Every finding on record at Accela Post Acute Care at Hamilton

Based on interviews, medical record review and review of pertinent facility documents on 10/20/2025 and 10/24/2025, it was determined that the facility failed to: a.) ensure that pressure ulcers were initially documented, assessed, and measured weekly as required by professional standards of practice; b.) implement and update care plans (CP) after a change in condition; c.) provide treatment and services to prevent two facility acquired pressure ulcers; one stage 3 and one stage 4.A review of Resident #3's Electronic Medical Record (EMR) revealed the resident arrived to the facility with no evidence of a pressure ulcer. Additional review of the EMR revealed a lack of adherence to physician orders, lack of monitoring, a failure to implement CP, and a lack of assessments resulting in Resident #3 developing a stage 3 and a stage 4 pressure ulcer within 9 days of admission.This deficient practice occurred for 1 of 3 residents reviewed for pressure ulcers (Resident #3). This deficient practice was evidenced by the following:A review of the admission Record (an admission summary) reflected that Resident #3 was admitted to the facility with diagnoses that included but were not limited to; Acute osteomyelitis (bone infection) of the right ankle and foot, and orthopedic aftercare following surgical amputation (removal of body part).A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 07/22/2025, reflected that Resident #3 had a Brief Interview for Mental Status score (BIMS) of 11 out of 15, indicating that the resident was moderately impaired. Section M0210 revealed no pressure ulcer/injuries.A review of the the universal transfer form dated 07/15/2025 revealed a surgical wound and did not identify any pressure ulcers when Resident #3 transferred to the facility.Review of Resident # 3's admission assessment dated [DATE] revealed that no pressure ulcers were identified on admission to the facility. During an interview on 10/20/2025 at 1:40 P.M., the Unit Manager (UM) stated Resident #3 did not have pressure ulcers on arrival. A review of Resident # 3's CP reveals a focus of Resident has a potential to develop Pressure Injury related to decreased/limited mobility with an initiated date of 7/17/2025 and an intervention of Weekly skin assessment and document. Report any changes. A review of Resident #3's EMR showed no evidence of weekly skin assessments. During an interview on 10/20/2025 at 1:40 P.M., the UM stated [Resident #3] does not have a completed skin assessment weekly like he should.A facility document labeled #1636 Pressure Skin Injury Date 7/24/2025 11:30 revealed [Resident #3] has a pressure wound to [their] bilateral buttock. A review of Resident #3's EMR showed no evidence of an initial wound assessment. During an interview on 10/20/2025 at 1:40 P.M., the UM stated there is no skin only eval [evaluation] from 7/24, when the wound was found. During an interview on 10/20/2025 at 2:18 P.M., the Director of Nursing (DON) stated that if a wound is found the nurse should complete a skin eval [evaluation] every time.if it's not documented, it's not done.A review of Resident #3's Progress Notes (PNs) from admission revealed no communication regarding a pressure injury until a PN dated 07/24/2025 at 2:40 P.M., when LPN #4 documented Writer was notified by nursing aide [certified nursing assistant] that resident [Resident #3] has wounds on [their] buttock that needed to be dressed. [Resident #3] does not have any current orders to administer wound care. Writer went to assess patients' buttock. [Resident #3] has a pressure wound to [their] bilateral buttock.MD notified of wounds. In an interview with UM on 10/20/2025 at 1:40 P.M., the UM said it's rare for a person to find a stage 4 wound for the first time and that Resident #3 did not have a pressure ulcer on arrival.A review of Resident #3's Order Summary Report (OSR) from 07/15/2025 through 08/12/2025 showed an order placed on 7/25/2025 for Secura Protective External Cream 10% (Zinc Oxide (Topical)). Apply to right buttock topically every shift for Skin integrity and Medihoney Wound/Burn Dressing External Gel (Wound Dressings) Apply to left buttock topically every day shift for wound care cleanse wound with NSS [normal saline solution], pat dry. Apply medihoney and cover with optifoam dressing. The OSR revealed an order placed on 7/27/2025 for Medihoney Wound/Burn Dressing External Gel. Apply to bilateral buttock topically every day shift for wound care cleanse wound with NSS, pat dry. Apply medihoney and cover with optifoam dressing. A review of Resident #3's EMR showed no evidence of daily wound assessments or daily wound care was provided. A review of the PN dated 8/09/2025 at 5:08 A.M., revealed Dressing done to sacral wound. There was no further evidence that daily wound assessments or daily wound care was provided.In an interview on 10/20/2025 at 11:34 A.M., Licensed Practical Nurse (LPN) #1 stated wound care is done daily. In an interview on 10/24/2025 at 10:06 A.M., the UM stated that nurses should document every wound care daily in the nurses' notes or the Treatment Administration Record (TAR). The UM further stated no I don't see daily wound documentation in [Resident #3's] chart, no the policy was not followed.A review of Resident # 3's CP revealed a focus of I have PRESSURE INJURY OF STAGE 4 ON MY RT (right) BUTTOCK AND STAGE 3 ON MY LT (left) BUTTOCK r/t [related to] Decreased/limited mobility., Incontinence, AND BKA [below knee amputation] with an initiated date of 7/29/2025 and an intervention of Assess/record/monitor wound healing (SPECIFY FREQ) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 07/31/2025. During an interview on 10/20/2025 at 1:40 P.M., the UM stated the incident report was put in on 7/24/2025 and the CP was not put in until 7/29/2025 but there should be a CP from the start.A review of Resident #3's TAR from July 2025 and August 2025 revealed no evidence the wound care treatments were implemented for Resident #3's bilateral buttocks wounds from 07/24/2025 through 08/12/2025.A review of the Documentation Survey Record (DSR) V2 for July 2025 indicated an intervention/task of Barrier Cream after incontinence care. The review revealed that this task was not initialed as completed for:9 of 16 day shifts as follows, July 16, 17, 21, 22, 25, 26, 28, 30 and 31, 2025.9 of 16 evening shifts as follows, July 16, 17, 19, 20, 22, 25, 26, 27, and 31, 2025.6 of 17 night shifts of July 21, 22, 25, 26, 27, and 31, 2025.Further review indicated an intervention/task of MONITOR - Turn and reposition. The review revealed that this task was not initialed as completed for:9 of 16 day shifts as follows, July 16, 17, 21, 22, 25, 26, 28, 30 and 31, 2025.9 of 16 evening shifts as follows, July 16, 17, 19, 20, 22, 25, 26, 27, and 31, 2025.6 of 17 night shifts of July 21, 22, 25, 26, 27, and 31, 2025.A review of the DSR V2 for August 2025 indicated an intervention/task of Barrier Cream after incontinence care. The review revealed that this task was not initialed as completed for:3 of 12 day shifts as follows, August 1, 5, & 7, 2025.9 of 11 evening shifts as follows, August 1, 2, 3, 5, 6, 7, 8, 9, & 11,2025.9 of 11 night shifts as follows, August 1, 2, 3, 5, 6, 7, 9, 10, & 11, 2025.Further review indicated an intervention/task of MONITOR - Turn and reposition. The review revealed that this task was not initialed as completed for:3 of 12 day shifts as follows, August 1, 5, & 7, 2025.9 of 11 evening shifts as follows, August 1, 2, 3, 5, 6, 7, 8, 9, & 11,2025.9 of 11 night shifts as follows, August 1, 2, 3, 5, 6, 7, 9, 10, & 11, 2025.A review of Resident #3's EMR showed no evidence the orders were implemented as ordered.In an interview on 10/20/2025 at 9:02 A.M., Certified Nursing Assistant (CNA) #2 stated they check residents every 2 hours, and more frequently if needed, for incontinence and it is documented at the end of their shift in the POC (Plan of Care), or the Documentation Survey Report (DSR). In an interview on 10/20/2025 at 1:40 P.M., when questioned about documentation, the UM stated the CNAs document in the POC for incontinence and repositioning and if it is not documented, then it is not done. In an interview on 10/20/2025 at 2:18 P.M., when questioned about documentation, the Director of Nursing (DON) stated the CNAs should get report from the nurses and the CNAs are expected to document in the POC. The DON further stated if it's not documented, it's not done.A review of Resident #3's EMR reveals wound evaluations for both wounds were initially documented with measurements on 7/29/2025. In an interview on 10/20/2025 at 1:40 P.M., the UM stated it's not typical to wait 5 days for wound evaluations and that there should be skin evaluations completed after the wound is identified from the start of the wound.A review of Resident #3's EMR revealed no documentation of notification to Resident #3's family. In an interview on 10/24/2025 at 10:06 A.M., the UM stated I don't have anything documented that the [representative] was notified. In an interview on 10/20/2025 at 2:18 P.M., the DON stated when a wound is identified the family should be notified.A review of Resident #3's Weekly Wound Evaluation V2 with an effective date of 7/29/2025 and electronically signed on 7/31/2025 by the UM revealed the following:Wound #1Wound Location: RT ButtockEtiology: AcquiredType: PressureStage: IVOverall impression: First observation, no reference, epithelial tissue present (pink)Drainage: Moderate SerousWound measurements length X width X Depth: 4.0X2.0X0.7 [unit of measure not specified]Peri-wound tissue: Normal, irregularTreatment: Medihoney and daily dressing changes - offload when possible Wound #2Wound Location: LT ButtockEtiology: AcquiredType: PressureStage: IIIOverall impression: First observation, no reference, epithelial tissue present (pink)Drainage: Moderate SerousWound measurements length X width X Depth: 4.0X1.0X2.0 [unit of measure not specified]Peri-wound tissue: Normal, irregularTreatment: Medihoney and daily dressing changes - offload when possible Review of Resident #3's Weekly Wound Evaluation V2 with an effective date of 8/05/2025 and electronically signed on 8/6/2025 by the UM revealed the following:Wound #1Wound Location: RT ButtockEtiology: AcquiredType: PressureStage: IVOverall impression: Improving, epithelial tissue present (pink)Drainage: Moderate SerousWound measurements length X width X Depth: 3.0X1.0X0.4 [unit of measure not specified]Peri-wound tissue: Normal, irregularTreatment: Medihoney and daily dressing changes Wound #2Wound Location: LT ButtockEtiology: AcquiredType: PressureStage: IIIOverall impression: improving, epithelial tissue present (pink)Drainage: Moderate SerousWound measurements length X width X Depth: 2.0X1.0X0.2 [unit of measure not specified]Peri-wound tissue: Normal, irregularTreatment: Medihoney and daily dressing changes In an interview on 10/24/2025 at 10:06 A.M., the UM stated based on the review of the CP and facility policy that Resident #3 was not being properly monitored for wounds. In an interview on 10/24/2025 at 11:20 A.M., the DON stated that Resident #3 did not have a pressure ulcer on arrival to the facility and that an assessment should have been completed when the wound was discovered. She further stated the nurses are expected to provide care as described in the physician's orders and are expected to be documenting based off the policy; indicating that the documentation should be thorough and should reflect what's going on in real time. When questioned if Resident #3's wound was monitored according to the facility's policy the DON stated, No.In an interview on 10/20/2025 at 11:12 A.M., CNA #1 stated that when a resident is admitted to the facility the CNA and a nurse will complete a skin assessment on arrival to evaluate any skin concerns and the nurse will document the concerns.In an interview on 10/20/2025 at 11:34 A.M., LPN #1 stated for new residents admitted to the facility they complete a skin assessment and document it in the skin assessment profile.A review of the facility's policy titled Pressure Injury Risk Assessment with a revised date of March 2020 revealed under General Guidelines: 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition, under Documentation: The following information should be recorded in the resident's medical record utilizing facility forms: 2. The date and time and type of skin care provided, if appropriate . 4. Any change in the resident's condition if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified .13. Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care, if indicated, and under Reporting: 4. Notify Family, guardian or resident update if new skin alteration noted.A review of the facility's policy titled Prevention of Pressure Injuries with a revised date of April 2020 revealed under Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADL's (Activities of Daily Living).A review of the facility's policy titled Wound Care with a revised date of October 2010 revealed under Preparation: 1. Verify that there is a physician's order for this procedure and under Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc) obtained when inspecting the wound.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed under Policy Interpretation and Implementation: 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.

Complaint #: 2638834Based on interview and review of facility documents on 10/20/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 09/28/25 through 10/11/2025, revealed that the facility failed to provide RN coverage for all shifts on 09/28/25 and 10/06/2025.The surveyor reviewed the facility's policy titled Staffing updated October 2017 which indicated under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment and under Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.NJAC 8:39-25.2(h)

Repeat Deficiency Based on observations, interviews, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. Prior to the survey, the surveyor accessed the facility's website which listed the facility's name as Accela Post Acute Care at [NAME] at the address listed for the registered name Spring Hills Post Acute [NAME]. On 2/4/25 at 7:30 AM, upon arrival to the facility, the surveyors observed signage on the building which read, Accela Post Acute Care [NAME]. That name did not correspond with the CMS licensed, approved name and provider registered name Spring Hills Post Acute [NAME]. On 2/4/25 at 7:35 AM, upon entering the facility, the surveyors observed signage on the wall which read Spring Hills Post Acute [NAME]. The surveyor observed a sign on the receptionist desk in the front lobby which read Accela Post Acute Care [NAME]-All Visitors, please SIGN IN . At that time, License Practical Nurse/Supervisor (LPN/S) #1 greeted the surveyors wearing a black jacket with the logo Accela. On 2/4/25 at 10:23 AM, during entrance conference with the surveyor, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated Accela was managing the facility as of 9/1/24 and they (Accela) are in the process of buying it. At that time, the surveyor requested the NJ approved license and the application, form 855B, for the name change to CMS from the LNHA. A review of the facility provided license revealed the New Jersey Department of Health Division of Certificate of Need & Licensing issued a license to [NAME] AMOP, LLC (Limited Liability Company) was licensed to operate Spring Hills Post Acute [NAME], effective 5/1/2024, Expires: 4/31/2025, Issued: 4/19/2024. On 2/4/25 at 3:15 PM, the surveyor interviewed the LNHA and the Regional LNHA, who stated the signage on the building was changed on 1/3/25. At that time, the LNHA provided a letter dated 9/10/24, to the Department of Health Certificate of Need and Healthcare Facility Licensure. A review of the letter dated September 10, 2024, revealed .effective September 4, 2024, [NAME] AMOP LLC, the licensed operator of the skilled nursing facility formerly doing business as Spring Hills Post Acute [NAME] has changed its trade name to Accela Post Acute Care at [NAME] .The change is limited to the doing business as name only. On 2/7/25 at 10:00 AM, during a follow up interview with the surveyor, the LNHA confirmed no approval for name change could be provided. He stated he spoke to his corporate office and 2 lawyers who stated they (the facility) only needed to do the notification. The LNHA also confirmed at that time the 855B notification to CMS was not completed. On 2/7/25 at 12:59 PM, the survey team met with the LNHA, DON, Regional LNHA, and the [NAME] President of Nursing and presented the above concerns. On 2/07/25 at 03:04 PM, a review of 10 employee files revealed 5 of those employees signed an Accela onboarding packet. A review of the packet revealed a memorandum (memo), dated 8/27/2024. The memo was on Accela Healthcare letter head with the Subject Line: Welcome to the Accela Family. Further review of the memo read: On behalf of the entire Healthcare team, we are thrilled to welcome you to the Accela Family .Our goal is to ensure that this transition is as seamless as possible. The letter was signed by the Director of Recruitment and Employee Experience. The packets were signed by the following employees: -Occupational Therapist #1, Date of Hire (DOH) 4/24/2015 -LPN/Unit Manager #1 DOH 7/22/24 -LPN #2, DOH 7/22/24 -Housekeeper, DOH 4/1/ 2018 -Registered Nurse # 1 DOH 8/24/2023 No additional information regarding the facility's name change was provided to the team. NJAC 8:39-5.1 (a)

Complaint # NJ 183474 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to document the circumstance for which randomly selected residents, from the facility provided discharge list from 9/1/24 to 2/14/25, were discharged to another long-term care (LTC) facility, for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed.This deficient practice was evidenced by the following: 1.The surveyor reviewed the electronic medical record (EMR) for Resident #182. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/24/24, revealed the resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. A review of the individual comprehensive care plan (ICCP) revealed a focus of resident wants to stay at facility, dated 8/16/23. A review of the progress notes revealed the following: -On 9/17/2024 at 22:16 (10:16 PM), A Social Service Note, Late Entry: Note Text: SW met with resident and discussed with POA (power of attorney) regarding LTC transfer. Provided options would like to proceed with [name redacted] transfer next week. -On 9/24/2024 at 9:18 AM, Social Service Note, Note Text: Resident scheduled for LTC transfer today to [name redacted]. Resident, POA still in agreement with this plan. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 2.The surveyor reviewed the EMR for Resident #183. A review of the Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus with Diabetic polyneuropathy (a condition in which the body has trouble controlling blood sugar and can cause nerve damage) and dysphagia, unspecified (difficulty swallowing). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 10 out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of the resident is LTC at facility, Date initiated: 12/20/23. A review of the progress notes revealed the following: - On 9/4/2024 at 14:03 (2:03PM), Social Service Note. Late Entry: Note Text: SW met with resident and spoke with POA via phone to discuss LTC transfer. Requested records be sent to [2 LTC facility names redacted]. -On 9/6/2024 at 14:04 PM, Social Service Note. Late Entry: Note Text: SW spoke with resident and family who want to proceed with LTC transfer to [name redacted]. Set up transport for p/u between 11-2 on 9/12 per their request . All parties in agreement with this plan. -On 9/11/2024 at 14:05 (2:05 PM), Social Service Note, Late Entry: Note Text: SW spoke with resident, family and [name redacted] to confirm d/c (discharge)for tomorrow. -On 9/12/2024 at 15:25 (3:25 PM), Nursing Note, Narrative: Resident escorted by family and was discharged to another facility. On 02/14/25 at 11:38 AM, the surveyor interviewed Resident #183's the resident's representative (RR)on the phone. The RR stated Resident #183 told the RR's spouse that they have to leave because the facility was bought out and the permanent (LTC) residents had to leave. The RR informed the surveyor that the resident was in that facility because it was local to the family. The RR added that everyday a family member would go to the facility. Resident #183 told the RR they (the facility) called a meeting with the suit. They gathered in the lunch area and told all the permanent residents that they had been bought out and they (the LTC residents) have to find a dwelling elsewhere and the facility will help as much as they can. The RR stated, we were not given a choice, all LTC had to leave immediately. We were completely shocked. The RR stated the SW was a great help to them. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 3. The surveyor reviewed the EMR for Resident #184. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and difficulty walking, not elsewhere classified. A review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 8 out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of resident wishes to remain LTC. Date initiated: 5/8/2024. A review of the progress notes revealed the following: -On 8/12/2024 at 12:42 PM. Social Service Note.Late Entry: Note Text: Annual care conference held with resident and POA, alongside team .continues with long term care status under MLTSS. Does not wish to be asked about return to the community .has no unwanted behaviors and is pleasant and cooperative with care, reports satisfaction overall. -On 9/11/2024 at 14:24 (2:42PM), Social Service Note.Late Entry: Note Text: SW spoke with resident and POA regarding LTC transfer. Requested records be sent to [name redacted for 2 LTC facilities]. -On 9/16/2024 at 14:24 (2:24 PM). Social Service Note. Late Entry: Note Text: Resident has been accepted to both facilities and would like to proceed with transfer to [name redacted] on 9/20. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 4. The surveyor reviewed the EMR for Resident #185. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Parkinsonism, unspecified (a disorder of the central nervous system that affects movement, often including tremors) and dysphagia, unspecified (difficulty swallowing). A review of the quarterly MDS, an assessment tool dated 9/24/24 revealed the resident had a BIMS score of 14 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of resident wishes to remain at facility. Date initiated: 6/6/2023. A review of the progress notes revealed the following: - On 11/21/2024 at 18:04 (6:04PM). Physician / Medical Provider Progress Notes . discharge planning to long-term care facility; Meds reviewed, continue current medication on discharge. - On 12/23/2024 at 12:33 PM. Nursing Note. Narrative: Pt (patient) was picked up . discharging to [name of LTC facility redacted]. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 5. The surveyor reviewed the EMR for Resident #186. A review of the AR, revealed the resident was admitted to the facility with diagnoses which included but were not limited to; amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function) and muscle wasting and atrophy not elsewhere classified, unspecified site. A review of the comprehensive MDS, an assessment tool dated 11/10/24, revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of the resident wishes to return home alone with private HHA (home health aide), Date Initiated: 11/03/2024 with an intervention of establish a pre-discharge plan with the resident/family/caregivers and evaluate progress, Date Initiated: 11/03/2024. A review of the progress notes revealed the following: - On 1/14/2025 at 20:17 (8:17PM) Physician / Medical Provider Progress Notes, revealed a Note Text: Pt is doing ok .will be transferred to a long-term facility soon. -On 1/15/2025 at 19:05 (7:05 PM), Nursing Note Narrative: At 5:34 pm, resident was discharged and transported to another nursing facility. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 6. The surveyor reviewed the EMR for Resident # 187 A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection, site not specified, Sepsis unspecified organism, and Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere. A review of the comprehensive MDS, dated [DATE], revealed the resident had a BIMS score of 11out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of [name redacted] wishes to remain at facility, Date initiated 8/3/23, a goal of [name redacted] will be long term placement in the facility, Date initiated 8/3/2023. A review of the progress notes revealed the following: - On 8/19/2024 at 14:08 (2:08 PM). Social Service Note, Late Entry: Note Text: Quarterly IDCP (interdisciplinary care plan) meeting held with resident and family via phone alongside team. Resident continues with LTC status, private pay. - On 9/20/2024 at 09:55 AM, Social Service Note, Late Entry: Note Text: SW spoke with resident and family regarding LTC transfer. They would like referrals sent to [names redacted of 5 LTC facilities]. Family will be touring the facilities in the upcoming days. -On 9/30/2024 at 09:56 AM, Social Service Note, Late Entry: Note Text: SW spoke with resident and [resident representative]. They are requesting LTC transfer on 10/2 to [name redacted] . set up transportation for 4:30 pick up. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. 7. The surveyor reviewed the EMR for Resident #188. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus without complications (a condition in which the body has trouble controlling blood sugar) and cellulitis of right lower limb (a serious bacterial skin infection). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS of 15 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of resident wishes to remain LTC, Date Initiated: 06/30/2024 with a goal of will be long term placement in the facility, Date Initiated: 09/22/2023. A review of the progress notes revealed the following: - On 9/4/2024 at 14:19 (2:19 PM),Social Service Note, Late Entry: Note Text: SW met with resident regarding LTC transfer. [identifier redacted] request I send records to [name redacted] and [name redacted]. - On 9/11/2024 at 14:20 (2:20 PM), Social Service Note, Late Entry: Note Text: Resident has been accepted to [name redacted] for LTC transfer and would like to proceed with d/c (discharge) on 9/18. Additional review of the EMR did not reveal documentation to support the reason for the transfer to another long-term care facility. On 2/14/24 at 10:28 AM, the surveyor interviewed Resident #188 on the telephone. The resident was agreeable to speak to the surveyor and confirmed that they were at another long-term care facility. The resident stated when they were admitted to the facility in 2023, they (the facility) didn't know what my plan (LTC) was. The facility suggested LTC and I was going to stay there (Springhills). The surveyor asked when did the facility tell you that you couldn't stay, They did not tell us that I could stay. The resident asked the surveyor to hold because someone was there helping them get out of bed, the call was disconnected. The surveyor tried multiple times to call the resident back but there was no answer. On 2/14/25 at 12:49 PM, the surveyors interviewed the Social Worker (SW), who stated she meets with residents and their family within 72 hours of admission for a care conference to talk about discharge planning. She stated upon request by a resident or their family would be a situation where a resident would leave the facility to another LTC facility. The SW stated if the resident transitions to LTC, she would assist or refer them with Medicaid planning, financial planner and/or elder care advisors. She stated the facility has always been both short term and LTC. The SW stated the new company came in September and the companies regional spoke to the staff that the company was geared more towards short-term rehab. The SW stated between her and the Licensed Nursing Home Administrator (LNHA) they met with residents and educated them on the change in management with the focus of short term rehabilitation and discussed their (the residents) options. She could not recall any facility-initiated discharges but stated she absolutely would be involved in a transfer to another facility. The SW stated a 30 day notice letting them (the resident) know their rights and she would look to the administrator to guide me with that process. She added, I can't force someone out, depending on the reason we would try to work with them. The SW stated, if it (transfer to another LTC facility) was a request it would be documented. At that time the surveyors reviewed the transfers of the above-mentioned residents with the SW, her responses were as follows: -Resident #182 requested a transfer because the [resident's representative] or family lives near there. -Resident #183 requested to go there because I think they knew someone who went there in the past and I think it was closer to the [resident representative] who had a family member in ocean county. She stated, there should be a note from me about why the transfer. -Resident #184 requested a local transfer because [identifier redacted] was happy here and we were offering transfers to stay here or transfer out and the resident wanted more of a long term care environment. -Resident #185 requested the transfer. -Resident # 186 requested the transfer because their primary care physician works in that facility. She stated if a resident requested a transfer it would be in my progress note. -Resident #187 requested a transfer because they were working with their family with multiple places. She stated, I think [identifier redacted] was content here. I think the place they went was smaller and the resident would get more individualized care. The SW added, we could have provided care for the resident here but that was their preference. -Resident #188 requested the referral because they knew someone that was going there. During that same interview, the SW stated, the facility did not tell them (the above residents) they could not stay. She could not speak to if a resident was happy here (the facility), in their home, why they (the facility) would give them (the residents) an option to leave. She added, it was a conversation, kind of a change in management, we (the facility) educated them (the residents) on their options . At that time the surveyors asked the SW to provide the above mentioned documentation. On 2/14/25 at 1:23 PM, the surveyors interviewed the LNHA, who stated the facility was licensed for Medicare and Medicaid and accepted both short term and long-term care residents. He added, most people come here for therapy. At that time, the surveyors reviewed the transfers of the above-mentioned residents with the LNHA. The LNHA stated he could only speak to the residents that were transferred since he started at the facility in November of 2024. His responses for 2 of the above mentioned residents that were transferred after he started at the facility: -Resident #186 was undecided on LTC or going home. I don't remember if the resident was told they could stay here. We (the facility) spoke to the resident about other facilities and recommended [name redacted] (the facility's sister facility) but the resident's doctor did not practice there. [Identifier redacted] was happy here, no complaints. I am not sure when the conversation started but once the resident's skilled part finished, then next step was LTC. The LNHA was unable to speak to whether the resident wanted to go to another LTC facility on their own. He added, [identifier redacted] just decided on their own, [identifier redacted] they wanted to go there. I didn't kick [identified redacted] out. He stated, I don't usually get involved in discharges. -Resident #185 was transferred probably because they were finished with rehab. He could not say she wasn't happy here. During this interview, the LNHA could not speak to why put a resident through a transfer if they were happy there. He added, they could technically stay here. On 2/14/25 at 1:42 PM, the surveyors interviewed the Director of Nursing (DON), who confirmed the facility accepts LTC residents and could not recall any facility-initiated discharges. At that time, the surveyors reviewed the transfers of the above-mentioned resident's with the DON, her responses were as follows: -Resident # 182 was a LTC resident but she did not know the reason the resident was transferred to another facility. She added the facility was able to care for the resident and that they seemed happy, nothing jumps out. Resident # 183 was a LTC resident but she did not know the reason the resident was transferred to another facility. She stated the facility was able to meet all [identifier redacted] needs, they seemed happy and never voiced complaints. -Resident # 184 was a LTC resident but she did not know the reason the resident was transferred to another facility. She added the facility able to meet all of the residents needs for care. -Resident #185 was a LTC resident but she couldn't recall the reason the resident was transferred to another facility. She added the facility was able to meet all the residents needs and could not recall the resident making any complaints. -Resident #186 was transferred to another facility because of insurance or maybe [identifier redacted] wanted to go. She stated the facility was able to meet all the residents needs and could not recall the resident making any complaints. -Resident #187 was a LTC resident but she couldn't recall the reason the resident was transferred to another facility. She stated the facility was able to meet all the residents need and could not recall the resident making any complaints. -Resident #188 was a LTC resident but she couldn't recall the reason the resident was transferred to another facility. She added the resident did not have any behaviors or skilled needs that the facility could not handle. At that time, the DON stated the discharge process from LTC to another LTC facility would be for the SW to get a list of LTC facilities requested by the resident or their family and send out a referral(s). Once a facility was agreed upon, typically the face sheet, discharge medication list, a transfer form, immunizations and any thing else the facility requested was sent to the receiving facility. During the same interview, the surveyors asked the DON if the above mentioned residents would be accepted back to the facility, she stated, I believe that if a resident wanted to come back, we would accept them back. As a DON, I would take back any or all of those residents from a nursing stand point. On 02/14/25 at 03:05 PM, the DON met with the surveyors and stated the SW only notifies the ombudsman's office of a discharge if the resident went to the hospital. She confirmed that she was unable to provide the surveyors with a written notification of discharge for the above residents. On 2/14/25 at 03:06 PM, during a follow up interview with the surveyors, the SW stated the facility had already provided all the progress notes for the above-mentioned residents which would include any of her documentation. She had nothing else to add. On 2/14/25 at 03:15 PM, the surveyors presented the above concerns to the DON and the [NAME] President of Nursing. 40042 A review of the facility's Admission Agreement revised 1/2021, revealed 3. Resident Rights .v.)The Resident is entitiled to at least thirty (30) days advance notice of transfer or discharge. A review of the facility's policy, Transfer or Discharge Notice revised 3/2021, revealed Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to transfer or discharge. 1. B. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 3. Except as specified below, the resident and his or her representative are given thirty (30)-day advance written notice of impending transfer or discharge from this facility. 5. The resident and representative are notified in writing of the following information: a. specific reason for the transfer or discharge; b. the effective date of the transfer or discharge; c. the location to which the resident is being transferred or discharged ; .8. The reason for the transfer or discharge are documented in the resident's medical record. NJAC 8:39-4.1(a)(31) (32)

Complaint #NJ00183474 Refer to F 622 Based on interviews, record review and review of facility documentation, it was determined that the facility failed to provide written notification of the transfer to the Office of the Long-Term Care (LTC) Ombudsman (LTCO) for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed for transfer to another LTC facility. This deficient practice was evidenced by the following: 1.The surveyor reviewed the electronic medical record (EMR) for Resident #182. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/24/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. A review of the individual comprehensive care plan (ICCP) revealed a focus of resident wants to stay at facility, dated 8/16/23. A review of the progress notes revealed on 9/24/2024 at 9:18 AM, Social Service Note, Note Text: Resident scheduled for LTC transfer today to [name redacted]. Resident, POA still in agreement with this plan. 2.The surveyor reviewed the EMR for Resident #183. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus with Diabetic polyneuropathy (a condition in which the body has trouble controlling blood sugar and can cause nerve damage) and dysphagia, unspecified (difficulty swallowing). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 10 out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of the resident is LTC at facility. Date initiated 12/20/23. A review of the progress notes revealed on 9/12/2024 at 15:25 (3:25 PM), Nursing Note, Narrative: Resident escorted by family and was discharged to another facility. 3. The surveyor reviewed the EMR for Resident #184. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and difficulty walking, not elsewhere classified. A review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 8 out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of resident wishes to remain LTC. Date initiated: 5/8/2024. A review of the progress notes revealed on 9/16/2024 at 14:24 (2:24 PM). Social Service Note. Late Entry:Note Text: Resident has been accepted to both facilities and would like to proceed with transfer to [name redacted] on 9/20. 4. The surveyor reviewed the EMR for Resident #185. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Parkinsonism, unspecified (a disorder of the central nervous system that affects movement, often including tremors) and dysphagia, unspecified (difficulty swallowing). A review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed revealed a focus of resident wishes to remain at facility. Date initiated: 6/6/2023. A review of the progress notes revealed on 12/23/2024 at 12:33 PM. Nursing Note. Narrative: Pt (patient) was picked up . discharging to [name of LTC facility redacted]. 5.The surveyor reviewed the EMR for Resident #186. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function) and muscle wasting and atrophy not elsewhere classified, unspecified site. A review of the comprehensive MDS, an assessment tool dated 11/10/24, revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of the resident wishes to return home alone with private HHA (home health aide), Date Initiated: 11/03/2024 with an intervention of establish a pre-discharge plan with the resident/family/caregivers and evaluate progress, Date Initiated: 11/03/2024. A review of the progress notes revealed on 1/15/2025 at 19:05 (7:05 PM), Nursing Note Narrative: At 5:34 pm, resident was discharged and transported to another nursing facility. 6. The surveyor reviewed the EMR for Resident # 187. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection, site not specified, Sepsis unspecified organism, and Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere. A review of the comprehensive MDS, dated [DATE], revealed the resident had a BIMS score of 11 out of 15, indicating the resident was moderately cognitively impaired. A review of the ICCP revealed a focus of [name redacted] wishes to remain at facility, Date initiated 8/3/23, a goal of [name redacted] will be long term placement in the facility, Date initiated 8/3/2023. A review of the progress notes revealed on 9/30/2024 at 09:56 AM, Social Service Note, Late Entry: Note Text: SW spoke with resident and [resident representative]. They are requesting LTC transfer on 10/2 to [name redacted] . set up transportation for 4:30 pick up. 7. The surveyor reviewed the EMR for Resident #188. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus without complications (disease (a condition in which the body has trouble controlling blood sugar) and cellulitis of right lower limb (a serious bacterial skin infection.) A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of [name redacted] wishes to remain LTC, Date Initiated: 06/30/2024 with a goal: [name redacted] will be long term placement in the facility, Date Initiated: 09/22/2023 A review of the progress notes revealed on 9/11/2024 at 14:20 (2:20 PM), Social Service Note, Late Entry: Note Text: Resident has been accepted to [name redacted] for LTC transfer and would like to proceed with d/c (discharge) on 9/18. On 02/14/25 at 12:43 PM, the surveyor requested the written discharge transfer notices that were given to the above 7 residents from the License Nursing Home Administrator (LNHA) for review. On 02/14/25 at 3:05 PM, the Director of Nursing (DON) met with the surveyors and stated the Social Worker (SW) only notified the ombudsman's office of a discharge if the resident went to the hospital. She confirmed that she was unable to provide the surveyors with a written notification of discharge for the above residents. On 2/14/25 at 3:06 PM, during an interview with the surveyors, the SW stated the facility had already provided all the progress notes for the above-mentioned residents which would include any of her documentation. She had nothing else to add. No additional information was presented to the surveyors. On 2/14/25 at 3:15 PM, the surveyors presented the above concerns to the DON and the [NAME] President of Nursing. 40042 A review of the facility's policy, Transfer or Discharge Notice revised 3/2021, revealed Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to transfer or discharge. 3. Except as specified below, the resident and his or her representative are given thirty (30)-day advance written notice of impending transfer or discharge from this facility. 5. The resident and representative are notified in writing of the following information: a. specific reason for the transfer or discharge; .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. NJAC 8:39-5.3; 5.4

REFER to F756 Based on observation, interviews and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times from December 2024 until surveyor inquiry February 2025. 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. The deficient practice was identified for one (1) of one (1) resident, (Resident #21), reviewed for dialysis services and was evidenced by the following: On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). The resident also stated that they went out of the facility for dialysis on Tuesdays, Thursdays and Saturdays at approximately 10 AM and returned from dialysis approximately 4 PM. The resident added that they were waiting to be picked up this morning. On 2/5/25 at 8:32 AM, during the morning medication administration (med pass) observation, the surveyor with Licensed Practical Nurse (LPN #1) reviewed the electronic administration record (EMAR) for Resident #21. LPN #1 stated that she was not administering the resident's Sevelamer (Renvela) because the EMAR computer screen indicated d/c (discontinue) pending confirmation. LPN# 1 explained that meant they were verifying orders because there may be multiple orders. The surveyor reviewed the electronic medical record for Resident #21. A review of the Admission Record revealed diagnoses that included, but not limited to, chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential (primary) hypertension (high blood pressure). A review of a comprehensive admission Minimum Data Set, an assessment tool used to facilitate the management of care, with an assessment reference date of 12/7/2024, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's individualized interdisciplinary care plan revealed a focus area, with an initiated date of 1/30/25, Resident has end stage renal disease and is on HD (hemodialysis) at [name and place redacted] on T (Tuesday)-TH (Thursday)-SAT (Saturday) chair time 11 AM. An intervention/task included, but not limited to, Ensure medication schedule is adjusted to administer medications when I am in the facility. A review of the resident's February 2025 Order Summary Report (OSR) reflected a physician's order (PO) dated 1/21/25 for HD Dialysis Tue, Thurs, Sat @ (at) [name of dialysis facility, address and phone number redacted] P/U (pick up) time: 10 AM chair time: 11AM. Further review revealed a PO with a start date of 1/25/25 for Sevelamer HCl (hydrochloride) Oral tablet 800 MG (Sevelamer HCl), Give 3 tablet by mouth with meals for ESRD until 2/28/25. There was no PO found to d/c (discontinue) pending confirmation. A review of the February 2025 electronic medication administration record (EMAR) indicated a medication administration time of 12 NOON that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed the following: -on 2/1/25 at 8:00 AM, 12 NOON and 5 PM, on 2/2/25 at 8 AM and 12 NOON and on 2/4/25 at 8 AM and 5 PM, all had a code number 9 entered for administration which corresponded to Other/see progress notes. A review of the corresponding electronic progress notes (EPN) had the following: -on 2/1/25 and 2/2/25 had no Note Text with an explanation. -on 2/4/25 at 8:02 AM had a Note Text: pharmacy contacted awaiting from pharmacy. -on 2/4/25 at 4:41 PM had a Note text: pending pharm delivery as is new order , 0 [name of electronic back up medication supply machine redacted]. On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated that she was unaware that there was an issue with Renvela or any medications for Resident #21. The UM/LPN was aware that the medications had to be scheduled for when the resident was in the facility because they went out of the facility for dialysis. The surveyor, with the UM/LPN reviewed the February EMAR. The UM/LPN was unable to explain why there was a code number 9 entered for administration. The UM/LPN verified that 9 meant the medication was not administered and there should be a progress note explaining. The surveyor with the UM/LPN went to the medication cart and the UM/LPN stated that there was Renvela tablets labeled for Resident #21 available in the medication cart. The UM/LPN was unable to speak to why there was an issue with the Renvela. The UM/LPN added that there should not be a time of 12 NOON for the Renvela on Tuesdays, Thursdays and Saturdays because the resident was out to dialysis. Further review of the resident's December 2024 and January 2025 EMAR and EPN revealed the following: -on 12/3/24, 12/5, 12/7, 12/10, 12/12, 12/14, 12/17, 12/19, 12/21, 12/23, 12/26, 12/28 and 12/30 the 12:00 PM doses of Renvela indicated that the medication was not administered. The EMAR indicated on 12/3/24, 12/5, 12/7, 12/12, 12/14 that the resident was Absent from home without meds. There was a corresponding EPN for 12/10/24, 12/21, 12/23, 12/26, 12/28 and 12/30 that indicated the resident was at dialysis. -on 12/27/24 and 12/30/24 the 9 AM doses of Calcitriol (medication used to treat low calcium levels caused by kidney disease) Oral capsule 0.25 micrograms (MCG) Give 0.25 MCG by mouth one time a day every Mon, Wed, Fri for supplement indicated that the medication was not administered. There was a corresponding EPN on 12/27/24 n/a (not available) and on 12/30/24 awaiting. -on 12/3/24, 12/5, 12/10, 12/12, 12/17, 12/19, 12/21, 12/23, 12/26, 12/28 and 12/30 the 2:00 PM doses of Heparin (medication used to prevent blood clots) Sodium (Porcine) injection solution 5000 Unit/milliliter (ML), Inject 1 ML subcutaneously every 8 hours for blood clot prevention indicated that the medication was not administered. The EMAR indicated on 12/3/24, 12/5 and 12/28 that the resident was Absent from home without meds. In addition, on 12/12 the EMAR indicated Absent from home with meds. There was a corresponding EPN for 12/10/24, 12/19, 12/21, 12/23, 12/26 and 12/30 that indicated the resident was at dialysis. -on 1/9/25, 1/11 and 1/13 the 12:00 PM doses of TUMS oral tablet chewable (Calcium Carbonate) (Antacid) Give 2 tablet by mouth with meals for dialysis indicated that the medication was not administered. There was a corresponding EPN for 1/11 and 1/13 that indicated the resident was at dialysis. -on 1/2/25, 1/4, 1/6, 1/7, 1/8, 1/13, 1/14, 1/15, 1/25, 1/28 and 1/30 the 12:00 PM doses of Renvela indicated that the medication was not administered. The EMAR indicated on 1/4/25 that the resident was Absent from home without meds. There was a corresponding EPN for 1/25, 1/28 and 1/30 that indicated the resident was at dialysis. In addition, the corresponding EPN for 1/6/25, 1/7, 1/8, 1/13, 1/14 and 1/15 indicated that for the 8 AM, 12 NOON and 5 PM doses of Renvela were not available, awaiting from pharmacy or on order. On 2/7/25 at 8:58 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not completed a medication administration inservice for the nurses. The CP added that she will do an inservice after completing a med pass with that specific nurse. The CP also stated that she tells the nurses that if a medication was not available then to enter the code number 9 in the EMAR but then the physician had to be called to get instructions on what can be done about not having the medication. The CP added that the nurses cannot just document that the medication was not available or awaiting from pharmacy. The CP also stated that the nurses needed to get instructions from the physician fairly quickly when a medication was not available. The CP then stated that a resident that goes out to dialysis had to have their medications scheduled to accommodate them being out of the facility. The CP added that the physician would be contacted, and specific orders would be given as to the timing. On 2/7/24 at 10:34 AM, the surveyor interviewed the UM/LPN, who stated that she was unsure why the PO for Resident #21 had not been updated to accommodate the times the resident was out to dialysis. The UM/LPN added that usually a medication ordered for three times a day would only be ordered twice a day on dialysis days and scheduled for times when the resident was in the facility. On 2/7/25 at 3:18 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged medications had to be scheduled to accommodate the resident being out to dialysis. A review of a facility policy Administering Medications dated as revised April 2019 provided by the DON reflected Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders). A review of the undated facility policy End-Stage Renal Disease, Care of a Resident with provided by the DON reflected Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. In addition, the policy revealed Education and training of staff includes, specifically f. timing and administration of medications, particularly those before and after dialysis. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

REFER to F698 Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from December 2024 until surveyor inquiry for one (1) of six (6) residents, (Resident #21), reviewed for medication management. The deficient practice was evidenced by the following: On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). The resident also stated that they went out of the facility for dialysis on Tuesdays, Thursdays and Saturdays at approximately 10 AM. The resident added they were waiting to be picked up this morning. On 2/5/25 at 8:32 AM, during the morning medication administration observation, the surveyor with Licensed Practical Nurse (LPN#1) reviewed the electronic administration record (EMAR) for Resident #21. LPN#1 stated that she was not administering the resident's Sevelamer (Renvela) because the EMAR computer screen indicated d/c (discontinue) pending confirmation. LPN#1 explained that meant they were verifying orders because there may be multiple orders. The surveyor reviewed the medical record for Resident #21. A review of the resident's February Order Summary Report (OSR) reflected a physician's order (PO) dated 1/21/25 for HD Dialysis Tue, Thurs, Sat @ (at) [name of dialysis facility, address and phone number redacted] P/U (pick up) time: 10 AM chair time: 11AM. Further review revealed a PO with a start date of 1/25/25 for Sevelamer HCl (hydrochloride) Oral tablet 800 MG (Sevelamer HCl), Give 3 tablet by mouth with meals for ESRD until 2/28/25. There was no PO found to d/c (discontinue) pending confirmation. A review of the December 2024, January 2025 and February 2025 EMARs indicated there were medication administration times for Renvela, Calcitriol, TUMS and Heparin that occurred during the time that the resident was out of the facility at dialysis. A review of corresponding electronic progress notes for December 2024, January 2025 and February 2025 indicated that the Renvela, Calcitriol, TUMS and Heparin were not administered because the resident was out of the facility at dialysis. On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN), who stated that she was unaware that there was an issue with Renvela or any medications for Resident #21. The UM/LPN was aware that the medications had to be scheduled for when the resident was in the facility because they went out of the facility for dialysis. On 2/7/25 at 8:58 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that a resident that goes out to dialysis had to have their medications scheduled to accommodate them being out of the facility and she has made the recommendation. The CP added that the physician would be contacted, and specific orders would be given as to the timing. In addition, the CP stated that she felt the facility had improved in responding to her recommendations. A review of the Nursing Summary Report provided by the Director of Nursing (DON), dated December 6, 2024 that was completed by the CP, revealed that a recommendation was made for Resident #21, Please be sure that the medication times are charted to accommodate resident's dialysis schedule. The report was signed as completed by the Nursing Supervisor/Registered Nurse (NS/RN) and dated 12/8/24. A review of the Nursing Summary Report provided by the DON, dated January 7, 2025 that was completed by the CP, revealed that a recommendation was made for Resident #21, Please be sure that the medication times are charted to accommodate resident's dialysis schedule. Please evaluate Sevelamer scheduled 1200 on dialysis days The report was signed as completed by the NS/RN and dated 1/28/24. On 2/7/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the evening NS/RN completed the CP recommendations. The DON verified that the Nursing Summary Report indicated that the NS/RN had acted upon the CP recommendations. On 2/7/25 at 10:53 AM, the surveyor attempted to contact the NS/RN via telephone. On 2/7/24 at 10:34 AM, the surveyor interviewed the UM/LPN, who stated she was unsure why the POs for Resident #21 had not been updated to accommodate the times the resident was out to dialysis. The UM/LPN added that usually a medication ordered for three times a day would be only ordered twice a day on dialysis days. On 2/7/25 at 3:18 PM, the surveyor interviewed the DON, who acknowledged that medications had to be scheduled to accommodate the resident being out to dialysis. The DON stated that she thought the CP recommendations were completed because the NS/RN had signed the reports. The DON added that she had put a call out to the NS/RN. A review of the facility's policy Pharmacy Services-Role of the Consultant Pharmacist dated as revised April 2019 was provided by the Licensed Nursing Home Administrator had not included a time frame for the facility's response to the CP recommendations pertaining to medication irregularities. NJAC 8:39-29.3(a)(1)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 3 of 5 randomly selected CNA (CNA # 3, #4, #5) files reviewed for in-service training. This deficient practice was evidenced by the following: On 2/07/25 at 9:17 AM, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #3 was hired on 4/1/22, CNA #4 was hired on 6/15/23, and CNA #5 was hired on 1/19/23. The facility could not provide evidence of in-service education training for the current 12-month period from hire date. On 2/07/25 at 2:01 PM, the Licensed Nursing Home Administrator (LNHA), in presence of survey team, stated that the facility cannot find the education for CNAs # 3,4 and 5. The LNHA stated the responsibility for ensuring the annual education on the regulatory topics, such as abuse, were completed by himself as well as with assistance from the corporate team as needed. He stated that the annual education should be reviewed when the annual evaluation was completed. He stated he was not versed on the exact topics, but he knew 12 hours were required. The LNHA stated the CNA education was important to make sure they (the CNAs) have their skills to know what they are doing. He further stated that the CNA in-service files were maintained by the Human Resource department. A review of the facility policy In-service Training Program, Nurse Aide dated May 2019, included Annual in-services . are no less than 12 hours per employment year. A review of an undated facility job description for Human Resource Director included Ensure training and in-services are provided on a regularly scheduled basis ., and Ensure that appropriate training records are maintained for staff personnel. A review of an undated facility job description for Director of Nursing Services included Develop and participate in the planning, conducting, and scheduling of timely in-service training classes ., and assist in developing annual in-service training programs for the nursing staff and ensure these programs meet the continuing education requirements. A review of an undated facility job description for Certified Nursing Assistant included Attend and participate in scheduled training and educational classes. NJAC 8:39-43.17 (b)

Based on interviews and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure reference checks were completed for 6 of 10 newly hired employee files reviewed. This deficient practice was evidenced by the following: On 2/7/25, the surveyor reviewed Ten (10) randomly selected new employee files which revealed the following: 1. Licensed Practical Nurse (LPN)/Unit Manager with a Date of Hire (DOH) of 7/22/24, did not have a previous employee reference on file. 2. LPN #2 with a DOH of 7/22/24, did not have a previous employee reference check on file. 3. LPN/Nurse Supervisor with a DOH of 7/22/24, did not have a previous employee reference check on file. 4. Registered Nurse #1 with a DOH 7/30/24, did not have a previous employee reference check on file. 5. Physical Therapist with a DOH 6/19/24, did not have a previous employee reference check on file. 6. Dietary staff with a DOH of 11/1/24, did not have a previous employee reference check on file. On 2/7/25 at 11:04 AM, the surveyor interviewed the Human Resources/Staffing Coordinator (HR/SC), who stated he was responsible for the employee files since August of 2024. He added the Director of Rehabilitation (DR) was responsible for the therapist's files. He stated new employees should have a physical, 2 TB testing (Mantoux tuberculin skin test-a test for tuberculosis (a serious bacterial disease that affects the lungs)), a background check, a license check and 3 reference checks before they start work. The HR/SC reviewed the above mentioned files in the presence of the surveyor and confirmed that the 6 employees did not have an employee reference check in their files. He stated he identified some of the employee files were missing physicals and the two-step TB test in October of 2024. He added he started a Quality Assurance & Performance Improvement Plan (QAPI) in October. On 2/7/25 at 11:51 AM, the surveyor interviewed the DR, who stated she was responsible for reference checks for her therapists. She stated she remembered doing the reference check for the above mentioned physical therapist but she does not keep a copy of it. She was unable to explain why she doesn't keep a copy. On 2/7/25 at 2:35 PM, the surveyor conducted a follow up interview with the HR/SC, in the presence of the survey team. He presented the surveyor with a copy of his QAPI dated 1/14/25. A review of the QAPI revealed Tracking and Reporting: As of 1/14 we are at less than 35 % completion .Working on completing Physicals and PPD (TB Test) files. At that time the HR/SC stated that he will now add the employee reference checks to his QAPI since the surveyor brought it to his attention. On 2/7/25 at 12:59 PM, the survey team met with the LNHA, DON, Regional LNHA, and the [NAME] President of Nursing and presented the above concerns. No addition information was presented. A review of the facility provided New Employee Checklist for HR (Human Resources) revealed Human Resource: reference form and references checks (back of application): check box reference #1, check box reference #2.

Complaint #NJ00176931 Based on interviews, record review and pertinent facility documents, it was determined that the facility failed to investigate an allegation of poor nursing care for 1of 4 residents (Resident #232) reviewed for abuse. This deficient practice was evidenced by the following: A review of the facility provided Reportable Event Record Report dated 319/2024, revealed the facility reported an event alleging that the resident had poor nursing care while at the facility to the New Jersey Department of Health (NJDOH). The surveyor reviewed the electronic medical record (EMR) for Resident #232. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus with Diabetic Chronic kidney disease (a condition in which the body has trouble controlling blood sugar that can affect the kidneys) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions). A review of the admission Minimum Data Set, an assessment tool dated 12/27/23, revealed the resident had a Brief Interview for Mental Status of 13 out of 15, indicating the resident was cognitively intact. A review of the individual comprehensive care plan (ICCP) revealed a focus of potential for a mood issue related to [their] recent admission to the center, Date Initiated: 12/28/2023 with Interventions: Educate the resident/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance, Date Initiated: 12/28/2023. A review of the progress notes did not revealed any notes or allegations of the above mentioned event. On 2/5/25 at 2:24 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated examples of abuse was neglect in care, physical, rough care, and hitting. She stated she would ask what happened and then notify the Director of Nursing (DON). LPN #1 stated an incident report would be done, and written statements would be obtained. On 2/5/25 at 12:31 PM, the surveyor interviewed LPN/Unit Manager (UM) #1, who stated examples of abuse was physical, verbal, neglect, from anyone punching, pulling, or yelling at someone. She stated she would have to report it immediately to the DON and the Licensed Nursing Home Administrator (LNHA). LPN/UM #1 stated it would have to be reported to the state (NJDOH), an incident investigation would be done and statements would be obtained. On 2/5/25 at 12:36 PM, the surveyor interviewed Certified Nursing Assistant # 1, who stated I would go to DON and have to give a statement. On 2/5/25 at 12:39 PM, the surveyor interviewed the DON, who stated types of abuse was resident to resident, staff to resident, sexual, financial abuse, mental manipulation, neglect, not feeding someone, or just not caring for the patient. She stated she would interview the resident ask for more information date and time. The DON stated an overall investigation would be done which included going back 72 hours and interview from all the nurses and aides that took care of patient. She stated she would report the event to Ombudsman and the NJDOH within 2 hours. She added definitely a written investigation would be done and the investigation would be kept. On 2/5/25 at 12:50 PM, the surveyor interviewed LPN/Nursing Supervisor (LPN/NS) #1, who stated types of abuse was elder abuse, financial, physical and emotional. She stated she would report it to the DON and the LNHA, a grievance would be taken and statements would be taken from all parties involved. LPN/NS #1 stated the purpose of the investigation was to get to the bottom of the situation and to make sure they feel safe in the building. She stated she remembered Resident #232 but did not remember the resident or their son complaining about anything. On 2/5/25 at 12:55 PM, the surveyor conducted a follow up interview with the DON, who stated the purpose of an investigation was to substantiate the claim, every claim should be taken seriously to see what was going on, to help us to know our patients and our staff and to follow through to make sure the concerns were addressed. On 2/05/25 at 1:02 PM, the surveyor interviewed the LNHA, who stated he was the abuse officer. He stated types of abuse was sexual, verbal, physical, monetary abuse and neglect. He stated, I would call the state (NJDOH) and complete the form to the Ombudsman. The LNHA stated an investigation would be started that included collecting statements from residents or family members and staff, a summary would be written, and draw up a conclusion. He stated it was important to do an investigation to see if other residents are in harm's way. During that same interview, the LNHA confirmed that there was no investigation for the above mentioned reportable event for Resident #232. He stated they (the facility) looked through the files and no one could not find anything else (for the event). He added the event should have had an investigation but we (the facility) could not find one. On 2/7/25 at 12:59 PM, the survey team met with the LNHA, DON, Regional LNHA, and the [NAME] President of Nursing and presented the above concerns. No additional information or investigations were presented. A review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, revealed Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect resident from any further harm during investigation. A review of the facility's policy Grievances/Complaints, Record, and Investigating revised April 2017, revealed Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actins will be taken to resolve the grievance(s). Policy Interpretation and Implementation: 1. The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. 2. Upon receiving a grievance and complaint report, the grievance office will begin an investigation into the allegations .4. The investigation and report will include, as applicable: .b. the circumstances surrounding the alleged incident .9. A copy of the resident Grievance/Complaint Investigation Form: must be attached to the Resident Grievance/complaint form and filed in the business office. 10. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. NJAC 8:39 4.1 (a) (5)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 2/5/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of five (5) residents, (Resident #21 and #82), that were administered medications by two (2) of three (3) nurses that were observed. The deficient practices were evidenced by the following: 1. On 2/5/25 at 8:36 AM, during the morning medication administration pass, the surveyor observed Licensed Practical Nurse (LPN#1) administering medications to Resident #21. The resident stated that they would like their pain medication and their cough medicine. On 2/5/25 at 8:37 AM, the surveyor observed LPN#1 preparing to administer the resident's pain medication and cough medication. LPN#1 reviewed the electronic medication administration record (EMAR) which revealed a physician's order (PO) for Guaifenesin Oral Liquid 100 MG/ML (Guaifenesin), Give 10 ML by mouth every 6 hours as needed (PRN) for cough 10 ML=200 MG. LPN#1 removed a bottle of Tussin DM (Guaifenesin with Dextromethorphan) 100 milligrams(MG)/5 milliliter (ML) from the medication cart and stated that the Tussin DM was an over-the-counter/house stock (OTC/HS) medication, meaning that the bottle was not labeled for a specific resident because the facility purchased the medication, and it could be administered to any resident that had a PO. LPN#1 stated that Tussin DM was the OTC/HS cough medicine. On 2/5/25 at 8:41 AM, the surveyor observed LPN#1 administer 10 ML of Tussin DM to Resident #21. On 2/5/25 at 8:44 AM, upon returning to the medication cart, the surveyor with LPN#1 reviewed the electronic medication administration record (EMAR) for the PRN cough medication. The surveyor asked LPN #1 why the EMAR indicated Guaifenesin but had not indicated Dextromethorphan (DM). The LPN#1 stated that the DM did not matter and that was the OTC/HS that was in the medication cart. (ERROR #1) The surveyor reviewed the electronic medical record for Resident #21. A review of the Admission Record revealed diagnoses that included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and Diabetes Mellitus (high blood sugar). A review of the comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 12/7/2024, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report (OSR) revealed an active physician's orders (PO) with a start date of 1/21/25 for Guaifenesin Oral Liquid 100 MG/5 ML (Guaifenesin), Give 10 ML by mouth every 6 hours as needed for cough 10 ML=200 MG. On 2/5/25 at 1:30 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she was responsible for educating the staff and that medication administration observations were performed by the Consultant Pharmacist (CP). The DON added that medications were administered as per PO. A review of the facility OTC/HS list provided by the Director of Nursing (DON) indicated that the facility supplied Robitussin (Guaifenesin). There was no Tussin-DM listed. On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN), who stated that Tussin DM cannot be substituted for Guaifenesin (Robitussin). The surveyor, with the UM/LPN, observed the Tussin DM in medication cart #1. The UM/LPN stated there was no Robitussin in medication cart #1 and would have to look into it. On 2/5/25 at 11:13 AM, the UM/LPN returned to the surveyor and stated that medication cart #2 had the OTC/HS Robitussin and showed the surveyor a bottle labeled Guaifenesin 100 MG/5 ML and stated that should have been administered to Resident #21. The UM/LPN explained that the assignment of residents was split between the nurses and depending on the census, the room Resident #21 was in could have their medications kept in either medication cart #1 or #2. On 2/7/25 at 8:58 AM, the surveyor interviewed the CP via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not completed a medication administration inservice for the nurses. The CP stated that she was not familiar with LPN#1 and thought she may have been an agency nurse. The CP also stated that the PO must match the medication being administered and that Tussin DM could not be substituted for Guaifenisen. On 2/7/25 at 3:18 PM, the surveyor interviewed the DON who stated that LPN#1 had no medication administration observation completed. The DON added LPN#1 was an agency nurse and had reached out to the agency but had not received documentation of a medication administration observation. There was no facility medication administration inservice provided to the surveyor. 2. On 2/5/25 at 8:49 AM, during the morning medication administration pass (med pass), the surveyor observed LPN #2 preparing to administer five (5) medications to Resident #82. LPN#2 removed an OTC/HS Lidocaine 4% patch from the medication cart and then stated that the PO on the EMAR indicated Lidocaine 5% for Resident #82. LPN #2 returned the Lidocaine 4% patch to the medication cart and stated the Lidocaine 5% patch had to come from the provider pharmacy and there was none in the medication cart for Resident #82. On 2/5/25 at 8:37 AM, the surveyor observed LPN#2 administer four (4) medications to Resident #82. The Lidocaine 5% patch was not administered. On 2/5/25 at 9:31 AM, the surveyor interviewed LPN#2 who stated Resident #82 was alert and oriented to person, place and time. LPN #2 also stated that she would have to call the provider pharmacy to obtain the Lidocaine 5% patch for Resident #82. On 2/5/25 at 12:54 PM, the surveyor interviewed Resident #82, who stated that they had not received any pain patch today, but they were not in pain at the moment and knew that they could ask the nurse for a pain pill if needed. The resident also stated that they thought the physician had said the patch would help and thought the physician would have to order the patch and the nurses would have to get it delivered but wasn't sure if that had happened. On 2/5/25 at 12:57 PM, the surveyor interviewed LPN #2, who stated that she had sent a message to the provider pharmacy via an app on her phone but had not heard back yet. LPN#2 also stated that the process when a medication was not available was to call the pharmacy and wait until the medication came in. LPN #2 then added that maybe she could call the physician to see if the 4% patch could be used. (ERROR #2) The surveyor reviewed the medical record for Resident #82. A review of the Admission Record revealed diagnoses that included but not limited to; rhabdomyolysis (a breakdown of muscle tissue). A review of the OSR revealed an active PO with a start date of 2/4/25 for Lidoderm Patch 5% (Lidocaine), Apply to per additional directions topically one time a day for lower back pain for 14 days. A review of the resident's electronic progress notes (EPN) indicated on 2/5/25 at 9:04 AM, LPN #2 had entered a Note Text: Lidoderm Patch 5% (Lidocaine), Apply to per additional directions topically one time a day for lower back pain for 14 days, awaiting from pharmacy. Sending followup. In addition, the EPN revealed at 1:16 PM, after surveyor inquiry, LPN#2 indicated Called MD (physician) calling service to speak with MD to see if lidocaine patch order can be changed to house stock 4%. Awaiting call back. Then, at 1:33 PM, LPN#2 indicated Spoke with Dr. [name redacted] received new order for 4% lidocaine patch daily. Order placed. On 2/5/25 at 1:30 PM, the surveyor interviewed the DON, who stated that she was responsible for educating the staff and that medication administration observations were performed by the CP. The DON also stated that if a medication was not available to be administered then the physician was to be contacted for follow up as to what to do and that the physician can order an alternative medication. The DON added that she would solicit help to follow up as soon as possible in order to provide the medication in a timely manner. A review of a Medication Pass Observation dated 11/12/24 provided by the DON and was completed by the CP for LPN#2 indicated that the percent error rate was 14.6%. The form indicated that one of the errors that occurred was a medication that was not administered within one hour of prescribed time. On 2/7/25 at 8:58 AM, the surveyor interviewed the CP via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not completed a medication administration inservice for the nurses. The CP added that she will do an inservice after completing a med pass with that specific nurse. The CP also stated that she tells the nurses that if a medication was not available then to enter Code 9 in the EMAR but then the physician had to be called to get instructions on what can be done about not having the medication. The CP added that the nurses cannot just document that the medication was not available or awaiting from pharmacy. The CP also stated that the nurses needed to get instructions from the physician fairly quickly when a medication was not available. On 2/7/25 at 3:18 PM, the surveyor interviewed the DON, who stated that the medication observation completed by the CP was followed up with an inservice with that nurse by the CP after the observation. The DON added that there was no further follow-up. A review of a facility policy Administering Medications dated as revised April 2019 provided by the DON reflected Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders). Further review reflected The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, record review, interview, and facility policy review, the facility failed to prevent the potential for cross contamination by placing a resident with open wounds on Enhanced Barrier Precautions (EBP), meaning a gown and gloves be worn when performing high contact care, for one of two residents (Resident #7) with open wounds. The deficient practice was evidenced by the following: On 2/4/25 at 10:21 AM, the surveyor observed Resident #7 self-propelling their wheelchair in the hallway. The resident stated they can wheel the chair but can not stand. The surveyor observed a dressing on the right leg. The surveyor reviewed the electronic medical record (EMR) for Resident #7. A review of the Order Summary Report revealed a physician order (PO) dated 1/24/25 for Collagen-Antimicrobial External Sheet (Collagen-Antimicrobial) to the Right Lateral Ankle topically one time a day. There was also a PO dated 1/10/25 for Weekly Skin Checks every day shift every Friday. A review of the comprehensive admission Minimum Data Set (MDS), (an assessment tool) dated 1/10/25, revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating an intact cognition. In addition, the MDS reflected diagnoses that included but not limited to; hypertension (elevated blood pressure), diabetes (elevated blood sugar), and a pressure ulcer of the right ankle stage 4, and the presence of a diabetic foot ulcer. The Individual Comprehensive Care Plan (ICCP), initiated 1/16/25, included a focus area of impaired skin integrity. Interventions included diets and supplements as ordered and monitoring for signs of infection. On 2/5/25 at 9:30 AM, the surveyor observed Resident #7, lying in bed. The resident stated therapy is going well but slow. The resident also stated their leg dressing gets changed every day, and that it was not done yet today. The surveyor asked Resident #7 if the surveyor could observe the dressing change. The resident stated yes, that was fine. On 2/5/25 at 10:38 AM, the surveyor observed the treatment to the right leg by Licensed Practical Nurse (LPN) #1. LPN #1 pre-medicated Resident #7 for pain and then performed the treatments to the right calf and ankle as ordered with only gloves on. The surveyor had not observed EBP signage or personal protective equipment (PPE) supply bin at the resident's doorway or in the room. On 2/05/25 at 12:43 PM, the surveyor interviewed the Infection Preventionist/LPN (IP/LPN) who stated that EBP, meaning a gown and gloves should be worn when performing high contact care, and were needed for the presence of wounds. When asked about Resident #7, she stated that the resident's wound was a diabetic ulcer which was resolved today. When reminded that EBP was not in place prior to today, she further stated that prior to today, the wound physician classified the resident's wounds as diabetic, and that her understanding was that since the wounds were classified as diabetic and not pressure ulcers then EBP was not needed. On 2/7/25 at 09:33 AM, the surveyor observed the resident lying in bed, with a dressing noted to the right leg. On 2/7/25 at 11:07 AM, the surveyor interviewed the Director of Nursing (DON), who stated that if a resident had a wound, EBP were needed. On 2/7/25 at 11:47 AM, the IP/LPN thanked the surveyor for bringing to her attention Resident # 7 had open wounds and was not on EBP. The IP/LPN stated that she double checked, and the wounds were chronic, including a current tiny opening. She further stated that she just put the resident on EBP. When asked what should have been done, she stated the resident should have been on EBP all along since there were open wounds. On 2/07/25 at 12:59 PM, the surveyor interviewed the DON and the [NAME] President of Nursing, and both confirmed that Resident #7 should have been on EBP since admission due to the presence of open wounds. A review of facility provided policy Isolation - Categories of Transmission-Based Precautions Revised October 2018 revealed: Enhanced Barrier Precautions Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs(multi-drug resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiting gown and glove use for Enhanced Barrier Precautions include: Wound care: any skin opening requiring a dressing. N.J.A.C. 8:39-19.4 (a)

Complain #: NJ171631 Based on interview and record review on 05/13/2024 and 05/14/2024, it was determined that the facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for 1 of 5 residents (Resident #2) reviewed for MDS accuracy. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, under Section M: Skin Conditions .M0210 Unhealed Pressure Ulcers/Injuries .Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Coding Tips If an ulcer/injury arises from a combination of factors that are primarily caused by pressure, then the area should be included in this section as a pressure ulcer/injury. Under DEFINITIONS STAGE 1 PRESSURE INJURY An observable, pressure related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters .persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues. NON-BLANCHABLE Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device. The surveyor reviewed the closed medical record for Resident #2: According to the Admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/07/2023 indicated that Resident #2 had a BIMS (brief interview for mental status) score of 13 indicating the resident was cognitively intact. The MDS further indicated under Section M (used to assess skin condition during a 7-day look-back period), M0150 is this resident at risk of developing pressure ulcers/injuries Indicated No. M0210, Unhealed Pressure Ulcers/Injuries indicated that the Resident did not have a pressure ulcer. Review of Resident #2's Admission Evaluation assessment dated [DATE], under diagram revealed the resident was admitted with a Sacral wound with slough. Review of facility documentation showed on 12/5/2023 Resident #2 was seen by the Wound Care for Sacral Ulcer. During the interview with the Surveyor on 05/13/2024 at 2:18 P.M., the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed Resident #2 was admitted to the facility with sacral ulcer. During the interview with the Surveyor on 05/14/2024 at 10:36 A.M, the MDS Coordinator (MDSC) confirmed that previous MDS staff (who no longer work in the facility) miscoded the 12/07/2023 assessment, Section M. She further stated the MDS should have reflected that Resident #2 had a sacral ulcer. The Surveyor attempted to reach the previous MDS coordinator but was unsuccessful. The job description for Care Navigator/MDS Coordinator Job Description, undated, indicated Duties and Responsibilities Conducts patient assessments to determine the patient's prior level of function to establish patient centered goals, treatment plans that focus on recovery and discharge planning. Review of the facility policy titled Comprehensive Assessment, dated 04/2023, indicated Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. NJAC 8:39-11.2(e)(1)

Complaint #: NJ 171631 Based on interview, medical record review, and review of other pertinent facility documentation on 5/13/2024 and 5/14/2024, it was determined that the facility failed to develop a Baseline Care Plan (BCP) for a newly admitted resident with a Sacral wound. This deficient practice was identified for Resident #2, 1 of 5 residents reviewed for BCP. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the Admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/07/2023 indicated that Resident #2 had a BIMS (brief interview for mental status) score of 13 indicating the resident was cognitively intact. Review of Resident #2's Admission Evaluation Assessment revealed the resident was admitted with a Sacral wound with slough. Review of facility documentation revealed there was no BCP initiated for Resident #2 upon admission to address Resident #2's Sacral wound. During an interview with the Surveyor on 5/13/2024 at 1:3 P.M, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that Resident #2 should have had a BCP in place for their sacral wound. The LPN/UM continued that all newly admitted residents should have a BCP upon admission. During an interview with the Surveyor on 5/13/2024 at 2:18 P.M., the Director of Nursing (DON) stated the BCP is a roadmap to the resident so that all parties (departments) know the care of the resident. The DON continued to say, if a resident is admitted with a pressure ulcer, the admitting nurse will put in a wound consult, document the wound, obtain treatment for the wound and initiate a BCP with all appropriate interventions. When presented with Resident #2's CP, the DON acknowledged there was no BCP initiated upon admission. During the survey, the Surveyor attempted to reach the admitting nurse for Resident #2 but was unsuccessful. Review of the facility policy, Care Plans-Baseline with a revised date of 04/2023, indicated under Policy Statement that, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The facility policy continued under Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders; c. Dietary orders; d. Therapy orders. NJAC 8:39-11.2(d).

Complaint #: NJ171631 Based on interview, observation, record review, and facility policy reviewed on 5/13/2024 and 5/14/2024, it was determined that the facility failed to provide 1 of 5 residents (Resident #2) reviewed for Activities of Daily Living (ADLs) with showers twice a week as scheduled. The Certified Nursing Aide (CNA) also failed to follow their job description. This deficient practice was identified for Resident #2, and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the Admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/07/2023 indicated that Resident #2 had a BIMS (brief interview for mental status) score of 13 indicating the resident was cognitively intact. The MDS also indicated the resident needed partial/moderate assistance with ADL. Review of Resident #2's comprehensive Care Plan (CP), identified that Resident #2 has a self -care performance deficit. A CP Intervention. indicated, Bathing/Showering: Assist-one. Review of the facility Documentation Survey Report v2 (DSR) dated for December 2023, and January 12th 2024, revealed Resident #2's shower days were on Wednesdays and Saturdays during the 7:00 A.M to 3:00 P.M. shift. Review of Resident #2's December 2023, DSR, indicated no shower was provided on 12/02/2023 (Saturday), 12/09/2023 (Saturday), December 16,2023 (Saturday), December 20,2023 (Wednesday) and December 30, 2023 (Saturday). Review of Resident #2's January 2024 DSR, indicated no shower was provided on 1/10/2024 (Saturday). Review of Resident #2's Progress Notes (PNs) dated for December 2023 through January 2024, revealed no documentation for refusal of shower on the aforementioned dates. During a telephone interview on 5/14/2024 at 12:26 P.M., with the Certified Nuring Assistant (CNA) assigned to Resident #2, she stated, the CNAs were responsible to provide showers to all residents twice weekly on their scheduled shower days. The CNA stated that if the ADL sheet was left blank, then more than likely I did not do the showers. She further stated, sometimes the resident (Resident #2) would refuse their shower. When asked if refusal should be documented, she said Yes, if a resident refuses shower, we (CNAs) should document refusals in the Point of Care (POC) and also inform the nurse. During an interview on 5/14/2024 at 11:43 A.M., the Licensed Practical Nurse/Unit Manager (LPN/UM), revealed the CNAs were responsible to provide shower to the residents twice weekly on their scheduled shower days, and document in the POC. She confirmed blank spaces on the POC will indicate the task was not completed. The LPN/UM said the expectation is for all task to be completed and documented daily. During an interview on 5/13/2024 at 2:18 P.M., the Director of Nursing (DON) stated her expectation is for all task and documentation to be completed daily by the CNAs. She further stated blank spaces on the POC will indicate the task was not done. When asked by the Surveyor about the blank spaces on Resident #2's DSR, the DON said, technically there should be no blanks on the POC. During the exit conference on 5/14/2023 at 2:26 P.M., the DON in the presence of the Administrator and Nursing Consultant confirmed Resident #2 shower days were Wednesday and Saturdays on the 7:00 A.M. to 3:00 P.M., shift and acknowledged the blank spaces. Post survey, an email was sent by the Administrator on 5/15/2024 containing a written statement dated 5/14/2024 from the CNA previously interviewed by the Surveyor during the survey. The statement revealed: I recall having Resident #2 as an aide during their stay at Spring Hills [NAME]. Resident #2 did refuse showers often during his/her stay here and would (I) give her bed baths at his/her request. I recognize that I should've documented all the care that I performed in POC. However, there was at no time I did not provide care as scheduled and as needed at the resident's request. Review of the facility's policy titled; Bathing and Showering, dated 04/2023, under Policy indicated: The facility will offer showers and tub baths to residents in accordance with their preferences. Under Policy Interpretation and Implementation, indicated: 1. The facility will offer showers and tub baths to residents twice per week. 4. Provision and refusals of shower and or tub baths will be documented in the medical record by the certified nursing assistant and /or licensed nurse. Review of the facility undated job description for Certified Nursing Assistant under Purpose revealed: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. Under Duties and Responsibilities Assist residents with bath functions (i.e., bed bath, tub, or shower, etc ) as directed. NJAC 8:39-27.2(i)

Complaints: NJ 157428, NJ 160764, NJ 161041, NJ 162453, NJ 167007 Based on observations, interviews, and record review, the facility failed to respond in a timely manner to the resident's requests for assistance for one Resident (R)27 of 27 sample residents. Findings include: Review of R27's Admission Record located in the resident's electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, urinary tract infection, adjustment disorder, and dysphagia. Review of R27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/23 revealed the resident Brief Interview for Mental Status Score (BIMS) of 11 out 15 points indicating that she had moderately impaired cognition. The resident was dependent on staff for activities of daily living and toileting. The resident was occasionally incontinent of urine and frequently incontinent bowel. During an interview on 10/16/23 at 11:30 AM R26 revealed that on the 3-11 and 11-7 shifts there was usually a two-to-three-hour delay in staff responding to call lights. Observation on 10/16/23 at 2:20 PM revealed the flashing call light over R27's room. R27 could be heard calling for help. No staff observed at the nurses' station. Observation on 10/16/23 at 2:31 PM revealed R27's call light remained on and the resident was calling for assistance. Unidentified staff observed walking down the hallway but did not acknowledge R27's call light. Observation on 10/16/23 at 2:47 PM revealed the resident's call light was still flashing and the resident was calling for assistance. Staff member (Speech Therapist) returned another R1 to his room from activities. The therapist walked past R27's room and did not acknowledge the resident's call for assistance. Observation on 10/16/23 at 3:05 PM revealed R27's call light was still flashing, and the resident was calling for assistance. A Nursing Assistant (NA)7 returned to the unit and went to R27's room. The resident had been left on the commode. The CNA assisted the resident in cleaning up and returned the resident to her bed. Interview on 10/16/23 at 3:10 PM with NA7 revealed that staff had been trained to answer the resident's call light as soon as possible. She was unaware how long the resident's call light had been on. NA7 stated she was not assigned to the resident but would find out who was. Observation 10/17/23 at 10:00 AM revealed R27 was in bed with her breakfast. The resident had two water bottles that had spilled in her bed. The top and bottom sheets on the bed were wet. The resident's bed jacket and gown were wet. The resident's call light was placed on the night stand out of the resident's reach. The resident stated she needed help in getting cleaned up. The call light was placed within the resident's reach to call for assistance. R27 stated it took a long time for the staff to answer her call light, and sometimes it was almost two hours that she must wait. Observation on 10/17/23 at 10:14 AM revealed R27's call light was flashing, and she was calling for help. At 10:15 AM the Assistant Administrator stuck his head in the door. R27 told the Assistant Administrator that she had been calling for help. The resident showed the Assistant Administrator that her bedding and clothing was wet. The Assistant Administrator left the room without turning off the resident's call light. The Assistant Administrator could be heard telling the staff that the resident needed to be changed. At 10:17 AM a NA8 entered the room and told the resident that he would be back to get her cleaned up and left the room. NA8 entered another resident's room and did not return to R27's room. The resident's call light was still flashing. At 10:20 AM the Infection Preventionist (IP) entered the room and told the resident she would be back to clean her up. At 10:23 AM the Assistant Administrator entered the resident's room and observed the resident and left. At 10:26 AM a female staff member entered the resident's room to remove breakfast tray but did not tell the resident the staff would be in to assist her in getting changed. At 10:31 AM R27's call light remained flashing with no staff member responding. At 10:35 AM NA8 answered the resident's call light and proceeded to provide care to the resident. During an interview on 10/18/23 at 10:45 AM NA8 stated he was not assigned to the resident and had assumed the person assigned to the resident would respond to her call light. NA8 stated that he was busy trying to get his resident ready for physical therapy. Interview with the Assistant Administrator on 10/18/23 12:45 PM revealed that it was an expectation that resident's call lights were answered in a timely manner. The Assistant Administrator stated that the resident should not have waited that long before her wet bedding and clothing were changed. The Assistant Administrator stated that every attempt was made to meet the residents' needs in a timely manner. NJAC 8:39-4.1(a)12

Complaint #: NJ 151270, NJ 162453 Based on interview, record review and review of facility policy, the facility failed to notify the responsible party/family of one Resident (R)5 of 27 sample residents regarding R5's return to the facility with the x-ray and treatment results after the resident's emergency room visit. Findings include: Review of R5's Admission Record located in the resident's electronic medical records (EMR) revealed the resident was admitted to the facility 10/27/21 with diagnoses that included diabetes mellitus type II, malignancy of the prostate, dysphagia, hemiplegia, and fall history. The resident was discharged home on 11/24/21. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/21 located in the resident's EMR section titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating the resident had severely impaired cognition status; the resident was dependent on staff for all activities of daily living; incontinent of bladder and bowel; had impairment of lower extremities; and fall history at home. Review of R5's Nurses' Notes, dated 11/16/21 at 5:57 PM, located in the resident's EMR section titled Progress Notes revealed a noise was heard coming from R5's room. The resident was found lying on his right side on the floor. The resident stated he was trying to go to the other room and fell . The resident was examined, and skin assessment completed. No open areas were noted at this time. It was documented that the physician and the family were notified of the fall. Review of R5's Nurses Notes, dated 11/18/21 at 8:00 PM, located in the resident's EMR section titled Progress Notes revealed the resident was sitting in a wheelchair at the nurses' station when the resident attempted to stand up. Before the nurse could reach the resident, he fell backwards landing on his buttocks and hands. The resident was assessed for injuries. It was discovered the resident had sustained a deep open wound on top of the left hand that was actively bleeding. The resident sustained no other injuries. R5's spouse was notified of the fall and injury to the left hand. The physician was also notified. The resident was later transported to the emergency room for evaluation and treatment. The nurse attempted to contact R5's spouse but there was no answer. Review of R5's Nurses' Notes, dated 11/19/21 at approximately 3:00 AM, located in the resident's EMR section titled Progress Notes revealed the resident returned from the emergency room with ten steri-strips applied to the skin tear on left hand. It was documented that the resident had x-rays (hand and arm) and cat scan done which were negative. However, there was no documentation that resident's wife/family was notified of the resident's returned to the facility. On 10/17/23 at 8:40 PM a telephone interview was conducted with R5's family member. The family member stated no one from the facility notified them that the resident was sent to the emergency room for x-rays and treatment. When the family received a bill from the hospital, they began to ask questions as to how the resident sustained the injury to his hand. On 10/20/23 at 1:30 PM a telephone interview was conducted with Licensed Practical Nurse (LPN)5. LPN5 stated she remembered the resident and the fall incident. LPN5 stated R5 attempted to stand up from the wheelchair without the brakes in place and the resident fell backwards before she could reach him. LPN5 stated the resident did injure his hand during the fall. LPN5 stated that she attempted to contact R5's spouse but there was no answer when she called. LPN5 acknowledged that she did not remember notifying the resident's spouse of the resident's return to the facility. She assumed that the day shift nurse would notify the family. Interview with the Director of Nursing (DON) on 10/20/23 at 1:45 PM revealed she was not the DON at that time. However, there was an expectation that the nurse would have notified the family of the resident's return to the facility after receiving treatment. Review of the facility's policy titled Change in a Resident's Condition or Status, with a revision date of 05/23, read in part Our facility promptly notifies the resident, his or her attending physician and the resident's representative of changes in the resident's medical/mental condition or status. The nurse will notify the resident's representative when it is necessary to transfer to a hospital/treatment center. NJAC 8:39-13.1 (c)

Complaint # NJ 166867 Based on interview, record review, and policy review, the facility failed to ensure the resident assessment accurately reflected the resident's skin conditions for one (Resident (R) 9) of 27 sampled residents. This failure could result in the residents' individual needs not being addressed. Findings include: Review of R9's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R9's Admission Assessment Form, dated 08/10/23 and located in the resident's EMR under the Assessments tab, revealed R9 was admitted to the facility with intact skin. Review of R9's admission Minimum Data Set (MDS), located in the resident's EMR under the MDS tab and with an Assessment Reference Date (ARD) of 08/12/23, indicated R9 was not at risk for pressure ulcers and did not have any unhealed pressure ulcers. Review of R9's modified admission MDS, located in the resident's EMR under the MDS tab with an ARD of 08/12/23, revealed an updated Section M, dated 10/18/23 at 3:05 PM, to reflect R9 was at risk for pressure ulcers upon admission and had one unstageable Deep Tissue Injury (DTI) upon admission. During a telephone interview with the MDS Coordinator (MDSC) on 10/19/2023 at 11:23 AM, the MDSC was asked why the resident's admission MDS was modified. The MDSC stated she thought the pressure ulcer had healed between then and now, but the Director of Nursing (DON) said the ulcer was present on admission and had opened afterwards. The MDSC stated she had received the information from DON this week. The MDSC stated there had been confusion because it was healed and then not healed. The MDSC stated the original admission MDS had been incorrect. Review of the facility's undated MDS Coordinator Job Description document revealed that the MDS coordinator is responsible to Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and Center policies . Ensue that appropriate health professionals are involved in the assessment and ensure that all members of the assessment team arc aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification. NJAC 8:39-11.1

Complaint # NJ 167007 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 three residents (Resident (R) 3, R26 and R27) reviewed for base line care plans out of 30 sampled residents. Findings include: 1. Review of R3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/23 and located in the electronic medical record (EMR) section titled MDS, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident's cognition was intact. It was documented that the resident required limited assistance with one-person physical assistance with all activities of daily living (ADLs), had incontinence of bladder and bowel, had an unsteady balance and gait but was able to stabilize with assistance. It was also documented that the resident required the use of a wheelchair for mobility. Review of R3's Care Plans, located in the resident's EMR section titled Care Plans, failed to reveal a baseline care plan for R3. During an interview on 10/18/23 at 2:30 PM, R3 stated that he never received any document discussing his plan of care within the 48 hours of his admission to the facility. The resident stated he and his sister have attended the care plan meetings since his admission to the facility and he never received any document describing his care and treatment. 2. Review of R26 admission MDS, with an ARD of 09/27/23 and located in the resident's EMR section titled MDS, revealed the resident had a BIMS score of 11out 15, indicating the resident had moderate cognition impairment. It was documented that the resident required extensive assistance with two-persons physical assistance for all ADLs and was continent of bladder and incontinent of bowels. Review of R26's Care Plan, located in the resident's EMR section titled Care Plans, revealed the resident had only a comprehensive care plan developed and no baseline care plan. An interview on 10/18/23 at 12:39 PM with R26 and his significant other revealed they did not remember receiving or signing for a baseline care plan within the first 48 hours of his admission to the facility. 3. Review of R27's admission MDS, with ARD of 10/01/23 and located in the resident's EMR section titled MDS, revealed the resident had a BIMS score of 11out of 15, indicating the resident had moderately impaired cognition. It was documented that the resident required substantial assistance to dependent on staff for ADLs, required setup for meals, was incontinent of bladder and bowel, and utilized a wheelchair for mobility. Review of R27's Care Plans, located in the resident's EMR section titled Care Plans, revealed the resident had comprehensive care plan but not a baseline care plan within 48 hours after admission to the facility. Interview on 10/19/23 at 9:10 AM with Licensed Practical Nurse (LPN) 9 revealed the baseline care plan is developed during the admission process. LPN9 stated that she did not know who was responsible for ensuring that the resident received a copy of the care plan. Interview on 10/19/23 at 10:48 AM with the Minimum Data Set Coordinator (MDSC) revealed the baseline care plan was completed by the floor nurse during the admission process. The MDSC also stated that she did not participate in the care plan process, so she did not know if the resident or responsible party receives a copy of the baseline care plan. The MDSC also stated that she assumed the Social Services Director probably ensured the baseline care plan was given to the resident and/or family. During an interview on 10/19/23 at 2:58 PM, the Social Services Director (SSD) provided copies of the comprehensive care plan. The SSD stated the baseline care plan is completed by the floor nurse with the resident's admitted . The SSD stated she was unaware that the baseline care plan should be signed by the resident or responsible party and the signed copy of the baseline care plan given to the resident within 48 hours of the resident's admission. Review of the facility policy titled Care Plans - Baseline, with a revision date of 05/2023 reads in part . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission .The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident . NJAC 8:39-11.1

Complaint #: NJ 155628, NJ 158542, NJ167007, NJ 166867 Based on record review, interviews, and facility policy review, the facility failed to ensure wound care treatment was documented as provided according to physician orders for one Resident (R)3 out of 27 sample residents. Findings include: Review of R3 Admission Record located in the resident's electronic medical record (EMR) section titled Profile revealed the resident was admitted to the facility 08/25/23 with diagnoses that included malignant neoplasm of the prostate, osteosarcoma status post resection and total humerus resection. Review R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/31/23 located in the EMR section titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating the resident's cognition was intact. The resident required limited assistance with one-person physical assistance for all activities of daily living. The resident had incontinence of bladder and bowel. The resident was at risk of skin breakdown. The resident had an open lesion of the left upper extremity that required dressing. Review of R3's physicians' orders, revised on 08/20/23, located in the resident's EMR section titled Orders revealed the wound care orders to cleanse the left upper extremity wound with normal saline solution (NSS) and apply medical grade Medi Honey and cover with foam dressing every day shift. Review of R3's physician orders, dated 08/26/23, located in the resident's EMR section titled Orders revealed the orders for wound care to left upper arm, apply betadine to area of dehiscence, cover with dry gauze, and cover with tegaderm every day and evening shift for wound care. Review of R3's Nursing Notes, dated 10/19/23 at 3:01 PM, located in the resident's EMR section titled Progress Notes, revealed Wound care administered to left upper arm. Minimal drainage present. No redness noted to left upper extremity or left chest area. No bleeding, odor or signs of infection noted. The open area to the left upper extremity was cleansed with NSS, patted dry. Medi honey and calcium alginate was applied to the site. The area was covered with border gauze dressing. Review of R3's Treatment Administration Records (TAR) located in the resident's EMR section titled Order - Reports revealed the resident's wound care treatment was not documented on the following dates: 08/30/23, 08/31/23, 09/04/23, 09/08/23, 09/10/23, 09/11/23, 09/26/23, 09/27/23, 10/04/23, 10/10/23, 10/12/23, and 10/13/23. Interview on 10/19/23 at 3:15 PM with Licensed Practical Nurse (LPN)1 revealed that she worked on 9/10/23, 09/26/23, and 09/27/23 but did not remember if she performed the resident's wound care on those days. LPN1 stated that sometimes they were short staffed and not all the residents' treatments were performed. But even though short staffed she did her best to meet the residents' care needs. Interview on 10/20/23 at 9:45 AM with LPN7 revealed that she worked the 7:00 AM to 7:00 PM shift on 10/10/23 and was familiar with R3's wound care. LPN7 stated that the resident's sister was very insistent about have the resident's dressing changed and sometimes the sister would take it upon herself to change the resident's dressing. LPN7 stated she believed she provided the wound care but forgot to document the wound care in the resident's EMR. Interview on 10/20/23 at 10:10 AM with the Director of Nursing (DON) revealed that she was aware of the R3's sister's concern about the resident's dressing being saturated. The DON stated the staff had tried with the resident and the family member to ensure the resident's needs were being met including wound care. The DON did not document it on the grievance logs because she thought the concern was resolved. During the interview, the resident's TAR was reviewed for August 2023, September 2023, and October 2023. The DON acknowledged that wound care was not documented consistently and if the wound care was not done as ordered this could have slowed down the healing process. The DON was asked to identify the nurses responsible for wound care on the identified days. By the end of the survey DON had not provided the requested information. Review of the facility's undated policy titled Wound Care revealed Review the resident's orders and care plan for special needs of the resident .The following information should be recorded in the resident's medical record: l. The date and lime the wound care was given. 2. The type of wound care given. 4. Any change in the residents' condition . Report other information in accordance with facility policy and professional standards of practice. NJAC 8:39-27.1 (a)

PART A: Based on observation, interview, a review of records and other pertinent facility documents, it was determined that the facility failed to ensure: a.) the implementation of their outbreak response plan by implementing and maintaining an infection prevention and control surveillance system and a cohort tracking system for residents that were under investigation for COVID-19; b.) staff assignments were cohorted appropriately to prevent the spread of COVID-19; c.) used gowns were not continuously worn during a staff assignment between caring for residents that were confirmed positive for COVID-19 and a resident who had no known history of COVID-19; and, d.) gowns were not worn between caring for residents in the same PUI cohort group. This deficient practice was identified during the tour of 2 of 2 nursing units (Unit 1 and Unit 2) conducted on [DATE]. On [DATE], the surveyor reviewed the facility's COVID-19 outbreak response plan, the resident and staff line list, infection data reporting sheets, and other pertinent documents the facility provided as they related to COVID-19. The documents revealed that there was no system in place to appropriately track the cohort group of residents who were under investigation for COVID-19, and there was no method of an effective infection surveillance system. Upon observation and interview, it was identified that facility staff was provided with a reusable face mask and gloves and a weekly allotment of two disposable gowns, one N-95 mask, three pairs of shoe coverings, and hairnets. During the tour, it was identified that the nursing, therapy, and social work staff continuously wore their gowns when caring for residents who were under investigation for COVID-19 when additional gowns and personal protective equipment (PPE) were available in storage bins on 2 of 2 units. During tour of the COVID-19 wing located on Unit 1, it was identified that a Licensed Practical Nurse (LPN #4) shared a Certified Nursing Aide (CNA) assignment covering the entire unit which consisted of residents who were in four different cohort groups (including residents who were confirmed positive for COVID-19, recovered from COVID-19, potentially exposed and under investigation for COVID-19, and residents who had tested negative for COVID-19). The LPN was observed wearing an improperly donned gown coming out of the room of two residents who were identified as confirmed positive for COVID-19, then entered a room and closed the door of a resident who was a person under investigation (PUI) for COVID-19 without removing the contaminated PPE. The interviews revealed that LPN #4 had been continuously wearing the same single-use gown provided between the two resident cohort groups. In accordance with facility provided documents as of [DATE], the surveyor learned that 15 of 51 COVID-19 positive residents had expired between [DATE] to [DATE], with the outbreak ongoing as late as [DATE]. The facility's failure to appropriately track the residents under investigation for COVID-19 cohort group, implement an effective surveillance program, appropriately follow the US Centers for Disease Control and Prevention (CDC) guidelines for extending the use of PPE, and failure to cohort staff to the designated cohort groups to the extent possible, posed a serious and immediate threat to the safety and wellbeing of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on [DATE] at 5:45 PM. The immediacy was removed on [DATE] at 5:15 PM based on an acceptable Removal Plan implemented by the facility and verified by the surveyor during an onsite visit conducted on [DATE]. The evidence was as follows: On [DATE] from 9:58 AM to 11:05 AM, the surveyor interviewed with the Director of Nursing/Infection Preventionist (DON/IP) and the newly hired Corporate Registered Nurse (CRN). The DON/IP stated that the Licensed Nursing Home Administrator (LNHA) would not be at the facility today. The DON/IP noted that the facility utilized the U.S. Centers for Disease Control and Prevention (CDC) as the facility's nationally accepted guidelines for infection prevention and control for COVID-19. She further stated that the facility had implemented a method to extend PPE use, specifically the use of a face shield, and N-95 respirator masks. The DON/IP stated that staff used, gowns throughout the day on both units and that gowns were also continuously worn by staff on the COVID-19 wing cohorted (treating as a group) on Unit 1. The DON/IP continued that the facility was cohorting nursing and housekeeping staff by only keeping them assigned to residents that had tested positive for COVID-19, but that staff knew to use a well-to-ill rounding strategy, and that PPE could not be reused from a COVID-19 positive room to a COVID-19 negative or PUI room. The DON/IP added that the facility was also testing all residents for a baseline COVID-19 result on admission. If negative for COVID-19, they would be retested every week, and as needed. She continued that for those residents that tested positive for COVID-19, the facility would re-test them after their recovery period. The facility utilizes a test-based strategy to determine recovery by retesting the residents to ensure two lab-confirmed negative results within a few days apart. The DON/IP noted that the facility currently had residents in-house that had acquired the infection in the facility and tested positive for COVID-19, as late as [DATE]. The surveyor asked how many residents were confirmed positive for COVID-19, and the DON/IP stated that she thought there were eight (8) residents on the COVID-19 wing from resident rooms ,[DATE]. The surveyor asked for the facility's data tracking and surveillance related to their COVID-19 outbreak and any further documents or tools the facility was utilizing during the outbreak, including a PPE utilization/ burn rate (average calculation of daily consumption rate of each PPE used to estimate current PPE inventory with the burn rate to ensure adequate supplies are available). The DON/IP indicated that their primary tracking method was the resident outbreak line list, but that she also had a copy of her tracking of residents and staff who were tested for COVID-19. The DON/IP confirmed a Facility Outbreak Reporting Daily Survey was sent daily to the New Jersey Department of Health (NJDOH), which included cumulative numerical data. The surveyor also asked about the facility's PPE utilization/ burn rate, and the DON/IP stated she wasn't sure about that, but that she would check. The DON/IP acknowledged that she didn't maintain a current in-house data surveillance system, but that she could indicate the residents who were new admissions in the last 14 days and which residents had recovered from COVID-19 using the alphabetized resident census list. The DON/IP explained that Unit 1, rooms ,[DATE] were rooms designated for COVID-19 positive residents. The hallway running perpendicular to the COVID-19 unit was Unit 1 rooms ,[DATE], and was designated for new hospital admissions in the last 14 days and were under investigation for COVID-19. She added that Unit 2, rooms ,[DATE], were all negative for COVID-19. She said that the facility would put two Persons Under Investigation (PUI) for COVID-19 residents together in the same room if they were admitted the same day or one day apart, and quarantine them for 14 days with droplet precautions (a method of transmission-based precautions in which a gown, gloves, mask, and face shield are worn by staff when in close proximity or contact with the resident or the resident's environment to prevent the spread of infection). The surveyor asked the DON/IP how many COVID-19 positive residents the facility had on the census, and the DON/IP stated she believed there were either seven or eight residents. The surveyor then asked how many residents on the census were identified as PUI, and the DON/IP stated there was one, and it was an exposed roommate of a resident who had tested positive for COVID-19 (Resident #5). The surveyor asked the DON/IP how the facility identified residents who are PUI. The DON/IP stated that a PUI would be a resident who had symptoms of COVID-19 and has a test result pending and an exposed resident who had a roommate or staff that tested positive for COVID-19. She stated that none of the residents in the building currently had symptoms of COVID-19, so it was only one resident on the census that was a PUI (Resident #5). The surveyor asked if there were any other situations in which a resident would be considered a PUI, and the DON/IP stated that the facility tested all the residents for COVID-19, so she wasn't sure beyond that. The surveyor asked how the facility handled new admissions, and the DON/IP indicated that the facility placed the residents on a 14 day quarantine period and on droplet precautions. The DON/IP stated that the facility would also consider this cohort group under the PUI cohort because they were placing the residents newly admitted on droplet precautions because of an unknown exposure to COVID-19 in the hospital or community. The surveyor asked about residents who went out to [MEDICAL TREATMENT] or other specialized appointments outside the facility, and if they would be placed on droplet precautions. The DON/IP replied that the facility currently had no residents that go to a [MEDICAL TREATMENT] center or other specialized treatment centers for appointments. Still, if the facility did, they too would be placed on droplet precautions for the 14 days from their last appointment date. The DON/IP confirmed this would meet the facility's PUI definition due to an unknown exposure. Further, the surveyor reviewed the undated My In-House Tracker for testing of residents in the presence of the DON/IP. The surveyor identified that there was one (1) resident who had tested negative for COVID-19 on [DATE], and had refused subsequent weekly COVID-19 tests and resided on Unit 1. The DON/IP acknowledged this resident was also on droplet precautions and a PUI. The surveyor then asked how many residents of the current census were PUI? The DON/IP put a checkmark next to all the residents that were new admissions in the last 14 days. There were 15 residents, but she also added that 4 of the newly admitted residents had either had COVID-19 or recovered from COVID-19, so, therefore, 11 residents were PUI. She confirmed that the resident who refused subsequent testing and the resident that had a roommate that tested positive would put the facility total at 13 PUI. The surveyor reviewed the list more closely and noticed that the DON/IP identified a resident who was a PUI for being a new admission in the same room as a resident not identified as a PUI on the census list. The DON/IP indicated that the roommate completed their 14-day quarantine today, and the other roommate completes their 14-day quarantine tomorrow. The DON/IP acknowledged she did not have numerical calculations for the data for the three cohort groups to track the progress of the outbreak. At that time, the surveyor reviewed the rooms of the residents that were PUI with the floor plan, which revealed that the PUI's were spread throughout 2 of 2 units on various sides of the hallway and not cohorted to a single area or ensure they were separated from the residents who were non-ill, non-exposed. The DON/IP also acknowledged that the PUI cohort group of residents were placed in rooms throughout the 2 of 2 units. She admitted that she didn't have a surveillance tracker to identify where each PUI, COVID-19 positive, COVID-19 recovered, and COVID-19 negative resided within the building. On [DATE] at 11:10 AM, the surveyor toured Unit 2 (PUI/negative and not exposed/negative) with the CRN and observed the following: 1. The surveyor toured the Unit 2 hallway and observed that the PUI residents were not in a designated cohort area of the unit, but spread throughout the unit in various rooms throughout, and with a single PPE storage bin located outside the room of Resident #5. The storage bin was stocked with several long-sleeve gowns and gloves, a disposable thermometer, and a disposable stethoscope. On top of the bin was a bottle of alcohol-based hand gel (ABHG). A review of the staff assignment sheet for [DATE] revealed that nursing assignments were not cohorted to the extent possible when LPN #1 had an assignment with five residents that were PUI and three residents non-exposed and negative for COVID-19. The other nursing assignment consisted of five residents that were PUI and seven residents that were non-exposed and negative for COVID-19. At 11:15 AM, the surveyor observed an Occupational Therapist (OT) wearing a long sleeve disposable gown, N-95 respirator mask, a face shield exit the room of a resident who was identified as non-ill and non-exposed. At that time, the surveyor interviewed the OT and asked about her use of PPE while in the resident's room. The OT confirmed that the resident was not on droplet precautions, but stated she wore full PPE because COVID-19 was highly contagious and it's everywhere, so we have to wear PPE. The OT continued that she removed her PPE only when exiting the unit, and before lunch. She further stated, we re-use it. She noted the only time it would not be reused, was if she had to go to a COVID-19 positive resident. She confirmed she would wear the same gown between residents of the various cohort groups, which was okay as long as the resident didn't have COVID-19. At 11:29 AM, the surveyor observed a Physical Therapist (PT) exit the resident's room identified to be a PUI located near the end of the hallway on Unit 2. There was a stop sign to see the nurse before entering and a sign that indicated droplet precautions were required. The surveyor observed the PT exit the room while wearing a long-sleeve single-use gown, a face mask, face shield, and a hair net. She continued to walk down the hallway to a room behind the nurses' station wearing the contaminated PPE. The PT doffed her gown in the staging room and discarded it. The surveyor interviewed the PT, who stated that she only sees residents on Unit 2. She just completed an initial evaluation on that resident because he/she was just admitted from the hospital and was on droplet precautions for 14 days. The surveyor asked about the extended use of PPE, and the OT confirmed that gowns were reused between residents but only when going from droplet to droplet room. She added that she could not go from a resident room that was on droplet precautions while wearing the full PPE then go to a resident room that was not on droplet precautions, adding that the reason was that this could potentially cause cross-contamination. At 11:41 AM, the surveyor observed LPN #3 in the hallway wearing a long-sleeve isolation gown and a mask. LPN #3 stated that she was not functioning as a nurse but instead had a Certified Nursing Aide (CNA) assignment today, which included residents that were PUI and residents that were non-ill, non-exposed to COVID-19 and had tested negative for [MEDICAL CONDITION]. LPN #3 further stated that she wears the gown everywhere because the gown is a general gown to be worn for general care. She also said that if it got dirty, she would get a new one. She stated that while there were no COVID-19 residents on the unit, she would need to change her gowns if she had to go between two isolation rooms because of how COVID-19 spreads. LPN #3 stated that Unit 2 only had exposed residents because they were new admissions from the hospital or residents who had tested negative for COVID-19 and had completed the 14-day quarantine. LPN #3 added that the Receptionist puts PPE bags together, and each staff member would get one bag per week with ,[DATE] gowns, one N-95 respirator mask, a couple of shoe covers, and hair coverings. She stated that even though she received an individually packaged weekly allotment of PPE, there were gowns kept on the unit if more were needed. At 11:59 AM, the surveyor observed the Medical Records Coordinator (MRC) wearing a gown and face mask exiting the PPE staging room behind the nurses' station. The MRC stated that she was responsible for going to both units and delivering beneficiary notices to residents. The MRC said that she donned and doffed the PPE in the staging room behind the nurses' station and that she could wear the same gown between residents that were non-ill, non-exposed/negative for COVID-19, and that a new gown could be shared between PUI residents on droplet precautions. She stated that a new gown would be needed if going from a PUI to a not exposed resident and not ill. She continued that she would store her gowns in the staging area and put it in the clear plastic bag. 2. On the same day, [DATE] at 12:05 PM, the surveyor observed the meal truck delivered to the floor and noted the following during the lunch delivery service on Unit 2: At 12:08 PM, the surveyor observed the SW wearing the same blue short sleeve disposable gown deliver a regular non-disposable tray to a resident that was non-ill, not exposed, and had tested negative for COVID-19. The surveyor observed the SW enter the resident's room, place the tray on the bedside table, and adjusted the table and moved it closer to him/her with her bare hands. The SW then exited the resident's room and did not offer to assist the resident with a hand hygiene wipe or encourage them to use the hand hygiene wipe on the tray before the lunch service. She then exited the room and did not perform hand hygiene, and she immediately returned to the tray truck to pick up another tray. She took a tray for a resident that was identified as a PUI and on droplet precautions. She was not wearing a face shield or gloves and delivered the tray to the resident's room, touching the bedside table and adjusting the tray closer to the resident. The SW then exited the room, used ABHG, and walked down the hallway to the PPE staging area. At that time, the SW told the LPN/Charge Nurse that she needed a new gown because she went into a resident room on droplet precautions. The surveyor observed the LPN/Charge Nurse tell the SW that she could continue wearing the same gown that she had on, but that she would just have to only serve the rest of the lunch trays to PUI residents and on droplet precautions. The SW left the same gown on and continued to pass out lunch trays to residents on droplet precautions. The SW did not wear a face shield or gloves when handling the lunch trays and touching the resident's bedside tables. At 12:18 PM, the surveyor observed the LPN/Charge Nurse doff her PPE gown in the room behind the nurses' station; she then clipped it, allowing the gown to hang freely in the staging area room. At 12:28 PM, the surveyor interviewed the SW, who confirmed she was in-serviced on hand hygiene and how/when to don and doff PPE. The SW stated that she could wear the same gown when going from PUI to PUI, but she could not enter a resident room that was not a PUI afterward and would have to change her gown. The SW stated that she washes her hands with ABHG between contact with the resident or their environment. She said, I don't use the face shield much as the face shield is used more for the COVID unit. The SW stated that the face shield was to protect her from droplets from a cough or a sneeze and acknowledged it was difficult to predict if and when someone else coughs or sneezes. At 12:38 PM, the surveyor interviewed a CNA assigned to Unit 2. The CNA was not wearing a gown in the hallway but holding a new one. The CNA stated that COVID-19 was spread through droplets, and therefore, he would have to wear a gown, gloves, N-95 respirator mask, face shield, and shoe coverings when entering a PUI room. The CNA stated that a face shield was only needed to provide direct care to the resident; otherwise, it wasn't required to drop off a tray or just check on the resident. The CNA stated that if a resident developed symptoms of COVID-19, that the gown and other PPE could not be re-worn between other PUI resident rooms. He said that if the resident was symptomatic, the gown must be discarded in the resident's room and not in the staging area behind the nurses' station. At 12:45 PM, the surveyor interviewed the LPN/Charge Nurse regarding the meal delivery service. The LPN/Charge Nurse stated that all residents on Unit 2 get a non-disposable tray, but they would get a disposable tray if they were symptomatic. She noted that the dietary aide delivers the meal trucks to the unit's closed front door, and she or other staff go to the door to take it from them. She stated that the nurses are supposed to pass out the trays to all the residents who are non-COVID first, then the residents on droplet precautions. This would prevent cross-contamination while wearing the same gowns between the same resident cohort groups. 3. On [DATE] at 12:56 PM, the surveyor toured Unit 1 with the CRN, which included a hallway consisting of the following cohort groups: residents that were PUI for COVID-19, residents that were non-ill/negative for COVID-19, a resident that had recovered from COVID-19 and a resident who was a PUI because he/she refused to be retested for COVID-19. (This cohort did not correspond with what the DON/IP told the surveyor during an interview at 9:58 AM, in which the hallway was for new admissions and still within their 14-day PUI quarantine period.) Perpendicular to the Unit 1 hallway was the COVID-19 wing, which included residents that were either confirmed positive for COVID-19 or were in recovery from COVID-19. At 12:59 PM, the surveyor observed a Registered Nurse (RN) in the hallway of the COVID-19 wing of Unit 1. The RN was wearing an N-95 respirator mask, a face shield, and a long-sleeve disposable gown. At that time, the surveyor interviewed the RN who stated that her assignment consisted of rooms ,[DATE], and included residents that had tested positive for COVID-19, residents that were under investigation for COVID-19, and a resident who had tested negative for COVID-19 but was a PUI because he/she refused subsequent testing. The RN stated that she wasn't only assigned to COVID-19 residents, as she had other cohort groups in her assignment. She said, however, that she utilized a well-to-ill rounding strategy not to cross-contaminate. The RN stated that she had three residents that were confirmed (+) for COVID-19 (Resident #1, Resident #2, and Resident #3); This did not correspond with the number of confirmed positive cases, the line listing or what the DON/IP had told the surveyor during the interview at 9:58 AM. The RN stated that she would wear her same PPE for all COVID-19 positive residents, but if she had to see her PUI residents, she would have to remove her PPE and don new PPE. The RN confirmed that the same PPE could be worn between the same PUI to PUI resident room cohorts as well. At 1:00 PM, the surveyor observed LPN #4 wearing an N-95 respirator mask, a face shield, and a long-sleeve disposable gown in the hallway. The surveyor observed that the gown was not tied at the waist, and the ties were hanging loosely on her sides, nearly touching the floor. LPN #4 entered the private room of Resident #1, who was on the COVID-19 wing and closed the door behind her. At 1:04 PM, the surveyor observed LPN #4 exit the room of Resident #1, and immediately enter the room of Resident #2 and Resident #3, who were roommates on the COVID-19 wing and confirmed positive for COVID-19. LPN #4 was wearing the same PPE, and the single-use gown was still untied at the waist, causing the lower half of the gown to freely move as the LPN walked. LPN #4 then closed the door behind her. At 1:07 PM, the surveyor observed the same LPN #4 exit the room of Resident #2 and Resident #3 who were confirmed positive for COVID-19, wearing the same PPE, including the untied gown. LPN #4 then left the COVID-19 wing and proceeded to walk down the hallway where there were residents who were PUI and negative for COVID-19. The surveyor observed that as the LPN #4 walked down the non-COVID hall, as the LPN's untied, unsecured gown moved freely. The surveyor also identified that LPN #4 did not disinfect the face shield. The surveyor then observed LPN #4 enter a room down the non-COVID hallway. The surveyor followed and noted that the LPN #4 entered Resident #4's room, who had a sign on the door to stop and see the nurse before entering and a sign that read, Droplet Precautions. There was a PPE storage bin outside the resident's room stocked with new gowns and gloves. A review of the Census Report Dated [DATE], Resident #4 was a new admission on [DATE] and identified by the DON/IP as a new admission PUI. At approximately 1:12 PM, the surveyor observed LPN #4 exit the room of Resident #4 (PUI/baseline negative) wearing the same PPE, including the untied, unsecured gown and the face shield as she was wearing while in the COVID-19 positive room. As the LPN #4 exited Resident #4's room, and before the surveyor could stop or interview LPN #4, the Corporate RN pulled LPN #4 aside and told her to remove her PPE and get new PPE before proceeding any further. At approximately 1:16 PM, the surveyor observed the LPN #4 doff her PPE and perform hand hygiene at the pantry sink located across the hallway from Resident #4. The surveyor interviewed the LPN #4 at that time. LPN #4 stated that she was working as a CNA that day. LPN #4 noted that another CNA worked that day, and together they were assigned to the entire floor. LPN #4 confirmed that meant she was assigned to care for the COVID-19 residents, including Resident #2 and Resident #3, and residents that were PUI and had tested negative for COVID-19. She stated that Everyone here is on droplet precautions, and even though rooms (room numbers redacted) are non-COVID, we treat them like they have it. She further clarified that she wears a gown in all the rooms because the PUI residents might get COVID-19. LPN #4 also stated that Resident #4 was a PUI and had tested negative for COVID-19, but she still had to wear PPE when entering the room because the resident was on droplet precautions. LPN #4 stated that she went into Resident #4's room because his/her call light was on, and she wanted to check to see what the resident needed. She acknowledged she entered the room, closed the door, and then saw that LPN #5 was already in the room, so she opened the door and left. The surveyor asked LPN #4 when she dons and doffs her PPE, and she replied that she dons the PPE first thing in the morning and that she can wear the same PPE from PUI to PUI room. She stated that she could wear the same PPE between residents that were confirmed positive for COVID-19 but that she wasn't supposed to go from COVID-19 positive to PUI wearing the same PPE. The surveyor asked if she knew the status of Resident #2 and Resident #3, and the LPN #4 confirmed that those residents had recently tested positive for COVID-19 but were asymptomatic. She acknowledged she had just exited the room of Resident #2 and #3 (COVID-19 positive) before entering the room of Resident #4 (PUI/baseline negative) wearing the same PPE. The LPN #4's explanation of why she did that was because Resident #4's call light was on. LPN #4 added that the gowns should be tied and secured at the waist. At approximately 1:20 PM, the Corporate RN acknowledged that she saw LPN #4 exit the COVID-19 positive area while wearing the same PPE in which she had entered/exited a room for a PUI/baseline negative room. The CRN stated this was why she told the LPN #4 to change her PPE because she could not go from COVID-19 positive to a PUI room due to cross-contamination risks. At 1:22 PM, the surveyor interviewed the Corporate RN a second time. The surveyor asked the RN when she dons and doffs her PPE when she has an assignment that includes COVID-19 positive and PUI/baseline negative residents. The RN stated that if she had to go from COVID-19 positive to a PUI room, she would have to doff her PPE and apply new PPE, and she would take it from a fully stocked PPE bin in the hallway. The surveyor asked why that was important, and the RN stated, You just can't do that, even if I don't touch anything .it's because of cross-contamination. The RN further added that not changing the PPE from COVID to non-COVID could potentially expose the PUI resident to COVID-19. At 1:35 PM, the surveyor interviewed a Housekeeper who stated that she cleaned all the PUI resident rooms first, and she said that she would change her PPE between each PUI room, but when she gets to the COVID-19 wing, she would wear the same PPE throughout, except the gloves. The Housekeeper confirmed there was no short supply of PPE and always was accessible in the bins if she needed it. At 2:02 PM, the surveyor interviewed the LPN/Charge Nurse #2. The LPN/Charge Nurse #2 stated that staff could not go from COVID-19 positive rooms to a PUI resident room because that's dirty to clean and can cause spread of COVID-19. LPN/Charge Nurse #2 stated that even if the staff is not touching anything in the room, they shouldn't be over there at all while wearing the same PPE from a COVID-19 room. At 2:15 PM, the DON/IP showed the surveyor the PPE inventory and stated, we have a lot of gowns. The DON/IP noted that she was still looking for the PPE burn rate calculations that the surveyor had asked for that morning. She stated that she believed that the facility had ,[DATE] weeks of PPE in inventory. The Corporate RN said that the Corporate office had even more if needed. The DON/IP and Corporate RN confirmed that staff should not be going from COVID-19 positive to a PUI/baseline negative resident room, potentially exposing a resident to COVID-19. The DON/IP confirmed that the PPE process hasn't changed since she started working at the facility in [DATE], and that staff can wear the same PPE when caring for residents within the same cohort group. The surveyor asked for the US CDC guidelines that support this practice. No response was given. At 2:50 PM, the surveyor interviewed the LPN #5 in the room of Resident #4 (PUI/baseline negative) when LPN #4 entered the room. LPN #5 stated that she was assisting Resident #4 to the bathroom. LPN #5 said the resident was a PUI and had a negative baseline test, and he/she wasn't having any symptoms of COVID-19. LPN #5 stated that she was allowed to wear the same PPE when caring for residents in the same cohort group, but that the same PPE could not be worn from COVID-19 positive to a PUI room. LPN #5 also stated that if staff went from Resident #2 and #3 (COVID-19 positive) to Resident #4 (PUI/baseline negative) wearing the same PPE, it could potentially spread [MEDICAL CONDITION] to Resident #4. LPN #5 further stated that gowns should not be worn behind the nurses' station. The LPN added that LPN #4 entered Resident #4's room because the call light was on, and she closed the door behind her but didn't touch anything but the doors/doorknobs in the resident's environment. At 3:57 PM, the surveyor observed LPN #6 walking down the hallway wearing a long sleeve single-use gown. The gown was not tied at the neck or waist. The surveyor interviewed LPN #6, who stated that she worked the ,[DATE] PM evening shift. She just finished getting a report for all the residents on her assignment, which included rooms (room numbers redacted) (which included COVID-19 positive, PUI, and negative for COVID-19 cohort groups). She stated she was about to check on her residents. The surveyor asked about the unsecured ties on her gown, and LPN #6 began tying them in front of the surveyor and acknowledged that they should be tied securely. The surveyor reviewed the facility's policies and CDC guidelines for COVID-19. A review of the facility's Prevention and Control of [MEDICAL CONDITION] policy signed as reviewed on [DATE] included to Identify dedicated employees to care for resident under investigation of COVID-19 and or who have confirmed COVID-19 patients and provide infection control training. It further included providing the right supplies to ensure the easy and cor (TRUNCATED)