Based on observation and interview, it was determined that the facility failed to maintain the prior year's State of New Jersey (State) inspection results and post the location of those results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 10/16/24 at 11:00 AM with 6 alert and oriented residents chosen by the facility. Six of 6 residents stated they did not know where to find the State inspection results. The surveyor looked for the most recent State inspection results (8/10/23) on each of the 3 nursing units (LP, SP, HP) on 10/17/24 at 9:00 AM. The LP Nursing Station had a plastic binder holder affixed to the front wall of the station. The binder contained 2017 and 2018 State inspection results. The HP Nursing Station had no visible binder available at the station. The surveyor asked the nurse supervisor for the binder. The nurse looked for the binder and was unable to locate it. A few minutes later she located the binder in a closed closet behind the nursing station. The binder contained 2019 inspection results. The surveyor returned the binder to the nurse. She placed the book back into the closed closet behind the nursing station. The surveyor showed the binders to the Director of Nursing (DON) on 10/17/24 at 9:15 AM while in the HP day room. The DON confirmed the most recent inspection results of 8/10/23 were not posted in the books. She stated she would update the binders. The DON returned to the surveyor on 10/17/24 at 9:30 AM. She stated the Administrator found current inspection reports on the nursing units in a pile of other binders on the counter of the nursing stations. The surveyor did not observe binders with current inspection results in an area that would be accessible to residents, families, or the public. NJAC 8:39-9.4(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure staff follow the physician's order for the use of side rails for 1 of 21 residents, (Resident #56) and b.) ensure staff follow the physician's order according to the facility's policies and standards of clinical practice for 1 of 3 nurses, Licensed Practical Nurse (LPN)), for 1 of 9 Residents (Resident #252) observed during medication administration. 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. 1.On 10/10/24 at 10:45 AM, the surveyor observed Resident #56 in bed with his/her eyes open with two full padded side rails in use. The resident did not respond to the surveyor and the surveyor was unable to interview the resident. On 10/18/24 at 10:35 AM, the surveyor observed Resident #56 in bed with their eyes closed. The surveyor observed two full padded side rails in use. The surveyor reviewed Resident #56's admission Record which reflected that the resident was admitted to the facility with the diagnoses which included but were not limited to dementia and depression. The surveyor reviewed the Minimum Data Set (MDS), an assessment tool dated 5/26/24 which assessed Resident #56 had a brief interview for mental status score of 2 out of 15 which indicated a severe cognitive impairment. Further review of the MDS revealed Resident #56 was dependent on staff for activities of daily living (ADLs) and transfers from the bed to the chair. A review of Resident #56's care plan (CP) reflected a focus area for ADL function and mobility effective date 5/28/24 that included an intervention that the resident will be provided one side rail up in bed for positioning. A review of the current physician's orders (PO) reflected a PO for 1 side rail up when in bed for positioning. The CP had an original order date of 1/17/20 and a renewal date of 10/8/24. A review of the Side Rail assessment dated [DATE] indicated .Side rails are indicated and serve as an enabler to promote independence in bed mobility .side rails are not considered a restraint device .provide one side rail up in bed for positioning . A review of Resident #56's Side Rail assessment dated [DATE] indicated .Side rails are indicated and serve as an enabler to promote independence in bed mobility .side rails are not considered a restraint device .provide one side rail up in bed for positioning . A review of Resident #56's Consent form for the use of 1 side rail was signed by the resident's daughter and facility social worker and dated 12/1/21. On 10/17/24 at 11:42 AM, the surveyor interviewed the Director of Building Services who stated that the facility ordered the side rails from the original manufacturer of the bed frame. He further stated that he ordered standard size siderails. On 10/18/24 at 10:36 AM, the Director of Nursing (DON) accompanied the surveyor to resident #56's room and the DON and surveyor together observed Resident #56 was in bed with 2 full padded side rails up. The DON confirmed that the PO was for 1 side rail, a Side Rail Assessment should have been completed quarterly and a PO should have been obtained prior to the use of 2 side rails. A review of the facility policy entitled, Physician Orders dated/revised 7/10/24 reflected .A licensed professional nurse will carry out and follow orders written by the physician. 2.) On 10/16/24 at 9:47 AM, the surveyor observed the LPN prepare medications for Resident #252 that included a physician order (PO) for losartan 25 milligram (mg) tablet, give 1 tablet by oral route once daily at 9:00 AM, for hypertension with Parameters to hold for systolic blood pressure (SBP) less than 110 and a PO for metoprolol succinate ER 25mg give 1 tablet by oral route once daily, give with meals every day at 9:00 AM, with parameters to hold for SBP less than 100 and to hold for pulse less than 56 beats per minute. The LPN stated that he had already taken Resident #252's vital signs earlier that morning. The surveyor asked the LPN what time he had taken them. The LPN replied, about an hour ago, and proceeded to administer the two blood pressure medications. On 10/16/24 at 1:06 PM, the surveyor interviewed the LPN in the presence of another surveyor who acknowledged that he should have taken Resident #252's vital signs within 15 minutes of administering the blood pressure medications per facility policy. On 10/16/24 at 1:34 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. The DON stated that the LPN should have retaken the vital signs prior to administering the medications. A review of the facility policy, Administration of Medications Procedure dated/revised 4/24, included .vital signs should be taken no more than 15 minutes prior to removal of medications from the unit dose package or bottle .after taking the vital signs necessary, the medications may be removed .offer a full glass of water or juice with the medication and ensure the resident has swallowed the medications. No further information was provided by the facility. NJAC 8:39-27.1(a), 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficient practice was identified for 1 of 1 resident (Resident #22,) reviewed for ADL care and was evidenced by the following: On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 in bed with the Certified Nursing Assistant (CNA) assigned to their care in their room. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. Resident #22 stated that he/she would like to go to the salon to have their nails cleaned and manicured. The CNA told the resident she would see if the resident was on the list to go to the salon. On 10/16/24 at 12:00 PM, the surveyor observed Resident #22 in the HP front dining room seated in a wheel chair. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. On 10/17/24 at 9:53 AM, the surveyor observed Resident #22 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. On 10/17/24 at 10:15AM, the surveyor, in the presence of another surveyor, interviewed the CNA. The CNA stated that CNAs were only responsible for cleaning the residents nails, but the activity staff were responsible for clipping and filing their nails. The surveyor showed the CNA Resident #22's nails. The CNA acknowledged that they were long, jagged and soiled with a brown substance underneath. The surveyor asked the CNA why she hadn't cleaned Resident #22's fingernails. The CNA did not respond to the surveyor's question. On 10/17/24 at 10:22 AM, the surveyor, in the presence of another surveyor, interviewed the Licensed Practical Nurse (LPN) assigned to Resident #22's care. The LPN stated that the CNAs were responsible for cleaning, clipping and filing resident's nails. A review of the admission Record revealed Resident #22 had been admitted with diagnoses which included but were not limited to; dementia, end-stage heart failure, and chronic respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues.) A review of the most recent Annual Minimum Data Set (MDS) an assessment tool, dated 3/22/24, included but was not limited to; a brief interview of mental status (BIMS) score of 0 of 15 which indicated the resident had a severe cognitive impairment. Section GG documented that Resident #22 required moderate assistance with personal hygiene. A review of the Care Plan documented a focus area date effective 3/25/24, the resident required assistance with ADL care and mobility. Interventions included but were not limited to . encourage resident to participate in ADL care. On 10/17/24 at 3:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. On 10/18/24 at 8:44 AM, the DON provided the surveyor with a copy of the Salon List dated 10/10/24. A review of the list reflected that Resident #22 would go to the Salon, as requested. It further document that their last visit was 9/12/24. A review of the facility provided, Certified Nurse Aide Job Description undated, included but was not limited to; Assists resident with or performs Activities of Daily Living (ADL). A review of the facility provided, ADL policy & procedure revised 8/24, included but was not limited to; Purpose . to ensure that the residents are receiving the assistance they need from staff according to their personal preference. A review of the facility provided Resident care and infection control undated, included .nails should be cleaned and trimmed/filed when needed, this is part of day-to- day standard of care. Activities may apply polish only . NJAC 8:39-27.1(a), 27.2(g)

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's order and failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory therapy, Resident #22. 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. On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 lying in bed with Oxygen (O2) delivered via a nasal cannula (NC) tubing attaached to the O2 concentrator at 2 liters per minute (LPM)). The surveyor observed that there was an additional NC tubing dated 10/4/24 attached to a portable O2 tank that was on the back of Resident #22's wheelchair. The NC tubing was hung over the portable tank and it was not contained in a bag. On 10/17/24 at 9:53 AM, the surveyor observed Resident #22 lying in bed with O2 delivered at 2.5L via a NC tubing attached to the O2 concentrator. The surveyor observed that additional NC tubing dated 10/12/24, was attached to a portable O2 tank on the back of the wheelchair. The NC tubing was hung over the portable tank and it was not contained in a bag. A review of Resident #22's admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, end-stage heart failure, and chronic respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues.) A review of Resident #22's most recent Annual Minimum Data Set (MDS), an assessment tool, dated 3/22/24 included; a Brief Interview for Mental Status (BIMS) score of 0 of 15 which indicated the resident had a severe cognitive impairment. Section GG documented that Resident #22 required moderate assistance with personal hygiene and Section O documented that the resident was receiving respiratory treatment which included O2 therapy. A review of the Care Plan documented a focus area effective 3/25/24 which included: Resident has a Respiratory Disorder: dyspnea (shortness of breath) related to end-stage congestive heart failure (CHF). Interventions included but were not limited to: Oxygen therapy as per physician order and to provide treatments per physician order. A review of the October 2024 Physician's Orders revealed an active physician order (PO) with an order date of 2/13/22 and renewed of 10/8/24 for: O2 at 2LPM (liters per minute) per NC every shift. On 10/17/24 at 10:15 AM, the surveyor, in the presence of another surveyor, interviewed the CNA who stated that the night shift was responsible for ensuring that the NC tubing was stored properly in a plastic bag. The surveyor asked the CNA if she should have discarded the tubing and obtained a new one since they both observed the tubing was not stored properly in a bag. The CNA confirmed that she should have discarded the contaminated tubing and obtained a new clean tubing. On 10/17/24 at 10:22 AM, the surveyor, in the presence of another surveyor, interviewed the Licensed Practical Nurse (LPN) assigned to the care of Resident #22. The surveyor showed the LPN the O2; the LPN confirmed that the O2 was infusing at 2.5 LPM and that the PO was for 2LPM. The LPN acknowledged that during his morning rounds, he should have checked that the Oxygen was infusing per the physician order and should have checked to see that the NC tubing was stored properly in a bag. On 10/17/24 at 3:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON stated the facility policy was that the O2 tubing should be stored in a bag when not in use. A review of the facility provided,RN/LPN Job Description undated, included but was not limited to .the nurses will provide safe and effective nursing care in accordance with the nursing practices and policies of the facility, NJ DOH and CMS guidelines .practices infection control according to established facility and department policies . A review of the facility provided, Oxygen Therapy policy and procedure dated/revised 6/12/24, included the following: A licensed professional nurse will administer oxygen via cannula or mask as prescribed by physician .check the order in the resident's chart for amount of oxygen and frequency of administration .change oxygen tubing and bag weekly; keep tubing in bag when not in use . On 10/18/24 at 11:30 AM, the survey team met with the LNHA and DON. No additional information was provided by the facility. N.J.A.C. 8:39- 19.4(a); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) reconciliation and accountability of dispensed and administered controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) to Resident #19, and discrepancies were identified, for the narcotic stored in the medication cart located on the high side of the LP unit, and b.) reconciliation of Controlled Drug Inventory Record (CDIR; shift to shift log, a count/signature of two (2) nurses for narcotic accountability) were consistently signed/completed for the medication cart located on the B-side of the HP unit. The deficient practice was identified for one (1) of two (2) medication carts reviewed during the medication storage and labeling task and was evidence by the following: 1.) On 10/17/24 at 9:16 AM, the two (2) surveyors and the Registered Nurse (RN) began the inspection of the narcotic medication cart inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box) located on the high side of the LP unit. In the presence, of a surveyor, and the RN, the surveyor observed that the CDIR was not signed by two (2) nurses for that day. At that time, the RN stated that she did not sign the shift-to-shift log with the 11:00 PM, to 7:00 AM shift nurse that morning, because she had noticed that the 3:00 to 11:00 PM nurse had not signed Resident #19's Individual Patient Controlled Drug Record (IPDCR; declining inventory sheet used to track removal of a controlled drug from inventory) for Tramadol 50 mg (a narcotic medication, indicated for pain) that was administered on 10/16/24 [the night before]. At that time, the RN could not explain how the two (2) nurses from the 3:00 PM to 11:00 PM shift nurse and the 11:00 PM to 7:00 AM shift nurse who conducted the shift-to-shift count for accountability on 10/16/24, did not identify the discrepancy prior to her shift. The RN informed the surveyors that she had notified the Nursing Supervisor and would let the Director of Nursing know of the shift-to-shift count discrepancy. On 10/17/24 at 9:24 AM, in the presence of a surveyor and the RN, the surveyor observed Resident #19's bingo card (blister packet which contains the medication) with a pharmacy label for Tramadol 50mg contained 10 tablets. At that time, the surveyor compared the bingo card against the IPCDR for Resident #19's Tramadol. The IPCDR log reflected a documented quantity of 11 remaining. At that time, the RN informed both surveyors that the discrepancy was that the 3:00 PM to 11:00 PM nurse had not signed the removal of the Tramadol from inventory (IPCDR log) however the nurse had signed the Medication Administration Record for 10/16/24, an attestation of administration . The surveyor reviewed the medical record for Resident #19. According to the Resident Face Sheet (an admission summary) Resident #19 was admitted to the facility with diagnosis that included but was not limited to low back pain. Further review of the qMDS reflected Resident #19 received scheduled and as needed (PRN) pain medications. The resident reported moderate level of pain intensity. Review of the quarterly Minimum Data Set (qMDS), an assessment tool dated 8/20/24, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated that the resident was cognitively impaired. Review of the electronic Medication Administration Record (eMAR) for October 2024, included a physician order for Tramadol 50 milligram (mg) by oral route every 12 hours as needed (PRN) for pain. The physician order start date was 2/12/24. The surveyor compared the eMAR against the IPCDR which reflected that the Tramadol was not signed on the IPCDR as removed from the inventory but was signed administered on eMAR on 10/16/24. Review of the eMAR for September 2024, included a physician order for Tramadol 50 milligram (mg) by oral route every 12 hours as needed for pain. The physician order start date was 2/12/24. The surveyor compared the eMAR against the IPCDR which revealed the following: -on 9/13/24 at 2:00 PM, the IPCDR was signed as removed from inventory but was not signed on the eMAR as administered. -on 9/23/24 at 8:57 PM, the IPCDR was signed as removed from inventory but was not signed on the eMAR as administered. On 10/17/24 at 1:08 PM, during an interview with two (2) surveyors, Resident #19 stated she was not in pain and confirmed receiving Tramadol last night but could not recall the other dates. On 10/17/24 at 3:07 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON, the surveyor discussed the concern regarding the missing accountability, reconciliation and discrepancy of the IPCDR log against Resident #19's eMAR. On 10/18/24 at 9:13 AM, the DON stated that she had investigated the discrepancy between the IPCDR and the eMAR. The DON stated that there were two (2) different nurses involved who both stated that the PRN medication was in fact removed from inventory but was refused by the resident. Both nurses neglected to document the refusal, and the disposal of the narcotic medications. Both nurses were given education on medication administration and narcotic protocols. The DON acknowledged the concern. 2.) On 10/17/24 at 10:17 AM, the surveyor, in the presence of another surveyor and the RN/Nursing Supervisor (RN/NS) began the narcotic medication cart inspection, located in the B-side of the HP unit. At that time, the surveyor reviewed the shift-shift log for October 2024 which reflected the following: -10/7/24 at 7:00 AM, the nurse going on duty was blank (two (2) nurses' signature was not found). -10/7/24 at 3:00 PM, the nurses going on and off duty were blank. -10/7/24 at 11:00 PM, the nurse going off duty was blank. -10/9/24 at 7:00 AM, the nurse going on duty was blank. -10/10/24 at 7:00 AM, the nurse going on duty was blank. -10/10/24 at 3:00 PM, the nurse going off duty was blank. -10/12/24 at 11:00 PM, the nurse going off duty was blank. On 10/17/24 at 3:07 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON, the surveyor discussed the concern regarding the shift-to-shift reconciliation of controlled dangerous substance were not consistently signed/completed. On 10/17/24 at 10:50 AM, in the presence of the two (2) surveyors, the RN/SP confirmed the missing signatures on the CDIR, and acknowledged that the shift to shift log should have been signed by two (2) nurses. The RN/NS stated that he would ensure education be provided to the nursing staff and would inform the DON of the discrepancy. On 10/18/24 at 9:58 AM, the DON stated that she had investigated the concern for the missing shift to shift signature for reconciliation of the narcotic medications. The DON stated that two (2) nurses were involved and were given education regarding the importance of the shift-to-shift reconciliation. The DON acknowledged the errors. Review of the undated, facility provided policy, Nursing Medication Administration included the following: Narcotics must be counted shift- to-shift and discrepancies should be reported to the Supervisor/ DON when noted. Narcotics need to be signed off on declining sheet at the time they are taken out of the bingo card then signed on the eMAR after resident has taken the medication. If the resident declines Med once removed it, then needs to be cosigned as wasted and a note written in progress notes. NJAC 8:39- 27.1(a), 29.2 (a) (d), 29.4 (i)(k), 29.7(c)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring proper hand hygiene was performed prior to dining services and hand wipes were used and discarded appropriately . This deficient practice was identified on 1 of 3 nursing units (HP) and evidenced by the following: On 10/10/24 at 12:00 PM, the surveyor observed twenty residents seated in the HP front dining room preparing for their lunch meal. On 10/10/24 at 12:20 PM, the surveyor observed the Certified Nursing Assistant (CNA) assisted the residents with their hand hygiene. The surveyor observed the CNA cleaned a resident's hands with hand wipes, applied a clothing protector and without performing hand hygiene, cleaned another resident's hands with a hand wipe, applied a clothing protector and without performing hand hygiene reached back into the container of hand wipes, removed 4 wipes and handed them to four different residents. The four unsampled residents cleaned their hands and handed the soiled wipes back to the CNA. The CNA discarded the 4 wipes into the trash and without performing hand hygiene applied clothing protectors to the four residents. On 10/11/24 at 11:50 AM, the surveyor observed dining services in the HP front dining room. On 10/11/24 at 11:55 AM, the surveyor observed the activity coordinator (AC) donned a pair of gloves, used a hand wipe to clean a resident's hands then tied the plastic trash bag to the back of the resident's wheelchair and discarded the gloves and wipe into the bag. The AC, without sanitizing her hands, donned a new pair of gloves, cleansed a resident's hands, and discarded the wipe and gloves in the trash bag that was tied to the back of the resident's wheelchair. On 10/11/24 at 12:05 PM, the Activity Director (AD) entered the HP front dining room, and the surveyor observed the AD remove the plastic trash bag from the resident's wheelchair. At that same time, the surveyor asked the AD if the AC should have tied the trash bag to the back of a resident's wheelchair. The AD replied that she would not have done that, but everyone is different. The surveyor asked the AD if it was an Infection Control/dignity concern. The AD did not respond to the surveyor's inquiry. On 10/11/24 at 12:08 PM, the surveyor interviewed the AC who acknowledged that she should have sanitized her hands between residents and confirmed she should not have tied a trash bag to the back of a resident's wheelchair. On 10/11/24 at 12:54 PM, the surveyor interviewed the CNA who stated that her process during dining services was to put on gloves, use a hand wipe to clean a resident's hands, discard the wipe in the trash, remove and discard the gloves, and put on a new pair of gloves to clean another resident's hands. The surveyor asked the CNA if she was in serviced to perform hand hygiene between gloves changes. The CNA replied, no. The surveyor asked the CNA why she did not follow her regular process for cleaning resident's hands yesterday as the surveyor had observed the CNA had not used gloves, nor had she sanitized her hands between residents. The CNA replied she had not practiced appropriate hand hygiene because she was nervous. The CNA acknowledged that she should have performed hand hygiene between residents. On 10/16/24 at 1:22 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The LNHA stated that the AC had been educated on proper infection control practices. On 10/17/24 at 3:03 PM, the survey team met with the LNHA and DON who confirmed that the staff should sanitize their hands between residents. A review of the facility's policy entitled, Hand Hygiene reviewed 6/24 included .Hand hygiene is considered the most important procedure for preventing the spread of infection .hand hygiene must be performed after all resident care/contact .after removing gloves and any other personal protective equipment . NJAC 8:39 - 19.4(a)(m)(n); 27.1 (a)

Based on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received a performance review for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: A review of the facility provided, Licensed annual education, competencies, and performance reviews, dated January 2023 to October 2024, did not reveal performance reviews for the five (5) randomly selected CNAs. On 10/16/24 at 11:24 AM, during an interview with the surveyor, the Human Resources Director (HRD) stated that the Director of Nursing (DON) was in-charge of education, competencies (lecture, training, pre and posttests) and performance reviews for the nursing staff. On 10/17/24 at 11:57 AM, during an interview with the surveyor, the DON stated that the performance reviews were conducted based on the results of the competencies. When a nursing staff's competencies resulted with a concern, then a performance review was conducted. The DON stated that the 5 randomly selected CNAs did not have concerns with their competencies and confirmed that the CNAs had no performance reviews on file. The DON also stated that the performance reviews for all nursing staff were based on the result of the competencies. On 10/17/24 at 1:02 PM, the surveyor requested from the DON and the Licensed Nursing Home Administrator, for the policy and procedure for the competencies and performance reviews of the nursing staff. On 10/18/24 at 9:00 AM, in the presence of two surveyors and the DON, the surveyor discussed the concern with the CNAs performance reviews that was not conducted at least every 12 months, and the education provided was not based on the performance review. A review of the facility policy provided, Employee Training and Performance Management, dated 2/6/23, included that staff were required to work competently, effectively, and safely to care for its residents. To ensure that all staff meet this requirement the following policy ensured that employees were consistently monitored and trained/educated as needed to ensure they completed their job/task successfully. No additional information was provided. N.J.A.C. 8:39-43.17 (b)

Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 3 of 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor requested to review the QA meeting sign in sheets for the last 3 quarters dated September 5, 2024, July 16, 2024 and May 23, 2024, upon entrance. A review of the QA meetings sign in sheets revealed that the Infection Control Preventionist (IP) had not been in attendance for the three meetings. On 10/15/24 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the IP was not able to attend the QAPI meetings since that staff member works the evening shift (3-11) and is also the nursing supervisor. The DON stated that they do received reports from the IP, who meets with the DON often. A review of the Quality Assurance Performance Improvement (QAPI) Program, dated July 2024, revealed that the members of the QAPI shall include but not be limited to: Medical Director, Director of Nursing, Director of Social Services, Director of Admissions, Director of Rehabilitation, Director of Activities, Director of Admissions, and Director of Building Services. The QAPI Plan did not indicate that the IP should be in attendance. N.J.A.C. 8:39-33.1 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for one resident (Resident (R)98) of one resident reviewed for base line care plans out of 24 sampled residents. Findings include: Review of R96's Face Sheet located in the resident's electronic medical records (EMR) section titled Print Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, colostomy, diverticulitis of large intestine with perforation and abscess, acute respiratory failure with hypoxia, and pleural effusion. Review of R96's Baseline Care Plan located in the resident's EMR section titled Care Plans revealed the resident had a baseline care plan dated 07/21/23. The care plan identified the resident had the following problems identified: self-care deficit; at risk for falls; and at risk for alteration in skin integrity. The care plan was unsigned by the resident. During an interview on 08/07/23 at 2:30 PM R96 revealed that she did not receive a copy of the baseline care plan within 48 hours after admission to the facility. The resident stated she signed several forms upon admission to the facility but did not remember receiving a document that described the care that she would receive. During an interview on 08/09/23 at 9:20 AM Registered Nurse (RN)2 revealed any nurse could develop and revise a care plan but usually the interdisciplinary team was responsible for developing care plans. The baseline care was started by the floor nurse but it was Social Services who was responsible for issuing the base line care plan to the resident. During an interview on 08/10/23 at 9:35 AM the Social Services Director (SSD) revealed that she or the per diem social service person was responsible for issuing the base line care plans to the resident. The base line care plan was signed by the resident and a copy given to the resident. The SSD also stated a note was written in the resident progress notes documenting this action. The SSD reviewed the resident's progress notes and could not find any documentation that the resident had received her base line care plan. Review of a facility policy title Care Plans with a revision date 11/21 reads in part .Have an initial interdisciplinary Care Plan initiated within 48 for those residents found to be at risk for pressure ulcers, falls, abuse, and pain. NJAC 8:39-11.2(c)(d)

Based on observations, interviews, record review, and facility policy review, the facility failed to provide timely morning (AM) care for one of one resident (Resident (R)40) reviewed for Activities of Daily Living (ADLs) out of a total sample of 24 residents. Findings include: Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. R40's functional status was extensive assistance with toileting and personal hygiene. R40 was documented as a one-person physical assist for bathing. Review of R40's care plan dated 01/19/23 in section under Focus: revealed that the resident has been care planned for the following interventions by the staff: To be assisted out of bed by 7:30 AM. To call for assistance prior to transferring. To offer to assist to bathroom every two hours. To offer and assist with AM care by 8AM. To provide incontinent care as needed for urinary incontinence. To provide assistance with ADL care and mobility, requiring at least one person assistance. Initial observation of R40 on 08/07/23 at 10:00 AM revealed she was in her bathroom being assisted by staff. Observation on 08/09/23 at 9:56 AM revealed R40 was getting a bed bath by CNA2 while resident was sitting on the toilet. CNA2 was found with a towel, cleaning R40 while R40 was sitting on the toilet, without any clothing on. CNA2 stated she was giving R40 a bed bath instead of R40 getting a shower. Observation on 08/09/23 at 10:34 AM revealed R40 was sitting in the dining room finishing a late breakfast meal. Review of the Resident CNA Documentation Record from 08/01/23 to 08/10/23 under the Task section for Toileting, revealed that R40 did not have any documented toileting for August 1, August 5 and for August 9, 2023, on the 7:00 AM - 3:00 PM shift. It was also revealed that this section of the record did not show that the resident was on every two-hour toileting schedule. During an interview on 08/07/23 at 4:40 PM R40 revealed she wore briefs for accidents. She stated she used to stay wet a lot of times for long periods of time when she lived in a different area of the facility. During an interview on 08/08/23 at 1:05 PM CNA4 revealed that she was very familiar with R40 and had been caring for her since the resident was re-located from the 2nd floor. She stated the resident could clearly communicate her needs verbally, required one-two person to assist with her ADL (Activities of Daily Living), which included incontinence care. CNA4 stated she was aware that R40 had a stroke and that incontinence checks were usually every one-two hours for those residents. During an interview on 08/09/23 at 9:56 AM CNA2 and R40 revealed that R40 was supposed to be getting her shower today but CNA2 stated the resident did not want a shower. However the resident expressed that she did want her shower today which was part of her ADL care to have showers two times a week. During an interview on 08/10/23 at 9:50 LPN2 revealed she was not aware that R40 had not been cared for yet or had her breakfast. She stated R40 was usually awake early and already cared for by this time. During an interview on 08/09/23 at 10:30 AM CNA4 revealed R40 did not usually refuse her showers, that she did indeed want her shower today, and CNA4 was able to give her a shower. During an interview on 08/10/23 at 2:30 PM CNA2 acknowledged that she was late getting R40 up the morning of 08/09/23 and admitted she may have spent too long getting other residents ready for their day. She stated this may have delayed getting R40 ready for her day with her shower as part of her ADL and bowel/bladder incontinent care needs. A telephone interview with R40's daughter on 08/09/23 at 11:05 AM revealed that R40 used to live in a different area of the facility and became more dependent on staff after having a stroke, at times in April 2022. She stated R40 had not fully returned to her prior level of function and required assistance from the staff more than she used to. She stated R40 wore briefs and that she found her soaked wet a few times and reported her concerns immediately to the DON and staff. She stated her mother was not always incontinent, but she could not get herself to the bathroom in a timely manner. She stated she asked the facility to place the resident on a toileting schedule, which she stated had not been done. She believed that if her mother was offered a toileting schedule and that if the staff had better time management, that this would have been very helpful for her mother's incontinence care. During an interview on 08/10/22 at 11:22 AM the DON revealed R40 suffered a second stroke in April 2022 and used to live in an unpopulated section of the facility up until June 2022. The DON revealed that the unpopulated area was for more independent residents than R40, who could mostly care for themselves. The DON believed that R40 was mostly independent. The DON also revealed that the unpopulated area was difficult for staff to attend too because most of the residents were in the more populated area and therefore acknowledges that it was possible the staff did not get to R40 in a timely manner to address her needs. Review of the facility's policy titled CNA [Certified Nurse Aide] Care Plan revealed that all residents will have a CNA care plan that reflects the resident's care needs and issues. It also revealed that the care will be updated by the licensed nurse whenever there was a change in a resident's condition and that the assigned CNA would check the care plan at the beginning of each shift in order to determine a resident's needs. NJAC 8:39-4.1(a)22 NJAC 8:39-27.2(d)(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Medication errors were noted for two out of 25 medications observed, affecting two residents (Resident (R)70 and R12) for a medication error rate of 8%. Findings Include: 1. Review of R70's annual MDS with an ARD of 06/12/23, found in the EMR under the MDS tab, revealed R70 was admitted to the facility on [DATE] and had a BIMS score of 13 out of 15, which indicated R70 was not cognitively impaired. The MDS also indicated R70 had a diagnosis of but not limited to hypertension, diabetes mellitus, stroke, and depression. Review of R70's Physician Orders, dated 08/04/23, found in the EMR under the Orders tab, revealed Carbamide Peroxide 0.65% ear drops Instill 5 drops in each ear TID (9:00 AM, 1:00 PM, and 5:00 PM) for 5 days. During an observation on 08/08/23 at 4:20 PM, Licensed Practical Nurse (LPN)6 stated, I won't administer these until around 7:00 PM because the resident can't hold his head over good when sitting up in the chair. LPN6 documented on the Medication Administration Record (MAR) the following for these ear drops: admin (administer) at 7:20 PM for the date of 08/08/23. During an interview on 08/09/23 at 3:00 PM, the Director of Nurses (DON) stated, The nurse should had given the ear drops an hour before or an hour after the time that the physician had ordered it to be given. Review of the policy titled, Administration of Medications Procedure, revised 11/21, read in part . Medications will be passed 1 hour before or 1 hour after the administration time . 2. Review of R12's annual MDS with an ARD of 07/09/23, found in the EMR under the MDS tab, revealed R12 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15, which indicated R12 was not cognitively impaired. The MDS also indicated R12 had a diagnosis of but not limited to hypertension, diabetes mellitus, arthritis, and depression. Review of R12's Physician Orders, dated 06/19/19, found in the EMR under the Orders tab, revealed Loteprednol 0.5% 1 drop each eye BID (twice a day). LPN6 administered one drop in the left eye as ordered by the physician. Then the nurse attempted to administer one drop in the right eye. When this happened, a mist was observed to spray into the right eye instead of one drop as ordered by the physician. LPN6 stated, I don't know how much I gave because I didn't get one drop out of the bottle when I squeezed it. During an interview on 08/09/23 at 3:00 PM, the DON stated, the nurse should had felt how light the bottle was and obtained a new bottle prior to administering the right amount to be given to this resident. NJAC 8:39-29.2(d)

Based on observation, interviews, and facility policy review, the facility failed to ensure two of two medication carts on the secured unit were locked while unattended. This had the potential to affect two (Resident (R)3 and R37) of 16 residents who were in the dining room on the secured unit while the med carts were observed unlocked. R3 and R37 could ambulate/self-propel themselves while in the dining room. Findings include: Review of R3's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 06/03/23, revealed R3 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R3 was severely cognitively impaired. The MDS recorded R3 had diagnoses which included dementia, stroke, hypertension, and coronary artery disease. R3 was coded as only requiring supervision with moving around on unit. Review of R3's Care Plan located in the EMR under the Care Plan tab, dated 06/03/2023, revealed the resident could ambulate independently with supervision as needed. Review of R37's quarterly MDS with an ARD of 06/15/2023, revealed a BIMS score of 14 out of 15 indicating no cognitive impairment. R37 was coded as requiring extensive assistance in transfers to bed, chair, or wheelchair. An observation was made on 08/09/2023 at 2:00 PM of R37 self-propelling herself a little at a time in the dining room. During an observation/interview on 08/07/23 at 12:42 PM in the secured unit, Medication Cart A was left in the dining room unlocked by Licensed Practical Nurse (LPN)3. On 08/07/23 at 1:00 PM, LPN3 stated, I am to lock the med cart when I am not around the cart. I am pulled in so many ways I forget to do this. R3 and R37 were in the dining room while the med cart was observed unlocked. During an observation/interview on 08/09/2023 at 12:18 PM Medication Cart B was left unlocked in the dining room on the secured unit. LPN1 stated I should had locked the Med Cart when I leave it. When I came back to it, I noticed that it was unlocked so I locked it back. During an interview on 08/10/2023 at 9:00 AM the DON stated, The medication carts are to be left locked. Review of the policy titled Medication Storage dated 11/21 revealed .Medication rooms, carts and medication supplies are to be locked at all times or attended by persons with authorized access . NJAC 8:39-29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to promote the dignity and independence for three of three residents (Resident (R)88, R47 and R9) reviewed for dining in a total sample of 24 residents. Specifically, R88 and R47 were observed being assisted with feeding by staff standing throughout the meal service. Additionally, R9 was observed to sit and wait for lunch to be served while other residents were already served. Findings include: 1. Review of R88's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed R10 was admitted to the facility on [DATE] with diagnoses that included Nontraumatic intracerebral hemorrhage (bleeding in the brain) and Unspecified dementia. Review of R88's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23, located in the resident's EMR under the MDS tab indicated the facility assessed R88 to have a Brief Interview for Mental Status (BIMS) score was zero out of 15, indicating R88 was severely cognitively impaired. The MDS also indicated R88 required limited assistance and one-person physical assist for eating. Review of R88's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R88 was ordered a regular diet, regular texture, thin liquids. 2. Review of R47's admission Record, located in the resident's EMR under the Profile tab, revealed R47 was admitted to the facility on [DATE] with diagnoses that including, Senile degeneration of brain and Dementia. Review of R47's quarterly MDS with an ARD of 06/26/23, located in the resident's EMR under the MDS tab indicated the facility assessed R47 to have a BIMS score was zero out of 15, indicating R47 was severely cognitively impaired. The MDS also indicated R47 required limited assistance and one-person physical assist for eating. Review of R47's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R47 was ordered a Puree diet, with thin liquids. 3. Review of R9's admission Record located in the resident's EMR under the Profile tab, revealed R9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and hyperlipidemia. Review of R9's quarterly MDS with an ARD of 07/06/23, located in the resident's EMR under the MDS tab indicated the facility assessed R9 to have a BIMS score of zero of 15 which indicated the resident was severely impaired. The MDS also indicated R9 required total dependence of one staff for eating. Review of R9's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R22 was ordered a regular ground-national dysphagia diet level two with thin liquids. During an observation of the lunch meal on 08/07/23 at 12:55 PM - 1:30 PM, Certified Nursing Aide (CNA)1 was observed to be standing while feeding R88 their lunch in the dining area. During an observation of the breakfast meal on 08/08/23 at 9:10 AM - 9:20 AM, Activities Coordinator (AC) was observed to be standing while feeding R47 their breakfast in the dining area. During an observation of the lunch meal on 08/08/23 at 1:01 PM - 1:30 PM, R9 was observed to be sitting at the table for 29 minutes without their meals while other residents had been served their meal. Staff were observed to ask R9 were they hungry at 1:29 PM, R9 observed nodding head yes. During an interview on 08/07/23 at 1:15 PM, CNA1 stated they normally sit when assisting with meals, but they did not have a chair. CNA1 stated it was important to sit while assisting to ensure the residents felt comfortable. During an interview on 08/09/23 at 1:20 PM, the AC stated they did not have any feeding assistance training prior to assisting with meals. The AC stated they were told to go assist with meals by a supervisor and just did it. The AC stated they were in-serviced after the meal observed on 08/08/23 by the Director of Nursing (DON) and instructed to sit or be at eye level when assisting with meals. During an interview on 08/09/23 at 1:42 PM, the DON stated that her expectations were for the residents to be served at the same time or at least around the same time as others. The DON stated if there was more than one resident that required assistance with feeding, they would have expected staff to assist residents two at a time. DON stated they also expect staff to be seated when assisting with feeding. The DON stated sitting would make the meal a more pleasurable interaction. Review of the facility's policy titled, Assisting/Feeding Residents Their Meals, revised date 11/21, revealed .4. For residents that need to be feed: a. sit next to the resident and do not stand and feed the resident . NJAC 8:39-4.1(a)12

Based on observations, interviews, and facility policy review, the facility failed to provide meals at regular times. Specifically, the facility failed to deliver resident meals in a timely manner, for three of three (Residents (R)24, R42, and R62) reviewed for meal service. This had the potential to affect residents receiving room trays, and residents eating in the LP unit's back dining room. Findings include: In an interview with the Dietary Manager (DM) on 08/07/23 at 9:30 AM, he stated the mealtimes for all dining rooms were as follows: 8:30 AM breakfast; 12:30 PM lunch; and 5:15 PM dinner. The food was prepared in the main kitchen and transported, via a heated cart, to each of the pantry kitchenettes to be served to the residents. The food arrived 45 minutes prior to each meal service and was placed on the pantry steam tables to be kept hot. 1. The following observations of the lunch meal service occurred on 08/09/23: The meal was identified to be BBQ chicken or grilled hotdog on a bun, coleslaw, corn on the cob and fresh watermelon slice. Observation of the back dining room at 11:45 AM, revealed individual coleslaw cups and watermelon slices in the refrigerator. Corn on the cob, diced carrots, mechanical soft meats, and pureed meats were in containers on the steam table. Hotdogs were being grilled outside by the kitchen staff. Twelve residents were seated outside, under the canopy, at 11:50 AM, waiting for lunch to be served. All other residents were either in their respective dining rooms or in their rooms awaiting their meals. At 12:30 PM, the BBQ chicken was placed on the outside grill to be cooked. At 12:50 PM, a container of grilled hotdogs was delivered to the back dining room. The Dietary Aide (DA)1 said she was waiting for the grilled BBQ chicken before serving the six residents seated at the tables for lunch. At 12:52 PM, the residents seated outside were served. At 12:54 PM, the first meal was served in the front dining room to a resident who chose a hotdog. The BBQ chicken was delivered to the front dining room at 12:58 PM and by 1:00 PM, all residents in the front dining room had been served their meals. At 1:02 PM, the back dining room had not started meal service as DA1 said she did not have pureed carrots, required for the pureed diets. DA1 said I cannot serve the residents until I have all the right food for the purees. At 1:10 PM, the Registered Dietician (RD) retrieved the pureed carrots from the main kitchen. At 1:23 PM, all residents in the back dining room were eating, and the last room tray was delivered on the LP wing, 53 minutes after the 12:30 PM posted mealtime. In an interview with resident (R)62, at 1:30 PM, while eating her corn on the cob, R62 said she really liked the corn on the cob, but some things are cold, at meals in reference to the long wait to be served. When asked, none of the remaining five residents in the back dining room said the food was cold. It was stated that the smell of the BBQ made them hungry. 2. The following observations of the breakfast meal service occurred on 08/10/23: At 8:15 AM, observation of the back dining room pantry kitchenette on the LP unit revealed scrambled eggs, hashbrown patties, and oatmeal on the steam table. At 8:29 AM, no residents had arrived in the dining room for breakfast. At 8:34 AM, two residents were at the tables for breakfast. At 9:00 AM, all residents in the dining room had been served breakfast, however the DA3 had to request more milk for residents who requested cold cereal, bagels for resident room trays, and more scrambled eggs as she had run out of what had been initially sent. At 9:15 AM, the last room tray was delivered on the LP unit, 45 minutes after the posted mealtime of 8:30 AM. In an interview with R42, at 9:20 AM, he said the food temperature was ok, but the trays do come late sometimes. R42 ate his breakfast in his room, in bed. In an interview with R24, at 9:25 AM, he said the breakfast was pretty good, but sometimes it's cold. R24 ate his breakfast in his room, in bed. In an interview with the DM on 8/10/23 at 9:20 AM, he said the DA1 could have served the diced carrots, just mash them, she didn't have to delay the meal service. The DM could not state why the BBQ chicken was being cooked at the time the meal should have been served. In response to the dietary staff having to ask for additional food items which delayed the meal service for breakfast, the DM said they did not supply extra food on the carts, they had the staff call the kitchen for requests. In an interview with the Clinical Nutrition Manager/RD on 08/09/23 at 2:48 PM, she stated the previous BBQ had run very well without delays in meal service. She could not state why it was so late on 08/09/23. Review of the facility's policy titled, Resident Food Services, updated 01/18, revealed Monitor delivery of meals to residents to ensure timeliness and appropriateness of service. NJAC 8:39-17.2(f)

Based on observations, interviews, and facility policy review, the facility failed to keep the food storage bins clean and failed to ensure opened food was dated, labeled, and sealed. This had the potential to affect 91 of 93 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: During an initial tour of the kitchen on 08/07/23 at 9:30 AM, with the interim Dietary Manager (DM) present, the following observations were made: Dry Storage and Freezer: a. Four large bins, containing flour, sugar, breadcrumbs, and rice respectively, were observed to have dirt and grime on the top and sides of each container. b. An open container of peanut butter was observed on a shelf. There was no date identifying when the peanut butter was opened. c. A box of baking powder, open to air, was observed on the shelf. The baking powder had no date to identify when it had been opened, nor was the box sealed in a plastic bag or container. d. A bag of pancake mix, open to air, was observed on a shelf. The pancake mix had no date identifying when it was opened nor was it sealed in a plastic bag or container. e. A bag of chocolate cake mix was observed, sealed in plastic wrap, with no date identifying when it had been opened. f. A large toaster was observed, uncovered, on a food preparation table. The toaster was observed to have crumbs, dirt, and a white substance on the inside of the machine as well as dry pasta noodles underneath. g. Fish fillets, left open to air in the freezer and subject to freezer burn, were observed inside an open box. h. Undated Blitzes, were observed uncovered and subject to freezer burn, on top of a box in the freezer. The DM confirmed the observations and said, the large containers should have been cleaned on Sunday, I do not know what happened. The DM said the toaster had not been used, however he did not know why it had not been cleaned and covered. Review of the facility's cleaning schedule for the kitchen revealed back of the house cleaning duties as well as front of the house cleaning duties identified as daily, weekly, and when used. The large bins in the dry storage area were not listed on the cleaning schedule. Review of the facility's policy titled Food and Supply Storage, dated 01/19, revealed All food, non-food items and supplies used in food preparation shall be stored in such a manner as to Prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Use the Unidine green label, Medvantage label or Ecolab Prep N Print label; complete all sections on the label. Products are good through the close of business on the date noted on the label. Use food grade plastic bags for food storage. Do not use garbage can liners. Store bulk materials in NSF [National Sanitation Foundation] approved containers that have tight fitting lids. Label both the bin and the lid. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of R37's EMR, located on the Profile tab, revealed R37 was admitted on [DATE]. Additional review of the EMR, Diagnosis List located under the Profile tab revealed the following diagnoses of but not limited to hypertension, dementia, Parkinson's Disease, anxiety disorder and depression. Review of R37's quarterly MDS with an ARD of 06/15/23, revealed a BIMS score of 14 indicating R37 is cognitively intact. Further review of the MDS revealed R37 required extensive assistance and two-person physical assist for bed mobility, transfer, locomotion on unit and extensive assistance with one-person physical assist for dressing, toilet use and personal hygiene. During an observation made on 08/07/23 at 10:35 AM, the call light cord was located behind the headboard of the bed lying on the floor. Asked resident how she would call for the Nurse/CNA if she needed them. The resident stated, I would just yell loud until someone came to help me. On 08/08/23 at 9:20 AM, the call bell cord was observed on the floor behind the headboard of the bed, lying on the floor. An unidentified CNA came while this surveyor was still in the room. The CNA picked up the breakfast tray and left without checking to see if the resident's call bell was in reach. On 08/09/23 9:10 AM, during the Medication Pass observation with Licensed Practical Nurse (LPN)5, the surveyor observed the call bell cord on the floor behind the headboard. LPN5 and CNA were in the room with the surveyor. LPN5 and CNA left the room with the surveyor and the staff members did not put the call bell in an area the resident would be able to reach. During an interview on 08/09/23 at 10:00 AM, LPN5 stated I did not even look to see if her call bell was in place or not. During an interview on 08/09/23 at 3:00 PM the DON stated, No it (call light) wouldn't be where they could get it. Review of the facility's, undated, policy titled, Call Bell Monitoring and Responsibility, revealed Call bells are to be left within reach at all times. NJAC 8:39-31.8(c)9 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure four residents (Residents (R)24, R37, R42 and R56) of 24 sample residents had their call lights within reach when in their rooms, specifically when they were in their beds. This failure created the potential for the residents not to have a means of directly contacting caregivers. Findings include: 1. Review of R24's admission Record, located under the ADT [Admission, Discharge, Transfer] tab of the electronic medical record (EMR) revealed R24 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Palliative Care, Chronic Respiratory Failure, and Chronic Congestive Heart Failure. Review of R24's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/29/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Per the MDS, R24 required extensive assistance with personal care. During an observation on 08/07/23 at 3:08 PM, R24's call light was observed to be tied to the right siderail, which was down. The call light was out of reach of the resident who was in bed. During an observation on 08/08/23 at 9:14 AM, R24's call light was observed to be tied to the right siderail which was down. The call light was behind the resident, who was in bed, and out of reach of R24. During this observation, R24 stated I don't need it anyway. R24 said I don't want to be bothered to try to reach it (call light), when asked. During an observation on 08/09/23 at 9:25 AM, R24's call light was tied to the right bedrail, out of reach of the resident, who was in bed. The bedrail was down. R24 said he wanted the siderail up at night because he was afraid of falling out of bed if he turned over. When asked if R24 could reach the call light to call for assistance where it was tied to the siderail, he said no, I'll fall out for sure [while trying to reach the call light]. The call light was observed tied to the siderail on 08/09/23 at 10:05 AM and 10:43 AM, out of reach of the resident who was in bed during the observations. On 08/10/23 at 9:30 AM, while R24 was in bed, his call light was observed to be tied on the right bedrail. The bedrail was down, and the call light was out of reach of the resident. R24 said he'd been hollering for someone to bring me cream for my coffee. When asked, R24 said he didn't know where the call light was, I usually just yell, but you're the only who heard me. In an interview with a Certified Nursing Assistant (CNA)3, on 08/10/23 at 11:31 AM, she said we always put the call lights on the bed. When asked about R24's call light being tied to the siderail, CNA3 said I thought it was on the bed. In an interview with the Registered Nurse (RN)1, on 08/10/23 at 11:18 AM, she said, the call lights need to be in reach and that she would need to make sure the CNAs are putting the call lights where the residents could reach them. 2. Review of R42's admission Record, located under the ADT tab of the EMR revealed R42 was admitted on [DATE] with diagnoses including hemiplegia (paralysis) following infarct (stroke) affecting left nondominant side. Review of R42's annual MDS, located in the EMR under the MDS tab with an ARD of 06/08/23, revealed the resident had a BIMS score of 11 out of 15, indicating the resident had moderately impaired cognition. Per the MDS, R42 required extensive assistance with personal care. During an observation of R42 on 08/07/23 at 10:56 AM, while in bed, the resident's call light was observed on the floor on the left side of the bed. R42 said he was unable to use his left side. R42 said he did not know the call light was on the floor. During an observation on 08/08/23 at 9:10 AM, R42 was sitting up in bed eating his breakfast. The resident's call light was on the bed, on his left side. When asked, the resident said he thought he could reach it with his left hand but was unable when he tried. During an observation on 08/09/23 at 9:23 AM, R42 was observed in bed eating his breakfast. The resident's call light was observed to be on his left side, closer to his pillows. The resident said he is unable to use his left side. During an observation on 08/10/23 at 9:30 AM, R42 was in bed eating breakfast. The resident was observed to have two pillows behind his head. The call light was observed to be clipped to the sheet, behind the two pillows, on the resident's left side. When asked how he would call for assistance, R42 said I don't know. The resident confirmed that he could not reach across his body, behind the pillows, to reach the call light. 3. Review of R56's admission Record, located under the ADT tab of the EMR revealed R56 was admitted on [DATE] with diagnoses including hemiplegia following cerebral infarct affecting left nondominant side. Review of R56's quarterly MDS, located in the EMR under the MDS tab with and ARD of 05/20/23 revealed the resident had a BIMS score of four out of 15, indicating severely impaired cognition. Per the MDS, R56 required extensive assistance with personal care. During an observation of R56 on 08/07/23 at 11:13 AM, while in bed, the resident's call light was observed on the floor behind the resident's bed. The resident stated that she had had a stroke and was not able to use her left hand/arm. On 08/07/23 at 4:02 PM, R56 was observed in bed with the call light on the floor behind the bed. During an observation of R56 on 08/08/23 at 9:30 AM, the resident was observed in bed eating her breakfast. The call light was observed on the left side of the bed toward her pillow. When asked, R56 demonstrated that she could not reach across her body to reach the call light with her right hand. When asked how she would call for assistance if needed, R56 said she would wait for someone to come in. During an observation on 08/09/23 at 9:30 AM, R56 was observed in bed. CNA4 came into the room to deliver the resident's breakfast. The resident's call light was observed on her left side near her pillow. CNA4 said she did not realize the call light should be on the resident's right side because she cannot use her left hand. CNA4 did not indicate that R56 could not use the call light if it was accessible on her right side. CNA4 did not move the call light to the resident's right side. On 08/10/23 at 11:18 AM, R56 was observed while asleep in bed. The call light was observed on the resident's left side. During an interview with CNA3 on 08/10/23 at 11:31 AM, CNA3 said the call lights would extend to the right side for the residents who needed that. CNA3 did not indicate that R56 could not use the call light if it was accessible on her right side. In an interview with the Director of Nurses (DON) on 08/10/23 at 12:00 PM, she said all CNAs were trained regarding call light placement for the residents and that the nurses should be checking to see if they are placed correctly for each resident. On 08/10/23 at 2:09 PM, R56 was observed in bed. The call light was observed on her left side close to the pillow, out of reach of the resident.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to keep medications separated by route of administration in two of four medication carts observed (cart 2A and cart 2B). Findings included: 1. During a concurrent observation and interview regarding medication cart A on 11/09/2021 at 8:19 AM, a container of suppositories was seen placed on top of a box of medication to be taken by mouth. Registered Nurse (RN) #1 stated that she always stored medications of different routes this way. On 11/09/2021 at 8:50 AM, an observation was made of the drawers inside medication cart B. Section 1 of cart B contained: - Ophthalmic (eye) ointment - Oral drops - Eye drops Section 2 of cart B contained: - Caltrate soft chews (calcium supplement) - Bioene mouth spray (for dry mouth) - Restasis eye drops (for dry eyes) - Ocusoft lid scrub (to cleanse the eye lid) - Flonase nasal spray (for allergies) - Vitamin B12 for intramuscular injection (vitamin supplement) RN #2 was interviewed at the time of the observation and stated she had been taught medications should be stored by route of administration. RN #2 added that all nurses were responsible to make sure the different routes of medication were stored separately and stated she did not have time that morning to make sure the medication cart was in good order. The Assistant Director of Nursing (ADON) was interviewed on 11/10/2021 at 12:12 PM. The ADON stated medications should be stored in the medication cart by route of administration. She added that all eye drops should be stored together, all nasal sprays together and suppositories should be kept in the treatment cart and not with oral medications. The ADON stated she had seen the condition of the medication carts A and B and had arranged the medications by route after she had been notified by RN #1 and RN #2. The Director of Nursing (DON) was interviewed on 11/11/2021 at 9:58 AM. The DON stated she expected medications to be stored in different sections of the cart and grouped by route of administration. The Administrator was interviewed on 11/11/2021 at 10:30 AM and stated she expected nursing staff to follow the facility's policy related to medication storage. Review of the facility's policy, Medication Storage, with a review date of 11/2019, indicated orally administered medications are kept separate from externally used medications such as suppositories, liquids, lotions and tablets. Eye medications are kept separate from ear medications. New Jersey Administrative Code § 8:39-5.1(a)

Based on observations, interviews, policy review, and review of the New Jersey Administrative Code (NJAC) 8:24 for food sanitation, it was determined that the facility failed to handle food in a sanitary and safe manner on one of the four observed halls (B hall-second floor) during the lunch meal. Facility staff were observed handling ready-to-eat food with their bare hands. Findings included: Reference: NJAC 8:24-3.3 Protection from contamination after receiving (a) Requirements for preventing contamination from hands include the following: 2. Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment, except when washing fruits and vegetables . 1. The facility admitted Resident #104 on 01/14/2019 with diagnoses that included mood disorder, anxiety, and depression. Resident #104's 10/21/2021 quarterly Minimum Data Set (MDS) indicated the resident had moderate cognitive impairment, scoring 10 on the Brief Interview for Mental Status exam. The resident was identified on the MDS as requiring supervision with eating. On 11/09/2021 at 1:15 PM, Certified Nursing Assistant (CNA) #8 was observed serving the lunch meal to Resident #104. CNA #8 uncovered the resident's plate and then using their bare hand, passed Resident #104 a sandwich. CNA #8 was interviewed on 11/09/2021 while leaving Resident #104's room. CNA #8 stated they had washed their hands prior to going into the room and before touching the food. The CNA stated since they had washed their hands before going into the room, they saw no problem with touching Resident #104's sandwich with their bare hands. CNA #8 reported not receiving any training that indicated needing to wear gloves when touching other people's food. An interview was held with Registered Nurse (RN) #2 on 11/09/2021 at 1:35 PM. RN #2 stated any time residents' food was touched by staff serving the food, gloves should be worn. RN #2 stated it was never ok to touch another person's food with your bare hands because you would not want to cause cross contamination of germs. The Assistant Director of Nursing (ADON) was interviewed on 11/10/2021 at 12:12 PM. The ADON identified themself as the infection preventionist (IP) for the facility. The ADON stated bare hands should not be used to touch residents' food. The ADON added even if a staff member washed their hands prior to serving food, touching another person's food with bare hands was not acceptable. The ADON added touching another person's food with bare hands increased the risk of bacteria and virus transmission. The Director of Nursing (DON) was interviewed on 11/11/2021 at 9:44 AM. The DON stated when food was touched, gloves should always be worn. The Administrator was interviewed on 11/11/2021 at 10:30 AM. The Administrator stated the expectation was for staff to follow the facility's policy on food handling. The facility's policy titled, Food Handling Guidelines, revised 01/2021, indicated, single use gloves are worn when preparing foods that will not be cooked again and while serving food. New Jersey Administrative Code 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility admitted Resident #89 with diagnoses that included encephalopathy (brain swelling), seizure disorder, dementia, difficulty walking, and muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, which indicated severe cognitive impairment. The resident required extensive two-person physical assistance with bed mobility, transfers, and toileting, and required extensive one-person physical assistance with dressing, personal hygiene, locomotion, and eating. Bed rails were not indicated for use on the MDS. The November 2021 computerized physician orders (CPO) revealed and order with a start date of 09/14/2021 for one side rail up in bed for positioning. The revised care plan, updated 09/15/2021, revealed the resident had a neurological disease and seizure disorder. Interventions included pad to both upper side rails used and enablers for safety and monitor for complications caused by involuntary movement. Resident #89 was observed on 11/08/2021 at 9:24 AM, 11:02 AM, and 2:26 PM with both side rails up while the resident was in bed. Both side rails were padded. Only one bed rail was ordered for use. Observations on 11/09/2021 at 10:00 AM and 2:30 PM revealed both side rails were padded and up while the resident was in bed. Only one bed rail was ordered for use. On 11/08/2021 at 2:30 PM, one arrow sticker was observed on the right side of the bed, indicating to floor staff that only the right bed rail should be used when the resident was in bed. A bed rail assessment, dated 11/10/2021, revealed the rails were used for positioning, and only one was needed for the resident. During a resident group meeting, held with five (Residents #2, #13, #26, #68, and #118) cognitively intact residents, on 11/09/2021 at 11:00 AM, revealed they all had bed rails on their beds when they first came to the facility. Resident #13 and Resident #68 said they currently had bed rails on their beds. Resident #13 said the bed rails kept them in bed, but they required staff assistance to get in and out of bed. Resident #68 said they felt safe with their bed rails up and needed total assistance from staff to get out of bed. Neither resident said they signed a consent form for the use of bed rails on their beds. An interview with Certified Nurse Aide (CNA) #5, on 11/09/2021 at 2:32 PM, revealed side rails were used for many of their residents. The CNA said the residents were assessed by nursing for the need and use of side rails, and the family signed waivers for their use. CNA #5 said the number of side-rails each resident used was indicated by up-arrows on the side of the headboard the rails were supposed to be used on. CNA #5 said Resident #89 used one bed rail on the right side of the bed. The CNA said Resident #89 should not have both rails up. They said the one side rail was to help the resident reposition themself. An interview with CNA #6, on 11/09/2021 at 2:37 PM, revealed side rails were ordered by the physician and indicated for use by arrows on the headboard of each resident. The CNA said if both side rails were used, there should be a consent waiver in the medical chart of the resident. CNA #6 said nursing and physical therapy assessed the residents for bed rail use. They said siderails were used for residents who had a history of falls or a neurological condition. CNA #6 was not sure if Resident #89 should have one or two bed rails up. The CNA said the resident had used the side rails for positioning. They said the side rails were padded to protect the resident if they experienced a seizure. They said the nurse informed them of changes to the residents and the number of bed rails ordered for use. An interview with Licensed Practical Nurse (LPN) #4, on 11/09/2021 at 2:43 PM, revealed bed rails were used for residents who had neurological disorders or seizures. LPN #4 said some residents used one bed rail for positioning. They said there were arrow stickers on the side of the headboards that indicated which bed rail to have raised. They said physician orders and consent were needed for residents to use bed rails. They said nursing and the therapy department assessed the resident's need for bed rails. They said bed rails were included in the resident's care plan and included the reason for and number of bed rails. LPN #4 said Resident #89 had a seizure disorder and had orders for one siderail to be up for positioning. They said the resident should not have two bed rails up. LPN #4 was not able to find the consent form in the resident's chart. LPN #4 said they did not know where the consent forms were kept since they were not in the medical chart. On 11/09/2021 at 2:43 PM, LPN #4 went to check the bed rails of Resident #89. As LPN #4 entered the room, CNA #6 exited the room. CNA #6 said they had forgotten to put the left bedrail down after providing incontinence care to the resident after lunch. CNA #6 said they just repositioned the resident and lowered the left bedrail. The bed rail on the left side of the bed was observed to be lowered. During an interview on 11/09/2021 at 3:25 PM, the Director of Rehabilitation (DOR) stated all residents were screened for therapy upon admission. Physical therapy (PT) screened for bed mobility, and nursing determined if siderails were up when a resident was in bed and if siderail pads were used. PT did not determine a resident's siderail use. Siderails would be up when a resident was in bed to keep a resident from falling. The DOR then stated residents had tried to crawl over the siderails, and there was always the potential for injury with falls. There were no consents or formal assessments done to determine siderail usage. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. The MDS Coordinator further stated two siderails in the up position would be a restraint if they were stopping a resident from getting out of bed. They were not coding siderails as a restraint on the MDS because residents used them for positioning. Siderail use should be in the care plan and reviewed monthly. During an interview on 11/10/2021 at 12:00 PM, the Director of Nursing (DON) stated there were no consents for siderails and they had no restraints in the building. The DON then stated a restraint was anything that impeded a resident's normal movement, and full siderails would only be a restraint if they were preventing a resident from getting out of bed. If a resident attempted to climb over or around a siderail, it could be more dangerous than if the siderail was not there. During an interview on 11/10/2021 at 12:12 PM, the Assistant Director of Nursing (ADON) stated facility staff should not put two siderails in the up position because a resident could injure themself on the siderails. Some CNAs would put both side rails up for resident safety, but that was a restraint. During an interview on 11/10/2021 at 1:26 PM, the DON stated they were not aware the facility did not have a system to assess residents, get consents, and monitor siderail use. This was important for consistency and resident safety, and a resident should be able to move around. During an interview on 11/10/2021 at 1:40 PM, the Administrator stated a restraint was anything that restricted a resident's regular movement. The facility just implemented a siderail assessment on 11/10/2021 and would start getting consents for siderail use. The Administrator then stated it was important to assess residents and get consents so the resident and family could know the risks and benefits of siderail use. They needed to make sure a side rail was the safest recommendation for each resident. A review of the undated facility policy titled, Policy and Procedures for Restraints, revealed the facility's processes will address the use of restraints. These processes will recognize and protect residents' rights and ensure that when used, the restraints are safe and appropriate based upon a documented medical symptom. These processes utilize the key elements of care planning and delivery of the individually established plan of care that includes thorough assessments by interdisciplinary team member. A review of the facility's policy titled, Department of Nursing: Side Rails, dated 02/26/2009, revealed, All residents will be assessed by the nurse for safe use of side rails upon admission and readmission. 5. The facility admitted Resident #133 with diagnoses that included Parkinson's, dementia, arthritis, and osteoporosis. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was three, which indicated severe cognitive impairment. The resident required extensive two-person assistance with bed mobility and dressing and was totally dependent on one or two staff for transfers, bathing, locomotion, eating, toileting, and personal hygiene. The resident had no falls during the previous quarter but was an identified fall risk. Bed rail use was not indicated on the MDS. The November 2021 computerized physician orders (CPO) revealed an order with a start date of 03/29/2021 for two side rails up in bed for positioning. The revised care plan, updated 03/09/2021, revealed bed rails were not included in the resident's care plan as a focus or intervention. There had been no update to the care plan to include bed rail use for the resident following the physician's order on 03/29/2021. Resident #133 was observed on 11/08/2021 at 9:26 AM, 11:00 AM, and 2:28 PM with both side rails up while the resident was in bed. Observations on 11/09/2021 at 10:03 AM and 2:32 PM revealed both side rails up while the resident was in bed. On 11/09/2021 at 2:32 PM, two arrow stickers were observed on either side of the bed, indicating to floor staff that both bed rails should be used when the resident was in bed. Observations on 11/10/2021 at 9:03 AM and 2:18 PM revealed both side rails up while the resident was in bed. Resident #133 had no assessment or consents for the use of bed rails in their medical chart or electronic medical record. During a resident group meeting, held with five (Residents #2, #13, #26, #68, and #118) cognitively intact residents, on 11/09/2021 at 11:00 AM, revealed they all had bed rails on their beds when they first came to the facility. Resident #13 and Resident #68 said they currently had bed rails on their beds. Resident #13 said the bed rails kept them in bed, but they required staff assistance to get in and out of bed. Resident #68 said they felt safe with their bed rails up and needed total assistance from staff to get out of bed. Neither resident said they signed a consent form for the use of bed rails on their beds. An interview with Certified Nurse Aide (CNA) #5, on 11/09/2021 at 2:32 PM, revealed side rails were used for many of their residents. The CNA said the residents were assessed by nursing for the need and use of side rails, and the family signed waivers for their use. CNA #5 said the number of side-rails each resident used was indicated by up-arrows on the side of the headboard the rails were supposed to be used on. CNA #5 said Resident #133 used both side rails. CNA #5 said the family requested the use of rails, so the resident did not fall when the resident attempted to crawl out of bed. The CNA said the resident had a history of falls. They said the resident had no falls while residing at the facility. An interview with CNA #6, on 11/09/2021 at 2:37 PM, revealed side rails were ordered by the physician and indicated for use by arrows on the headboard of each resident. The CNA said if both side rails were used, there should be a consent waiver in the medical chart of the resident. CNA #6 said nursing and physical therapy assessed the residents for bed rail use. They said siderails were used for residents who had a history of falls or a neurological condition. They said the nurse informed them of changes to the residents and the number of bed rails ordered for use. CNA #6 said Resident #133 used both bed rails at the request of the family. CNA #6 said the resident was a fall risk and would try to climb out of bed if the bed rails were not up. CNA #6 said the family signed a waiver that was in the medical chart. She said the resident had not suffered a fall since residing at the facility. An interview with Licensed Practical Nurse (LPN) #4, on 11/09/2021 at 2:43 PM, revealed bed rails were used for residents who had neurological disorders or seizures. LPN #4 said some residents used one bed rail for positioning. They said there were arrow stickers on the side of the headboards that indicated which bed rail to have raised. They said physician orders and consent were needed for residents to use bed rails. They said nursing and the therapy department assessed the resident's need for bed rails. They said bed rails were included in the resident's care plan and included the reason for and number of bed rails. LPN #4 said Resident #133 was a fall risk and would try to get out of bed without the siderails. They said the family of the resident requested the use of bed rails for the safety of the resident. LPN #4 said the resident had suffered no falls while residing at the facility. They said the consent signed by the family should be in the medical chart. LPN #4 was not able to find the consent form in the resident's chart. LPN #4 said they did not know where the consent forms were kept since they were not in the hard chart. During an interview on 11/09/2021 at 3:25 PM, the Director of Rehabilitation (DOR) stated all residents were screened for therapy upon admission. Physical therapy (PT) screened for bed mobility, and nursing determined if siderails were up when a resident was in bed and if siderail pads were used. PT did not determine a resident's siderail use. Siderails would be up when a resident was in bed to keep a resident from falling. The DOR then stated residents had tried to crawl over the siderails, and there was always the potential for injury with falls. There were no consents or formal assessments done to determine siderail usage. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. The MDS Coordinator further stated two siderails in the up position would be a restraint if they were stopping a resident from getting out of bed. They were not coding siderails as a restraint on the MDS because residents used them for positioning. Siderail use should be in the care plan and reviewed monthly. During an interview on 11/10/2021 at 12:00 PM, the Director of Nursing (DON) stated there were no consents for siderails and they had no restraints in the building. The DON then stated a restraint was anything that impeded a resident's normal movement, and full siderails would only be a restraint if they were preventing a resident from getting out of bed. If a resident attempted to climb over or around a siderail, it could be more dangerous than if the siderail was not there. During an interview on 11/10/2021 at 12:12 PM, the Assistant Director of Nursing (ADON) stated facility staff should not put two siderails in the up position because a resident could injure themself on the siderails. Some CNAs would put both side rails up for resident safety, but that was a restraint. During an interview on 11/10/2021 at 1:26 PM, the DON stated they were not aware the facility did not have a system to assess residents, get consents, and monitor siderail use. This was important for consistency and resident safety, and a resident should be able to move around. During an interview on 11/10/2021 at 1:40 PM, the Administrator stated a restraint was anything that restricted a resident's regular movement. The facility just implemented a siderail assessment on 11/10/2021 and would start getting consents for siderail use. The Administrator then stated it was important to assess residents and get consents so the resident and family could know the risks and benefits of siderail use. They needed to make sure a side rail was the safest recommendation for each resident. A review of the undated facility policy titled, Policy and Procedures for Restraints, revealed the facility's processes will address the use of restraints. These processes will recognize and protect residents' rights and ensure that when used, the restraints are safe and appropriate based upon a documented medical symptom. These processes utilize the key elements of care planning and delivery of the individually established plan of care that includes thorough assessments by interdisciplinary team member. A review of the facility's policy titled, Department of Nursing: Side Rails, dated 02/26/2009, revealed, All residents will be assessed by the nurse for safe use of side rails upon admission and readmission. New Jersey Administrative Code 8:39-4.1(a) 6 Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure residents were free from physical restraints, which included the use of side rails to the bed, for five (Resident #134, Resident #25, Resident #96, Resident #133, and Resident #89) of twelve residents reviewed for physical restraints. Findings included: 1. The facility admitted Resident #134 with diagnoses of dysphagia (difficulty swallowing food or liquids), dementia, chronic obstructive pulmonary disease, hypothyroidism, anemia, type two diabetes, and hyperlipidemia (elevated lipid levels in the body). A review of Resident #134's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #134's cognitive skills for daily decision making were severely impaired. Resident #134 required extensive, two-person assistance with bed mobility. A further review of Resident #134's MDS revealed a bed rail was not used. A review of Resident #134's care plan, dated 07/19/2021, revealed a focus of skin integrity with an intervention in place to use side rail pads when in bed. A review of Resident #134's physician's consolidated orders, dated 11/2021, revealed an order started on 07/16/2021 for one side railing to be up on the bed for positioning. An observation on 11/08/2021 at 10:30 AM revealed Resident #134 lying on their back in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. An observation on 11/08/2021 at 10:45 AM revealed Resident #134 lying on their back, leaning to the left while in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. An observation on 11/09/2021 at 12:15 PM revealed Resident #134 lying on their back, leaning to the left while in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. A review of Resident #134's medical record revealed there was no consent or assessment completed for the use of siderails. During an interview on 11/09/2021 at 12:35 PM, Certified Nurse Aide (CNA) #1 stated Resident #134 was combative during care and moved around a lot while in bed. Resident #134 could move side to side while in bed, and the side rails were padded for protection from injury. CNA #1 further stated they did not know if Resident #134 tried to get out of bed but had not tried to crawl over the railings. During an interview on 11/09/2021 at 2:10 PM, CNA #2 stated Resident #134's side rails were padded because the resident was so combative and would fidget while in bed. The full side rails were in place to protect Resident #134 from falling out of bed. CNA #2 then stated there was an arrow pointing up on the left side of Resident #134's headboard telling staff the left side rail needed to be up, but there was not an arrow on the right side of the headboard. CNA #2 did not know why two side rails were up while Resident #134 was in the bed. During an interview on 11/09/2021 at 2:35 PM, Registered Nurse (RN) #1 stated Resident #134 had two side rails up while in bed because Resident #134 was restless and moved around a lot while in bed. Resident #134 did not try to get out of bed or crawl over the side rails, but Resident #134 was a high fall risk. During an interview on 11/09/2021 at 3:25 PM, the Director of Rehabilitation (DOR) stated all residents were screened for therapy upon admission. Physical therapy (PT) screened for bed mobility, and nursing determined if siderails were up when a resident was in bed and if siderail pads were used. PT did not determine a resident's siderail use. Siderails would be up when a resident was in bed to keep a resident from falling. The DOR then stated residents had tried to crawl over the siderails, and there was always the potential for injury with falls. There were no consents or formal assessments done to determine siderail usage. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. The MDS Coordinator further stated two siderails in the up position would be a restraint if they were stopping a resident from getting out of bed. They were not coding siderails as a restraint because residents used them for positioning. Siderail use should be in the care plan and reviewed monthly. Resident #134 should have one side rail in the up position for positioning when in the bed. During an interview on 11/10/2021 at 12:00 PM, the Director of Nursing (DON) stated there were no consents for siderails and they had no restraints in the building. The DON then stated a restraint was anything that impeded a resident's normal movement, and full siderails would only be a restraint if they were preventing a resident from getting out of bed. If a resident attempted to climb over or around a siderail, it could be more dangerous than if the siderail was not there. During an interview on 11/10/2021 at 12:12 PM, the Assistant Director of Nursing (ADON) stated facility staff should not put two siderails in the up position because a resident could injure themself on the siderails. Some CNAs would put both side rails up for resident safety, but that was a restraint. Resident #134 should have one siderail up for positioning. During an interview on 11/10/2021 at 1:26 PM, the DON stated they were not aware the facility did not have a system to assess residents, get consents, and monitor siderail use. This was important for consistency and resident safety, and a resident should be able to move around. During an interview on 11/10/2021 at 1:40 PM, the Administrator stated a restraint was anything that restricted a resident's regular movement. The facility just implemented a siderail assessment on 11/10/2021 and would start getting consents for siderail use. The Administrator then stated it was important to assess residents and get consents so the resident and family could know the risks and benefits of siderail use. They needed to make sure a side rail was the safest recommendation for each resident. A review of the undated facility policy titled, Policy and Procedures for Restraints, revealed the facility's processes will address the use of restraints. These processes will recognize and protect residents' rights and ensure that when used, the restraints are safe and appropriate based upon a documented medical symptom. These processes utilize the key elements of care planning and delivery of the individually established plan of care that includes thorough assessments by interdisciplinary team member. A review of the facility's policy titled, Department of Nursing: Side Rails, dated 02/26/2009, revealed, All residents will be assessed by the nurse for safe use of side rails upon admission and readmission. 2. The facility admitted Resident #25 with diagnoses of depression, hypertension, bipolar, anxiety, disorganized schizophrenia (disorganized behavior and speech), and anxiety. A review of Resident #25's annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #25 required extensive two-person assistance with bed mobility. A further review of Resident #25's MDS revealed a bed rail was not used. A review of Resident #25's care plan, dated 08/10/2021, revealed a focus of activities of daily living (ADL) function. Resident #25 required extensive assistance with bed mobility, and an intervention of one side rail up when in bed to aid in positioning. A review of Resident #25's care plan, dated 08/10/2021, revealed a focus of history of falls. Resident #25 was a high risk for falls due to fall assessment, impaired balance, and mobility, with an intervention of one side rail up when in bed to assist in positioning. A review of Resident #25's physician's orders, dated 11/2021, revealed an order started on 08/02/2018 for one side rail up for positioning. An observation on 11/09/2021 at 12:14 PM revealed Resident #25 lying in bed, leaning to the left side, and full side rails were in the raised position on each side of Resident #25. The bed was in the lowest position, with floor mats on each side of the bed. During an interview on 11/09/2021 at 12:40 PM, Certified Nurse Aide (CNA) #1 stated Resident #25 tried to climb over the rails and out of bed, which is why the full side rails and floor mats were in place for the resident's safety. An observation on 11/09/2021 at 2:08 PM revealed Resident #25 lying in bed, leaning to the left side. Full side rails were in the raised position on each side of the resident. Resident #25's knees were bent and leaning on the left side rail. A review of Resident #25's medical record revealed there was no consent or assessment completed for the use of siderails. During an interview on 11/09/2021 at 2:11 PM, CNA #2 stated that when Resident #25 was in bed, the full side rails were in the up position and fall mats were on the floor because Resident #25 tried to climb out of bed. The side rails kept Resident #25 in the bed. CNA #2 further stated Resident #25 tried to crawl over the side rails and would scoot to the foot of the bed to get out through the opening between the end of the side rail and the footboard of the bed. CNA #2 further stated a resident's care plan reflects whether a resident should have raised siderails. There was an arrow on either the right or left side of the headboard telling staff which siderail needed to be raised. CNA #2 further stated they did not know why both siderails were in the up position, when Resident #25 had only one arrow on the right side of the headboard. During an interview on 11/09/2021 at 2:35 PM, Registered Nurse (RN) #1 stated Resident #25 had a low bed, full side rails, and floor mats on the floor next to the bed because the resident tried to crawl out of bed. Resident #25 would also scoot down to the foot of the bed and get out of the bed through the opening between the end of the siderail and the footboard. RN #1 further stated Resident #25 had been found on the mats at the foot of the bed but had never climbed over the siderail. Although staff indicated Resident #25 had tried crawling over the side rails and out of bed, a review of the resident's medical record did not indicate that occurred. Incident reports from the previous 90 days were reviewed and there had been no incidents related to Resident #25. During observations from 11/08/2021 through 11/11/2021, the resident was not seen trying to crawl over the side rails or out of bed. During an interview on 11/09/2021 at 3:25 PM, the Director of Rehabilitation (DOR) stated all residents were screened for therapy upon admission. Physical therapy (PT) screened for bed mobility, and nursing determined if siderails were up when a resident was in bed and if siderail pads were used. PT did not determine a resident's siderail use. Siderails would be up when a resident was in bed to keep a resident from falling. The DOR then stated residents had tried to crawl over the siderails, and there was always the potential for injury with falls. There were no consents or formal assessments done to determine siderail usage. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. The MDS Coordinator further stated two siderails in the up position would be a restraint if they were stopping a resident from getting out of bed. They were not coding siderails as a restraint because residents used them for positioning. Siderail use should be in the care plan and reviewed monthly. Resident #25 should have one side rail in the up position for positioning when in the bed. During an interview on 11/10/2021 at 12:00 PM, the Director of Nursing (DON) stated there were no consents for siderails and they had no restraints in the building. The DON then stated a restraint was anything that impeded a resident's normal movement, and full siderails would only be a restraint if they were preventing a resident from getting out of bed. If a resident attempted to climb over or around a siderail, it could be more dangerous than if the siderail was not there. During an interview on 11/10/2021 at 12:12 PM, the Assistant Director of Nursing (ADON) stated facility staff should not put two siderails in the up position because a resident could injure themself on the siderails. Some CNAs would put both side rails up for resident safety, but that was a restraint. Resident #25 could get out of bed on their own and had a history of falls, so the CNAs would put both siderails up. During an interview on 11/10/2021 at 1:26 PM, the DON stated they were not aware the facility did not have a system to assess residents, get consents, and monitor siderail use. This was important for consistency and resident safety, and a resident should be able to move around. During an interview on 11/10/2021 at 1:40 PM, the Administrator stated a restraint was anything that restricted a resident's regular movement. The facility just implemented a siderail assessment on 11/10/2021 and would start getting consents for siderail use. The Administrator then stated it was important to assess residents and get consents so the resident and family could know the risks and benefits of siderail use. They needed to make sure a side rail was the safest recommendation for each resident. A review of the undated facility policy titled, Policy and Procedures for Restraints, revealed the facility's processes will address the use of restraints. These processes will recognize and protect residents' rights and ensure that when used, the restraints are safe and appropriate based upon a documented medical symptom. These processes utilize the key elements of care planning and delivery of the individually established plan of care that includes thorough assessments by interdisciplinary team member. A review of the facility's policy titled, Department of Nursing: Side Rails, dated 02/26/2009, revealed, All residents will be assessed by the nurse for safe use of side rails upon admission and readmission. 3. The facility admitted Resident #96 with diagnoses of toxic encephalopathy (neurologic disorder caused by exposure to heavy [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility admitted Resident #89 with diagnoses that included encephalopathy, seizure disorder, dementia, difficulty walking, and muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, which indicated severe cognitive impairment. The resident required extensive two-person physical assistance with bed mobility, transfers, and toileting, and required extensive one-person physical assistance with dressing, personal hygiene, locomotion, and eating. Bed rails were not indicated for use on the MDS. The November 2021 computerized physician orders (CPO) revealed and order with a start date of 09/14/2021 for one side rail up in bed for positioning. The revised care plan, updated 09/15/2021, revealed the resident had a neurological disease and seizure disorder. Interventions included pad to both upper side rails used and enablers for safety and monitor for complications caused by involuntary movement. The care plan did not specify how many bed rails to use according to the physician's orders. Resident #89 was observed on 11/08/2021 at 9:24 AM, 11:02 AM, and 2:26 PM with both side rails up while the resident was in bed. Both side rails were padded. Only one bed rail was ordered for use. Observations on 11/09/2021 at 10:00 AM and 2:30 PM revealed both side rails were padded and up while the resident was in bed. Only one bed rail was ordered for use. On 11/08/2021 at 2:30 PM, one arrow sticker was observed on the right side of the bed, indicating to floor staff that only the right bed rail should be used when the resident was in bed. An interview with Licensed Practical Nurse (LPN) #4, on 11/09/2021 at 2:43 PM, revealed bed rails were used for residents who had neurological disorders or seizures. LPN #4 said some residents used one bed rail for positioning. They said there were arrow stickers on the side of the headboards that indicated which bed rail to have raised. They said physician orders and consent were needed for residents to use bed rails. LPN #4 said nursing and the therapy department assessed the resident's need for bed rails. They said bed rails were included in the resident's care plan and included the reason for and number of bed rails. LPN #4 said Resident #89 had a seizure disorder and had orders for one siderail to be up for positioning. They said the resident should not have two bed rails up. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. They were not coding siderails as a restraint on the MDS because residents used them for positioning. The MDS Coordinator stated siderail use should have its own care plan but sometimes it was just listed in the interventions for other focus care areas. During an interview on 11/10/2021 at 2:45 PM at 2:45 PM, the Director of Nursing (DON) stated they expected a resident's care plan to be up to date and followed. The individualized care plan was in place so staff could recognize resident needs and provide individualized care based on personalized needs and preferences. During an interview on 11/10/2021 at 2:50 PM, the Administrator stated the expectation was that a resident's care plan was followed to ensure the best quality of care. Care plans needed to be individualized to each resident to ensure the physician's orders were followed to maintain optimum health. A review of the facility's policy titled, Department of Nursing: Care Planning, dated 08/13/2009, revealed, All residents will have an interdisciplinary care plan in conjunction with all MDS assessments. 5. The facility admitted Resident #133 with diagnoses that included Parkinson's, dementia, arthritis, and osteoporosis. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was three, which indicated severe cognitive impairment. The resident required extensive two-person assistance with bed mobility and dressing, and was totally dependent on one or two staff for transfers, bathing, locomotion, eating, toileting, and personal hygiene. The resident had no falls during the previous quarter but was an identified fall risk. Bed rail use was not indicated on the resident's MDS. The November 2021 computerized physician orders (CPO) revealed and order with a start date of 03/29/2021 for two side rails up in bed for positioning, every day. The revised care plan, updated 03/09/2021, revealed bed rails were not included in the resident's care plan as a focus or intervention. Resident #133 was observed on 11/08/2021 at 9:26 AM, 11:00 AM, and 2:28 PM with both side rails up while the resident was in bed. Observations on 11/09/2021 at 10:03 AM and 2:32 PM revealed both side rails up while the resident was in bed. On 11/09/2021 at 2:32 PM, two arrow stickers were observed on either side of the bed, indicating to floor staff that both bed rails should be used when the resident was in bed. Observations on 11/10/2021 at 9:03 AM and 2:18 PM revealed both side rails up while the resident was in bed. An interview with Licensed Practical Nurse (LPN) #4, on 11/09/2021 at 2:43 PM, revealed bed rails were used for residents who had neurological disorders or seizures. LPN #4 said some residents used one bed rail for positioning. They said there were arrow stickers on the side of the headboards that indicated which bed rail to have raised. They said physician orders and consent were needed for residents to use bed rails. LPN #4 said nursing and the therapy department assessed the resident's need for bed rails. They said bed rails were included in the resident's care plan and included the reason for and number of bed rails. LPN #4 said Resident #133 was a fall risk and would try to get out of bed without the siderails. They said the family of the resident requested the use of bed rails for the safety of the resident. LPN #4 said the resident had suffered no falls while residing at the facility. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. They were not coding siderails as a restraint on the MDS because residents used them for positioning. The MDS Coordinator stated siderail use should have its own care plan but sometimes it was just listed in the interventions for other focus care areas. During an interview on 11/10/2021 at 2:45 PM at 2:45 PM, the Director of Nursing (DON) stated they expected a resident's care plan to be up to date and followed. The individualized care plan was in place so staff could recognize resident needs and provide individualized care based on personalized needs and preferences. During an interview on 11/10/2021 at 2:50 PM, the Administrator stated the expectation was that a resident's care plan was followed to ensure the best quality of care. Care plans needed to be individualized to each resident to ensure the physician's orders were followed to maintain optimum health. A review of the facility's policy titled, Department of Nursing: Care Planning, dated 08/13/2009, revealed, All residents will have an interdisciplinary care plan in conjunction with all MDS assessments. New Jersey Administrative Code 8:39-11.1 Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive care plan for five (Resident #134, Resident #25, Resident #96, Resident #133, and Resident #89) of 30 residents reviewed for care planning. Findings included: 1. The facility admitted Resident #134 with diagnoses of, dysphagia (difficulty swallowing), dementia, chronic obstructive pulmonary disease, hypothyroidism, anemia, type two diabetes, and hyperlipidemia (high cholesterol). A review of Resident #134's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #134's cognitive skills for daily decision making were severely impaired. Resident #134 required extensive, two-person assistance with bed mobility. Further review of Resident #134's MDS revealed a bed rail was not used. A review of Resident #134's care plan, dated 07/19/2021, revealed a focus of skin integrity with an intervention in place to use side rail pads when in bed. The use of side rails was not listed as a focus or intervention on the care plan. A review of Resident #134's physician's consolidation of orders, dated 11/2021, revealed an order started on 07/16/2021 for one side rail up on the bed for positioning. An observation on 11/08/2021 at 10:30 AM revealed Resident #134 lying on their back in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. An observation on 11/08/2021 at 10:45 AM revealed Resident #134 lying on their back, leaning to the left while in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. An observation on 11/09/2021 at 12:15 PM revealed Resident #134 lying on their back, leaning to the left while in bed. A full side rail was in place on both sides of Resident #134. There was a pad in place over each side rail. During an interview on 11/09/2021 at 12:35 PM, Certified Nurse Aide (CNA) #1 stated Resident #134 was combative during care and moved around a lot while in bed. Resident #134 could move side to side while in bed, and the side rails were padded for protection from injury. CNA #1 further stated they did not know if Resident #134 tried to get out of bed, but the resident had not tried to crawl over the railings. During an interview on 11/09/2021 at 2:10 PM, CNA #2 stated Resident #134's side rails were padded because the resident was so combative and would fidget while in bed. The full side rails were in place to protect Resident #134 from falling out of bed. CNA #2 then stated there was an arrow pointing up on the left side of Resident #134's headboard telling staff the left side rail needed to be up, but there was not an arrow on the right side of the headboard. CNA #2 did not know why two side rails were up while Resident #134 was in the bed. During an interview on 11/09/2021 at 2:35 PM, Registered Nurse (RN) #1 stated Resident #134 had two side rails up while in bed because Resident #134 was restless and moved around a lot while in bed. Resident #134 did not try to get out of bed or crawl over the side rails, but Resident #134 was a high fall risk. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. They were not coding siderails as a restraint on the MDS because residents used them for positioning. The MDS Coordinator stated siderail use should have its own care plan but sometimes it was just listed in the interventions for other focus care areas. During an interview on 11/10/2021 at 2:45 PM at 2:45 PM, the Director of Nursing (DON) stated they expected a resident's care plan to be up to date and followed. The individualized care plan was in place so staff could recognize resident needs and provide individualized care based on personalized needs and preferences. During an interview on 11/10/2021 at 2:50 PM, the Administrator stated the expectation was that a resident's care plan was followed to ensure the best quality of care. Care plans needed to be individualized to each resident to ensure the physician's orders were followed to maintain optimum health. A review of the facility's policy titled, Department of Nursing: Care Planning, dated 08/13/2009, revealed, All residents will have an interdisciplinary care plan in conjunction with all MDS assessments. 2. The facility admitted Resident #25 with diagnoses of depression, hypertension, bipolar, anxiety, disorganized schizophrenia, and anxiety. A review of Resident #25's annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #25 required extensive two-person assistance with bed mobility. Further review of Resident #25's MDS revealed a bed rail was not used. A review of Resident #25's care plan, dated 08/10/2021, revealed a focus of activities of daily living (ADL) function. Resident #25 required extensive assistance with bed mobility, with an intervention of one side rail up when in bed to aid in positioning. A review of Resident #25's care plan, dated 08/10/2021, revealed a focus of history of falls. Resident #25 was a high risk for falls due to fall assessment, impaired balance, and mobility, with an intervention of one side rail up when in bed for positioning. A review of Resident #25's physician's orders, dated 11/2021, revealed an order started on 08/02/2018 for one side rail up for positioning. An observation on 11/09/2021 at 12:14 PM revealed Resident #25 lying in bed, leaning to the left side, and full side rails were in the raised position on each side of Resident #25. The bed was in the lowest position, with floor mats on each side of the bed. During an interview on 11/09/2021 at 12:40 PM, Certified Nurse Aide (CNA) #1 stated Resident #25 tried to climb over the rails and out of bed, which was why the full side rails and floor mats were in place for the resident's safety. An observation on 11/09/2021 at 2:08 PM revealed Resident #25 lying in bed, leaning to the left side. Full side rails were in the raised position on each side of the resident. Resident #25's knees were bent and leaning on the left side rail. During an interview on 11/09/2021 at 2:11 PM, CNA #2 stated when Resident #25 was in bed, the full side rails are in the up position and fall mats are on the floor because Resident #25 tried to climb out of bed. The side rails kept Resident #25 in the bed. CNA #2 further stated Resident #25 tried to crawl over the side rails and would scoot to the foot of the bed to get out through the opening between the end of the side rail and the footboard of the bed. CNA #2 further stated a resident's care plan reflects whether a resident should have raised siderails. There was an arrow on either the right or left side of the headboard telling staff which siderail needed to be raised. CNA #2 further stated they did not know why both siderails were in the up position when Resident #25 had only one arrow on the right side of the headboard. During an interview on 11/09/2021 at 2:35 PM, Registered Nurse (RN) #1 stated Resident #25 had a low bed, full side rails, and floor mats on the floor next to the bed because the resident tried to crawl out of bed. Resident #25 would also scoot down to the foot of the bed and get of the bed through the opening between the end of the siderail and the footboard. RN #1 further stated Resident #25 had been found on the mats at the foot of the bed but had never climbed over the siderail. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. They were not coding siderails as a restraint on the MDS because residents used them for positioning. The MDS Coordinator stated siderail use should have its own care plan but sometimes it was just listed in the interventions for other focus care areas. During an interview on 11/10/2021 at 2:45 PM at 2:45 PM, the Director of Nursing (DON) stated they expected a resident's care plan to be up to date and followed. The individualized care plan was in place so staff could recognize resident needs and provide individualized care based on personalized needs and preferences. During an interview on 11/10/2021 at 2:50 PM, the Administrator stated the expectation was that a resident's care plan was followed to ensure the best quality of care. Care plans needed to be individualized to each resident to ensure the physician's orders were followed to maintain optimum health. A review of the facility's policy titled, Department of Nursing: Care Planning, dated 08/13/2009, revealed, All residents will have an interdisciplinary care plan in conjunction with all MDS assessments. 3. The facility admitted Resident #96 with diagnoses of toxic encephalopathy (a neurological disorder caused by exposure to heavy metals), sepsis, chronic obstructive pulmonary disease, Alzheimer's disease, dementia, anxiety, and depression. A review of Resident #96's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Further review of Resident #96's MDS revealed a bed rail was not used. A review of Resident #96's care plan, dated 07/01/2021, revealed a focus of skin integrity with an intervention of a side rail pad to the one side rail when in bed. The use of side rails was not listed as a focus or intervention on the care plan. A review of Resident #96's physician's orders, dated 11/2021, revealed an order started on 08/12/2021 for one side rail up for positioning. An observation on 11/08/2021 at 10:30 AM revealed Resident #96 lying in bed with two full side rails in the up position. Resident #96 was resting their head on one of the side rails, and no padding was present on the rails. An observation on 11/08/2021 at 12:15 PM revealed Resident #96 lying in bed with two full side rails in the up position. An observation on 11/08/2021 at 3:07 PM revealed Resident #96 lying in bed with two full side rails in the up position. During an interview on 11/09/2021 at 12:28 PM, Certified Nurse Aide (CNA) #1 stated the two side rails were in the up position to prevent Resident #96 from getting out of bed. Resident #96 had never tried to climb over the side rails. During an interview on 11/09/2021 at 1:05 PM, CNA #7 stated the two side rails were in the up position because Resident #96 was confused and would try to leave the bed on their own. During an interview on 11/09/2021 at 2:15 PM, CNA #2 stated Resident #96 tried to get out of bed on their own, and the two side rails were in the up position for safety. An observation on 11/09/2021 at 2:27 PM revealed no arrow on either side of the headboard indicating which side rail was to be in the up position. During an interview on 11/09/2021 at 2:35 PM, Registered Nurse (RN) #1 stated the two side rails were in the up position because Resident #96 tried to get up out of bed. RN #1 further stated the pads were in place because if a resident leaned on the siderails too long it could cause redness or bruising. During an interview on 11/10/2021 at 10:24 AM, the MDS Coordinator stated they had no restraints in the building. The MDS Coordinator then stated nursing should do a siderail assessment for siderail use; this assessment was implemented starting 11/10/2021 because siderails were being investigated. They were not coding siderails as a restraint on the MDS because residents used them for positioning. The MDS Coordinator stated siderail use should have its own care plan but sometimes it was just listed in the interventions for other focus care areas. During an interview on 11/10/2021 at 2:45 PM at 2:45 PM, the Director of Nursing (DON) stated they expected a resident's care plan to be up to date and followed. The individualized care plan was in place so staff could recognize resident needs and provide individualized care based on personalized needs and preferences. During an interview on 11/10/2021 at 2:50 PM, the Administrator stated the expectation was that a resident's care plan was followed to ensure the best quality of care. Care plans needed to be individualized to each resident to ensure the physician's orders were followed to maintain optimum health. A review of the facility's policy titled, Department of Nursing: Care Planning, dated 08/13/2009, revealed, All residents will have an interdisciplinary care plan in conjunction with all MDS assessments.

Based on observations, interviews, and record reviews, it was determined that the facility failed to clean the glucometer used to test blood sugars for two of two residents (Resident #64 and Resident #82) during medication pass. The facility also failed to maintain the integrity of a clean area of the unit by exiting the isolation area without discarding their personal protective equipment (PPE) and by removing resident's water pitchers for one of one isolation unit observed (second floor). This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. Findings included: 1. The facility admitted Resident #82 on 03/16/2020 with diagnoses that included diabetes mellitus. Review of the current physician's orders included directions for the staff to check the resident's blood sugar before meals and at bedtime. On 11/09/2021 at 8:33 AM, Registered Nurse (RN) #1 was observed taking the glucometer out of the medication cart. Taking the glucometer to Resident #82 with gloves on, the nurse performed the blood glucose test for Resident #82. RN #1 then took the glucometer and placed the glucometer onto the medication cart top. She removed her gloves and placed the gloves and the blood glucose strip into the sharps container. RN #1 then donned gloves, removed an alcohol pad from the medication cart, opened the pad and cleaned the glucometer. She placed the glucometer on the top of the medication cart and disposed of the gloves. When interviewed at this time, RN #1 stated she was unsure of what bacteria and viruses the alcohol wipe killed. RN #1 stated this was her normal way of cleaning the glucometer. RN #1 was then observed going into Resident #64's room. RN #1 took the glucometer into Resident #64's room, completed the fingerstick blood sugar test, and then placed the glucometer on top of the medication cart. RN #1 removed her gloves and then donned a clean set of gloves. The nurse wiped the glucometer with two alcohol wipes and then placed the glucometer back on top of the medication cart. After removing the gloves, RN #1 placed the glucometer in the top drawer of the medication cart. Licensed Practical Nurse (LPN) #5 was interviewed on 11/10/2021 at 10:30 AM. LPN #5 stated a special cleaning wipe stored in a purple plastic tub was used to clean glucometers. The LPN removed the plastic tub of wipes from the bottom drawer of the medication cart and showed a tub of Germicidal Disinfectant wipes and explained the wipes had bleach in them. LPN #5 stated after using a glucometer, the staff were expected to wipe the glucometers with the disinfectant cloth, cover the glucometer with the cloth for a specified amount of time, but could not give the specified time, and then allow the glucometer to dry before using it on another resident. The Assistant Director of Nursing (ADON) was interviewed on 11/10/2021 at 12:12 PM. The ADON identified themself as the Infection Preventionist for the facility. The ADON stated staff were expected to use the wipes containing bleach when cleaning the glucometer. The ADON added after cleaning the glucometer, staff should allow the glucometer to air dry before completing a fingerstick blood sugar test on the next resident. The ADON stated alcohol wipes should not be used since the alcohol wipes were an antiseptic agent (a cleaning agent used to reduce organisms and reduce the chance of infection) and not a germicidal agent (a cleaning agent that kills bacteria and viruses). The Director of Nursing (DON) was interviewed on 11/11/2021 at 9:48 AM. The DON stated staff had been taught and were expected to use wipes that contained bleach to clean glucometers. The DON stated since blood could not always be visualized on the glucometers, an agent that killed germs needed to be used. The DON stated an alcohol wipe would not be effective in cleaning the glucometer. The Administrator was interviewed on 11/11/2021 at 10:30 AM. She stated her expectation included staff following the facility's policy to clean glucometers. Review of the facility's policy, Extended Precautions, revised July 2019 indicated, shared equipment (Accucheck [glucometer] machine, pulse oximeter, etc.) must be cleaned and disinfected (with Dispatch---see policy and procedure) according to the manufacturer's recommendation, prior to use with another resident. Review of the Assure Platinum Blood Glucose Monitoring System user instruction manual indicated on page 47, that the glucometer could be cleaned and disinfected using a commercially available EPA-registered disinfectant detergent or germicidal wipe. 2. On 11/08/2021, 11/09/2021, 11/10/2021, and 11/11/2021, a plastic barrier curtain with a zippered opening was observed on the second floor on the right side of the elevator entrance. On the plastic curtain were signs that indicated the resident care area behind the plastic zippered curtain was an isolation area. Signs on the plastic barrier curtain indicated all personal protective equipment (PPE) should be used. A cart with PPE was observed sitting at the edge of the closed curtain. The cart was filled with gowns available for staff use. On the resident care side of the plastic zippered barrier was a large trash receptacle that was easily available for staff use. Observations were made during the initial tour of the isolation unit on 11/08/2021 of staff going in and out of the plastic barrier curtain without removing their PPE although there was a trash can on the dirty side of the plastic curtain. On 11/09/2021 at 2:45 PM, observations were made of Certified Nursing Assistant (CNA) #9 going from the resident care isolation area through the plastic zippered barrier without removing her gown. The CNA was observed going to the kitchen area of the unit and returned to the resident care isolation unit with the gown remaining in place. On 11/10/2021 at 9:26 AM, CNA #9 was observed leaving the resident isolation unit wearing her isolation gown. The CNA had a resident's water pitcher in her hand. The CNA unzipped the plastic barrier and took the water pitcher to the kitchen area of the unit and then returned through the plastic barrier and into the resident isolation area. At this time, the CNA acknowledged she had removed a resident's water pitcher from the isolation area of the unit, taken the pitcher to the kitchen which was not included in the isolation area, filled the pitcher with ice and water and returned. CNA #9 was able to explain the plastic zippered barrier was placed to separate the isolation area from the area that was not on isolation. The CNA was able to explain the trash bin was there for staff to use for PPE. CNA #9 stated they had been taught the only time PPE had to be removed was when staff left the second floor and went to another floor. The CNA was unable to remember who had taught that. On 11/10/2021 at 9:30 AM, CNA #2 was seen wearing PPE as they unzipped the plastic barrier and exited to the kitchen area. On return, the CNA did not use hand sanitizer and was carrying a box of cereal and a spoon they retrieved from the kitchen area. The CNA stated the plastic barrier was to keep the germs from the isolation area apart from the rest of the unit and the trash bin was for disposal of PPE prior to leaving the unit. When asked, the CNA stated a nurse (could not identify the nurse) had told the CNA that PPE was okay to wear beyond the plastic barrier and into the kitchen and then return to the isolation unit. Licensed Practical Nurse (LPN) #5 was interviewed on 11/10/2021 at 10:30 AM. LPN #5 reported having worked several days in the residential isolation unit. The LPN stated the plastic barrier with a zipper had been placed due isolation initiation after a co-worker had tested positive for COVID-19. The nurse stated the trash bin was by the curtain so PPE could be disposed of before leaving the unit. LPN #5 added all gowns should be removed before exiting the isolation unit, even if the staff were going to the kitchen area of the unit that was outside the curtain. On return, staff were expected to don a new gown and use hand sanitizer before entering the isolation unit. The Assistant Director of Nursing (ADON) was interviewed on 11/10/2021 at 12:12 PM. The ADON stated they functioned as the infection preventionist (IP) for the facility as well. The ADON stated the zippered plastic barrier had been installed to provide isolation after the residents had a potential exposure to a staff member with COVID-19. The ADON added the purpose of the plastic barrier was to provide a division between the dirty area where the residents lived and the clean area which was where the dining area and kitchen were located. The ADON added the expectation was for staff to doff their gowns prior to leaving the isolation unit and dispose of the gowns in the trash bin by the curtain. On return to the isolation unit staff should don a new gown and use hand sanitizer. The ADON stated as the facility's IP the expectation was that staff follow the generally accepted practice for donning and doffing PPE in an isolation area. The Director of Nursing (DON) was interviewed on 11/11/2021 at 9:48 AM. The DON stated the isolation unit started as staff walked through the zippered plastic barrier. The DON added that gowns were available as soon as staff arrived on the unit and staff were expected to have gowns on before entering through the zippered plastic barrier. On exiting the unit, the DON stated staff were expected to remove the gown and place the gown in the trash bin before passing through the zippered plastic barrier. The DON added residents' water pitchers should not be taken outside of the isolation area since this would contaminate the clean area including the dining area and the kitchen. The Administrator was interviewed on 11/11/2021 at 10:30 AM and verbalized the expectation that staff were to follow the infection control policy and guidelines for isolation. New Jersey Administrative Code § 8:39-19.4(a)1-6