that the courtyard area with the large gazebo was not being used often and that may have been because of the way that it had looked. 3.) On 5/28/25 at 9:09 AM, the surveyor, accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM) #2, toured the nourishment room on the A-Unit. Upon entering the nourishment room, the surveyor smelled a musty odor. The surveyor requested that LPN/UM #2 open the locked cabinet under the sink. At 9:16 AM, the Director of Maintenance (DM) arrived at the unit and removed the lock from the cabinet under the sink. When the cabinet was opened, the musty odor intensified and the surveyor observed the base of the cabinet with two big water marks, multiple brown and black stains, and black substances. The lower interior back wall of the cabinet was also noted to have water marks, stains, and a black substance. At that time, the surveyor interviewed the DM, who stated, it looks like the drain leaked under there. We didn't realize that the drain leaked. He further stated that the maintenance department did rounds, but they do not look under the sink. The DM then confirmed that there was a musty odor. He also stated that the building should be maintained in good repair and that he would repair the drain to ensure it no longer leaked. 4.) On 5/28/2025 at 9:32 AM, the surveyor, accompanied by the LPN/UM #1, toured the B-Unit nourishment area and observed garbage bags, two wet floor signs, a small white basket, and a vase stored under the sink. When LPN/UM #1 moved the items, the surveyor observed multiple areas containing a black substance on the interior lower back wall of the cabinet, and the interior base of the cabinet also had multiple small pieces of debris. A that time, the surveyor also observed the caulking was not intact where the countertop met the wall near the sink. LPN/UM #1 confirmed the findings and agreed that it was not maintained in good repair. 5.) At 9:43 AM, on the B-Unit, the surveyor observed a lightly running water fountain heavily stained around the faucet area leading down to the drain. At that time, the surveyor interviewed the housekeeper (HK), in the presence of LPN/UM #1, who stated that the porter should clean the water fountains daily. On 5/28/2025 at 12:48 PM, the surveyor interviewed the Director of Housekeeping, who stated that the water fountains at the facility did not work and have not been in service since he had been working there (3 years). He further stated that the porters should clean the water fountains daily. A review of the facility's undated Maintenance Service policy, included: It is the policy of this facility that maintenance service be provided to all areas of the building, grounds, and equipment. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. Maintaining the grounds . in good order. Providing routinely scheduled maintenance service. NJAC 8:39-31.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 5/22/25 at 10:52 AM, during the initial tour, Resident #175 was not in his/her room and the surveyor observed a surgical shoe on the countertop. On 5/23/25 at 11:09 AM, the surveyor observed Resident #175 resting in bed while wearing a hinged brace and a surgical shoe on his/her right leg. The surveyor reviewed the medical record for Resident #175. A review of the admission Record revealed the resident had diagnoses which included, but were not limited to, fracture of shaft of right tibia (the inner and typically larger of the two bones between the knee and the ankle) and subsequent fracture of metatarsal (any of the bones of the foot). A review of the resident's comprehensive MDS, dated [DATE], included the resident had a BIMS score of 10 out of 15, which indicated the resident's cognition was moderately impaired. A review of the resident's ICCP included a focus area, dated 5/12/25, that the resident had a potential for pressure ulcer/injury development. Interventions included: Assist the resident with bed mobility and toileting as needed, assist/remind/cue the resident to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Further review of the ICCP included a focus area, dated 5/12/25, that the resident had a self care performance deficit related to impaired balance. Interventions included: No weight bearing on right leg until 6/17/25, encourage the resident to discuss feelings about self-care deficit, and monitor/document/report to provider any changes as needed. The ICCP did not include the hinged knee brace on his/her right knee or the surgical shoe. A review of the Order Summary Report (OSR), dated as of 5/23/25, included the following physician orders (PO): A PO, dated 5/20/25, for a hinged knee brace to right knee. There was no PO for the surgical shoe. On 5/23/25 at 11:29 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #6 who stated the hinged knee brace and surgical shoe should be included on the resident's care plan. On 5/23/25 at 11:45 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who stated the nurses or the MDS Coordinator updated the care plan. At that time, LPN/UM #4 pulled up Resident #175's electronic medical record and confirmed that the hinged right knee brace and the surgical shoe was not included on the resident's care plan. She further stated that the care plan should have been updated to include them. 3.) On 5/22/25 at 10:56 AM, during the initial tour, Resident #173 was not in his/her room and the surveyor observed heel booties on the resident's windowsill. On 5/27/25 at 9:39 AM, the surveyor observed Resident #173 in a wheelchair in the hallway and wearing a sling on his/her right arm. On 5/28/25 at 10:53 AM, the surveyor observed Resident #173 wearing a sling on his/her right arm and the resident stated, My arm doesn't work too well. The surveyor reviewed the medical record for Resident #173. A review of the admission Record revealed the resident had diagnoses which included, but were not limited to, flaccid (a muscle or tissue that is weak) hemiplegia (paralysis or severe weakness on one side of the body) and cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die). A review of the resident's comprehensive MDS, dated [DATE], included that the resident had a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had an impairment to the upper and lower parts of one side of the body. A review of the ICCP included a focus area, dated 5/12/25, that the resident had a pressure ulcer injury and was at risk for a new injury. Interventions included: Administer treatments as ordered and monitor for effectiveness, assist the resident with bed mobility and toileting as needed, and assist/remind/cue the resident to turn and reposition. Further review of the ICCP did not include the use of the sling on the right arm or heel booties. A review of the Order Recap Report (ORR), dated 4/1/25 to 5/31/25, included a physician's order (PO), dated 4/22/25, for bilateral heel booties for protection while in bed every shift. Further review of the ORR did not include the sling to the right arm. On 5/28/25 at 10:55 AM, the surveyor interviewed LPN/UM #4 who confirmed that the heel booties and the sling were not on the care plan. The LPN/UM further stated that the devices should have been included on the care plan because they were part of the resident's care. On 5/28/25 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the care plans were updated quarterly and as needed. The DON further stated that Resident #173's heel booties and sling should have been included in the care plan. Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's a.) risk for wandering, b.) medical devices, and c.) history of seizures. This deficient practice was identified for 1 of 5 residents (Resident #108) reviewed for accidents, 1 of 1 resident (Resident #175) reviewed for pressure ulcers, 1 of 1 resident (Resident #173) reviewed for positioning, and 1 of 3 residents (Resident #127) reviewed for hospitalizations and was evidenced by the following: 1.) On 5/29/25 at 10:05 AM, the surveyor observed Resident #108 sitting in a chair in the dayroom on the locked unit. The resident had a wander guard (a device that alarms if it is near a restricted area) on his/her right wrist. When asked about the wander guard, the resident stated, it is to keep track of me. The surveyor reviewed the medical record for Resident #108. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, unspecified dementia, major depressive disorder, persistent mood disorder, obsessive compulsive disorder, and generalized anxiety disorder. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/19/25, included the resident had a Brief Interview for Mental Status score of 10 out of 15, which indicated the resident's cognition was moderately impaired. A review of the resident's Wandering/Elopement assessments revealed the following: On 8/10/24, the resident scored a 9 which indicated he/she was at risk to wander. On 11/10/24, the resident scored a 12 which indicated he/she was a high risk to wander. On 2/10/25, the resident scored a 12 which indicated he/she was a high risk to wander. On 5/12/25, the resident scored a 12 which indicated he/she was a high risk to wander. A review of the progress notes included a General Nurses Note, dated 8/28/24, that revealed the resident was out of bed wandering the nursing unit. Further review of the progress notes included a Behavioral Note, dated 1/11/25, that revealed the resident was wandering into other resident rooms. A review of the individual comprehensive care plan (ICCP) did not include a focus area that the resident was at risk for wandering, nor did it include interventions related to wandering. On 5/29/25 at 10:07 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #6 who stated that most of the residents on the unit were at risk for wandering which was why the unit was locked. The CNA explained that if a resident had a wander guard, it would alarm at the facility's exit doors and that wander guards were important to prevent a resident from eloping. On 5/29/25 at 10:13 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated residents at risk for wandering wore a wander guard that would alarm at the facility's exit doors. The LPN explained that each resident was assessed for their wander risk quarterly by the Unit Managers. The LPN added that the comprehensive care plans were initiated by the nurses and that the purpose of the care plan was for staff to know how to care for the residents. On 5/29/25 at 10:18 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated all of the residents on the unit were at risk for wandering which was why the unit was locked. The LPN/UM explained that residents were assessed for their wander risk on admission and then quarterly. The LPN/UM also stated that the comprehensive care plan was initiated on admission and the purpose of the care plan was to communicate to staff the potential problems and interventions for the residents. On 5/29/25 at 11:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated most of the residents on the locked unit were at risk for wandering. The DON explained that residents were assessed for their risk for wandering quarterly and as needed. The DON also stated that if a resident was identified as a risk for wandering based on the assessment, the comprehensive care plan should be initiated right away. The DON added that the purpose of the care plan was to let staff know the residents' specific needs. At that time, the surveyor informed the DON that Resident #108 was identified as a risk for wandering according to the Wandering/Elopement assessment, dated 8/10/24, but did not have a care plan focus area related to wandering. The DON then confirmed that the resident should have had a care plan related to his/her risk for wandering. 4.) On 5/27/25 11:14 AM, the surveyor observed Resident #127 lying in bed with his/her eyes closed. On 5/28/25 at 10:55 AM, the surveyor reviewed the medical record for Resident #127. A review of the admission Record revealed the resident had diagnoses which included, but were not limited to, personal history of venous thrombosis and embolism (blood clot), polyneuropathy (a condition where multiple peripheral nerves are damaged, affecting different parts of the body), and seizures. A review of the comprehensive MDS, dated [DATE], included the resident had a BIMS score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the assessment revealed that the resident was taking an anticonvulsant (medication used to treat seizures). A review of the Order Summary Report (OSR), for May 2025, included, the following physician's orders (PO): A PO, with a start date of 12/30/24 and discontinuation date of 12/31/24, for Oxycarbazepine 300 milligrams (mg), give three tablets by mouth two times a day for seizures. A PO, with a start date of 12/31/24, for Oxycarbazepine 300 mg, give three tablets by mouth two times a day for seizures. A review of the Progress Notes (PN) for May 2024, October 2024 and December 2024 included the following: On 5/21/24 at 11:59 PM, the resident was admitted to the hospital with a diagnosis of multiple seizures. On 10/29/24 at 9:45 PM, the resident was admitted to the hospital with a diagnosis of lactic acidosis (a condition where the blood becomes too acidic) and break through seizures. On 12/29/24 at 9:03 PM, the resident was admitted to the hospital with a diagnosis of seizures. A review of the resident's ICCP did not include the resident's diagnosis of seizures or that the resident was taking anticonvulsant medications. On 5/28/25 at 10:27 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated that the care plan should be developed within 24 to 48 hours of admission and updated as needed. He stated that the care plan included the needs and goals of the residents. LPN #2 stated that if a resident had a diagnosis of seizures and was on antiseizure medications it should be on the care plan. On 5/28/25 at 10:35 AM, the surveyor interviewed LPN #3 who stated the nurses, the Unit Managers, and other departments were responsible for creating and updating the care plan. She stated the care plan included the resident's needs and interventions. LPN #3 stated if a resident had a history of seizure that would be on the care plan because they had to ensure they were able to monitor that resident. On 5/28/25 at 10:38 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated the care plan was the road map for the medical professionals on how to care for the resident. She stated that the care plan should be initiated upon admission within 24 to 48 hours and include the medical history. When asked if Resident #127 had a history of seizures, LPN/UM #2 stated she was unsure. At that time, LPN/UM #2 reviewed the electronic medical record (EMR) and confirmed the resident had a diagnosis of seizures. She then reviewed the care plan and confirmed she did not see a care plan for seizures or anticonvulsant. LPN/UM #2 stated that she would expect the diagnosis of seizures and the medications to be on the care plan, so staff could follow seizures protocols. On 5/28/25 at 11:05 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated a care plan included medical diagnosis and interventions. The ADON stated that if a resident had a history of seizures that should be reflected in the care plan. The ADON explained the seizure interventions and safety inventions should be included on the care plan. On 5/28/25 at 11:33 AM, the Director of Nursing (DON) in the presence of the survey team stated the care plan was detailed according to the resident's needs. The DON stated that a resident's medical diagnosis and medications should be on the care plan. She stated that the care plan should be initiated on admission, and they capture as much as possible. The DON stated she would expect a seizure diagnosis, the medications, and/or both on the care plan. She stated that a care plan was important so staff could review and get a snapshot of the resident's needs and interventions. The DON stated from December 2024 to now (May 2025) she would have expected the seizure diagnosis to be on the care plan and acknowledged it should have been on the care plan. On 5/30/25 at 9:37 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, confirmed Resident #127 did not have a care plan for his/her seizure diagnosis or for the anticonvulsant medication. A review of the undated facility's Seizure Precautions policy included: 1. The facility will review the resident's medical history, resident or resident representative reports of prior history of or diagnosis of a seizure disorder, or conditions that could precipitate seizure activity. 2. The facility will review the resident's medications history to ascertain if anticonvulsant medications is being administered for seizure control. A review of the facility's Care Planning - Interdisciplinary Team policy updated 2024, included, The interdisciplinary team is responsible for the development of resident care plans. 1. The resident care plans are developed according to the timeframes and criteria established by 483.21. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). NJAC 8:39-27.1(a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 5/27/25 at 12:49 PM, the surveyor reviewed the personnel files for five CNAs. 1.) CNA #1, with a date of hire of 3/29/22, had their most recent Employee Evaluation completed on 1/30/24. 2.) CNA #2, with a date of hire of 4/28/10, had their most recent Employee Evaluation completed on 2/7/24. 3.) CNA #3, with a date of hire of 4/3/20, had their most recent Employee Evaluation completed on 3/6/24. 4.) CNA #4, with a date of hire of 3/29/17, had their most recent Employee Evaluation completed on 2/9/24. 5.) CNA #5, with a date of hire of 3/20/23, had their most recent Employee Evaluation completed on 3/18/24. On 5/28/25 at 8:59 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Assistant Director of Nursing (ADON) was responsible for completing the CNA annual performance evaluations, CNA education, and CNA competencies. On 5/28/25 at 9:04 AM, the surveyor interviewed the ADON who stated the previous DON used to do the performance evaluations up until she was terminated one month prior. The ADON stated that she had assumed the responsibility when the prior DON left and she was still trying to catch up. The ADON confirmed that the annual CNA Employee Performance Evaluations were not completed on an annual basis as required. On 5/28/25 at 11:53 AM, the surveyor interviewed the DON who stated that the importance of completing the Employee Performance Evaluations were to give credit where credit was due, to determine the need for improvement, and to provide education in real time if there were an issue. On 5/29/25 at 12:24 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the concern regarding the facility's failure to complete the annual CNA Employee Performance Evaluations. A review of the facility's Performance Evaluations policy, updated January 2025, included: Performance evaluations will be completed on all employees at least annually. Performance evaluations will be completed by the employee's department director and supervisor and reviewed by the administrator and/or his/her designee. The completed performance evaluations will be placed in the employee's personnel file. NJAC 8:39-43.17 (b)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 2 of 5 refrigerators designated for resident food, and was evidenced by the following: 1.) On 5/22/25 at 10:19 AM, during the initial tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD), observed a black bin containing four pitchers of juice for the residents. The bin had a whitish residue throughout its interior and exterior and the cart that the bin was resting on was stained. At that time, the FSD confirmed the findings as she took a paper towel and wiped the base of the bin. The whitish residue transferred onto the paper towel when wiped. The FSD then stated that the bin and cart should be cleaned after each meal. On 5/28/25 at 11:34 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the kitchen equipment should be maintained in a clean and sanitary manner. 2.) On 5/28/2025 at 9:48 AM, the surveyor, accompanied by Licensed Practical Nurse/ Unit Manager (LPN/UM) #4, observed the following in the Nourishment Room refrigerator on the Subacute Unit. The following items were not labeled and dated: A bottle of Relish A single container of yogurt A bottle of steak sauce Three bottles of dressing Three bottles of opened beverages One unopened bottle of water At that time, LPN/UM #4 discarded the items and stated that she was unaware who the items belonged to. She further stated that when a resident brought in food items, it should be labeled with the resident's name and dated. 3.) On 5/28/2025 at 10:01 AM, the surveyor, accompanied by LPN/UM #3, observed the following in the Nourishment Room refrigerator on the C-Unit: A clear plastic container containing fried chicken, labeled and dated. A clear container with sliced pineapples, labeled and dated. A clear container with unidentifiable food, labeled and dated. A box of shrimp scampi, labeled and dated. At that time, the surveyor interviewed LPN/UM #3, who stated that the above food items belonged to the staff. The surveyor further observed the following in the same refrigerator, unlabeled and not dated: A multi-pack of sliced cheese. A bottle of syrup A bottle of steak sauce A bottle of taco sauce A bottle of mayonnaise A bottle of mustard At that time, the surveyor interviewed the LPN/UM #3, who stated that the items were brought in by the staff and was available for all the residents on the unit. On 5/28/205 at 11:34 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the staff food should be separated from the residents' food. He further stated that all food items should be labeled with the resident's name or room number and dated. On 5/28/2025 at 12:14 PM, the surveyor interviewed the Director of Nursing (DON) who stated that staff's food should be stored in a separate refrigerator and not among the resident's food. She further stated that all food items should be labeled with the resident's name so that it is not given to the wrong person and dated to ensure that spoiled food is not given to the residents. A review of the facility's Dietary Department Cleaning Policy, updated July 2024, revealed: The Dietary Department is committed to maintaining a clean, safe, and sanitary environment for residents, staff, and visitors. Clean and sanitize all food preparation surfaces and equipment after each use. A review of the facility's Unit Refrigerators policy, undated, included, This facility does provide a unit base refrigerator for resident use and nourishment. The policy of this facility is also to ensure safe and sanitary use of any unit base refrigerator. Leftovers shall be dated upon receipt and discarded within three days. NJAC 18:39-17.2(g)

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to implement their Antibiotic Stewardship Program by not utilizing a standardized infection surveillance criteria to determine if antibiotic use was appropriate. This deficient practice was identified for 5 of 5 residents (Resident #34, #77, #107, #109, and #382) reviewed for antibiotic use and was evidenced by the following: 1.) Review of the Infection Control Log for January 2025 revealed Resident #34 had a urinary tract infection (UTI) with an onset date of 12/30/24. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 12/30/24. There was no evidence that a standardized infection surveillance criteria was used when the antibiotic was prescribed. 2.) Review of the Infection Control Log for February 2025 revealed Resident #382 had a UTI with an onset date of 2/21/25. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 2/21/25. There was no evidence that a standardized infection surveillance criteria was used when the antibiotic was prescribed. 3.) Review of the Infection Control Log for March 2025 revealed Resident #109 had a UTI with an onset date of 3/19/25. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 3/19/25. There was no evidence that a standardized infection surveillance criteria was used when the antibiotic was prescribed. 4.) Review of the Infection Control Log for April 2025 revealed Resident #77 had an infection in his/her chest. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for pneumonia on 4/13/25. There was no evidence that a standardized infection surveillance criteria was used when the antibiotic was prescribed. 5.) Review of the Infection Control Log for May 2025 revealed Resident #107 had an infection in his/her urine. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 5/9/25. There was no evidence that a standardized surveillance infection criteria was used when the antibiotic was prescribed. On 5/28/25 at 10:34 AM, the surveyor interviewed the Infection Preventionist (IP) who stated the facility was not utilizing any standardized infection surveillance criteria for antibiotic use. The IP explained that the facility only used the Antibiotic Start Tracking Form and documented the resident's symptoms in the electronic medical record. The IP then stated that the facility started using the McGeer Criteria for infection surveillance three days prior to the survey team entering the facility. The IP added that it was important to use a standardized infection surveillance criteria to prevent the overuse of antibiotics which could create antibiotic resistance. On 5/28/25 at 11:28 AM, the surveyor interviewed the Director of Nursing (DON) who stated the IP was responsible for the Antibiotic Stewardship Program. The DON explained that the IP used an Antibiotic Start Tracking Form when antibiotics were started, but that it was not a standardized infection surveillance criteria form. The DON further stated that the IP should use a standardized infection surveillance criteria, such as the McGeer Criteria, to prevent antibiotic resistance. Review of the facility's Antibiotic Stewardship Program policy, undated, included the following: 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . iii. The facility uses the CDC's [Centers for Disease Control and Prevention] NHSN [National Healthcare Safety Network] Surveillance Definitions, updated McGeer criteria, to define infections. NJAC 8:39-19.4(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ 176168 Based on observations and interviews during a complaint survey on 5/06/25, it was determined that the facility failed to maintain a clean and homelike environment for 1 of 13 rooms on a nursing unit (C Unit). The deficient practice was evidenced by the following: At 10:08 AM, Unit Manager/Licensed Practical Nurse (UM/LPN) toured unit with Surveyor and observed dry brown substance on the grab bars by the toilet, a large amount of the same dry brown substance on the back of the toilet, on the wall behind the toilet, and on the bathroom floor by the toilet in room [ROOM NUMBER]. At 10:17 A.M., during the observation in the bathroom of room [ROOM NUMBER], the Director of Housekeeping (DH) entered. The Surveyor showed the brown substance that was noted above to the DH. The DH stated that he was unsure if the housekeeper had cleaned the bathrooms and would inform them to clean the bathroom. At 12:45 P.M., accompanied by the UM/LPN, the Surveyor returned to room [ROOM NUMBER], and observed the dry brown substance on the back the toilet and on the grab bars by the toilet. DH was called to the room by UM/LPN, the DH stated the bathroom was cleaned by the housekeeper. The Surveyor showed the DH the brown substance was still on the back of the toilet and the grab bars. The DH further stated he would have the housekeeper go back to the room and scrub the brown substance off the back of the toilet and grab bars. On 5/06/2025 at 12:47 P.M., DH stated it was important to keep living areas sanitary to prevent the spread of infection. The DH further stated that room [ROOM NUMBER] was a difficult bathroom to clean due to the resident getting feces all over each time the resident used the bathroom. Review of the undated facility policy titled Routine Cleaning and Disinfection revealed under Policy, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Under Policy Explanation and Compliance Guidelines, .4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch area to include, but not limited to: .g. Toilet seats. NJAC 8:39-4.1(a) (11); 27.1 (a)

Based on observations, interviews, and review of facility policy the facility failed to maintain a clean and safe environment on three of three resident care wings. Observations revealed residents' furniture in disrepair and loose commode seats in resident's bathrooms. Findings include: Observations during the facility's initial tour on 4/17/23 at 10:40 AM revealed the following: A1. A Wing *R59's overbed table with puncture marks on top of the table exposing wood splinters. The plastics edges of the table peeling away from the wood exposing wood splinters; also has beige colored dried splatter on the legs of the table. Second overbed table with exposed wood edges. *R117's bathroom with trash debris on floor; loose commode seat. Clothing on the floor. *Blue padded Geri chair on the A wing with uneven leg rests and dried red spillage. 2. B Wing *Resident (R)125's room had trash debris on floor (i.e., medication cup and bits of paper); night stand bottom cabinet drawer coming apart. *R56's room's nightstand door is off track and does not close completely. The closet door is coming off the hinges. The bathroom in this room had a loose commode seat. Both residents in this room utilized the commode. 3. C Wing *Chair at nurses' station with the arm of the chair covered with an abdominal pad and then wrapped with an ace wrap. The arm of the chair was missing the covering and metal frame exposed with sharp edges. *The nurses station cracked sharp edges around the top of the nurses' station. The wall of the nurses' station had several areas with missing tiles or brocade; these areas were covered with duct tape. During a secondary environmental observation conducted on 04/20/23 at 12:45 PM with the Maintenance Director revealed the following: B1. A Wing *R67's overbed table with puncture marks on top of the table exposing wood splinters. The plastics edges of the table peeling away from the wood exposing wood splinters. Second overbed table with exposed wood edges. *R97's bathroom with trash debris on floor; loose commode seat *Day Room desk drawer missing a handle. Desktop with peeling edges exposing wood splintered edges. 2. B Wing *R125's night stands bottom cabinet drawer coming apart exposing sharp edges. *R56's nightstand door is off track and does not close completely. The closet door is coming off the hinges. The bathroom in this room has a loose commode seat. *R123's clothing closet door coming off the hinges. 3. C Wing *The nurses station cracked sharp edges around the top of the nurses' station. The wall of the nurses' station had several areas with missing tiles or brocade; these areas were covered with duct tape. An interview with the Maintenance Director (MD) during the environmental tour on 04/20/23 at 12:45 PM revealed the staff are expected to record any maintenance problems in the designated maintenance notebook kept at the nurses 'station. The MD stated he reviewed the maintenance repair log this morning and there were none of the concerns that were identified during this tour. The MD acknowledged there was an issue with some of the residents' furniture. Damage to the overbed tables is caused by water spillage that is left to sit. Some of the overbed tables will need to be replaced. The MD acknowledged that he does not have a maintenance or environmental schedule to ensure the equipment is operational and the environment is safe for residents. C1. During observations conducted by a second surveyor, on 04/17/23 at 10:38 AM, 04/18/23 at 9:20 AM, and 04/19/23 at 9:17 AM, R10's walls were observed to having scuffing, peeling, and chipping of paint and plaster near the head of the bed, corner of the wall near the foot of the bed, and near the closet area. R10 stated her walls had been in disrepair for more than four years. During an observation and concurrent interview on 04/19/23 at 9:20 AM, the Assistant Director of Nursing (ADON) confirmed R10's walls were in disrepair. The ADON stated, the walls were reported to the Director of Maintenance (DM) at least a month ago. The ADON was unable to state who reported the disrepair of the walls to the DM. During an observation and concurrent interview on 04/19/23 at 9:54 AM, the DM confirmed the disrepair of R10's walls. The DM stated, the staff put maintenance requests in the logbook and the logbook is checked daily. The DM stated the issue with R10's walls had not been reported by the staff. The DM stated the disrepair of the walls may have been noted by the other maintenance staff during rounding. The DM stated he would check the rounding logs. During a follow-up interview on 04/19/23 at 10:05 AM, the DM stated the issue with R10's wall had been noted on a rounding audit on 03/29/23. The DM stated, We have not gotten to it as of yet. We just hired a new guy. I don't know how long it has been like that, but the walls were painted before that resident moved into the room. Review of untitled maintenance logs, dated 03/29/23, provided by the DM from a file in his office, revealed, R10's room Needs paint and spackle behind bed. Review of the facility undated policy titled Preventative Maintenance Program revealed the policy documented A Preventative Maintenance Program shall be developed to and implemented to ensure the provision of a safe, functional, sanitary and comfortable environment for residents, staff and the public. The policy also documented The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds, and equipment are maintained in a safe and operable manner. Review of undated facility policy titled, Preventative Maintenance Program, indicated, The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. NJAC 8:39-4.1(a) NJAC 8:39-31.2(e) NJAC 8:39-31.8(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that four of four residents (Resident (R) 48, R50, R83 and R124) reviewed for bed rail use had documented alternatives to the use of bed rails attempted prior to the use of the bed rails. This failure had the potential to increase the potential for accidental entrapment or injury when an alternate assistive device may have been effective. Findings include: 1. Review of R48's printed admission Record from the facility electronic medical record (EMR), Profile tab, showed an admission date of 01/30/23, readmission date of 03/16/23, with medical diagnoses that included encephalopathy, protein calorie malnutrition, chronic respiratory failure with hypoxia, paroxysmal atrial fibrillation, heart failure, ascites, bacteremia, and chronic obstructive pulmonary disease (COPD). During an interview with R48 on 04/18/23 at 12:36 PM, it was noted he had bilateral bed rails. When asked if the facility had advised him of the risks and benefits of the rails, or if he signed an informed consent, R48 stated not that he remembered. Review of R48's admission Minimum Data Set [MDS], located in the EMR under the MDS tab, assessment reference date (ARD) 02/05/23 showed a Brief Interview for Mental Status [BIMS] score of 12 out of a possible 15, or indicative of being cognitively intact. Observations of R48's bed on 04/18/23 at 3:02 PM, 4/19/23 at 10:30 AM and 12:48 PM showed the bilateral bed rails in place towards the head of the bed, in the up position. A review of the 01/30/23 and 03/16/23 Assist Bar/Side Rail from the EMR Evaluations tab showed R48 had been informed of the risks/benefits of rails and had consented. Both forms were completed on the date of admission/readmission and stated an alternative to bed rail attempted prior to the use of the rails was resident education on bed mobility, transfers. During a follow-up interview on 04/19/23 at 1:10 PM regarding if the facility had attempted any alternatives before the bed rails were put on the bed, R48 responded No, they were on the bed when I got to the room. They didn't try anything else. When queried if they discussed using something other than the rails, R48 stated, No ma'am, they didn't. In an interview on 04/20/23 at 3:05 PM regarding the Assist Bar/Side Rail form completed by her on 03/16/23 for R48, Unit Manager (UM) 1 stated, When they [resident] first comes in, if alert and oriented we go over the paper and ask them if they want them [rails] or not. If not alert and oriented, we go over the paper with the family and ask the family if they want them or not. When asked if she attempted or presented any alternatives to the bed rails to R48, UM1 responded No. In a follow-up interview at 3:22 PM, UM1 was asked if the bed rails were on the bed when the residents are admitted and responded Yes. 2. Review of R50's printed admission Record from the EMR Profile tab showed an admission date of 09/24/22, readmission on [DATE] with medical diagnoses that included acute kidney failure, cerebral infarct, transient cerebral ischemic attacks, asthma, anxiety disorder, heart failure, and a history of falling. Observation of R50's bed showed: 04/17/23 at 4:08 PM bilateral bed rails in upper position (by head of bed (HOB) 04/18/23 at 3:40 PM bilateral rails in upper position 04/19/23 at 12:15 PM bilateral rails in upper position 04/19/23 at 4:30 PM one rail was in the upper position, the other was lowered which was in the middle of the mattress (where one would sit up to get out of bed). 04/20/23 at 10:10 AM the bed has one rail in the upper position and one in the lower position in the middle of the mattress. Review of R50's admission MDS ARD 03/08/23 showed a BIMS score of five out of a possible 15, or indicative of severe cognitive impairment. Review of the 09/24/22 Assist Bar/Side Rail form, printed from the EMR Evaluations tab, completed on admission showed attempted alternatives as resident education on bed mobility, transfers. A review of R50's hard [paper] chart showed a Consent for Use of Side Rails form that was blank for the recommendations with a check mark by the I DO consent to the use of side rail(s) recommended above. I understand that I have the right to refuse the use of side rail(s) or can revoke this consent at any time. signed by R50's daughter but not dated. In an interview on 04/20/23 at 3:18 PM regarding the completion of the 09/24/22 Assist Bar/Side Rail form UM3 stated, If [resident] alert and oriented, we ask if they would like rails to enable turning; if not alert and oriented, we ask the family if they would like in place. We give them the risk/benefits and have them sign a consent. When asked if alternatives to rails were attempted, UM3 responded No because that is part of the admission packet. We offer the bed rails. When asked if bed rails were on the bed when the resident is admitted , UM3 stated, Yes, they are already on the bed. 3. Review of R83's printed admission Record from the EMR Profile tab showed an admission date of 02/15/23, readmission date of 03/23/23, with medical diagnoses that included osteomyelitis, chronic respiratory failure with hypoxia, lower limb amputation, protein calorie malnutrition, heart disease, end stage renal disease, pleural effusion, shortness of breath, and encephalopathy. Observation of R83 while in his bed on 04/17/23 at 1:23 PM showed him asleep in bed with bilateral upper quarter rails. On 04/18/23 at 11:05 AM, R83 was asleep in bed with upper quarter rails, in the up position. Review of R83's hard chart showed a Consent for Use of Side Rails that was totally blank with the exception of a check mark by I DO consent to the use of side rail(s) recommended above. I understand that I have the right to refuse the use of side rail(s) or can revoke this consent at any time. signed by the resident on 02/27/23. On 04/19/23 at 10:30 AM, R83 was asleep in bed with bilat upper quarter rails; same at 12:48 PM and at 1:10 PM. Review of the 02/27/23 and 03/26/23 Assist Bar/Side Rail forms printed from the EMR Evaluations tab showed attempted alternatives as resident education on bed mobility, transfers. During an attempted interview on 04/20/23 at 10:15 AM, R83 did not seem to understand questions about the bed rails as he would wiggle them and say, No it's not coming off. When asked if he used the rails, he again stated No and wiggled the rail again. In an interview on 04/20/23 at 3:32 PM, regarding the completion of the 03/26/23 Assist Bar/Side Rail form, Registered Nurse Supervisor (RNS)1 stated, When they [resident] come in we explain the uses, risks and benefits with the patient or family and ask them yes or no if they want them. When asked if any alternatives were attempted, RNS1 stated, We don't have anything else, so no. RNS1 confirmed the bed rails are on the bed when the resident is admitted . 4. Review of R124's printed admission Record from the EMR Profile tab, showed a facility admission date of 02/16/23, readmitted on [DATE], with medical diagnoses that included protein calorie malnutrition, chronic respiratory failure, left knee arthritis from bacteria, anxiety disorder, sleep apnea, pneumonia, and acute kidney failure. Review of R124's, 02/16/23 and 03/26/23 Assist Bar/Side Rail forms from the EMR Evaluations tab showed attempted alternatives as resident education on bed mobility, transfers, and the latter form also showed family education on bed mobility, transfers. A review of R124's admission MDS, ARD 03/29/23 showed a BIMS score of 12 out of a possible 15, indicative of being cognitively intact. During a brief interview on 04/17/23 at 2:30 PM, R124 was noted to have bilateral side rails down in the middle position of the mattress (where one would sit to stand up out of bed). When asked if the rails kept the resident from getting out of bed due to the position, R124 stated she had bad knees and she had to learn to walk again and she couldn't get out of bed without assistance. Observation on 04/18/23 at 2:50 PM showed R124 in bed working with therapy, with bilateral side rails in the middle mattress position. Review of R124's hard chart showed a Side Rail Consent in chart for upper 1/4 partial rail and lower 1/4 partial rail signed for by her durable power of attorney for healthcare. In a follow-up interview on 04/19/23 at 12:15 PM showed R124 seating in a wheelchair, her bed has one rail in the upper (HOB) position, and one in the lowered (middle of mattress) position. When asked if R124 had had any alternatives to the bed rails attempted, she responded she had no clue what else would have worked, but no, no alternatives attempted, and the rails were on the bed when she arrived. Observation on 04/19/23 at 4:30 PM showed R124 asleep in bed with bilateral bed rails in the lowered (middle of mattress) position. An interview with the licensed nurse that completed the 03/26/23 Assist Bar/Side Rail form was unsuccessfully attempted. The 02/16/23 form was completed by UM1 who had stated she does not attempt any alternatives. During an interview on 04/19/23 at 4:14 PM regarding alternatives attempted prior to bed rail usage and her expectations, the Director of Nursing (DON) stated they provided a therapy screening. When clarified if any alternatives to bed rails were attempted, the DON stated, If using for enablers or mobility like in sub-acute, we don't; if using for fall risk we might try a perimeter mattress, bed alarm, or floor mats. It's patient specific though. The DON stated her expectation of what should be done prior to bed rail use, she responded, Therapy should evaluate for risk of entrapment as well as use of the side rail. Review of the undated facility policy titled Proper Use of Bed Rails showed It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side[sic] rails, safety rails, grab bars and assist bars. Policy Explanation and Compliance Guidelines: . 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs unless siderail is utilized to promote residents[sic] highest level of physical functioning and contribute the individuals [sic]psychosocial well-being by enhancing independence and mobility. NJAC 8:39-27.1(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to handle clean linen in sanitary manner to prevent contamination before transporting to the resident care units. The facility failed to store nebulizer masks in a sanitary manner for three residents(R)10, R335, and R86) of five respiratory residents sampled from a total 33 residents. Findings include: 1. Observation during a tour of the facility's laundry on 04/19/23 at 11:23 AM revealed housekeeper (HSK)12 preparing clean linen for transport to the resident care areas. HSK 12 was observed taking the clean bed sheet from the prep table, as he removed the clean sheet from the table the bottom edge of the sheet dragged on the floor. The staff member then started to fold the bed sheet while holding the sheet against his body. Once the sheet was folded, he placed the sheet on the prep table. HSK 12 repeated this manner of folding bed sheets seven times. The staff member folded bath towels and residents' gowns by holding the items against his body while folding. An interview with HSK12 on 04/19/23 at 11:30 revealed the staff had received training on how to fold laundry and transport to the resident care areas. The employee demonstrated folding the bed sheet. Again, the edge of the sheet touched the floor but this time the employee did not hold the sheet against his body. The employee was unaware of the concern. Continued tour of the laundry department on 04/19/23 at 11:40 AM revealed a heavy stained sink where employees performed handwashing. The sink had brown and beige stains; some stains had a hard gummy consistency. The wall behind the sink had brown splatter stains. The soap dispenser had beige color splatter marks. The floor of the laundry room had several tiles with missing pieces. The floor had a black residue built-up especially around the areas with missing or cracked tiles. Also, the laundry room had an open window with a screen that had a large amount of white lint collected. During an interview with the housekeeping director (HSKD) on 04/19/23 at 12:10 PM the observation of the HSK12 handling the clean linen was described. The HSKD stated the employee handled the clean linen incorrectly. By letting the edge of the sheet touch the floor it was contaminated; and when folding the laundry, the items should not be held against the staff member's body, and again stated this was another form of contamination. The HSKD stated this was not the way the employees have been trained to handle clean linen. The HSKD also stated the sink in the laundry room had been a great concern for him. He and the Maintenance Director had tried several chemicals to remove the stains and had been unsuccessful. The HSKD stated a new sink would be necessary. The HSKD acknowledged there were several cracked and missing tiles in the laundry room floor. He stated not only was it an infection control issue but also a safety issue. Review of the facility's undated policy titled Handling Clean Linen revealed it was the facility's policy It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. 1. Review of R10's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R10 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of R10's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/08/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R10 was moderately cognitively impaired. Review of R10's Order Summary Report, located in the EMR under the Orders tab, revealed the following order dated 12/12/22: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] (Ipratropium-Albuterol) 1 vial inhale orally every 8 hours for COPD. This order was discontinued on 01/09/23. During observations on 04/17/23 at 10:38 AM, 04/18/23 at 9:20 AM, and 04/19/23 at 9:17 AM, R10's nebulizer mask was observed on her bedside table, uncovered/unbagged. 2. Review of R335's admission Record, located under the Profile tab of the EMR, revealed R335 was admitted on [DATE] with a diagnosis of COPD. Review of R335's admission MDS, located in the EMR under the MDS tab with an ARD of 04/04/23, revealed the resident had a BIMS score of 12 out of 15, indicating R335 was moderately cognitively impaired. Review of R335's Order Summary Report, located in the EMR under the Orders tab, revealed the following order dated 03/29/23: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 12 hours for copd. During observations on 04/17/23 at 10:51 AM, 04/18/23 at 9:40 AM, and 04/19/23 at 9:25 AM, R335's nebulizer mask was observed on his bedside table, uncovered/unbagged. 3. Review of R86's admission Record, located under the Profile tab of the EMR, revealed R86 was admitted on [DATE] with diagnoses of COPD, sarcoidosis (inflammatory disease in which the immune system overreacts), and chronic respiratory failure with hypoxia Review of R86's admission MDS, located in the EMR under the MDS tab with an ARD of 03/09/23, revealed the resident had a BIMS score of 0 out of 15, indicating R86 was severely cognitively impaired. Review of R86's Order Summary Report, located in the EMR under the Orders tab, revealed the following order dated 04/06/23: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally four times a day for Sarcoidosis. During observations on 04/17/23 at 11:02 AM, 04/18/23 at 9:24 AM, and 04/19/23 at 9:20 AM, R86's nebulizer mask was observed on her bedside table, uncovered/unbagged. During an interview on 04/19/23 at 9:20 AM, the Assistant Director of Nursing (ADON) confirmed R10, R335, and R86's nebulizer masks were uncovered and unbagged on the residents' bedside table. The ADON stated, The nebulizer masks should be stored in bags. The process is to take off the tubing and store tubing and masks in bags. The nurses are responsible for the bagging of the masks. During an interview on 04/20/23 at 2:01 PM, the Administrator stated, If they [nebulizer masks] are supposed to be bagged and it is in our policy, that is what I expect. Review of an undated facility policy titled, Nebulizer Treatments, indicated, After treatment, nebulizer equipment will be placed in plastic bag at bedside. This policy further indicated, If the order is obtained from the physician to discontinue nebulizer usage, the nebulizer is to be returned to stock for carbonization. NJAC 8:39-19.4(k) NJAC 8:39-21.1(d)

Based on interview, document review, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect any of the current 136 residents that use a bed. Findings include: During the initial pool observations of the Sub-Acute and Suites halls, 20 residents were noted to have bed rails on their beds. On 04/19/23 at 4:15 PM a request for bed maintenance and inspection documentation was given to the Director of Nursing. On 04/20/23 at 7:45 AM, the maintenance's two, three-ring binders were on the table in the conference room upon arrival, the first contained the bed MIFUs. Review of the eight MIFUs of the bed types provided by the facility showed the Zenith 7000 and Liberty beds have items listed to be inspected every three and every six months; the Dynarex showed casters were to be inspected every six months; the Drive and the Patriot beds are to be inspected between placements of users; the Panacea showed a periodic inspection for compliance with the Warnings listed in the manual; the Invacare Carroll and American Spirit did not have any inspection recommendations Four Maintenance Bed Rail Entrapment Risk Assessments for the four residents reviewed for bed rails (see F700) were on the table outside of a binder and showed they were completed by the Director of Maintenance (DM) on 04/19/23. Review of the second three-ring binder showed Maintenance Bed Rail Entrapment Risk Assessment showed ALL beds were checked on 04/19/23. During an interview on 04/20/23 at 8:50 AM, the DM stated the four bed rail entrapment assessments for the four residents reviewed for bed rails (see F700) were done about, probably like 6:00 [clarified PM], yeah late, it wasn't early. The [name of Regional Nurse Consultant (RNC)] had asked me to go down and do the assessments and get the model numbers off of each of the beds. When asked how often do you check the beds for broken welds, frayed cords, loose bolts, etcetera, DM stated, We're [maintenance] regularly in and out of the rooms checking the beds but we don't have a regular audit for checking the beds. DM reviewed the Zenith MIFU and stated the recommendation was for Looks like 6 months and 3-month inspections. DM continued that the Maintenance department was advised when a new resident was being admitted and we check the bed, reprogram the remote, check the call light, the lights, all for the new resident, but we don't write it down. DM confirmed at that point in time, there were no records of bed inspections or maintenance. At 10:52 AM, DM provided a three-ring binder that showed the same bed rail inspection forms were complete before, in 2017. Review of the undated facility policy titled Bed Maintenance and Inspection showed .It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program. Policy Explanation and Compliance Guidelines: 1. A list of bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each. The Maintenance Director shall be notified of any new equipment brought into the facility. 2. The Maintenance Director shall review each manufacturer's recommendations and requirements for bed maintenance and bed inspections, and shall establish maintenance and inspection accordingly. 5. Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly [sic] inspection. NJAC 8:39-31.4(c)

Based on observation, interview, and record review, it was determined that the facility failed to follow an active physician's order to apply bilateral heel protectors (a cushioned pressure-relieving device for heels) (heel bows) while in bed. This deficient practice was identified for Resident #4, 1 of 3 residents reviewed for pressure ulcers, and was evidenced by the following: During the initial tour of the Sub-Acute Rehabilitation Unit on 03/11/21 at 10:26 AM, the surveyor observed Resident #4 lying supine in the bed with the head of bed (HOB) slightly elevated. The surveyor observed that Resident #4 had no heel bows or offloading of the bilateral lower extremities. The surveyor further observed that the resident's feet were lying directly on the mattress. When interviewed at that time, Resident #4 was unable to provide answers about the heel bow application. A review of the resident's Electronic Medical Record (EMR) revealed that Resident #4 was re-admitted to the facility with diagnoses which included but were not limited to cerebral infarction (stroke), hemiplegia affecting left non-dominant side (muscle weakness or partial paralysis on the left side of the body due to stroke), muscle weakness and dementia. A review of the resident's most recent annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/20/21, reflected that Resident #4 was severely cognitively impaired and required extensive assist with Activities of Daily Living (ADLs). The MDS further revealed that the resident had impairment to one side of the body and was at risk for developing pressure ulcers. The surveyor reviewed the 03/2021 Physician Order Sheet (POS), which reflected a physician's order dated 10/29/20 for heel bows to bilateral feet while in bed. The surveyor further reviewed the 03/2021 Treatment Administration Record (TAR), which revealed the corresponding physician's order for heel bows to bilateral feet while in bed. The surveyor also observed a handwritten FYI (For Your Information) documented in the hour section of the physician order. A review of Resident #4's Interdisciplinary Care Plan (CP), with the last care plan review, completed 03/15/21, revealed that the facility Interdisciplinary Team identified a Focus of potential for pressure ulcer/injury development related to his/her immobility from status post CVA (cerebral vascular accident) (stroke) with left hemiparesis and incontinence. Interventions included but were not limited to heel bows while in bed and left heel protectors in bed. On 03/16/21 at 11:11 AM, the surveyor observed Resident #4 resting in bed with the HOB slightly elevated. The surveyor observed that Resident #4 had no heel bows or offloading to the bilateral lower extremities. The surveyor observed that the resident's feet were lying directly on the mattress. The surveyor made the same observation on 03/17/21 at 9:46 AM. During an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) on 03/18/21 at 10:28 AM, the LPN/UM stated that Resident #4 was a long-term resident and required total assist with ADLs. The LPN/UM further noted that the resident had a history of wounds and that the wounds were resolved. On 03/18/21 at 10:34 AM, the surveyor observed Resident #4 resting in bed with the HOB slightly elevated. The surveyor observed that Resident #4 had no heel bows or offloading to the bilateral lower extremities. The surveyor observed that the resident's feet were lying directly on the mattress. During a follow-up interview with the LPN/UM on 03/18/21 at 10:44 AM, the surveyor inquired about Resident #4's heel bows. The LPN/UM stated that the resident should have had heel bows to bilateral feet when in bed. At which time, the surveyor and the LPN/UM donned on the required Personal Protective Equipment and entered the resident's room. Upon entering the resident's room, the LPN/UM stated that she could see that Resident #4's extremities did not have the heel bows applied to bilateral heels. When interviewed, the LPN/UM said that Resident #4 should have had heel bows applied to bilateral heels when in bed and that the nurse was responsible for making sure they were applied as ordered. The surveyor observed LPN/UM search Resident #4's room for his/her heel bows. The LPN/UM was unable to locate Resident #4's heels bows. During an interview with the surveyor on 03/19/21 at 1:18 PM, the Director of Nursing (DON) stated that she expected the resident's heel bows to be applied as ordered. The surveyor reviewed the facility's Assistive Devices and Equipment policy, with the updated date of October 2020 provided by the DON. The policy revealed that the facility would provide, maintain, and supervise the use of assistive devices and equipment for residents. NJAC 8:39-27.1(a)