Every finding on record at Alameda Center for Rehabilitation and Healthcare

Complaint: 2587228Based on interviews, medical record review, and review of other pertinent facility documents on 12/29/2025, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #1, Resident #2, Resident #3, and Resident #7). This deficient practice occurred for 4 of 4 residents reviewed.The deficient practice was evidenced by the following:1.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: dementia, diabetes, and muscle weakness.According to the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/4/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further revealed the resident was dependent on staff for activities of daily living (ADLs).A review of Resident #1's POC flowsheet, a form utilized for documentation of ADL care by the Certified Nursing Assistants (CNAs) for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift (every shift)7-3 shift on 11/1/2025, 11/4/2025, 11/5/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/12/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/22/2025, 11/24/2025, 11/25/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/15/2025, 11/22/2025, and 11/30/2025.11-7 shift on 11/11/2025 11-7, 11/22/2025, and 11/28/2025. Toileting Hygiene QShift7-3 shift on 11/1/2025, 11/4/2025, 11/5/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/12/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/22/2025, 11/24/2025, 11/25/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/15/2025, 11/22/2025, and 11/30/2025.11-7 shift on 11/11/2025, 11/22/2025, and 11/28/2025. A review of Resident #1's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift7-3 shift on 12/1/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/5/2025, 12/11/2025, 12/13/2025, 12/19/2025, 12/20/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/25/2025, 12/26/2025, 12/27/2025.11-7 shift on 12/25/2025.Toileting Hygiene QShift7-3 shift on 12/1/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/5/2025, 12/11/2025, 12/13/2025, 12/19/2025, 12/20/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/25/2025, 12/26/2025, and 12/27/2025.11-7 shift on 12/25/2025.22. According to the AR, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: dementia, anxiety, and diabetes. According to the most recent comprehensive MDS, an assessment tool dated 12/10/2025, Resident #2 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident required supervision with ADLs. A review of Resident #2's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 11/21/2025, 11/23/2025, 11/24/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/30/2025.11-7 shift on11/19/2025.Toileting Hygiene QShift7-3 shift on 11/21/2025, 11/23/2025, 11/24/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/30/2025.11-7 shift on 11/19/2025. A review of Resident #2's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 12/4/2025, 12/9/2025, 12/17/2025, 12/20/2025, 12/22/2025, 12/26/2025, and 12/27/2025.3-11 shift on 12/17/2025.Toileting Hygiene QShift:7-3 shift on 12/4/2025, 12/9/2025, 12/17/2025, 12/20/2025, 12/22/2025, 12/26/2025, and 12/27/2025.3-11 shift on 12/17/2025.3. 3. According to the AR, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: muscle weakness, chronic obstructive pulmonary disease, acute kidney failure. According to the most recent comprehensive MDS, an assessment tool dated 12/18/2025, Resident #3 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident required substantial assistance with ADLs. A review of Resident #3's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 11/9/2025,11/15/2025, 11/19/2025, and 11/23/2025.3-11 shift on 11/8/2025, 11/9/2025, 11/22/2025, 11/23/2025, and 11/30/2025.11-7 shift on 11/18/2025 and 11/19/2025. Toileting Hygiene QShift:7-3 shift on 11/9/2025, 11/15/2025, 11/19/2025, and 11/23/2025.3-11shift on 11/8/2025, 11/9/2025, 11/22/2025, 11/23/2025, and 11/30/2025.11-7 shift on 11/18/2025 and 11/19/2025.A review of Resident #3's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 12/6/2025, 12/7/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025. 3-11 shift on 12/6/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025. Toileting Hygiene QShift:7-3 shift on 12/6/2025, 12/7/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025.3-11 shift on 12/6/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025.4. According to the AR, Resident #7 was admitted to the facility with diagnoses which included but were not limited to: alzheimer's, diabetes, and heart failure. The resident was discharged from the facility prior to this complaint survey.According to the most recent comprehensive MDS, an assessment tool dated 8/8//2025, Resident #7 had a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further revealed the resident required moderate assistance with ADLs. A review of Resident #7's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for August 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 8/1/2025, 8/2/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/24/2025, and 8/26/2025.11-7 shift on 8/7/2025 and 8/8/2025.Toileting Hygiene QShift:7-3 shift on 8/1/2025, 8/2/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/24/2025, and 8/26/2025.11-7 shift on 8/7/2025 and 8/8/2025. On 12/29/2025 at 10:25 A.M., the surveyor interviewed CNA#1 who stated that that the CNAs were to document the care they provided in the POC for their shift. The CNA further stated that if care was documented in the POC it meant the care was completed. On 12/29/2025 at 10:30 A.M., the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/ UM) who stated that the CNAs documented care in the kiosk. She stated that she thought they only had to document ADLs once a shift. She further stated that the unit managers were responsible for making sure the documentation was completed by the end of the day shift and the supervisors were responsible on the other shifts. On 12/29/2025 at 1:20 P.M., the surveyor interviewed the Director of Nursing (DON) in the presence of the Regional DON. The DON stated that the CNAs were responsible for documenting in the POCs. She stated herself, the unit managers, and the supervisors were responsible for checking that the ADL documentation was completed every shift. The DON stated it was important that the CNAs documented ADLs, so that the care was accurately reflected in the resident's medical record. The DON further stated that the ADL documentation should not be blank for any shift. A review of the facility's policy titled Charting and Documentation with a revised date of July 2017 revealed under Policy Statement, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Under Policy Interpretation and Implementation,, 8. Documentation of procedures and treatments will include care-specific details, may include the following but not limited to: a. the date and time the procedure/treatment was provided.NJAC 8:39-27.1 (a)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 3 of 5 unit pantries (Units 2, 3, and 4). This deficient practice was evidenced by the following: On 06/30/2025 at 10:32 AM, the surveyor inspected the Unit 3 pantry in the presence of the Licensed Practical Nurse and Unit Manager #1 (LPN/UM #1) and observed the following: white debris was present inside of the microwave, a cabinet drawer panel was not intact and slid back and forth, and an aluminum pan containing white debris was found inside the cabinet. On 06/30/2025 at 10:48 AM, the surveyor inspected the Unit 4 pantry in the presence of the Licensed Practical Nurse and Unit Manager #2 (LPN/UM #2) and observed the following: light brown debris on the wall next to the refrigerator. On 07/02/2025 at 10:34 AM, the surveyor inspected the Unit 2 pantry in the presence of the Licensed Practical Nurse and Unit Manager #3 (LPN/UM #3) and observed the following: light brown, powdery debris on the wall vent; black, sticky residue on the wall next to the refrigerator; and a loose white rack. Brown, dry debris was also found inside the cabinets. On 06/30/2025 at 10:35 AM, during an interview with the surveyor, the LPN/UM #1 said that the microwave should be clean, the drawer should not be damaged, and dirty items such as the aluminum pan should not be stored in the cabinet. She noted that housekeeping is responsible for cleaning the pantry daily. 06/30/2025 at 10:50 AM, during an interview with the surveyor, the LPN/UM #2 said that housekeeping is responsible for cleaning the pantry. 07/02/2025 at 10:15 AM, during an interview with the surveyor, the LPN/UM #3 said that the debris should not be present on the vents, walls or inside the cabinets, and that the loose white rack should be properly secured. 07/02/2025 at 10:34 AM, during an interview with the surveyor, the Maintenance and Housekeeping Director, said that housekeeping is responsible for cleaning the unit pantry areas, while nursing staff are responsible for maintaining edible items inside the refrigerators and cabinets. Maintenance handles repairs: however, nursing staff must report broken items through the electronic maintenance system. Maintenance checks the system daily, and every request entered triggers an immediate notification to maintenance. The system categorizes repairs as critical, high, medium, or low priority, and requests are addressed based on parts availability and severity, with critical issues handled promptly. A review of the facility's dated policy 01/2025, titled, Safe and Homelike Environment, revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. N.J.A.C. 8:39-31.3(a)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include a positioning device. This deficient practice was identified for 1 of 35 residents reviewed for resident-centered care plans (Resident #208), and was evidenced by the following: On 06/26/2025 at 09:48 AM, the surveyor observed Resident #208 ambulating using a cane, the left arm was observed in the sling. According to the admission Record, Resident #208 was admitted with diagnosis that included, but were not limited to, cerebral vascular accident (a stroke) and hemiplegia (weakness on one side of the body) A review of Resident #208's Quarterly Minimum Data Set, an assessment tool dated 05/06/2025, revealed that he/she was cognitively intact. A review of Resident #208's Care Plan with an effective date of 06/25/2025 reflected that this resident had limited physical mobility. The use of the sling was not included in the interventions. A review of Resident #208's Care Plan with an effective date of 01/28/2025 reflected that this resident had hemiplegia/hemiparesis related to a stroke. The use of the sling was not included in the interventions. On 07/01/25 at 09:10 AM, the Licensed Practical Nurse/ Nurse Manager LPN/NM stated the Resident #208 utilized the sling. The LPN/NM stated that the sling should be included on the resident care plan. She acknowledged that Resident #208's sling was not included in the care plan. On 07/02/25 at 12:00 PM, the Director of Nursing acknowledged that Resident #208's care plan did not include the use of the sling. A review of the facility provided policy titled, Care Plans, Comprehensive Person-Centered, with an original issue date of 01/03/2025, reflected 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. NJAC 8:39-11.2

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 1 of 35 residents reviewed (Resident #120). This deficient practice was evidenced by the following: On 6/30/2025 at 12:09 AM, the surveyor observed Resident #120 in the dining with a palm guard on left hand. The surveyor reviewed the medical record for Resident #120. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Chronic Obstructive Pulmonary Disease and Generalized Muscle Weakness. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/28/25 included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severly impaired. Section GG identified that the resident was not coded for any upper extremity contractures. A review of previous MDS assessments also revealed that the following dates did not identify Resident #120's upper extremity contracture: quarterly submitted on 3/29/24; annual submitted on 6/28/24; quarterly submitted on 9/27/24; and the quarterly submitted on 12/27/24. A review of the Physician Order Summary Report included the following physician orders (PO): A PO, with an order start date of 6/20/2025, to Apply (Left) Palm Protector to be work after AM care and remove at PM Care or as tolerated to prevent further contracture. During an interview with the surveyor on 7/1/2025 at 11:40 PM AM, Actifing Director of Rehabilitation (ADOR) reviewed Resident #120's rehabilitation documentation with the surveyor. It was determined that the resident's contracture was first identified in 8/3/2024 with left hand tightness and joint immobility. When asked if this date should be considered the onset of the contracture, the ADOR confirmed. During an interview with the surveyor on 7/2/2025 at 9:52 AM, Licensed Practical Nurse (LPN #1) said that they were familiar with Resident #120 and confirmed that the resident has been had their contracture to the left hand since their last admission. During an interview with the surveyor on 7/2/2025 at 10:15 AM, Director of MDS (DMDS) stated that the MDS coordinators were responsible for signing off all entries as accurate. Upon review of Resident #120's 3/28/25 MDS, DMDS confirmed that contracture was not identified. When questioned if Therapy Notes were reviewed or discussed prior to a resident's MDS submission, DMDS responded that if there was documentation of the contracture then it should have been identified on the MDS. A review of the facility provided Resident Assessment Instrument (RAI) Process Policy with Revision Dated: 1/3/2025, identified under Purpose: To ensure that the MDS for each resident is completed accurately and timely in accordance with State and Federal regulations. The following was identified under Scope: This policy and procedure applies to the Interdisciplinary Team which may include [ .] Director of Rehabilitation and nursing staff in resident care. NJAC 8:39-33.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 06/30/2025 at 10:48 AM, the surveyor inspected the pantry refrigerator on Unit 4 in the presence of the Licensed Practical Nurse and Unit Manager #2 (LPN/UM #2) and observed the following: a 14-ounce container of sour cream with an expiration date of 03/19/2025, and a quart of half and half with an expiration date of 06/20/2025. Additionally, six containers of food brought in from outside the facility were found without any labels or dates. A plastic bag containing an unidentified whitish edible substance lacked both a label and a use-by date, and a 15-ounce open plastic container of soup was found without an open date or use-by date. On 06/30/2025 at 10:50 AM, On 06/30/2025 at 10:48 AM, during an interview with the surveyor, the LPN/UM #2 said that expired food should not be stored in the refrigerator and that any food brought in from outside the facility should be properly labeled and dated according to the facility policy. On 07/02/2025 at 10:11 AM, during an interview with the surveyor, the Dietary Director said that nursing was responsible for maintaining pantry cleanliness, ensuring all food items are not expired, and verifying that outside food is properly labeled and dated. On 07/02/2025 at 12:00 PM, during an interview with the surveyor, the Director of Nursing said that food brought in from outside the facility should be labeled and dated and discarded after three days. A review of the undated facility policy, titled, Food and Nutrition Services, Subject: Foods Brought by Family or Visitor revealed, Perishable prepared foods will be checked by the designee housekeeper/nurse and discarded after 3 days of storage. Perishable manufactured foods stored in the manufacturer packaging will be discarded as per the best by or use by date. If no date, follow facility refrigerated storage guidelines of disposing items after 3 days of storage. A review of the undated facility policy titled, Labeling and Dating System Protocol, revealed, Follow manufactures expiration date on all un-opened or opened product. All fresh and frozen foods must be dated with the date it was received into the kitchen, unless purveyor shipping label on it. Make sure to not date over or cover the manufacturer's expiration date on the product. Day 1 is the first day of labeling. N.J.A.C 8:39-17.2 (g)

Based on observations, interview, and review of facility policy, it was determined that the facility failed to appropriately dispose of medication in accordance with currently accepted professional principles. The deficient practice was identified for 1 of 5 nurses observed during the Medication Administration task. The deficient practice was evidenced by the following: On 07/01/2025 at 8:57 AM during medication pass on the second floor, Licensed Practical Nurse (LPN) # 1 poured one tablet of aspirin 81 milligrams (mg) and one tablet of clopidogrel 75mg (blood thinner medication). As LPN # 1 continued, the cup of tablets spilled and the tablets came to rest on top of the medication cart. At that time, LPN # 1 picked up the tablets with her gloved hand, turned the glove inside-out and threw it in the trash can. After LPN # 1 completed the medication administration, the surveyor asked LPN # 1 how should she dispose of medications that are not being administered. She replied, They have a jug for it in the cart. At that time, LPN # 1 showed the surveyor the bottle of Drug-Buster (solution used to dissolve medications) in the bottom drawer of the medication cart. At that time, LPN # 1 said, Oh my God, I threw it out in the trash! On 07/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing replied, Drug buster in the cart. when the surveyor asked how should medications be disposed of if they are spilled. The Director of Nursing replied, Because no one can take the medication. after the surveyor asked why is it important to dispose of the drugs in the drug buster. A review of the facility policy titled Storage of Medications revealed, 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. N.J.A.C. § 8:39-29.7

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer medication in accordance with prescriber orders, specifically administering an intravenous antibiotic outside of the prescribed time of administration. The deficient practice was identified for 1 of 1 resident (Resident # 328) reviewed for Antibiotics. The deficient practice was evidenced by the following: A review of Resident # 328's physician's orders located in the Electronic Medical Record (EMR) revealed an orders for daptomycin intravenous solution reconstituted 500mg (milligram) and ceftaroline fosamil intravenous solution reconstituted 600 mg (Both antibiotics, medications used to treat infections) A review of Resident # 328's Care Plan located in the EMR revealed a focus that the resident is on IV (intravenous) medications related to bacteremia (bacterial infection of the blood). A review of the Medication Audit Report located in the EMR revealed the following administrations for daptomycin intravenous solution outside of the scheduled administration time: 06/22/2025 scheduled for 9:00 AM; was administered at 10:47 AM 06/23/2025 scheduled for 9:00 AM; was administered at 10:29 AM 06/28/2025 scheduled for 9:00 AM; was administered at 10:24 AM A review of the Medication Audit Report located in the EMR revealed the following administrations for ceftaroline fosamil intravenous solution outside of the scheduled administration time: 06/20/2025 scheduled for 10:00 PM; was administered at 11:18 PM 06/29/2025 scheduled for 2:00 PM; was administered at 3:14 PM 06/30/2025 scheduled for 2:00 PM; was administered at 3:11 PM On 06/27/2025 at 10:52 AM during an interview with the surveyor, Licensed Practical Nurse/Unit Manager (LPN/UM) # 1 said, From my training, it would be one hour before and one hour after. when the surveyor asked what is your expectation on how late medications can be given before or beyond their scheduled time. Secondly, she said, If its after the hour, contact the medical doctor. after the surveyor asked should an IV antibiotic be given an hour past its administration time. Thirdly, she said, It could degrade the effectiveness of the medication. after the surveyor asked why is it important to give antibiotics at their scheduled time. Lastly, the LPN/UM # 1 concluded by saying Prioritize the time management and prioritize was should be given first. after the surveyor asked if there is a reason medication such as IV antibiotics would be given past their administration time. On 07/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing (DON) replied, An hour after when the surveyor asked when would a medication be considered late. The DON replied, They should inform the primary care provider. when asked what should the nurse do if mediations are being administered late. Lastly, she replied, To ensure the therapeutic level when asked why would it be important to hang an IV antibiotic within the scheduled time. A review of the facility policy Administering Medications dated 1/3/2025 revealed but not limited to the following, 4. Medications are administered in accordance with prescriber orders, including any required time frame. and 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication N.J.A.C. § 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by A.) leaving a nasal cannula out of a bag, exposed to air and B.) not having a physician's order for oxygen administration. The deficient practice was identified for 2 of 4 (Residents # 22, 215) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following: On 06/26/2025 at 10:23 AM during the initial tour, the surveyor observed Resident # 215 in their room. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) wrapped and resting on top of an oxygen concentrator. The nasal cannula was not in a bag and it was exposed to air. At that time, Resident # 215 said he/she wears the nasal cannula only at night. On 6/27/2025 at 9:11 AM while in Resident # 215's room, the surveyor observed the nasal cannula left on top of the concentrator not in a bag, exposed to air. On 6/30/2025 at 9:57 AM while in Resident # 215's room, the surveyor observed the nasal cannula left on top of the concentrator not in a bag. On 7/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing stated, It should be bagged when the surveyor asked how should a nasal cannula be stored. A review of the physician's orders located in the Electronic Medical Record (EMR) revealed Resident # 215 had an order for, O2 [oxygen] continuously at 2 liters per minute via nasal cannula at bed time. A review of Resident # 215's Care Plan located in the Electronic Medical Record revealed, [Resident # 215] has oxygen therapy r/t [relate to] ineffective gas exchange. On 06/30/2025 at 11:19 AM, during an interview with the surveyor, the Infection Preventionist replied, Any tubing not being used has to be in a plastic bag. She further said, Don't want it touching every surface. A review of the facility policy titled, Oxygen Administration dated 1/3/2025 did not reveal how to store oxygen tubing when not in use. N.J.A.C. § 8:39-27.1 B) On 06/26/25 10:14 AM, during the initial tour, the surveyor observed an oxygen sign on Resident #22's door and saw the resident with a nasal cannula on her/his face. On 06/30/2025 at 11:34 AM, the surveyor observed Resident # 22 in their room. At that time, the surveyor observed a nasal cannula in use by the resident. During the interview, Resident # 22 stated he/she wears the nasal cannula with 2 Liters of oxygen, as needed, since admission to the facility. On 07/01/25 08:49 Licensed Practical Nurse (LPN) # 1 on the 6th floor, during an interview with the surveyor stated residents with oxygen would require physician orders and identified that the order should contain the reason for the order, the length of time (continuous vs PRN), how much, and any monitoring parameters, as well as how the oxygen would be delivered. On 7/02/2025 at 09:38 AM during an interview with the surveyor, the Unit Manager (UM) of 6th floor confirmed there was not a physician order for Resident #22's oxygen while checking the EMR. The UM stated that Resident #22 should have an order for the oxygen administration. On 7/02/2025 at 09:57 AM during an interview with the surveyor, the DON stated, Residents with oxygen should have orders on their chart. A review of the physician's orders located in the EMR revealed Resident # 22 did not have a physician order for oxygen administration. A review of Resident # 22's CP located in the EMR revealed, [Resident # 22] has oxygen therapy r/t Respiratory illness. A review of the facility policy titled; Oxygen Administration dated 1/3/2025 under Purpose reveals: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. N.J.A.C. § 8:39-27.1

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a Physician's Order (PO) for an orthotic device for 1 of 2 residents (Resident#208) reviewed for positioning and mobility. On 06/26/2025 at 09:48 AM, the surveyor observed Resident #208 ambulating using a cane, the left arm was observed in the sling (an orthotic device). According to the admission Record, Resident #208 was admitted with diagnosis that included, but were not limited to, cerebral vascular accident (a stroke) and hemiplegia (weakness on one side of the body) A review of Resident #208's Quarterly Minimum Data Set, an assessment tool dated 05/06/2025, revealed that he/she was cognitively intact. Review of the Order Summary Report with active orders as of 06/30/2025 did not reveal an order for Resident #208's sling. On 07/01/2025 at 09:10 AM, the Licensed Practical Nurse/ Nurse Manager LPN/NM stated the Resident #208 utilized a sling. The LPN/NM stated that there should be a physician order for the use of the sling. On 07/02/2025 at 12:00 PM, the Director of Nursing acknowledged that Resident #208's physician orders did not include the use of the sling. Review of the facility provided policies did not speak to requiring a physician order for use of orthotic devices. NJAC 8:39-27.1 (a)

Complaint # NJ00172928 Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of clinical practice with following physician orders for the application of a treatment. This deficient practice was identified for 1 of 38 residents (Residents #378) reviewed for professional standards, and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, 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. A review of the admission Record for Resident #378 reflected that the resident was admitted to the facility with diagnoses which included but not limited to diabetes mellitus (a disease in which the body has trouble controlling blood sugar) and aftercare following surgical amputation. A review of the 04/05/2024 Order Summary Report for Resident #378 reflected physician orders (PO) for the following wound treatments: 04/05/2024 cleanse right leg and right foot 3rd, 4th and 5th toe amputation with normal saline solution, paint with betadine (antiseptic), cover gauze, wrap with kling (gauze dressing) as needed, and 4/5/24 Cleanse right leg and right foot 3rd, 4th and 5th toe amputation with nss, paint with betadine, cover gauze, wrap with kling every day shift. A review of the April 2024 Medication Administration Record (MAR) reflected the PO dated 04/05/2024 for the wound treatments. The start date for the wound treatments were 04/09/2024 not 04/05/2024 as ordered. On 07/02/2025 at 10:38 AM, the surveyor interviewed the Director of Nursing (DON) and the Regional Director of Nursing (RDON) regarding the missing wound treatments. The DON said that the clinical staff identified on 04/09/2024 in a clinical meeting that the treatments were not transcribed onto the MAR as ordered by the physician on 04/05/2024. The DON acknowledged that the physician orders for the application of the wound treatment was missed. The surveyor reviewed the facility's Wound Care policy reviewed and updated 12/20/24 which reflected 1. Verify that there is a physician's order for this procedure. The surveyor reviewed the facility's Physician Orders policy reviewed 01/03/2025 which reflected 5. All orders must be entered in the electronic health record by the nurse or therapist accepting or transcribing the order. NJAC 8:39-27.1(a)

Based on observation and interview, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 12/12/23 at 11:00 AM, the surveyor met with facility [NAME] President of Operations, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing and the Infection Preventionist for an entrance conference meeting. The facility was licensed for 250 beds and the facility census was 227 (the number of residents who currently resided at the facility). On 12/12/23 at 12:18 PM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). The surveyor observed two pallets of water in the basement. The FSD stated that it was enough water for 250 residents for three days. The FSD could not speak to the exact quantity that was there and stated he would get back to the surveyor with an exact count. On 12/20/23 at 9:51 AM, the surveyor conducted a follow up kitchen tour with the FSD in the presence of a second surveyor. The surveyor observed four pallets of water stored in the basement hallway which equaled 864 gallons (216 gallons per pallet). One pallet of water had a best if used by date of May 21, 2022. The FSD acknowledged that the water should have been used before that date. In addition, he acknowledged that he ordered water after surveyor inquiry. The FSD stated I got two pallets of water delivered on Monday and pointed to the pallets of water stored to the left. On 12/20/23 at 12:28 PM, the FSD acknowledged that he placed an order for water by phone, after surveyor inquiry, on 12/12/23 and received the water on 12/13/23 (an invoice was provided). On 12/20/23 at 1:40 PM, the surveyor interviewed the FSD who stated that the facility was required to maintain emergency water in the amount of one (1) gallon per resident per day for three (3) days. He stated he would use the number of licensed beds (250) to calculate the maximum amount needed. He further stated that the administrator was ultimately responsible for emergency food and water but it's my responsibility to order the emergency supplies and get them. On 12/20/23 at 4:02 PM, the LNHA acknowledged the concern regarding the emergency water in the presence of the survey team. Review of an undated facility policy Dining Services: Instructions for Implementing Menu to be Used in the Event of a Disaster or Emergency, included that the facility should maintain an adequate supply . of emergency water: one (1) gallon drinking water per day per every resident and staff member on duty. Review of the facility policy Disaster Planning - Emergency Water Plan revised April 2023, included In the event of a loss of utilities, water may be unavailable, or if available, it may be contaminated and in need of purification. In either case, the facility will need to have an adequate supply of water on hand . Recognizing that suppliers may be unable to deliver immediately, a three-day supply of water is recommended. It also included that A minimum of three (3) day supply of water should be available. The quantity of water that is needed can be determined by the following calculations: Drinking water 2 quarts (0.5 gallon) per person per day and All-purpose water 1 gallon per person per day. It further included, Rotate or discard water according to the manufacturers expiration date on the container. Review of a letter from a vendor regarding emergency water supply dated 11/1/23, included that In the event of an emergency, [name redacted] will have water available to purchase for your facility not in excess of our supply. NJAC 8:39-31.6 (n)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following: On 12/12/23 from 9:26 AM to 11:25 AM, the surveyor conducted a tour of the main kitchen in the presence the Food Service Director (FSD) and observed the following: At 10:11 AM, the surveyor observed a dish machine temperature log which was filled out for the afternoon (for lunch time). The FSD stated, They signed this early, I don't know why. At 10:24 AM, the surveyor observed orzo pasta wrapped in clear plastic with a use by date of 12/3. This was stored on a metal rack in the dry storeroom. The FSD stated, It's Orzo, maybe ten pounds and stated, I am not sure why they put it there and he removed it from the storage room. The surveyor observed an opened five pounds (lbs) container of Honey with no open date. The FSD stated, it should be good for seven days. At 11:00 AM, the surveyor observed several opened food items with no opened date or labels in the walk-in refrigerator as follows: -Seven hardboiled eggs in an opened clear package, with no opened date. -An opened one-pint container of Mayonnaise, with no opened date. -A 64 ounce (oz) opened gallon of Apple Juice, with no opened date. -An opened bag of shredded Mozzarella cheese wrapped in the original packet, with no opened date. The FSD stated, I am gonna throw it out. Majority of the food is good for seven days once its open. -An opened eight oz container of sour cream dated 10/28, the FSD stated, It's probably (the date) when it came it and It's probably somebody's personal sour cream. -One 17 oz bottle of unopened black raspberry juice and one 17 oz bottle of unopened cranberry lime juice. The FSD stated, It's somebody's personal juice because I don't order that. -Two and a half lbs. opened [name redacted] Greek yogurt, without a lid, covered with clear plastic wrap and dated 11/26. -Half four-inch pan with a half of a tomato wrapped in plastic wrap, not dated. The FSD stated, I told them so many times to date things, but they don't listen. -One gallon opened chunky Bleu cheese dressing, with no opened date. -An opened one gallon of regular milk, with no opened date. The FSD stated, It was probably opened today. At 11:25 AM, the surveyor conducted a tour of the Indian kitchen prep room with the FSD and Indian Cook (IC) # 1 and observed the following: -In the first white closet, there was a brownish yellow flaked snack stored in a small plastic container. The FSD stated, it's personal food and should not be there. IC#1 identified them as corn flake snacks. -In the black closet there was an opened five lbs. container of Cumin powder in it's original clear plastic bag packaging, with no opened date. The surveyor observed an unwrapped black immersion blender stored directly on the floor in the closet. IC #1 stated, its clean because its not used. The FSD explained to IC#1 that the blender can not just sit on the floor unwrapped, once it is used, it should be cleaned and a bag placed over it. -On top of the white reach in freezer there was a jacket in a large clear plastic bag . IC #1 stated, it belongs to another staff. The FSD stated, The jacket should not be in the kitchen, it should be in the locker. -There was a pan on the top of the black closet. The FSD identified it as a six-inch third pan that contained four boxes of of hashbrown potatoes (4.2 oz) with a best date of 9/23. -In a double door cabinet, under the prep table, there was an opened 32 oz bottle of lime juice, with no opened date. -On the bottom shelf of a double door cabinet there were two pairs of eyeglasses next to the lentil containers. IC #1 stated, they belong to IC #2 and the FSD stated, They (the glasses) shouldn't be there. -In the left top cabinet, there was an unidentified brown colored powder stored in a plastic container which had the name of a different manufactured item [name redacted]. The container had no label and no opened date. IC #1 stated, It's amchoor powder (a spice made from dried green mangoes). -In the left top cabinet there was a closed clear plastic container with two small packets wrapped in plastic, IC#1 identified the packets as an opened four lbs packet of pearl tapioca, with no opened date and an opened four lbs packet of [NAME] seeds (a type of rice/[NAME]), with no opened date. -A green cutting board that had multiple scratches/gouges and black, brown marks on it. -In the single door white refrigerator was an opened four lbs container of [name redacted] natural dahi (whole milk yogurt), with no opened date. On the outside of the refrigerator, the surveyor observed the Freezer Temperature Log sheet and the Refrigerator Temperature Log sheet for [DATE]. Review of the Indian kitchen preparation room's log labelled Freezer Temperature log for December 2023 revealed that the temperatures were documented for the refrigerator temperatures and not the freezer temperatures from December 2 to 12th. The IC#1 stated that staff filled out the log incorrectly. Review of the Indian kitchen preparation room's Refrigerator Temperature log for December 2023 revealed the temperatures were not filled in for the AM or PM for December 2,3,4,5,6,7,8,9,10,11, and 12. The FSD stated, I do not check temp logs in the Indian kitchen prep room as often as I should be. He then stated that the temperature log sheets should be checked daily, and I didn't. At 12:30 PM, in the main kitchen, the surveyor observed a metal rack with four shelves next to the pillar. The third shelf contained dry spices and other cooking ingredients. The surveyor identified the following: -An opened one gallon container of red hot sauce, with no opened date. -An opened 12 fluid (fl) oz glass bottle of red cooking wine, with no opened date. -An opened 12 fl oz glass bottle of white cooking wine, with no opened date. -Two 32 oz opened bottles of gravy mix, with no opened date. Review of the undated facility policy Record of Refrigeration Temperatures included a daily temperature record is to be kept of refrigerated items. It further included, the refrigerator temperatures must be 41 degree or below. Review of the undated facility policy Food Storage included all products shall be dated upon receipt or when they are prepared. It also included the following: - Label and date all storage containers as follows: 1. The received date should already be on it. 2. Date opened. 3. Date the item expires. Review of the undated facility job description for Director of Food Services included the following: - Perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of equipment and supplies. - Inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control. - Maintain a reference library of written material, laws, diet manuals, etc., necessary for complying with current standards and regulations and that will provide assistance in maintaining quality food service. - Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility. - Monitor dietary service personnel to assure that they are following established safety regulations in the use of equipment and supplies. - Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner. - Make weekly inspections of all dietary functions to assure that quality control measures are continually maintained. NJAC 8:39-17.2 (g)

Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to order an as needed (PRN) psychotropic medication for a 14-day period for 1 of 5 residents (Resident #125) reviewed for unnecessary medications. This deficient practice was evidenced by the following: During lunch observation on 12/12/23 at 1:04 PM, the surveyor observed resident #125 leave the dining room, asking staff if he/she could leave the room. The 2nd floor unit clerk directed the resident to his/her room. According to the Admission Record, Resident#125's was admitted to the facility with diagnoses that included but were not limited to: anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and unspecified Dementia, unspecified severity, with other behavior disturbances. The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/22/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 3 out of 15 which indicated that the resident had severe cognitive impairment. Further review of the MDS, revealed the resident was receiving antianxiety and antipsychotic medications. A review of the Electronic Medical Record (EMR) revealed a physician order (PO) dated 4/6/23 at 1600 (4:00 PM) for Alprazolam (Xanax, a medication given for anxiety) Tablet 1 MG (milligram), give 1 tablet by mouth every 8 hours as needed [PRN] for anxiety. Further review of the physician orders revealed an order dated 12/1/23 at 21:43, Alprazolam Tablet 1 MG, Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days. A review of the April medication administration record (MARs) revealed the medication was administered as follows: 4/6/23 at 17:02, 4/7/23 at 1714, 4/21/23 at 1808, 4/26/23 at 1650, 4/28/23 at 1703, and 4/30/23 at 1851. A review of the May MARs revealed the medication was administered as follows: 5/21/23 at 10:32 AM. A review of the June MARs revealed the medication was not administered. A review of the July MARs revealed the medication was administered on 7/31/23 at 17:17. A review of the August MARs revealed the medication was administered as follows: 8/12/23 at 1259, 8/15/23 at 2059, 8/22/23 at 1726, 8/23/23 at 1815, 8/25/23 at 1622, and 8/31/23 at 1721. A review of the September MARs revealed the medication was administered as follows: 9/1/23 at 1714, 9/5/23 at 1810, 9/7/23 at 1726, 9/8/23 at 1715, 9/13/23 at 1623, 9/14/23 at 1658, 9/16/23 at 1749, 9/18/23 at 1832, 9/19/23 at 1948, 9/21/23 at 0002, 9/25/23 at 1426, and 9/30/23 at 1531. A review of the October MARs revealed the medication was administered as follows: 10/2/23 at 1327 and 2233, 10/7/23 at 0910, 10/11/23 at 1728, 10/17/23 at 1640, 10/23/23 at 1659, 10/24/23 at 1612, 10/27/23 at 1405, 10/28/23 at 1144, and 10/29/23 at 1529. A review of the November MARs revealed the medication was administered as follows:11/3/23 at 1543, 11/4/23 at 0810, 11/5/23 at 1705, 11/7/23 at 1729, 11/8/23 at 2018, 11/9/23 at 1616, 11/10/23 at 1729, 11/13/23 at 1826, 11/15/23 at 1716, 11/18/23 at 1753, 11/21/23 at 0812, 11/22/23 at 1337, 11/24/23 at 1652, 11/25/23 at 1830, 11/29/23 at 1622. A review of the December MARs revealed the medication was administered on 12/1/23 at 0500. On 12/19/23 at 9:41 AM, the surveyor interviewed the Director of Nursing (DON), who stated that prn Antipsychotics should only be written for 14 days so that it can be reviewed as to what causes the behaviors. On 12/19/23 at 9:50 AM, in the presence of the surveyor, the DON reviewed the EMR and confirmed that the original PO for Xanax 1 mg by PO (by mouth) q (every) 8 hours as needed for anxiety was from 4/6/23. She also confirmed that there was not a duration of 14 days. The DON stated that there should be a duration so the resident could be re-evaluated to see if the medication was effective or if the medication should be titrated, increased or decreased. On 12/19/23 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the 2nd floor, who stated that the expectation of staff was to try and distract residents and to try non-pharmaceutical interventions before using medications to address behaviors. She then stated that the purpose was to monitor behaviors and how often the behavior occurs to see they needed something (medication) standing. On 12/19/23 at 1:54 PM, during a telephone interview, the pharmacist consultant supervisor stated that the reason that Xanax prn should have a 14-day duration was the new regulation to make sure safe alternates are used before Antipsychotics and antianxiety medications are used. On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the Licensed Nursing Home Administrator and the DON. No additional information was provided. A review of the facility's policy Antipsychotropic Use revised March 2023 revealed Procedure: 3. Any PRN psychotropic medication, excluding Antipsychotics, will be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she will document their rational in the resident's medical record and indicate the duration for the PRN order. 4. Any PRN antipsychotic medication will be limited to 14 days. If the attending physician or prescribing practitioner wishes to write a new order for PRN antipsychotic, he/she will evaluate the resident to determine if the new order for antipsychotic is appropriate. N.J.A.C 8:39-29.3 (d)

Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to respond to pharmacy consultant recommendations in a timely manner for 2 of 5 residents (Resident # 125 and #152) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. During lunch observation on 12/12/23 at 1:04 PM, the surveyor observed resident #125 leaving the dining room, asking staff if he/she could leave the room. The 2nd floor unit clerk directed the resident to his/her room. According to the Admission Record (AR), Resident#125 was admitted to the facility with diagnoses that included but were not limited to: anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and unspecified Dementia, unspecified severity, with other behavior disturbances. The annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/22/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 3 out of 15 which indicated that the resident had severe cognitive impairment. Further review of the MDS, revealed the resident was receiving antianxiety and antipsychotic medications. A review of the electronic Medical Record (eMR) revealed a physician order (PO) dated 4/6/23 at 1600 (4:00 PM) for Alprazolam (Xanax, a medication given for anxiety) Tablet 1 MG (milligram), give 1 tablet by mouth every 8 hours as needed (PRN) for anxiety. This order did not include a duration for the prn medication. Further review of the physician orders revealed an order dated 12/1/23 at 21:43, Alprazolam Tablet 1 MG, Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days. On 12/18/23 at 9:30 AM, the Director of Nursing (DON) provided the Consultant Pharmacist's Medication Regiment Review (CPMR) reports, which included the Medication Regimen Review (MRR), from 4/1/23. On 12/19/23 at 8:30 AM, a review of the CPMR for Resident #125 revealed the following: -MRR Priority Normal: dated 4/27/23, As per Federal Regulations all prn psychoactives should be written for 14 days. Please clarify Alprazolam prn to 14 days. -MRR, Priority Normal: dated 5/24/23, We have noticed that the prn anxiolytic Alprazolam has been renewed after 14 days (since 4/6/23). The purpose of the 14-day rule for PRN psychoactive medications is to place our resident's on safer alternatives to prevent falls and fractures. Please have resident re-evaluated and their anxiolytic therapy and consider safer alternatives such as antidepressant that can treat general anxiety disorder, psychotherapy, and other non-interventions. -MRR, Priority High: dated 6/22/23, 7/17/23, 8/31/23, 9/22/23, 10/19/23, and 11/17/23: We have noticed that the prn anxiolytic Alprazolam has been renewed after 14 days (since 4/6/23). The purpose of the 14-day rule for PRN psychoactive medications is to place our resident's on safer alternatives to prevent falls and fractures. Please have resident re-evaluated and their anxiolytic therapy and consider safer alternatives such as antidepressant that can treat general anxiety disorder, psychotherapy, and other non-interventions. A review of the Psychiatry Progress Note dated 12/1/23 revealed Monitored Psych Medications: Xanax 1 mg q 8 hours prn for anxiety . Plan: 3. specify duration of Xanax prn to 14 days. The facility failed to provide documented evidence that nursing or the physician addressed the pharmacy recommendations for Resident #125 from April 2023 to present. On 12/19/23 at 9:41 AM, the surveyor interviewed the DON regarding the process for the pharmacy consultant recommendations. She stated that they come through email. The nurses on the floor were responsible to follow up with the physician to make sure that the pharmacist's recommendations were addressed. She also stated that the unit managers should take the lead to make sure it was done. The DON stated that prn Antipsychotics should only be written for 14 days so that it can be reviewed as to what causes the behaviors. On 12/19/23 at 9:50 AM, in the presence of the surveyor, the DON reviewed the eMR and confirmed that the original PO for Xanax 1 mg by PO (by mouth) q (every) 8 hours as needed for anxiety was from 4/6/23. She also confirmed that there was not a duration of 14 days. The DON stated that there should be a duration so the resident could be re-evaluated to see if the medication was effective or if the medication should be titrated, increased or decreased. On 12/19/2023 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the 2nd floor, who stated that the expectation of staff was to try and distract residents and to try non-pharmaceutical interventions before using medications to address behaviors. She then stated that the purpose was to monitor behaviors and how often the behavior occurs to see they needed something (medication) standing. She stated that the pharmacy consultant recommendations came through emails that go to every floor and we (nurses) are supposed to go through the recommendations, verify diagnoses, clarify orders with the Nurse Practitioner or physician with the pharmacist recommendations. On 12/19/23 at 1:54 PM, during a telephone interview, the pharmacist consultant supervisor stated that the MRR's are emailed monthly to the facility, the DON, administrator, and to the unit manager. She then stated that we do not send them directly to the physicians. The facility should fax it or give to the physician. She stated that the reason that Xanax prn should have a 14-day duration was the new regulation to make sure safe alternates are used before Antipsychotics and antianxiety medications are used. On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the Licensed Nursing Home Administrator (LNHA) and the DON. No additional information was provided. 2. On 12/13/23 at 12:37 PM, the surveyor observed resident #152 in the dining room for lunch. The resident was dressed and wearing a hat. According to the AR, Resident#152's was admitted to the facility with diagnoses that included but were not limited to: schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and auditory hallucinations (sensory perceptions of hearing in the absence of external stimulus). The MDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored a 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS, revealed the resident was receiving antidepressant and antipsychotic medications. On 12/19/23 at 11:48, a review of the CPMR revealed the following pharmacy consultant recommendations for Resident #152 that were not addressed until 11/23/23: MRR, Priority Normal: dated 4/27/23: Please clarify Percocet PRN order to include degree of pain. Please clarify ICY HOT Patch order to include leaving patch on up to 8 hours per day and remove. MRR, Priority Normal: dated 5/24/23: The resident is on Olanzapine. Please do the monthly quantitative behavioral summary. Include target monitoring how many times it happened in one month, non drug interventions, side effects(if any), ;last psych visit, None seen in [name redacted-EMR]. MRR, Priority Normal: dated 5/24/23, 8/31/23: Please clarify and space Gabapentin evenly around the clock for around the clock pain coverage. Clarify to Gabapentin 300 mg q 8 hr 0600, 1400, and 2200. MRR, Priority High dated 5/24/23, 6/22/23, 7/17/23, 8/31/23, 9/22/23: Please clarify Percocet PRN order to include degree of pain. Please clarify ICY HOT Patch order to include leaving patch on up to 8 hours per day and remove. MRR, priority: Normal, dated 6/22/23: The resident's Amitriptyline was increased on 6/16/23. Please be sure to document mood, target behaviors and side effects in the nursing notes and address quantitative monthly behavior notes. MRR, Priority: Normal, dated 7/17/23: Code 9 was used many times in July, there is no nursing note in the progress notes for the reason. Please review documentation with the nursing staff. MRR, Priority: Normal, dated 7/17/2023, 8/31/23: The resident is on Olanzapine and Amitriptyline. Please do the monthly quantitative behavioral summary. Include target behavior, how many times it happened in one month, non-drug interventions, side effects (if any), last psych visit, None seen in [name redacted-EMR]. MRR, Priority: Normal, dated 8/31/23: Code 9 was used many times in August, there is no nursing note in the progress notes for the reason. Please review documentation with the nursing staff. MRR, Priority: High dated 9/22/23, 10/19/23: The resident is on Olanzapine and Amitriptyline. Please do the monthly quantitative behavioral summary. Include target behavior, how many times it happened in one month, non-drug interventions, side effects (if any), ;last psych visit, None seen in chart. None seen in [name redacted-EMR]. MRR, Priority High dated 10/19/23, 11/17/23: Please clarify Percocet PRN order to include degree of pain. MRR, Priority Normal, dated 10/19/23 and 11/17/23: Resident has an order for ICY Hot Patch (Menthol) to be applied once daily for 24 hours. Please be aware, the manufacturer recommends one patch be applied for no longer than 8 hours, and to be repeated for no more than 3 times daily. Please review this order with Physician. A review of PO revealed the following: -3/7/23 at 19:05 (7:05 PM), Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen) *Controlled Drug* Give 2 tablet by mouth every 8 hours as needed for pain, Discontinue on 11/23/23. -3/7/23 at 19:05, Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathic pain, facility time code: 0900-1400-2100. -4/6/23 at 14:24 (2:24 PM), Icy Hot External Patch 5 % (Menthol (Topical Analgesic)) Apply to lower back topically every day shift for Pain-discontinued 11/23/23 -5/19/23 at 14:30 (2:30 PM), OLANZapine Oral Tablet 10 MG (Olanzapine) Give 1 tablet by mouth in the evening for schizoaffective -6/16/23 at 13:41 (1:41 PM), Amitriptyline HCl Oral Tablet 50 MG (Amitriptyline HCl) Give 1 tablet by mouth at bedtime for depression -10/21/23 at 15:00 (3:00 PM), Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. -11/23/23 at 12: 50 AM, Icy Hot External Patch 5 % (Menthol (Topical Analgesic) Apply to lower back topically every shift for Pain Remove and replace patch q shift for pain A Review Psychiatry Progress Notes provided by facility revealed the following: -Psychiatry notes dated 7/7/23: Plan: 3. monitor and document changes in mood and behavior notify psychiatry as indicated. A review of the Medication Administration Record (MAR) and Treatment Administration records (TAR) reviewed form April to [DATE] did not reveal behavior monitoring or target behavior ordered or documented. A review of the progress notes from April to October 21,2022 did not reveal documentation for behavior monitoring or target behaviors. On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the LNHA and the DON. The facility failed to provide documented evidence that the physician addressed the pharmacy recommendations, behavior or target monitoring documentation for Resident #152. On 12/21/23 at 10:11 AM, the surveyor interviewed the DON, who stated behavior monitoring would be in the progress notes. She stated she will provide the target monitoring for resident. On 12/21/23 at 10:24 AM, the DON provided target behavior monitoring with a start date 10/21/23. On 12/21/23 at 10:40 AM, the DON provided behavior monitoring with a start date of 10/21/23. She confirmed, at that time, that there was no behavior monitoring documentation completed prior to that date. A review of the facility's policy, Medication Review revised April 2023 revealed: Procedure: 5. Facility should independently review each resident's medication regimen directly from the residents medical chart and with the Interdisciplinary Care Team members, resident or responsible party as needed. 6. Facility should ensure that the Facility Physicians/Prescribers are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRRS and the Director of Nursing to act upon the recommendations contained within the MRR. For those issues that require Physician/Prescriber interventions, Facility should encourage Physician/prescriber to either (a) accept and act upon the recommendations contained within the MRR or (b) reject all or some the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. NJAC 8:39-29.3 (1)

Based on interviews and review of pertinent facility documentation, it was determined that the facility allowed 9 of 13 Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified during NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: Facilities are advised as follows: I. TNAs (Temporary Nursing Assistant) A. Individuals who are working as TNAs must pass the nurse-aide written or oral exam and the State-approved clinical skills competency exam by May 11, 2023, or the end of the federal PHE (Public Health Emergency), whichever comes first. B. If a TNA does not pass the exams by the end of the federal PHE, the TNA may not work after May 11, 2023, unless the TNA meets the requirements of Paragraph C below. C. In order to work beyond May 11, 2023, TNAs must, by May 11, 2023: 1. Be enrolled in a NATCEP CNA training program, and 2. Have completed the first 16 hours of training, and 3. Be working in a facility before May 11, 2023. 4. Note that the TNA only has until September 10, 2023 to complete the NATCEP (Nurse Aide Training and Competency Evaluation Program) program and pass the exams. II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing. On 12/12/23 at 11:00 AM, during entrance conference the Licensed Nursing Home Administrator (LNHA) stated that they did not have any NAs. The LNHA was given the Nursing Staffing Reports to be completed for the two weeks of staffing prior to the recertification survey. On 12/14/23 at 10:05 AM, the surveyor met with the LNHA to inquire about the Nursing Staff Reports that listed 13 Non-Certified Aides in training (NAs). The LNHA apologized and stated I found out after entrance conference that we (the facility) had NAs. The surveyor requested a list of the NAs along with proof of their enrollment in a Certified Nursing Aide (CNA) school. On 12/14/23 at 11:38 AM, the LNHA provided the NA list but stated they were still in the process of updating the list. He stated that there should be a tracking process in place and they should have had the dates. HR was responsible for maintaining the records for the NAs. On 12/18/23 at 10:45 AM, the LNHA provided the updated NA list to the surveyor. On 12/18/23 at 12:51 PM, a review of the updated NA list provided by the facility revealed the following: NA #1, Date of Hire (DOH): 8/14/23, 120 days from date of hire: 12/12/2023, program completion: 8/30/23. NA #2, DOH: 8/7/2023, 120 days from date of hire: 12/5/2023, program completion: 9/6/2023. NA #3, DOH: 8/9/2023, 120 days from date of hire: 12/7/2023, program completion: 9/6/2023. NA #4, DOH: 8/1/2023, 120 days from date of hire: 11/29/2023, program completion: 9/6/2023. NA #5, DOH: 8/7/2023, 120 days from date of hire: 12/5/2023, program completion: 9/6/2023. NA #6, DOH: 8/3/2023, 120 days from date of hire: 12/1/2023, program completion: 9/6/2023. NA #7, DOH: 8/3/2023, 120 days from date of hire: 12/1/2023, program completion: 9/6/2023. NA #8, DOH: 7/27/2023,120 days from date of hire: 11/24/2023, program completion: 9/6/2023. NA #9, DOH: 7/30/2023, 120 days from date of hire:11/27/2023, program completion:9/6/2023. NA# 10, DOH AS NA: 10/5/2023, 120 days from date of hire: 2/2/2024, program completion:10/31/2023. NA #11, DOH: 11/20/2023, 120 days from date of hire: 3/19/2023, program completion: 11/11/2023. NA# 12, DOH: 11/20/23, 120 days from date of hire: 3/19/2024, program completion: 11/11/2023. NA# 13, DOH: 9/19/2023, 120 days from date of hire:1/17/2024, program completion: 10/28/2023. A review of the formal job offers letters to the above listed NAs revealed that All Certified Nursing Assistants are required to pass the state examination within 120 days of graduation from an accredited program. This is mandatory in order to continue employment with Alameda. A review of the facility's Nursing Schedule provided daily to the survey team from 12/12/2023 to 12/19/23, revealed the NAs listed as CNA's and were scheduled to work as follows: NA #1: night shift: 12/12, 12/13; evening & night shift:12/14; night shifts: 12/15, 12/18, 12/19. NA#2: day shift: 12/12; evening shift: 12/15; day shift:12/18. NA#3: evening shift: 12/12; night shifts: 12/13, 12/14; evening and night shift: 12/15; evening shift 12/16; evening & night shift: 12/17; evening shift: 12/18. NA# 4: night shift: 12/12; day shifts: 12/13, 12/14, 12/18. NA #5: day shifts: 12/12, 12/14, 12/15; evening shifts: 12/15, 12/16; day shifts: 12/18, 12/19. NA# 6: evening shift: 12/13; evening & night shift: 12/14, 12/15; evening shift: 12/16; night shift:12/17; evening shifts: 12/18; evening and night shift: 12/19. NA#7: evening shift: 12/12, 12/13; day and evening shift: 12/15; evening shifts: 12/17, 12/18. NA# 8: evening shifts: 12/12, 12/14, 12/18, 12/19. NA#9: day shifts: 12/12,12/13,12/14; evening shift 12/14; day and evening shift:12/15, 12/16; day shift 12/17/; day and evening shifts: 12/19. NA# 10: day shift: 12/12, 12/13; day and evening shift: 12/15, 12/16, day shift 12/17, 12/18; night shift: 12/19. NA# 11: evening and night shift: 12/13; day shift:12/15. NA#12: day and evening shift: 12/13. Day shift: 12/15. NA#13: day shift: 12/12, 12/13,12/16, 12/17; day and night shift: 12/19. On 12/19/23 at 9:41 AM, during an interview with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP), the ADON/IP stated that NAs must complete at least 16 hours of schooling to work as an NA and that they must compete the certification within 120 days from date of hire. She stated the reason was they have to learn regulations of safe practice, stay in the scope of practice, and to makes sure when in building they are providing care within guidelines. On 12/19/23 at 10:55 AM, the LPN/UM, on the 2nd floor, provided a staffing assignment sheet to the surveyor, NA #12 was listed on the assignment sheet as a CNA. The surveyor asked the LPN/UM about NA#12, the LPN/UM stated this was the first time she was working with her and did not know anything about her. On 12/19/23 at 11:00 AM, the surveyor interviewed NA#12, who was wearing her name badge which had her name and CNA listed below it. The surveyor asked if she was a CNA and she stated yes. The surveyor asked if she was a certified nursing aide and she stated well I completed my school and took the skills test, I will take the written part in February. She stated she started work about 3 weeks ago and they (Human Resources, HR) told me I had 120 days from my school completion date to take the test. On 12/19/23 at 11:10 AM, during a follow up interview with DON and ADON/IP, the DON stated that the UMs would know who the NA's are and would assign them a buddy CNA to go to for help. She then stated, the UM should know the NA because they are considered to be on orientation and should be monitored. On 12/19/23 at 11:20 AM, during an interview with the LNHA and Registered Nurse/Vice President of Clinical Services (RN/VPCS), the LNHA verified that NAs should be certified within 120 days from date of hire. He stated, he understands that tracking needs to be to done and that he started a tracking system. The LNHA confirmed at that time, that the NAs progress was not being tracked. The LNHA stated that the NAs all signed letters that they would obtain their certification within 120 days of completion of their schooling. On 12/19/23 at 11:40 AM, during an interview with NA#9, he stated he started working in August not sure of the exact date. He stated he finished CNA school in Sept and finished up my skills test. The surveyor observed NA#9 was wearing a badge that identified him as a CNA but stated he was working as a NA training to be a CNA. He state he was informed by the facility that he has to take his test by January. On 12/19/23 at 11:45 AM, during an interview with the surveyors, the LNHA stated that the HR Director (HRD) had been informed that NAs had to obtain certification within 120 days of completion of school. At that time, the LNHA confirmed that the certification must be obtained within 120 days from date of hire. He then confirmed again that the HRD was not tracking the NAs progress. The surveyor made the LNHA aware that 2 NAs (NA#12 and NA #9) that were currently working, were wearing name badges that listed them as CNAs. He stated that the purpose of badges with name and department was to identify staff to residents, visitors, and other staff members for their scope of practice. The LNHA stated the NA's would be taken off the schedule until they get their certification. On 12/20/23 at 10:10 AM, during an interview with the HRD, the HRD stated that NAs must show proof of being in school, or completion of school, and that they need to complete at least 3 days of schooling before starting work at the facility. He further stated that, I believe it is 16 hours but we require them to complete 3 days. He stated he had a system in place for tracking NAs progress, but he was unable to provide the tracking to the surveyor. On 12/20/23 at 12:10 PM, the LNHA again confirmed that the HRD did not have a tracking system for the NAs until the LNHA emailed him one. On 12/20/23 at 4:02 PM, the LNHA and the DON were made aware of the above findings. No additional information was provided to the survey team. N.J.A.C. 8:39-43.10

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for two (2) of six (6) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 12/20/23 for 1 of 5 nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 12/14/23 at 11:00 AM, the surveyor met with six (6) residents for council meeting. Two out of six residents stated that food temperatures varied depending upon if they ate in the dining room or in their rooms; if they ate in their rooms, the food was cold. One of the two residents further stated that this was a recurrent complaint at resident council meetings. On 12/20/23 at 11:11 AM, the Registered Dietitian (RD) surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. On 12/20/23 at 11:35 AM, the surveyor interviewed the evening cook in the presence of a second surveyor. He was setting up a five well steam table for lunch service on the fourth floor. He stated that it was working properly and that it warms up quick. On 12/20/23 at 11:57 AM, the surveyor observed kitchen staff deliver hot food in a food warmer to the unit pantry. On 12/20/23 at 12:50 PM, the surveyor observed the last tray delivered to the residents. At that same time the evening cook joined the dietary aide who was plating food from the steam table in the fourth-floor unit pantry. The surveyor took the temperatures of the following items in the presence of both food service staff and a second surveyor: Beef cubes teriyaki style: 122 degrees F Mixed vegetables: 117 degrees F Lo Mein noodles: 126 degrees F Sausage: 110 degrees F Puree beef: 123 degrees F Puree vegetables: 113 degrees F Mashed potatoes: 116 degrees F On 12/20/23 at 12:52 PM, the surveyor interviewed the two food service staff members in the presence of a second surveyor. The evening cook stated that beef should have been at 140-145 degrees F at which time the dietary aide agreed. On 12/20/23 at 1:20 PM, the surveyor interviewed the Food Service Director (FSD) in the presence of the survey team. He stated that food temperatures were checked before transport to the unit via warmer about five to ten minutes prior to service. The FSD further stated that to his knowledge all the steam tables were working properly. He stated, their process should maintain food temperatures, food should stay hot. He also stated that he had not done test trays and had not taken food temperatures on that unit. In addition, the FSD stated that there have been issues about food being cold discussed in resident council meetings. He stated that the facility did not have plate warmers and that hot food temperatures should be held at 165 degrees F. Review of an undated facility policy Dining Services Food Temperatures, indicated that acceptable serving temperatures for the following items were: Meat, entrees > 140 degrees F, but preferably 160-175 degrees F Potatoes, pasta > 140 degrees F, but preferably 160-175 degrees F Vegetables > 140 degrees F, but preferably 160-175 degrees F The policy also included to heat hot plates. NJAC 8:39-17.2(g), 17.4(e)

Based on observation, interview, and record review, it was determined that the facility failed to (a). properly label, store and dispose of medications in three (3) of seven (7) medication carts and in two (2) of three (3) medication storage room inspected, and b). failed to secure one (1) of three (3) narcotic lock boxes in 1 of 3 medication refrigerators inspected. This deficient practice was evidenced by the following: (a). On [DATE] at 10:20 AM, the surveyor inspected the 6th floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed a bottle of blood glucose test strips that was opened and had no opened date. The surveyor also observed a Basaglar insulin pen that was opened and dated but the resident's name on the vial did not match the resident's name that was on the medication bag that held the insulin pen. At that time, the surveyor interviewed LPN#1, who stated that an opened bottle of blood glucose strips should have been dated. LPN#1 further stated that the Basaglar insulin pen should have been stored in a bag that contained the same resident's name as was on the insulin pen. She also stated that prior to administering any insulin via a vial or pen that she will always assure that the resident's name on the product matched the resident who was receiving the insulin. On [DATE] at 10:40 AM, the surveyor inspected the 6th floor medication room refrigerator in the presence of LPN#1. The surveyor observed four bottles of Lorazepam (medication for anxiety) 2 mg (milligrams)/ml (milliliters) multi-dose injectable vials. The surveyor observed one vial of the Lorazepam 2mg/ml that was opened and not dated. At that time, the surveyor interviewed LPN#1 who stated that a vial of multi-dose Lorazepam should have been dated once opened. She also stated that the resident was no longer on the medication and that the medication should have been removed from active medication stock. On [DATE] at 10:45 AM, the surveyor inspected the 5th floor medication cart #2 in the presence of LPN#2. The surveyor observed an opened and undated vial of Lantus insulin. On [DATE] at 10:50 AM, the surveyor inspected the 5th floor medication room in the presence of LPN#2. The surveyor observed a bottle of Vitamin B-12 house stock that had an expiration date of ,d+[DATE]. At that time, the surveyor interviewed LPN#2 who stated that an opened vial of Lantus should have been dated and that an expired bottle of Vitamin B-12 should have been removed from active medication stock. On [DATE] at 11:15 AM, the surveyor inspected the 2nd floor medication cart #3 in the presence of LPN#3. The surveyor observed an opened and undated bottle of blood glucose test strips. At that time, the surveyor interviewed LPN #3 who stated that once a bottle of blood glucose test strips was opened that it should have been dated. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Blood glucose test strips once opened have an expiration date of 180-days. 2. Lorazepam 2mg/ml multi-dose injectable vial once opened have an expiration date of 28-days. 3. Lantus insulin vial once opened have opened have an expiration date of 28-days. b). On [DATE] at 10:40 AM, the surveyor inspected the 6th floor medication room refrigerator in the presence of LPN#1. The surveyor observed a locked narcotic refrigerator that contained a narcotic lock box that was not affixed to the refrigerator. The surveyor was able to pull the whole shelf with the narcotic box out of the refrigerator. The narcotic box contained 4 Lorazepam multi-dose injectable vials. At that time, the surveyor interviewed LPN#1 who acknowledge that the narcotic box inside the medication should have been affixed to the refrigerator. On [DATE] at 3:30 PM, the surveyor discussed the above concerns with the administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and the Infection Preventionist. There was no additional information provided. A review of the facility's policy for Medication Administration that was dated [DATE] and provided by the DON that included the following: G. Prior to Medication Administration: 3. Check expiration date on medication label. A review of the facility's policy for Storage of Controlled Medications that was dated [DATE] and provided by the DON included the following: 2. Schedule II through V medications and other medications subject to abuse or diversion are stored in either in a permanently affixed, double locked compartments separate from all other medications or in accordance with state regulations. 3. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator and/or in accordance with state regulations and facility policy. 10. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of, and then stored for five years or as required by applicable law or regulation. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 6 (six) residents (Resident #7) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/18/23 at 9:10 AM, during the medication administration observation, the surveyor observed a Licensed Practical Nurse (LPN) in the room of Resident #7. The surveyor observed the LPN checking the resident's identification bracelet and informing Resident #7 that she would be administering the resident's medications. The surveyor observed the resident in their bed and just finished eating breakfast. On 12/18/23 at 09:15 AM, the surveyor observed LPN preparing to administer (5) medications to Resident #7 which included one tablet of Benztropine 0.5 mg tablet (anti-tremor medication), one tablet of Vitamin D3 2000 tablet (supplement), two tablets Sodium Chloride 1 gram (low sodium levels), 5 ml of Valproic acid 250mg/ml (mood disorder) and one tablet of Zyprexa 5 mg tablet (mood disorder). The surveyor observed the LPN put one tablet of Benztropine, one tablet of Vitamin D, and 2 tablets of Sodium Chloride into a medication cup for a total of 4 tablets. The surveyor then observed the LPN add 5 ml of Valproic syrup into a measuring cup. The surveyor did not observe the LPN add Zyprexa into the medication cup. The surveyor then observed the nurse pour 120 ml of water into a cup. The surveyor checked the medication cup three more times which showed 4 tablets in the cup. The surveyor then observed the LPN administered the resident their medications. After administering Resident #7's medication the surveyor observed the LPN signed off the electronic medication administration record (EMAR) which included Zyprexa 5 mg. At that time, the surveyor interviewed the LPN who refused to acknowledge that she omitted Zyprexa. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to schizoaffective disorder (schizophrenia and mood disorder symptoms), hypo-osmolality and hyponatremia (produced by retention of water, by loss of sodium or both), and gastro-esophageal reflux disease without esophagitis (a digestive disease in which stomach acid or bile irritates the stomach but without involving inflammation of the esophagus. A review of the Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 11/10/23, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact. A review of the December 2023 Medication Review Report (MRR) which revealed a physician order (PO) dated 8/17/23, for Zyprexa oral tablet 5 mg, give 1 tablet by mouth in the morning for mood d/o (disorder). A review of the December 2023 electronic Medication Administration Record (eMAR) revealed an order dated 8/17/23, for Zyprexa oral tablet 5 mg, give 1 tablet by mouth in the morning for mood d/o and scheduled for 9:00 AM, and showed on 12/18/23 that Zyprexa was documented as being administered. On 12/20/23 at 3:30 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Infection Preventionist and discussed the above findings. No further information was provided. A review of the facility's policy for Medication Administration dated 04/30/23, which was provided by the DON, revealed that they were no policy that assure that prepared medications should be double check prior to medication administration. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observations, interviews, and record review, it was determined that the facility failed to a.) change the oxygen tubing as directed by the Physician order and follow the facility policy, b.) develop a care plan to address the resident requiring oxygen upon readmission to the facility and c.) re-evaluate the Physician's Order for the continuous need of oxygen at 4 liters (L) via nasal cannula. This deficient practice was identified for 1 of 1 resident, Resident #63, which was reviewed for oxygen therapy. This deficient practice was evidenced by the following: On 12/12/ 2023 at 11:20 AM, the surveyor entered the resident's room and observed the nasal cannula tubing (a device that delivers oxygen through a tube and into your nose) connected to an oxygen concentrator (a device which provides supplemental oxygen). The surveyor observed the nasal cannula tubing was labeled with the date of 11/15/2023. At this time, Resident #63 was observed sitting in the dining room, in a wheelchair, during group activities. The resident was not wearing oxygen. The surveyor reviewed the medical record of Resident #63. Review of the Admission Record (an admission summary) reflected that resident #63 was admitted to the facility with diagnoses which included but are not limited to: Benign Prostatic Hyperplasia (enlargement of the prostate gland), Hypertension (a condition in which the force of the blood against the artery walls is too high), and Respiratory Failure (a condition which makes it difficult to breathe on your own). Review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/24/23, revealed that Resident #63 had a Brief Interview for Mental Status (a tool used to identify the cognitive condition) score of 4 out of 15, which indicated that the resident was severely cognitively impaired. In section (I) of the MDS active diseases number I6200 respiratory failure was checked and in section I8000 it was documented that the resident had acute respiratory failure unspecified with hypoxia (a condition in which you do not have enough oxygen in the tissues of your body) or hypercapnia (too much carbon dioxide in your blood). In section O of the MDS (Special Treatments, Procedures and Program) number 00100 oxygen therapy was not checked in the column under while a resident. This section indicated that resident #63 was not on oxygen during the observation period (the time period over which the resident's condition or status is captured by the MDS assessment). A review of the November 2023 Medication Administration Record (MAR) revealed a physician order dated 7/25/23 to CHANGE OXYGEN TUBING every night shift every Tues (Tuesday). Further review revealed the order had been signed as completed on 11/7/23, 11/14/23, 11/21/23, and 11/28/23. A review of the December 2023 MAR revealed a physician order dated 7/25/23 to CHANGE OXYGEN TUBING every night shift every Tues (Tuesday). Further review revealed the order had been signed as completed on 12/5/23; 12/12/23. A review of the December 2023 Treatment Administration Record (TAR) revealed a physician order dated 7/25/23 for O2 continuously at 4 LPM via nasal cannula every shift. Further review revealed that ordered had been signed as completed from 12/1/2023 to 12/11/2023 for the day, Eveni (evening), and night shifts. Review of the Weights and Vitals Summary revealed the resident's pulse ox was documented as 92% or higher on room air from 09/24/2023 until 12/12/23. Review of the care plan revealed that there was no care plan developed or implemented for oxygen use. On 12/18/2023 at 10:24 AM, this surveyor interviewed the Director of Nursing (DON), who stated prior to weaning a resident off continuous oxygen it should be discussed with the Physician or Nurse Practitioner, an assessment was completed for 3 or more days which included the oxygen saturation and the results were documented in the medication administration record and skilled nursing notes and discussed with the Physician or Nurse Practitioner to determine whether the order should be changed. The DON stated that respiratory equipment (nebulizer, oxygen tubing etc.) was changed on the 11-7 shift every Tuesday. On 12/18/2023 at 10:38 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that Resident #63 did not have oxygen on because he/she kept removing it. She stated that he/she does not become short of breath with exertion without oxygen. The LPN stated that oxygen tubing was changed weekly on the 11-7 shift. On 12/18/2023 at 10:47 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated the Resident #63 has not been wearing oxygen. She further explains that initially when it was ordered the resident would wear the oxygen but when the resident began to feel better, he/she began to remove it. The RN/UM stated that oxygen tubing was changed weekly by the 11-7 shift. On 12/18/2023 at 11:30AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that Resident #63 does not wear oxygen and that the resident does not become short of breath when being assisted with activities of daily living. On 12/19/2023 at 9:45AM, the surveyor interviewed the MDS Coordinator, who stated that Resident #63 was coded as not using oxygen during the observation period because the resident was not observed wearing oxygen during that time. Therefore, she coded Resident # 63 as not wearing oxygen. On 12/19/2023 at 10:21 AM, during a follow-up interview with the RN/UM regarding the care plan for Resident #63's oxygen was not initiated when the resident was readmitted to the facility. She stated, I forgot to initiate the oxygen care plan. The RN/UM stated that the Interdisciplinary Care Team (IDCP) was responsible for initiating and updating the care plan. Review of the facility's policy Oxygen Administration/Changing which was revised April 2023, revealed Policy: Oxygen administration will be carried out only with a physician's order. A licensed nurse or other staff person trained in the use of oxygen will be on duty and be responsible for the correct administration of oxygen to the resident.; Procedure: 11. Label oxygen tubing with the date and time opened. Change oxygen tubing weekly. NJAC 8:39-27.1(a)(b) NJAC 8:39-11.2(f)

Based on observations, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents (resident #178 and #119) reviewed for accurately coding the MDS. This deficient practice was evidenced by the following: 1. On 12/12/2023 at 11:15 AM, the surveyor observed Resident #178, sitting in a wheelchair, in activities. On 12/13/2023 at 1:00 PM, the surveyor observed Resident #178 in the dining room after lunch. The resident was sitting upright in the wheelchair and was awake and alert. The Resident responded verbally to the surveyor and stated that he/she was ok. On 12/14/2023 at 12:50 PM, the surveyor observed Resident #178 in the dining room for lunch, which was already served. The resident appeared well groomed and calm. A review of Admission Record (AR) revealed that resident #178 was admitted to the facility with diagnoses that included but were not limited to: dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and chronic kidney disease(longstanding disease of the kidneys leading to renal failure). Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/24/23, revealed under section B 0100(Persistent, vegetative state/no discernible consciousness) was coded yes. Due to section B 0100 being coded as yes, no Brief Interview for Mental Status (BIMS) [a tool used to screen and identify cognitive conditions] was assessed. During the observation period of the MDS (the time-period in which the resident condition or status is captured by the MDS assessment) the progress notes were reviewed and there were no notes which identified the resident as being comatose. The progress notes titled Skilled/COVID Documentation on 11/18/23; 11/19/23; 11/20/23; 11/21/23; 11/22/23; and 11/24/23 indicated that resident was awake, alert and verbally responsive with confusion. A review of an assessment titled, Social Service Department-Quarterly/Medicare Assessment/discharge date d 11/24/23, revealed: Section II. Orientation/BIMS; A. ORIENTATION/COMMUNICATION: 1. Persistent vegetative state/no discernible consciousness: O.No was selected. On 12/14/23 at 1:14 PM, the surveyor interviewed the Registered Nurse /Unit Manager (RN/UM) regarding completion and accuracy of the MDS. The RN/UM stated, I do not complete the MDS, the MDS Coordinator is responsible for completing and checking the MDS for accuracy. On 12/14/23 at 2:30 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team, who stated, that she had been employed at the facility since 2017 and has been doing MDS since 2021 and that she was responsible for doing the MDS for the fifth floor (the floor Resident #178 resided on). This surveyor discussed the coding of the MDS assessment dated [DATE] in which the resident was coded as being comatose. She stated , Resident #178 was not in a coma and that the section B 0100 was coded in error. This surveyor asked the MDS Coordinator who was responsible for checking the assessment for accuracy and she stated the MDS Director. This surveyor attempted to interview the MDS Director however was made aware by the Director of Nursing (DON) that she was away on vacation. On 12/18/23 at 9:41 AM, the surveyor interviewed the DON on the accuracy and completion of the MDS. The DON stated the MDS's were completed by both the MDS Coordinator and the MDS Director. She stated that the MDS Director was responsible for checking the accuracy of the assessment. 40042 2. On 12/18/2023 at 9:26 AM, the surveyor interviewed Resident #119, who stated that he/she used half side rails for repositioning in bed as well as an assist to get out of bed due to left side weakness. A review of the AR revealed the resident had diagnoses which included but were not limited to: a fracture of the left femur (hip), hemiplegia (paralysis of one side of the body) and hemiparesis following cerebrovascular disease affecting the right dominant side and lack of coordination. Review of the quarterly MDS dated [DATE], revealed the resident had BIMS score of 14 out of 15, which indicated that Resident #119 had an intact cognition. The MDS also coded section P0100 as the resident with a physical restraint with a bed rail used less than daily. Review of the Order Summary Report reflected a physician's order dated 1/18/23 for Half side rail to left side as enabler to increase independence in bed mobility when in bed, and Half side rail to right side as enabler to increase independence in bed mobility when in bed. On 12/14/23 at 2:30 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team. She reviewed the residents quarterly MDS dated [DATE] in the electronic medical record and acknowledged that she coded the resident as having side rail restraint's and that was a coding error. On 12/18/23 at 9:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN/UM) who stated that the side rails for Resident #119 were not restraints and were enablers for bed mobility. Review of the Consent for Siderail Use, dated 8/13/22, reflected that right and left half siderails were indicated as a mobility aid and for security as per resident preference. This document was signed and dated by the resident and the LPN/UM. Review of the Job Description MDS Coordinator revealed Job Summary:The MDS Nurse is to assess the residents' physical and mental function and document data on the Minimum Data Set forms completely and accurately. Under Duties and Responsibilities: 1. Interview residents, residents' representatives and others for information related to the minimum data set assessment. 2. Examine residents to collect information related to the minimum data set assessment. 3. Review medical records and records related to residents' health status to collect information related to the minimum data set assessment. 4. Enter data onto the computer program for minimum data set assessments. 5. Assume accountability and responsibility for accuracy of minimum data set (MDS) assessment information. Review of the facility's policy titled Resident Assessment Instrument (RAI) Process which was revised 04/2023, revealed Purpose: To ensure that the Minimum Data Sets (MDS) for each resident is completed accurately and timely in accordance with State and Federal regulations. To ensure that each resident is assessed for specific needs in order to attain or maintain the resident's highest practicable well-being. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) adequate screening of Covid-19 symptoms for visitors/vendors upon entrance into the facility; b.) an effective system of surveillance/tracking and cohorting of Covid-19 positive, persons under investigation (PUI) for Covid-19 and residents not exhibiting symptoms (non-ill or asymptomatic) of Covid-19; c.) staff assignments were designated to cohort groups appropriately to prevent the spread of COVID-19; c.) staff follow infection control protocols for doffing (removal) of personal protective equipment and performing hand hygiene when exiting a droplet isolation room and before entrance to a non-ill resident room; and d.) staff cleaned and disinfected equipment appropriately after use to address the risk of cross-contamination. This deficient practice was identified during tour on 5 of 5 nursing floors (2nd-6th floor) conducted on 04/18/2020. On 04/18/2020, the surveyor reviewed the facility's COVID-19 outbreak response measures to include the resident and staff line list, infection data tracking/surveillance 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 identify or track the resident cohort group who were non-ill to prevent their exposure to the virus. Upon observation and interview, it was identified that there was no designation of staff to care solely for the Covid-19, PUI and non-ill residents on all nursing units throughout the facility. Two non-ill, non PUI residents (Residents #2 and #6) resided in the same room as Covid-19 positive residents (Resident #1 and #5). The Covid-19 and PUI residents were located throughout the units on each floor and were not cohorted to one area to minimize the exposure risk to non-ill, non-exposed residents. An activity aide on the 4th floor entered a Covid-19 isolation room, wearing a gown, mask, faceshield and gloves to deliver meal trays to Residents #1 and #2. The aide did not doff the gown, mask, and gloves or perform hand hygiene prior to entering the room of non-ill residents (Resident #3 and #4) to deliver their trays. A Licensed Practical Nurse (LPN #4) on the 6th floor exited a PUI resident room carrying a used gown, gloves and a blood pressure cuff down the hallway where the gown and gloves were placed in a biohazard bin and the blood pressure cuff was placed on top of an isolation bin. LPN #4 did not perform hand hygiene prior to donning gloves and cleaning the blood pressure cuff and used her non-gloved hand to reach inside a container of disinfectant wipes to retrieve a wipe. Also, a glucometer on the 2nd floor was not cleaned in a manner to minimize cross-contamination. The glucometer was placed on top of the medication cart without being cleaned after use on a resident. In addition, the surveyor and an EMS person were not screened for symptoms of Covid-19 and exposure before granted entrance into the facility. In accordance with facility provided documents as of 04/18/2020 and interview, the surveyor learned that the facility had 24 Covid-19 positive residents, 10 PUIs awaiting testing results and 8 deaths since 04/01/2020. The latest onset of symptoms was on 04/16/2020. The facility's failure to adequately conduct surveillance to identify and track the non-ill resident cohort group, dedicate staff to designated cohort groups, follow isolation infection control protocols for PPE and disinfection of equipment, and adequately screen visitors upon entrance posed a serious and immediate threat to the safety and wellbeing of all non-ill residents residing in the facility. This resulted in an Immediate Jeopardy (IJ) situation that began on 04/18/2020 at 3:45 PM. The immediacy was removed on 04/19/2020 at 9:30 AM based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyor during an on-site visit survey conducted on 04/19/2020. The deficient practice was evidenced by the following: a.) On 04/18/2020 at 9:20 AM, the surveyor entered the facility. Upon entrance, the surveyor observed an electronic touchpad on a stand located next to a screening table that was set-up within the entrance. The table contained a tympanic (ear) thermometer and probes, Covid-19 infection control information, a visitor logbook, and a screening log that captured symptom and exposure questions and the temperature recordings. There was no staff member observed at the table. The receptionist (Staff #1), who was seated at the reception desk, approached the table. The surveyor identified self and explained the purpose of the visit. Staff #1 explained that she needed to obtain the temperature. She attached the probe to the thermometer, inserted in the surveyor's ear and obtained a temperature of 95.0 degrees Fahrenheit (F). The surveyor asked if Staff #1 had any further questions, if there was a questionnaire to complete or a logbook that needed to be signed. Staff #1 responded, No, you are good. The surveyor was asked to wait in the lobby, which was located behind the screening table, and Staff #1 returned to the reception desk. Staff #2, a Unit Secretary, then seated herself in the chair at the screening table. On 04/18/2020 at 9:28 PM, a resident was observed entering the facility by wheelchair that was being pushed by an EMS transport person. The resident was wearing a surgical mask and the EMS person was wearing a respirator. The EMS person stopped at the table for screening. Staff #2 asked the resident in Spanish how he/she was feeling. The resident replied that he/she was okay. Staff #2 took the resident's temperature and obtained a reading of 96.7 degrees (F). Staff #2 then took the EMS person's temperature and obtained a reading of 97.0 degrees (F). Staff #2 did not inquire if the EMS person had any symptoms and did not direct the EMS person to sign-in using the touchpad, visitor log or enter information on the screening logbook. The EMS person then wheeled the resident to the elevators, where he entered the elevator with the resident. On 04/18/2020 at 9:32 AM, the surveyor conducted an interview with Staff #1 and Staff #2. Staff #1 stated she fills in at the table when the staff assigned to the screening table are not available, such as break time. When asked about temperatures, she stated that a person with a temperature above 100.4 F would not be allowed in the facility. She was not sure what an acceptable low temperature was for a person and would only recheck the temperature if it was higher than 100.4 F. Staff #2 stated that the EMS person was transporting the resident back to his/her room and that all staff and visitors were supposed to sign-in through the touchpad and complete the symptom/temperature logbook. She continued that visitors were to sign-in through the touchpad, sign the visitor logbook and completed the symptom/temperature logbook. When asked why the surveyor and EMS person did not go through this screening process, Staff #2 stated that it was a mistake, and that both should have been screened in accordance with the policy. On 04/18/2020 at 1:12 PM, the Assistant Director of Nursing (ADON), who was also the Infection Control Coordinator, stated that all visitors and staff were screened upon entry. She stated that all staff enter through the front entrance and that both staff and visitors were to complete the questionnaire on the touchpad, sign-in on the logbook, answer the questions on the symptom logbook, have their temperatures taken, and then record the reading. The ADON stated that the front desk personnel should have screened the surveyor and the EMS person upon entry. Review of the In-service records provided by the ADON, dated 03/11/2020, indicated that both Staff #1 and Staff #2 attended the training for the monitoring of all staff and non-residents entering the building for signs and symptoms of Covid-19 virus. The in-service included that the facility will screen every staff member and vendor who enters the building through the following steps: A questionnaire will be filled out asking if they have any signs or symptoms of Covid-19; if they have recently returned from international travel within 14 days; if in the last 14 days, have they come in contact with anyone that tested positive for Covid-19; and do they reside in a community where there are cases of Covid-19. Anyone entering the building will have their temperature taken and if anyone has a temperature of 100.4 or higher, they will not be allowed to enter the building. The in-service did not include information regarding low temperature readings. Review of the facility's Infection Control policy on Coronavirus (Covid-19) policy provided by the ADON, dated last revised 03/2020, indicated that visitors with known or suspected Covid-19 will be restricted from entering the facility and that the facility will monitor visitors entering the facility for signs and symptoms. b.) During the entrance conference on 04/18/2020 at 9:35 AM, the ADON stated that the facility had a census of 156 with 5-7 residents hospitalized . She stated there were 24 active Covid-19 positive residents with 10 PUIs that were tested for the virus with results pending. The ADON stated that there were three units on each floor and that the Covid-19 positive and PUI residents were not separated into one area and were on every floor and unit. The ADON stated that staffing has been a challenge and that staff were not designated to care for a specific cohort group. She explained that she had been in daily contact with the Local Health Department who advised that this was alright since they have to suspect that everyone has been exposed. In reference to PPE, the ADON stated they keep a daily inventory and report to the state portal, along with the staffing. She added that they are preserving and are currently fine with PPE. The ADON explained that the Administrator was unavailable until Monday; the former DON resigned and a new DON was to start on Monday. She added that there was another ADON who was currently out sick. The ADON stated she had also been sick on 4/16 and 4/17 and returned to work today, 4/18/2020. On 4/18/2020 at 10:34 AM, the surveyor toured the 3 units on the 2nd floor. The surveyor noted that on rooms 201, 202, 205, 211, 217, and 222 there was signage on the doors to see the nurse before entering. The signs did not indicate the room was on isolation or the type isolation required. Outside of room [ROOM NUMBER], across from room [ROOM NUMBER], there was one 3-drawer, clear plastic bin (isolation set-up) that contained gowns only. There were no gloves or masks stored in the bin. There was no isolation set-up outside or near room [ROOM NUMBER] and 222. The isolation set-up located outside of room [ROOM NUMBER] contained gloves only. There were no gowns or masks stored in the bin. On 04/18/2020 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the 2nd floor census was 26, which included 15 Covid-19 positive and PUI residents, and that she and one Certified Nursing Assistant (CNA #1) were assigned to the floor and not any specific room. She stated that the signs posted on the resident room doors indicated that the resident was on isolation for Covid-19. LPN #1 stated the isolation was for droplet precautions and that the personal protective equipment (PPE) needed to care for the residents on isolation consisted of the use of gowns, gloves, masks, and face shields. LPN #1 stated that when going into the isolation room, she dons a surgical mask over the N95 (respirator mask), a gown, face shield, and gloves. Before exiting, she would remove and discard the gown, surgical mask and gloves. She would then perform hand hygiene and disinfect the face shield. She was unable to answer why the isolation bins were not stocked with the PPE needed to care for a resident on Covid-19 isolation for droplet precautions. LPN #1 stated PPE was ordered by administration and that she had just returned to work after being off a few weeks and she was still trying to get acclimated. On 04/18/2020 at 10:50 AM, the surveyor interviewed CNA #1 regarding PPE use in the isolation rooms. CNA #1 stated that she was told there was not a lot of PPE, so they need to preserve it. She stated that she tries to care for all non-Covid positive residents first and then care for the residents on isolation. CNA #1 explained that she does not change her mask and gown all of the time unless she was caring from a positive resident. CNA #1 stated the nursing staff were issued one respirator mask per day and that they use the surgical mask over the respirator when in the isolation room. CNA #1 stated she would let the LPN know if they were out of PPE in the isolation set-ups and they would get more but had not gotten the opportunity to do that yet. Review of the facility's Infection Control Policy on Coronavirus (Covid-19) policy provided by the ADON, last revised on 03/2020, indicated that immediate infection prevention and control measures will be put into place for a resident with known or suspected Covid-19. The policy included that the resident would be placed on Droplet Isolation. Review of the facility's policy on Transmission-Based Precautions provided by the ADON, dated revised 10/15/2019, indicated PPE must be readily available near the entrance to the resident's room for staff to use. On 04/18/2020 at 11:30 AM, the surveyor toured the 3 units on the 3rd floor. Upon arrival on the floor, LPN #2 was observed holding a blood glucose monitor (BGM) while walking towards the medication cart, located near the nurses' station. LPN #2 placed the BGM on top of the medication cart while removed the keys from her right pant pocket to open the medication drawer. During an interview at that time, LPN #2 stated she had just used the BGM on a resident to obtain the blood glucose reading. When asked if the BGM was cleaned prior to placing it on top of the medication cart, LPN #2 stated, No, I forgot. LPN #1 stated that she should have cleaned it with the disinfectant and wasn't thinking clearly. She elaborated that she was a new employee and just started a few days ago. The surveyor continued the tour of the floor and noted there was a sign on room [ROOM NUMBER], 318 and 321 that indicated to see the nurse before entering. Each room was occupied by one resident. There was no indication of the type of isolation required and there was no isolation set-up outside of room [ROOM NUMBER]. The isolation set-up outside of room [ROOM NUMBER] and 318 contained gloves, gowns, and surgical masks. During an interview with LPN #2 at 11:40 AM on 04/18/2020, she stated that the census on the floor was 28, which included 3 positive residents, and that she and two certified nurse aides were assigned to care for the floor with no designation of personnel to care for the Covid-19 positive residents. She stated that the door sign on the rooms indicated that the residents were on isolation precautions for Covid-19 and that staff were required to change their gown, gloves, surgical mask upon exiting the room. On 04/18/2020 at 11:44 AM, the surveyor conducted an interview CNA #1 and #2 who standing at the nurses' station together. Both CNAs stated they were new to the facility and that they were issued a respirator mask once a day. CNA #1 stated that she would wear her gown, gloves, mask, and faceshield into a Covid-19 positive room and then remove the gown and gloves and then wash her hands. CNA #2 stated that she would do the same, expect she would also remove the outer surgical mask that she would put on before going in and clean the face shield when she exited. They both stated that they try to leave the Covid-19 positive residents for last but they have to answer the call bells in those rooms and would go in and out as needed throughout their shift. On 04/18/2020 at 11:57 AM, the surveyor toured the 3 units on the 4th floor. During the tour, the surveyor observed that there was a sign on room [ROOM NUMBER] and 411's door that indicated to see the nurse before entering. room [ROOM NUMBER] had one occupant and room [ROOM NUMBER] was occupied by two residents. There was no indication of the type of isolation required. Outside of both room, there was an isolation set-up that contained gloves, gowns and surgical masks. On 04/18/2020 at 12 Noon, the surveyor interviewed LPN #3 who stated that the census was 43, which included 2 Covid-19 positive residents. She stated there were 3 CNAs and 2 activity aides assigned to care for all residents with no designation of staff for the Covid-19 positive residents. LPN #3 stated she recently returned to work after being sick and she was originally assigned to the 2nd floor but was pulled to the 4th floor today. When asked about the two residents in room [ROOM NUMBER], LPN #3 stated that only one of residents was Covid-19 positive (Resident #1) and the other resident (Resident #2) was not. LPN #3 stated that Resident #2 was not having any symptoms that she was aware of and had not been tested for the virus as of 04/18/2020. On 04/18/2020 at 12:11 PM, during the lunch meal tray pass, the surveyor observed an activity aide (AA #1), wearing a gown, face shield, respirator mask, and gloves as she pushed the meal tray delivery cart to room [ROOM NUMBER]. AA #1 removed a meal tray from the cart, entered room [ROOM NUMBER] and placed the meal tray on Resident #1's bedside table. She then returned to the food cart, removed a meal tray, entered room [ROOM NUMBER] and placed the meal tray on Resident #2's bedside table. Without removing her gloves and performing hand hygiene, AA #1 exited the room, returned to the cart and pushed the cart down the hallway to room [ROOM NUMBER]. She then removed a meal tray from the food cart and entered room [ROOM NUMBER], where she placed the tray on Resident #3's bedside table. She exited the room, returned to the cart, removed a meal tray and delivered it to Resident #4 in room [ROOM NUMBER]. The surveyor noted that rooms [ROOM NUMBERS] did not have signage posted on the doors to see the nurse before entering. On 04/18/2020 at 12:14 PM, the surveyor interviewed AA #1 who stated the 4th floor had a lot of dementia residents. She continued that the activity aides assisted where they could during this time, which included passing the meal trays. The surveyor asked about the signage on room [ROOM NUMBER]'s door. AA #1 responded that it meant it was an isolation room for Covid-19. She stated that the staff do the best they can and that although she was supposed to change her gown, gloves and mask, she did not do it during the meal pass because she was just trying to get the residents their meals. On 04/18/2020 at 12:16 PM, the surveyor interviewed AA #2 regarding the door signage and associated infection control protocols. AA #2 stated that the sign on the door indicated an isolation room and that the staff should change their gowns and gloves. On 04/18/2020 at 12:20 PM, the surveyor interviewed LPN #3 who stated that the activity aides have been very helpful with passing the meal trays. She stated when going into an isolation room to deliver the trays, the procedure consisted of changing gloves and performing hand hygiene before exiting. The line listing document, provided by the ADON on 04/18/2020 at the entrance conference at 9:35 AM, showed that Resident #1 was Covid-19 positive. The line listing also revealed that Resident #2, #3, and #4 were not listed as having Covid-19, pending Covid-19 test results or were a person under investigation (PUI) for the virus. The ADON stated that the line listing was current. Review of Resident #1's physician order sheet revealed an order dated 04/02/2020 for a Covid-19 Swab. The Lab Results Report, dated 04/06/19, revealed that [CONDITION(S)]-CoV-2 (Coronavirus Covid-19) was detected (positive for Covid-19). Review of Resident #2, #3, and #4's physician order sheets, progress notes, laboratory reports, and medication administration records revealed the resident were asymptomatic for Covid-19 and that there were no physician ordered tests or treatments for Covid-19. Review of the facility's Infection Control Policy on Coronavirus (Covid-19) policy provided by the ADON, last revised on 03/2020, indicated to limit only essential personnel to enter the room with appropriate PPE. The PPE included gloves, gown, respiratory protection, don mask when entering and exiting resident's room; eye protection that covers both the front and sides of the face, remove before leaving resident room. Hand hygiene using an alcohol-based hand sanitizer before and after all patient contact, contact with infection material and before and after removal of PPE, including gloves. On 04/18/2020 at 12:24 PM, the surveyor toured the 3 units on the 5th floor. Upon arrival the surveyor interviewed LPN #5 who stated the census was 47 with one positive resident in room [ROOM NUMBER]. LPN #5 stated that there was two CNAs assigned to the floor and that there was no designated staff to care for the Covid-19 resident. The surveyor noted that there was no signage on room [ROOM NUMBER] and that the room was occupied by two residents (Resident #5 and #6). LPN #5 reviewed the line listing document that showed that Resident #5 was Covid-19 positive. LPN #5 confirmed that Resident #6 was not on the line listing as having Covid-19, pending Covid-19 test results or was a person under investigation (PUI) for the virus. LPN #5 then entered the computer and confirmed that Resident #6 had not been ordered a test or was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated further she was not sure why she was cohorted with a resident that was positive for Covid-19. Review of Resident #5's physician order sheet revealed an order dated 04/10/2020 for a Covid-19 Swab. The Lab Results Report, dated 04/17/19, revealed that [CONDITION(S)]-CoV-2 (Coronavirus Covid-19) was detected (positive for Covid-19). Review of Resident #5's physician order sheets, progress notes, laboratory reports, and medication administration records revealed the resident was asymptomatic for Covid-19 and that there were no physician ordered tests or treatments for Covid-19. On 04/18/2020 at 12:43 PM, the surveyor toured the 3 units on the 6th floor. Upon arrival to the nurses' station, the surveyor observed LPN #4 with a blood pressure (BP) cuff in her hand as she entered room [ROOM NUMBER]. The room had a sign on the door that indicated to see nursing before entering and was occupied by two residents (Resident #7 and #8). LPN #4 obtained the BP on Resident #7, placed the BP cuff on the bedside table and then removed her gown and gloves. She balled the gown up and held it in her left hand. She then used her right hand, which held the used gloves, to pick up the BP cuff and exit the room. LPN #4 placed the BP cuff on top of the isolation set-up outside of room [ROOM NUMBER] and discarded the gown and gloves in the biohazard trash bin that was near the isolation set-up. Without performing hand hygiene, she removed the blue lid of the disinfectant, reached inside with her bare right hand, and removed a disinfectant wipe. LPN #4 then reached into the top drawer of the isolation set-up and removed a pair of gloves. She donned the gloves and used the disinfectant wipe to clean the BP cuff. On 04/18/2020 at 12:48 PM, during an interview with LPN #4, she stated that Resident #7 was recently tested for Covid-19 with results still pending. She explained that Resident #8 has presumed exposed and was ordered a Covid-19 test and a chest x-ray to rule out pneumonia. She stated that room [ROOM NUMBER] was an isolation room and that all equipment should be cleaned before used on another resident. LPN #4 stated that there wasn't a biohazard bin outside of the room, which was why she walked the used gown and gloves down to room [ROOM NUMBER]. She stated that she should have performed hand hygiene after discarding the gown and gloves and that she should not have opened the container lid to remove the disinfectant wipe. Review of Resident #7's physician order sheet revealed an order dated 04/16/2020 for a Covid-19 Swab. The Lab Results Report, dated 04/17/19, revealed that [CONDITION(S)]-CoV-2 (Coronavirus Covid-19) was detected (positive for Covid-19). Review of Resident #8's Medication Review Report, dated 04/19/2020, revealed an active order for a chest x-ray and Covid-19 test, dated 04/16/2020. The medical record did not contain documentation that the Covid-19 test was performed. Review of the line listing that was provided by the ADON on 04/18/2020, revealed that Resident #7 has a pending Covid-19 test result and that Resident #8 was not on the line listing as a PUI with a Covid-19 pending test. Review of the facility's Infection Control Policy on Coronavirus (Covid-19) policy provided by the ADON, last revised on 03/2020, indicated dedicated or disposable patient-care equipment should be used. If equipment must be used for more than one resident, it will be cleaned and disinfected before use on another resident. On 04/19/2020, the ADON was made aware of the above findings. She stated that she was off the last two days and the results of Resident #5 came in yesterday (04/17/2020) when she was not there. When asked why non-ill residents remained in the room with a person that was PUI and later tested positive, she stated that everyone was considered exposed and that the Local Health Department (LHD) was aware. Upon request for written documentation between the facility and the LHD, the ADON stated that the information was discussed over the telephone and they had nothing in writing. She stated that they cohort and separate residents that are positive and suspected and monitor for symptoms; however, they do not dedicate staff and do not have a specific floor or unit designated to cohort the Covid-19 positive and PUIs. She stated they talked about making a Covid-19 unit a few weeks ago but due to staffing were unable to do it. On 04/19/2020 at 10:00 AM, the surveyor spoke with the Administrator regarding the above issues. The Administrator stated that staffing has been a challenge and that they considered cohorting but the staff stated they would quit if they were designated to care for the Covid-19 positive residents. He stated the facility was in constant contact with the LHD, who stated that the entire building was assumed Covid -19 positive, and were following CDC guidelines. As far as the infection control issues, the Administrator stated that typically they have five unit managers that would be able to watch practices but they were all out sick. On 04/19/2020, a call was placed to the State Agency at the request of the Administrator and Owner. During the call, the Owner relayed the same information that was presented by the Administrator in the above interview. Review of the facility's Outbreak of Communicable Disease policy, dated last reviewed 01/2019, included that the Infection Control Coordinator and Director of Nursing will be responsible for receiving surveillance information and tabulating data and assigning nursing personnel, if appropriate to same resident group for the duration of the outbreak. The nursing staff would be responsible for initialing isolation precautions as directed or as necessary. Review of the NJDOH Communicable Disease recommendations for Long Term Care Facilities during Covid-19 Pandemic at https://www.state.nj.us/health/cd/documents/topics/NCOV/COVID_LTC_Recommendations.pdf, indicated: appropriate placement of PUI and positive COVID-19 case(s) and infection control precautions. For suspect or confirmed COVID-19 case(s), Standard and Transmission-based Precautions including use of a N95 respirator (or facemask, if unavailable), gown, gloves, and eye protection is recommended. Implement facility cohorting plan that allows for separation of residents, dedicating staff and medical equipment to each of these cohorts and allowing for necessary space to do so at the onset of an outbreak: Identify three cohort groups: 1.) Ill 2.) Exposed (not ill, but potentially incubating) and 3.) Not ill/not exposed. Dedicate resident specific equipment and supplies. If not possible, restrict dedicated equipment within a specific cohort with routine cleaning and disinfection between resident use. HCP assigned to affected unit(s) should not rotate to unaffected units. This restriction includes prohibiting HCP from working on unaffected units after completing their usual shift on the affectedunit(s). If a wing/unit has multiple ill residents, transition the impacted wing/unit to house only these residents whenthe facility cannot otherwise rapidly isolate them (i.e. ill cohort). If the facility is unable to effectively cohort the impacted wing/unit(s) then rapid isolation of the unaffectedwing/unit(s) is imperative. On 04/18/2020 at 3:45 PM, the surveyor met with the ADON, who stated she was the only one available. The ADON was advised of the failure to appropriately identify and track residents who were asymptomatic and PUI, and cohort Covid-19 positive residents; appropriately cohort staff assignments to reduce the transmission of COVID-19 while ensuring PPE and isolation signage was provided. The ADON was further advised of the facility's staff improper infection control protocols for PPE use, disinfecting of resident equipment, and Covid-19 screening of visitors placed the non Covid-19 positive residents in an Immediate Jeopardy (IJ) situation. The ADON was unable to provide documentation to refute the surveyor's findings. The IJ began on 04/18/2020 at 3:45 PM and the immediacy was removed on 04/19/2020 at 10:23 AM based on an acceptable Removal Plan which included the following: Cohorting all Covid-19 positive residents on the second floor and using a separate wing on the second floor for the PUI residents with dedicated staff for each area. All asymptomatic residents on the 2nd floor were moved to other floors. Staff were reeducated with return demonstration on hand hygiene and donning/doffing of PPE. Training in-service was given on isolation precaution and the proper disinfecting of equipment. The implementation of the removal plan was verified on-site on 04/19/2020. On 04/19/2020 at 9:45 AM, the surveyor toured all five nursing units, and verified though observation, interviews with facility staff and review of in-service education and revised facility documents that the Removal Plan had been implemented. NJAC 8:39-19.4; 27.1 (a)

C#: NJ , NJ 5 Based on observation, interviews, and record review, as well as review of pertinent facility documents on 6/11/18 and 6/12/18, it was determined that the facility failed to ensure a resident received the mechanically altered diet as ordered by the physician for 1 of 3 sampled residents (Resident #1). On 6/11/18, Resident #1, who had a physician's orders [REDACTED]. This created an Immediate Jeopardy (IJ) to the health and safety of Resident #1 and the potential to affect all residents who were on mechanically altered diet due to swallowing difficulties and at risk of aspiration. The IJ was identified on 6/12/18 at 1:29 p.m., when Resident #1 was served with a grilled cheese sandwich who had an order of puree diet, ground meats only. The facility submitted a Plan of Correction (P[NAME]) that included but was not limited to: inserviced staff on serving accurate diet according to physician's orders [REDACTED]. 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 4/7/18, showed that the Resident had a Brief Interview for Mental Status (BIMS) score of 11/15, which indicated that the Resident was moderately impaired in cognition. The MDS also indicated that the Resident required extensive assistance from staff with Activities of Daily Living (ADLs) and required supervision with eating. According to Resident #1's Care Plan (CP) initiated on 12/22/14, the Resident had the potential for altered nutrition related to Dementia and [MEDICAL CONDITION]. Interventions included but were not limited to: Provide diet as ordered and SLP (Speech Language Pathologist) as needed. The CP also showed that the Resident had impaired cognitive function/Dementia or impaired thought processes related to low BIMS score, initiated on 4/23/18. Interventions included but not limited to: Cue, reorient and supervise as needed. A review of the Order Summary Report (OSR), dated 6/1/18, showed an order for [REDACTED]. On 4/11/14, Resident #1 was evaluated by the SLP. The SLP documented on the form Speech Therapy SLP Evaluation and Plan of Treatment, under the section of Initial Assessment/Current Level of Function and Underlying Impairments, showed that Resident #1 was referred to SLP by the Nursing Department to assess swallowing function due to coughing while swallowing chopped meats. The SLP further documented that the Resident had history of Oropharyngeal Dysphagia. A review of the Speech Therapy Discharge Summary, under the section of discharge date d 4/15/14, in Long-Term Goals, showed: Ground meats and all other textures to be pureed. A review of the Speech Therapy (ST) Screening Form, dated 10/2/17, the SLP, indicated that Resident #1 had an annual screen and there was no change in overall function. The SLP also indicated that the Resident had a safe diet of ground textures with thin liquids. During the meal observation on 6/11/18 at 12:19 p.m., the surveyor observed that Resident #1, was eating a whole grilled cheese sandwich. The surveyor further observed the Resident's lunch tray was pushed on the side of the table with a meal ticket stating ground diet, ground meat, pureed sides. The Surveyor called the attention of the Charge Nurse (CN) and the surveyor asked if Resident #1 was allowed to eat the grilled cheese sandwich. The CN stated that Resident #1 liked grilled cheese sandwich. The surveyor asked again if the Resident was allowed to eat a whole grilled sandwich. The CN stated, Let me call the Dietician. The Dietician arrived on the unit on 6/11/18 at 12:29 p.m., the surveyor told the Dietician that Resident #1 was served a whole grilled cheese sandwich. The Dietician stated that the grilled cheese sandwich was not a ground diet, however he/she would check with the ST. In an interview with the ST on 6/11/18 at 12:56 p.m., the ST stated that the grilled cheese was not a ground diet because it was hard in texture. The ST further stated that Resident #1 was screened on 10/2/17, and there was no change in overall diet and stated I don't know why she's eating grilled cheese sandwich. The ST went on to state that Resident #1 was kept on the same diet because of safety reasons due to Resident's dentition and Dementia. The ST further explained the safety precaution was based on the Resident's function and the least restrictive diet to take all the calories without the risk of aspiration. In an interview with Resident #1 on 6/11/18 at 1:27 p.m., the Resident could not remember if he/she had grilled cheese for lunch and stated I think they just gave it to me and I ate it. Interview with Registered Nurse (RN #1) on 6/11/18 at 1:47 p.m., the RN indicated that he/she was the regular nurse assigned to Resident #1. The RN explained that he/she served the grilled cheese sandwich to Resident #1 because the Resident would not eat what was on the lunch tray and asked for a grilled cheese sandwich. The RN stated that he/she went to the Food Server and requested a grilled cheese sandwich. The RN further revealed that Resident #1 had grilled cheese sandwiches in the past, but refused to state the last time the Resident was served with a grilled cheese sandwich. The RN further revealed that prior to the incident, he/she was inserviced on the types of diet, diet consistencies, and checking of the meal ticket to verify the resident's diet before serving the tray. During a follow up interview with the ST and the Dietician on 6/11/18 at 2:14 p.m., they indicated that the grilled cheese sandwich that was served to Resident #1 was not puree in consistency and/or ground in texture. In an interview with the Nurse Educator (NE) on 6/11/18 at 3:13 p.m., the NE indicated that all new hires were inserviced on safe feeding which included but was not limited to: types of diet, diet consistencies and/or textures and checking the meal ticket to verify the resident's diet before serving the food. The NE confirmed that RN #1 had New Meal Arrangement, training in 3/2018, which included the aforementioned inservice on safe feeding. The surveyor requested to interview the Food Server on 6/11/18 at 3:45 p.m., however, the Food Server was not available for interview. In an interview with the DON on 6/11/18 at 4:17 p.m., the DON assured the surveyor that Resident #1 would not be served grilled cheese sandwiches until further assessed by the ST. The DON also revealed that on 6/11/18, RN #1 was re-inserviced on diet types, checking the meal ticket and referral to ST before changing the resident's diet. During a follow up interview with the Food Service Director (FSD) on 6/12/18 at 9:38 a.m., the FSD stated that the staff would ask the dietary staff for a grilled cheese sandwich and/or food alternates and preferences without verification of who the food was for. The FSD further stated that after what happened to Resident #1 on 6/11/18, the new intervention would be for Dietary Aides to only provide food upon being presented with the meal tickets which also applied to alternates/request and all sides orders. During a follow up interview with RN #1 on 6/12/18 at 10:12 a.m., the RN stated I'm aware of the diet, but still gave her the grilled cheese . The RN stated that he/she requested the grilled cheese sandwich without presenting the meal ticket to the Food Server. During a follow up interview with the Dietician on 6/12/18 at 1:45 p.m., the Dietician provided the form Diet Type Report,and it showed that there were 18 residents (including Resident #1) documented on the report who were on mechanically altered diets. A review of the facility's undated policy titled, Protocol For Dignified Dining Meals-Preparing And Serving, showed under Policy/Procedure: #18. Nursing personnel will check food for appropriate content, texture The facility's failure to ensure the correct consistency diet was provided according to the physician's orders [REDACTED].#1 and other 18 unsampled residents who were on mechanically altered diets. The IJ was identified on 6/12/18 at 1:29 p.m., when the Administration was notified and submitted a Plan of Correction (P[NAME]). The Administration was alerted of the concern about the incorrect diet consistency that was served to Resident #1, on 6/11/18. An acceptable P[NAME] was received on 6/29/18, as follows: Corrective Action: The RN and the Speech Therapist performed an assessment on (MONTH) 11th of Resident #1 and ensured and documented that there was no adverse reaction or harm. Resident #1 was also added to speech therapy case load for further evaluation of her ability to safely ingest food preferences. The facility counseled and reeducated the staff who provided Resident #1 with her preferred food on (MONTH) 11th to emphasize the need to follow resident diets as indicated on the meal ticket. Identification of at Risk Residents: All residents have the potential to be affected. All resident diets were reviewed and all residents were found to be receiving the correct diet ordered by the physician. Systemic Change: All Nursing Staff were re-educated on 6/12/18, following initial notification of the IJ by the surveyor, on following resident diets as indicated on the meal ticket. This include alternates and resident requests. This will be supervised by the nursing staff. All Dietary staff were re-educated on 6/12/18, following initial notification of the IJ by the surveyor, to follow the diet indicated on the meal ticket, including alternates and resident requests. Quality Assurance: All unit managers and supervisors will monitor at least 7 meals per week for accuracy to ensure provision of meals consistent with diet orders. They will in specific review whether the ticket matches the alternate diets, and monitor whether dietary aides are only serving food matching the ticket presented. All finding will be reported to the Director of Nursing. DON will report findings of audit to LNHA(Licensed Nursing Home Administrator) and Quality Assurance committee for a period of 90 days. Completion date: (MONTH) 12, (YEAR). NJAC 8:39 17.4(a)(1)(2) 8:39 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to implement care plan interventions for a resident, with a history of falls, who fell and sustained a [MEDICAL CONDITION]. This deficient practice occurred for 1 of 30 residents (Resident #5) reviewed for care planning and was evidenced by the following: Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/12, the physician ordered a bed alarm, chair alarm and low bed as interventions to prevent falls. A care plan was initiated on 12/6/12 which addressed the use of these interventions. The resident had falls on 12/5/12, 12/7/12 and on 12/29/12. On 12/31/12, the care plan was revised to include the use of 2 floor mats. According to the fall investigation provided by facility administration on 9/4/13 at 10 a.m., the investigation indicated that the resident was found on the floor in the resident's room on 3/9/13 at 7:05 a.m. by the Licensed Practical Nurse (LPN). According to the LPN's statement "during AM rounds resident was found on the floor lying on her left side, observed bed alarm disconnected, floor mats were found under the bed and bed was not in its lowest position." In the investigation summary, dated 3/11/13, the Director of Nursing (DON) stated that a decision was made to terminate the CNA due to not following the plan of care which resulted in a fall with fracture. The DON confirmed this in an interview with the surveyor on 9/4/13 at 10:45 a.m. Refer to F323 NJAC 8:39 11.2 (f)(i)

Based on observation, interview and record review, it was determined that the facility failed to provide care to prevent falls and injuries to residents who were identified at risk for falls and who had a history of [REDACTED].# 6 was left alone in the bathroom and fell off the toilet. This deficient practice occurred in 2 of 8 residents,esidents #5 and #6) reviewed for falls and was identified by the following: 1. During the initial tour on 8/28/13 at 10 a.m., Resident #5 was observed in the day room sitting in a wheelchair with an alarm attached to the wheelchair. The Unit Manager (UM) stated that the resident fell and fractured a hip in December or January. The surveyor observed the resident on 8/29/13 at 11:25 a.m. and again on 9/3/13 at 1:25 p.m., in the day room sitting in a wheelchair with a chair alarm. Facility staff was seated next to the resident engaging the resident in conversation. During both observations, the resident was observed attempting to stand from the wheelchair and the chair alarm sounded. Staff encouraged the resident to sit back and down and engaged her in activity. The surveyor reviewed Resident #5's medical record on 9/3/13. The resident was admitted to the facility on [DATE]. The interdisciplinary team identified the resident as being alert and confused and at risk for falls. Fall interventions were initiated on admission according to the Plan of Care (POC) dated 12/6/12 and physician orders [REDACTED]. Fall investigations were provided by facility administration and the surveyor reviewed the investigations on 9/4/13 at 10 a.m. Findings are as follows: At 10 p.m., on 12/5/12, the day of admission, the resident attempted to transfer self from the bed and slipped onto the floor. The floor mats were removed at that time according to the investigation. There were no injuries. On 12/7/12, at 8 a.m., the bed alarm sounded and the resident was found on the floor which resulted in a contusion on the resident's head and a trip to the emergency room . After that fall, the resident's room was moved closer to the nurses station. On 12/29/12, at 7 a.m., the bed alarm sounded and the nurse found the resident on the floor in front of the bed. The resident sustained [REDACTED]. On 2/23/13, at 2 p.m., while family was present, the resident attempted to stand while in the wheelchair and fell on the floor mat. The resident sustained [REDACTED]. According to the medical record, on 3/9/13 at 7:05 a.m., Resident #5 was found on the floor by the Licensed Practical Nurse (LPN) "while performing rounds." The LPN observed the resident lying on her left side on the floor. The resident was complaining of pain to the left hip. The physician was notified and ordered the resident be sent to the emergency room . The resident was admitted to the hospital with [REDACTED]. The resident was readmitted to the facility on [DATE] and the physician ordered routine and as needed pain medication. In a written statement dated 3/9/13, the Certified Nurses Aide (CNA) stated that the resident woke at 6:15 a.m. The CNA provided incontinence care. The CNA then stated that she sat with the resident and "was talking until the other CNA came." In a statement written on 3/9/13, the LPN stated that "during AM rounds resident was found on the floor lying on her left side, observed bed alarm disconnected, floor mats were found under bed and bed was not in its lowest position." This same LPN indicated on the Incident Report dated 3/9/13, that to prevent a reoccurrence, "reeducate staff to check alarms." A summary of the fall/fracture investigation was written by the DON on 3/11/13. According to the summary, the DON confirmed the information provided by the LPN that the resident was found with the bed alarm disconnected and the floor mats not in place per the plan of care. The DON's summary also inlcuded that this information was "confirmed by the incoming day nurses aide." The DON reviewed the POC (functioning bed alarm and mats on the floor) with the CNA who cared for the resident on the 11 p.m. to 7 a.m. shift. The DON concluded that the actions of the CNA "resulted in a fall with injury due to the lack of preventive interventions in place." The facility made the decision to terminate the CNA "due to not following the POC which resulted in fall with fracture." This information was confirmed during an interview with the DON on 9/4/13 at 10:45 p.m. Refer to F282 2. During the initial tour on 8/28/13 at 10:30 a.m., the Licensed Practical Nurse (LPN) stated that Resident #6 had a history of [REDACTED]. The surveyor observed the resident in a low bed against the wall with a bed alarm and floor mat in place. On 8/29/13 at 11 a.m., the surveyor observed Resident #6 in the day room. The resident was calm in a reclined geri-chair and was supervised by staff who were present conducting an activity. The surveyor reviewed the medical record on 9/3/13 and noted the following: A Physician order [REDACTED]. Release during ADLs, meals, and routine care and every 2 hours for 15 mins then reapply." Review of an Incident/Accident report dated 3/26/13 indicated that during toileting, Resident #6 was lowered to the floor by a CNA after losing balance. The Registered Nurse (RN) statement indicated that the lap buddy for proper positioning was still in use for this resident who needed "close supervision by staff." The Rehabilitation Fall Screen following the fall indicated "Pt is non-compliant with safety precautions." A PO dated 3/29/13 indicated "continue lap buddy" as Resident #6 "has tendency to bend forward." Review of an Incident/Accident report dated 4/17/13 indicated that Resident #6 "fell off the toilet onto the floor on left side." The CNA caring for the resident at that time wrote a statement confirming that the resident was left alone in the bathroom "to obtain supplies." The Steps to Prevent Recurrence included "Re-educate staff " and "Do not leave unattended in bathroom." The RN Supervisor statement confirmed that Resident #6 was "confused" and that the CNA "placed a resident who was at risk for falls on the toilet and left (the resident) unattended resulting in that resident falling." NJAC 8:39 27.1 (a)