Every finding on record at Barclays Rehabilitation and Healthcare Center

COMPLAINT #3156476 Based on observation, interview, medical record review, and review of pertinent facility documentation on 8/12/26 and 8/13/26, the facility failed to ensure the administration of the controlled medication Oxycodone 15 mg (milligrams) was accurately documented on the MAR (Medication Administration Record) and implement a system to consistently and accurately reconcile controlled medications. The facility also failed to provide the INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD for the missing supply of medication and staff failed to accurately complete the controlled substance count for Medication Cart #1 on the 8/2/26 11PM-7AM Shift.This deficient practice was identified for 2 of 2 residents sampled (Resident #6 and Resident #8) as evidenced by the following: A review of Resident #6's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: displaced trimalleolar fracture of the lower left leg (a break of the bones that form an ankle joint), complex regional pain syndrome, and hypertension. A review of Resident #6's Order Recap Report revealed a physician's order (PO) dated 6/8/26, for the following:-oxyCODONE HCL (hydrochloride (a chemical salt formed by combining hydrochloric acid with an organic base, most commonly to make medications water-soluble and stable)) Oral Tablet 15 MG (milligrams) (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for severe pain A review of Resident #6's INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD - 60 DOSE for oxyCODONE HCL 15 MG tab dated 6/10/26 - 6/19/26 revealed the following:-On 6/10/26 at 0605 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/10/26 at 1300 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/12/26 at 0028 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/13/26 at 0517 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/14/26 at 0513 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/14/26 at 1800 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/18/26 at 0237 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply.-On 6/19/26 at 0134 hours, one tablet of oxyCODONE HCL 15 MG was removed from the supply. A review of Resident #6's Medication Administration Record (MAR) for June 2026 revealed no documented evidence that the Oxycodone HCl 15 mg was administered by staff. A review of Resident #8's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: multiple sclerosis (a nervous system disease that affects your brain and spinal cord), acute kidney failure, and hypertension. A review of Resident #8's Order Recap Report revealed a PO order dated 10/24/25, for the following:-oxyCODONE HCL Oral Tablet 15 MG (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for severe pain A review of Resident #8's INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD - 60 DOSE for OXYCODONE 15 MG TAB dated 7/4/26 - 7/24/26 revealed the following:-On 7/4/26 at 0108 hours, one tablet of OXYCODONE 15 MG was removed from the supply.-On 7/8/26 at 2:20 AM, one tablet of OXYCODONE 15 MG was removed from the supply.-On 7/9/26 at 10:45 PM, one tablet of OXYCODONE 15 MG was removed from the supply.-On 7/12/26 at 2 AM, one tablet of OXYCODONE 15 MG was removed from the supply.-On 7/16/26 at 10:35 PM, one tablet of OXYCODONE 15 MG was removed from the supply.-On 7/17/26 at 6:35 AM, one tablet of OXYCODONE 15 MG was removed from the supply. A review of Resident #8's MAR for July 2026 revealed no documented evidence that the Oxycodone HCl 15 mg was administered by staff. A review of the LTC [Long Term Care] Reportable Event Survey submitted to the New Jersey Department of Health revealed that on 8/3/26, at 9 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) notified the Director of Nursing (DON) that a Registered Nurse (RN #1) reported that a supply of Oxycodone 15 mg was missing for Resident #8. The missing supply was discovered during the routine, controlled substance count on the 7AM-3PM shift for Medication Cart #1. The DON immediately initiated an investigation and determined that the Nurse Manager (NM) had been assigned to Medication Cart #1 on 8/1/26 for the day and evening shifts and on 8/2/26 for the day and evening shifts. Further review of the form revealed that the NM reported that the supply had been exhausted and was discarded. The facility provided a statement dated 8/4/26, made by the NM, which indicated that on 8/2/26 the NM gave the last dose of the Oxycodone 15 mg tablets and tore and destroyed the empty cards and left the sheet on the LPN/UM's desk. A review of the Control Substance pharmacy packing slip for Resident #8 revealed that facility staff signed the form, indicating that 60 tablets [2 blister packs] of oxyCODONE 15MG tablets were received on 7/22/26. There was no corresponding INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD that was provided to the surveyor. A review of the NARCOTIC COUNT SHEET for August 2026, Unit 1, Cart 1 revealed that during the 8/2/26 3PM-11PM shift the NM removed 1 [blister pack] from the total count, leaving 26 total remaining and on the 11PM-7AM shift's count, the NM and RN #2 signed that there were 26 total narcotics [blister packs] remaining in the cart. During an interview on 8/13/26 at 12:30 PM the LPN/UM stated that on the morning of 8/3/26 he arrived at the facility at approximately 6:30 AM and was informed by RN #1 that she went to administer Oxycodone to Resident #8 and there was none left and that she called the pharmacy for a refill and was told that 60 tablets had been delivered on 7/22/26. During a joint interview with the DON and the Licensed Nursing Home Administrator (LNHA) on 8/13/26, at 1:08 PM, the DON stated that upon her arrival to the facility on 8/3/26, the LPN/UM reported that there may be a missing medication, Oxycodone 15 mg, for Resident #8. The DON stated that she immediately began an investigation which involved reviewing the NARCOTIC COUNT SHEET for Medication Cart #1 and determining that one blister pack was removed on the 8/2/26 3PM-11PM shift by the NM. She stated that a search of all 4 med carts in the facility and both medication rooms was conducted and that she also searched for the corresponding INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD, which would have been needed to be filed if the blister pack had been removed. She stated that a search of the locked shredder box on the unit revealed the tops of two blister packs for Resident #8's oxyCODONE 15 mg tablets (photo provided), both indicating 30 of 60 tablets, that matched the corresponding pharmacy packing slip for a delivery that was received on 7/22/26. The DON stated that Resident #8 was prescribed Oxycodone 15 mg as needed and that there should have been pills remaining between 7/22/26 and 8/3/26. She also stated that an INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD would have been initiated for those 60 tablets and it was not located so they were unable to determine exactly how many tablets were missing. The DON further stated that the NM was interviewed and reported that both blister packs were empty and that she had disposed of the packs and placed the corresponding INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD on the LPN/UM's desk. When the surveyor asked if two blister packs had been removed should the count have reflected that 2 blister packs had been removed, the DON stated yes. When the surveyor asked why nurses signed off that only one had been removed, she stated that an error had been made and it should have been reported immediately. During a joint interview on 8/13/26, at 5:52 PM with the LNHA and the DON, the DON stated that she expected nurses to sign each resident's INDIVIDUAL PATIENT CONTROLLED SUBSTANCE ADMINISTRATION RECORD at the time the medication is removed from the blister pack for each narcotic medication and then they were to sign the MAR after the medication was administered. She stated that each MAR should have been signed accordingly for Resident #6 and Resident #8. A review of the facility's MEDICATION ADMINISTRATION policy, updated 11/22/25, revealed that medications should be signed after administration is completed. A review of the facility's undated NURSING DOCUMENTATION policy revealed that documentation was evidence that care was provided as ordered and that all documentation was to be entered into the electronic system. A review of the facility's INTERSHIFT NARCOTIC COUNT policy, updated 04/2026, revealed that nurses were responsible for the integrity of controlled substances and that the purpose of the policy was to ensure safety and accountability of controlled substances. The policy further indicated that the count was to be completed at each shift and that the oncoming nurse would document the total number of narcotics in the drawer. Any discrepancies were to be reported immediately. N.J.A.C. 8:39-29.7(c)

Based on observation, interview and record review, it was determined that the facility failed to provide necessary treatment services consistent with professional standards of practice by not ensuring a resident received blood sugar monitoring and insulin medication according to a physician's order for 1 of 5 residents (Resident #24) reviewed for unnecessary medications. The deficient practice was evidenced by the following.On 8/15/2025 at 11:45 AM, the surveyor observed Resident #24 self-propelling in the hallway, was talking to themselves, and appeared confused. The surveyor attempted to interview Resident #24, but they did not respond. A review of the medical record revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Dementia with agitation, major depressive disorder and Type 2 diabetes mellitus (DM).A review of the most recent comprehensive Minimum Data Set (MDS), (an assessment tool used to facilitate the management of care), dated July 23, 2025, reflected that the Brief Interview for Mental Status score was 0/15, which indicated that the resident's cognition was severely impaired. A further review of the MDS revealed the resident was receiving a hypoglycemic (including insulin) (medication that lowers blood sugar) during the last seven days or since admission. A review of the Order Summary Report (OSR) (physician's order sheet) dated August 2025 included the following Physician's orders (PO):-Insulin Lispro (medication used to lower blood sugar), inject as per sliding scale: if 151-200 [blood sugar levelgm/dl] = 2 units; 201-250 [blood sugar level] = 4 units; 251-300 [blood sugar level gm/dl]= 6 units; 301-350 [gm/dl blood sugar level] = 8 units; 351-400 [gm/dl blood sugar level]=10 units, subcutaneously (under the skin) before meals for DM call MD if BS < 70 or > 400 [blood sugar level gm/dl]; dated 7/1/25.-Basaglar (insulin glargine) inject 12 units subcutaneously at bedtime for DM; dated 7/28/25.-Blood sugar checks BID (twice per day) and call < 70 or > 250 two times a day for DM2. Dated 6/24/25.A review of the July 2025 and August 2025 electronic medication administration record (eMAR) revealed an order dated 7/2/25 for insulin Lispro sliding scale with the above referenced scale. The eMAR was plotted to record the blood sugar level and the corresponding insulin dose based on that blood sugar level. The times indicated were 7:30 AM, 8:00 AM and 11:00 AM. On 8/19/25 at 12:00 PM, the surveyor interviewed Resident #24's day shift Licensed Practical Nurse (LPN #1) who confirmed the resident had diabetes and was prescribed sliding scale insulin Lispro. LPN #1 stated the resident would have their blood sugar checked before meals, and then given their insulin dose based on the blood sugar level. When asked when mealtimes were on the unit the LPN #1 stated breakfast was between 8:00 AM and 8:15 AM, lunch was between 11:50 AM and 12:00 PM, and she was unsure when dinner was scheduled because she did not work the evening shift. At that time the surveyor and LPN #1 reviewed the resident's eMAR. LPN #1 acknowledged the eMAR administration times for insulin lispro did not coincide with the timing of the PO to be given before meals. LPN #1 further acknowledged there was no area designated to document the dinner time blood sugar level, or the corresponding dose of the insulin lispro that was provided. LPN #1 stated eMAR needed to be changed to reflect the appropriate times according to the PO. On 8/19/25 at 12:26 PM, the surveyor interviewed the acting LPN Unit Manager (LPN/UM) who confirmed the resident was on a sliding scale insulin lispro before meals. Together the surveyor and LPN/UM reviewed the resident's order for insulin lispro and compared it to their eMAR. LPN/UM acknowledged the timing on the eMAR did not reflect mealtimes and there wasn't a area designated to document the dinner time blood sugar level, or the corresponding insulin lispro dose. The LPN/UM could not locate any documentation on the eMAR that would reflect the medication being provided per the PO.On 8/19/25 at 12:50 PM the surveyor interviewed the Director of Nursing (DON) who confirmed the eMAR timing for insulin lispro did not reflect the appropriate mealtime schedule according to the PO. Together the DON and the surveyor next reviewed the CP reports for May, June and July of 2025. The DON stated the CP report was emailed monthly to the Licensed Nursing Home Administrator (LNHA) the unit managers (UM) and himself, and that the UM was responsible for following up on the reports with the physicians. The DON acknowledged the CP reports had not been reviewed for the three months until surveyor inquiry. After further review of the July 2025 eMAR the DON confirmed the resident did not receive their dinner time dose of insulin lispro 30/31 days, and confirmed after review of the August 2025 eMAR the resident did not receive their dinner time insulin lispro 18/18 days. The DON added there was no way to know if the resident had received a 4:00 PM (dinner time) dose of insulin lispro, because there was no 4:00 PM plotting area to document the BS or the administration of the insulin. The eMAR should have a block [an area designated] to record the BS and another to document the amount of insulin given. The DON added the nurse on the night shift was supposed to do a chart check, which was a review of the orders that were entered for that day, this included medications or lab orders, etc. The DON was unable to provide a copy of the chart check for the time period indicated, and acknowledged he was unable to confirm the chart check had been performed. On 8/19/25 at 1:44 PM, the survey team met with the facility Administration and the Chief Nursing Officer (CNO) for the facility. The CNO acknowledged the plotting for the insulin lispro on the eMAR was incorrect. The DON and the CNO acknowledged the way the order was plotted made it difficult to tell if the resident had been receiving a dose at dinner. On 8/19/25 at 3:08 PM, the surveyor interviewed the resident's evening Licensed Practical Nurse (LNP #2) who confirmed the resident had PO for insulin glargine at bedtime and insulin lispro for before meals. LPN #2 stated the insulin lispro dose at 4:00 PM was just started back up again, she stated she believed for the last month they were only monitoring the resident's blood glucose levels, and she had not been administering a dinnertime dose of insulin lispro. LPN #2 stated she had on the eMAR to only check blood sugar levels at 4:00 PM and confirmed she was only monitoring the resident's blood sugar and not giving a dose of insulin lispro. On 8/20/25 at 9:05 AM, the surveyor interviewed the consultant pharmacist via telephone. The CP confirmed she had made recommendations to give insulin lispro within 15 minutes of meals in her May 2025 report. The CP stated the typical timing should be 7:30 AM, 11:30 AM and 4:30 PM. The CP stated it was important to follow that schedule, especially sliding scale, because you didn't want the resident's blood sugar to bottom out (have the resident's blood sugar fall to a dangerous level). The CP stated it looked like to her that they had plotted the incorrect times for that insulin lispro order. They needed to make it for breakfast, lunch and dinner. The CP confirmed it did not look like the nurse was giving the dinner time dose. On 8/20/25 at 10:30 AM the surveyor attempted to interview via telephone the resident's physician and left a message with the service, the physician could not be contacted.On 8/20/25 at 12:32 PM the surveyor interviewed the facility 's Medical Director (MD) who stated he had spoken to the DON that morning and was informed Resident #24 had an incorrect insulin order. He reviewed the orders with the DON and admitted the order was confusing. The MD stated he would call the resident's physician to discuss the insulin dose error tomorrow. A review of the facility's Insulin Administration policy reviewed 10/24 included. insulin administration must be based on a physician's order, which includes the type of insulin, dosage and administration schedule.A review of the facility's Medication Transcription policy dated reviewed 10/24 revealed An accurate and current patient medication administration record (MAR) is critical for accurate medication administration and patient safety.Any apparent discrepancies between the MAR and the prescriber's orders will be communicated by nursing to the MD and clarification order sent to the pharmacy as needed.A review of the facility's Medication Administration policy dated reviewed 10/24 revealed .Medication ordered before a meal should be specific to manufacturer's recommendation and administered prior to the start of the meal. NJAC 8:39-27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from May, June and July 2025, for 1 of 5 residents (Resident #24) reviewed for unnecessary medications. The deficient practice was evidenced by the following: On 8/15/2025 at 11:45 AM, the surveyor observed Resident #24 seated in a wheelchair self-propelling with their feet down the hallway. The resident was talking to themselves and appeared confused. The surveyor attempted to interview the Resident #24, but they did not respond.A review of the medical record revealed the following information: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included dementia with agitation, major depressive disorder and Type 2 diabetes (DM). A review of the Order Summary Report (OSR) (physician's order sheet) dated August 2025 revealed a Physician's order (PO) dated 7/1/25 for insulin lispro (medication used to lower blood sugar), inject as per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 =10 units, subcutaneously (under the skin) before meals for DM call MD if BS < 70 or > 400.A review of the July 2025 and August 2025 electronic medication administration record (eMAR) revealed an order dated 7/2/25 for insulin lispro sliding scale with the above referenced scale. The eMAR was plotted to record the blood sugar level and the corresponding insulin dose based on that blood sugar level. The times indicated were 7:30 AM, 8:00 AM and 11:00 AM. A review of the Consultant Pharmacist (CP)- Nursing Summary Reports dated 5/15/25, 6/13/25 and 7/15/25 recommended insulin lispro (Ademelog/Humalog) should be administered within 15 minutes before a meal or immediately after a meal. On 8/19/25 at 12:00 PM, the surveyor interviewed Resident #24's day shift Licensed Practical Nurse (LPN #1) who confirmed the resident had diabetes and was prescribed sliding scale insulin lispro. LPN #1 stated the resident would get their blood sugar checked before meals and then given their insulin dose based on the blood sugar level. When asked when mealtimes were on the unit the LPN #1 stated breakfast was between 8:00 AM and 8:15 AM, lunch was between 11:50 AM and 12:00 PM, and she was unsure when dinner was scheduled because she did not work the evening shift. At that time the surveyor and LPN #1 reviewed the resident's eMAR. LPN #1 acknowledged the eMAR administration times for insulin lispro did not coincide with the timing of the PO to be given before meals. LPN #1 further acknowledged there was no spot to document the dinnertime blood sugar or the dose of the insulin lispro given and the eMAR should be changed to reflect the appropriate times according to the PO. On 8/19/25 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed the eMAR timing for insulin lispro did not reflect the appropriate mealtime schedule according to the PO. Together the DON and the surveyor reviewed the CP reports for May, June and July of 2025. The DON stated the CP report was emailed monthly to the Licensed Nursing Home Administrator (LNHA) the unit managers (UM) and himself, and that the UM was responsible for following up on the CP reports with the physicians. The DON acknowledged the CP reports had not been reviewed for the three months until surveyor inquiry. On 8/20/25 at 12:32 PM, the surveyor interviewed the facility's Medical Director (MD) who stated he had spoken to the DON that morning and was informed Resident #24 had an incorrect insulin order. He reviewed the orders with the DON and admitted the order was confusing. The MD stated he would call the resident's physician to discuss the incorrect insulin order tomorrow. A review of the facility policy titled Consultant Pharmacist during regular monthly visits reviewed 1/2025 included.The consultant pharmacist shall review and perform a drug regimen review for all residents monthly.The nursing and attending physician (or licensed designee) shall respond to the recommendations in a timely manner, per facility policy for non- urgent recommendations.Clinically significant irregularities. will be brought to the attention of nursing and addressed while the consultant is in the facility, as well as included in the monthly report. Nurses should promptly communicate with the prescriber to facilitate obtaining an answer by midnight of the next day. NJAC 8:39-29.3

Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to inform and offer educational material regarding Advance Directives (AD) written instruction including but not limited to living will, medication restrictions, and treatment restriction for the provision of healthcare when an individual is incapacitated) with a resident and/or legal representative. This deficient practice was identified for 2 of 2 residents (Resident #24, and Resident #25) reviewed for AD and was evidenced by the following: On 8/12/2025 at 10:31 AM, the surveyor observed Resident #25 in bed with tube feeding (food provided via a tube into the stomach) infusing. in room [ROOM NUMBER]-1. The surveyor attempted to talk to the resident, but the resident did not respond. On 8/12/2025 at 10:31 AM the surveyor reviewed the medical record for Resident #25 which revealed the following: A review of the admission Record (an admission summary) reflected that the resident was admitted with diagnoses which included but was not limited to; Epilepsy (neurological disorder), Diabetes Mellitus (disease that affects how the body uses blood sugar), Altered Mental Status (disruption of how your brain works), Cerebral Infarction (stroke). The admission Record indicated the resident was listed as a Full Code (all lifesaving care will be provided if their heart stops). There was no New Jersey Practitioner Orders for Life-Sustaining Treatment (POSLT- is not an AD and is used as a portable medical order in an emergency) in the medical record. There was no information that determined upon admission whether the resident had an advanced directive, or any documentation as to whether the resident or Resident Representative wished to formulate an advanced directive. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/28/2025, the resident had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating that the resident had a moderately impaired cognition. A physician's order (PO) dated 8/08/25, revealed Resident #25 was a Full Code, Order Type: Advanced Directive. A review of the resident's individualized care plan focus area indicated [Resident #25] has an advanced directive with a code status of FULL CODE. On 8/12/2025 at 12:35 PM the surveyor reviewed the medical record for Resident #24.A review of the admission Record (an admission summary) reflected that the resident was admitted to the with diagnoses which included, but was not limited to; Atrial fibrillation (irregular, rapid heart rhythm) and Cerebral Infarction (stroke). The admission Record indicated the resident was listed as a full code. There was a POSLT in the medical record, that indicated full code signed by the RR on 6/2/2025. There was no documented evident upon on admission regarding whether the resident had an advanced directive, and if not, determined whether the resident was offered to formulate an advanced directive. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 7/26/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that the resident was cognitively intact. A physician's order (PO) dated 7/19/24, revealed: Full Code, Order Type: Advanced Directive A review of the resident's individualized care plan focus area indicated [Resident #24] had a status of FULL CODE.On 8/19/2025 at 9:16 AM the surveyor interviewed Resident #24 who stated that no one had spoken to them about Advanced Directives. The resident further stated, I heard about it, but I don't know what it is. I would like to have information about it. On 8/13/2025 at 8:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated the POLST could take the place of the advanced directive. He further stated that typically residents do not get admitted with an advanced directive from the hospital. We rely on the POLST if they have one. The code status orders were entered from the POLST form. He then stated that he was not aware of documentation or education that the facility provided about AD if no AD existed. He stated that Social Services should have met with new admissions by the next day. The DON that the Social Worker should have met with Resident #24 and Resident #25 to discuss the AD On 8/14/2025 at 8:42 AM, the DON confirmed that there was no discussion and/or planning upon admission regarding AD with either Resident #24 or Resident #25 and/or the RP. In addition, he stated that resident #25's RP worked at the facility, and confirmed that no one had spoken with them regarding the AD. The DON stated that the Social Worker was responsible for discussing AD with residents upon admission. The surveyor was informed that the Social Worker resigned on Friday August 8th, 2025, and was unavailable for an interview. On 8/19/2025 at 1:41pm, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Chief Nursing Officer (CNO). The LNHA acknowledged that Residents #24 and #25 did not have an advance directive and there was no documentation that the resident/resident representative was provided education. The CNO added that residents should be asked if they have an AD, and if so the facility should request a copy, or if they did not have an AD, they should ask if they would like information to formulate an AD. The CNO further stated that residents also have the right to refuse. LNHA, DON and CNO acknowledged that AD were not addressed with residents #24 and #25 and should have been addressed upon admission. A review of the facility's policy Advanced Directives revised date of 1/2025, included: Policy: it is the policy of this facility to offer every resident, or their resident representative, the opportunity to make decisions about their own health by means of preparing an Advance Directive. Procedure: Upon admission, residents and/or their responsible party are asked if an Advanced Directive or Living Will exists. If an Advanced Directive or Living Will exists, it is reviewed and will be placed in the resident's chart. 1.Upon admission, residents and/or their responsible party are asked if an Advanced Directive or Living Will exists. 2. If an Advanced Directive or Living Will exists, it is reviewed and will be placed in the resident's chart. 3. If the resident is mentally competent, and an Advanced Directive/Living Will does not exist, he/she will be asked if he/she wishes to complete an Advanced Directive. Information pertaining to his/her rights regarding Advanced Directive/Living Will will also be given to the resident .NJAC 8:39-9.6 (a)(b)

Based on observation, interviews, record review, and review of facility documentation, the facility failed to maintain a resident's wheelchair, wheelchair right armrest, and bathroom in a clean and homelike condition. This deficient practice was identified for 1 of 2 residents reviewed for equipment and environmental care (Resident #44), and was evidenced by the following:Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to maintain a resident's wheelchair, wheelchair right armrest, and bathroom in a clean and homelike manner. This deficient practice was identified for 1 of 2 residents reviewed for environment (Resident #44), and was evidenced by the following:On 8/12/2025 at 9:32 AM, during the initial tour, the surveyor interviewed Resident #44 in their room and was seated in their wheelchair. The resident stated that their wheelchair was pretty dirty and was unsure when it was last cleaned. The surveyor observed visible debris and food-like particles on the wheelchair and noted that the right armrest was worn through, and the padding was exposed. On 8/13/2025 at 8:50 AM, the surveyor observed the rubber-like floor molding approximately eight inches was hanging off the wall toward the floor in Resident #44's bathroom.A review of Resident #44's medical record revealed that the resident was admitted with diagnoses including hemiplegia (paralysis one side of the body), hemiparesis (weakness one side of the body), cerebral infarct (stroke) and major depressive disorder(depression). The Quarterly Minimum Data Set (QMDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13/15, reflecting that the resident was cognitively intact. On 8/13/2025 at 9:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #44. The CNA stated that wheelchairs were cleaned regularly, and that the resident's wheelchair had been cleaned a few days prior. She then stated, she did not notice any dirt or damage to the wheelchair and was unaware of the worn armrest. When inquired regarding the hanging molding in the bathroom, the CNA stated that she did not notice it. She added that dirty wheelchairs were reported to Housekeeping and damaged wheelchairs were reported to Maintenance.On 8/13/2025 at 10:33 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) caring for Resident #44. The LPN stated that wheelchairs were washed weekly and acknowledged that the resident's wheelchair was soiled, and the armrest needed repair. The LPN also acknowledged the hanging molding in the bathroom and submitted a maintenance request in the presence of the surveyor.On 8/13/2025 at 10:44 AM, the surveyor observed the Maintenance Director stapling the hanging molding back onto the bathroom wall. Upon interview, he stated that room audits were conducted weekly however, he confirmed he was not made aware of the lifted molding. On 8/14/2025 at 8:46 AM, the surveyor interviewed the Housekeeping Director (HD), he stated that she maintained a wheelchair cleaning schedule. Resident #44's wheelchair was scheduled for cleaning on 8/13/2025 and the resident had previously refused cleaning on 7/16/2025. The HD stated that refusals are verbally reported to Nursing but are not documented. She also noted that she was out for two weeks in June and could not confirm whether the wheelchair was cleaned during that time.On 8/15/2025 at 8:51 AM, the surveyor interviewed the Director of Physical Therapy (PT) who stated that she works closely with Housekeeping and Maintenance to coordinate wheelchairs cleaning and repairs. If a resident arrived at therapy with a dirty or broken wheelchair, a work order was submitted, or the resident was transferred to a temporary chair so their chair could be cleaned by housekeeping. If the resident refused, Housekeeping and Nursing were notified. She stated that she does not document wheelchair cleaning refusals. She noted that Resident #44 last attended therapy the previous week and she did not notice any issues with the wheelchair.On 8/19/2025 at 9:03 AM, the surveyor interviewed resident #44 who stated, I would never refuse to have my wheelchair cleaned, I want it cleaned more. On 8/19/2025 at 9:12 AM the surveyor interviewed again the LPN who cared for Resident #44. The LPN stated that resident #44 never refused to have his wheelchair washed to me, if he did, I would document it. Review of the Maintenance logs for June 2025 indicated the following:Checklist-room [ROOM NUMBER]:Item listed to be checked included Main Door, Bed, T.V./Remote, Call Bell, Telephone, Clock, Nightstand, Over the bed table, Light switches/Electric Plugs. wheelchairs and floor molding were not included on the list. Review of June, July and August 2025 wheelchair cleaning schedule indicated the following: room [ROOM NUMBER] was scheduled to have his wheelchair cleaned on June 18th 2025, July 16th 2025, and August 13th 2025. On 8/19/2022 at 10:43 AM, the Administrator provided the policy titled, Cleaning and Disinfection of Resident- Care Items and Equipment reviewed 12/2024 The policy Statement indicated the following:Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy did not address wheelchair armrest replacement. NJAC 8: 39 -31.4 (c)

Based on interview and record review, the facility failed to immediately report an allegation of misappropriation of resident property for 1 of 1 residents (Resident #11) reviewed for personal property to the New Jersey Department of Health (NJDOH). This deficient practice was evidenced by the following: A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with the diagnoses which included but was not limited to end stage renal disease (kidney failure) and hypertension (high blood pressure). A review of the quarterly Minimum Date Set (MDS) and assessment that facilitates a resident's care dated 8/8/25, reflected that Resident #11 scored a 10 of 15 on the basic interview for mental status (BIMS) which indicated that the resident had moderate cognitive impairment and exhibited behaviors such as refusal of care. A review of the Care Plan (CP) did not reflect that the resident had accusatory behavior or fabricated stories.On 8/13/2025 at 8:45 AM, the surveyor interviewed Resident #11 who stated that agency Certified Nursing Assistances (CNAs) were breaking into the resident's locked drawer and stealing personal belongings such as perfume and soap. The resident stated that the administration and nurses were aware, but no one was doing anything about it. The surveyor observed the lock that was hanging on the drawer, and it was broken. The resident stated that they reported the missing soap the other morning (did not specify a date) to the nurse and the CNAs but did not know their last names. The resident stated that the police were not notified and the items that were stolen were not replaced. The resident stated that the missing perfume happened a couple months ago, and the perfume was not replaced by the administration at the facility. Stated that the family was aware of the missing items. On 8/13/2025 at 9:29 AM, the surveyor interviewed Resident #11's Resident Representative (RP) and asked the RP if they were aware of any issues that Resident #11 was having in the facility and the RP stated, What, the stealing that's going on. The RP stated that Resident #11 told her that an agency staff member was getting into the resident's locked drawer and stealing soap and perfume. She stated that the stealing started in May of 2025 and was reported to the Licensed Nursing Home Administrator (LNHA) in May. The RP stated that she bought Resident #11 a bottle of perfume that cost 100$ at Christmas and the perfume went missing. The RP stated that she had reported the missing perfume to the primary care nurse and to administration. She stated that the facility was supposed to replace the perfume but did not. The RP stated that the Administration did not have Resident #11 or RP fill out any paperwork or statements regarding the missing perfume. She stated that the police were not notified and that no one from the facility followed up with the RP with any conclusion of an investigation. She stated that Resident #11 was provided with a locked drawer after the perfume went missing but was not notified that the drawer lock was currently broken. She stated the on Monday 8/11/25, Resident #11 told the RP that soap was missing from the drawer in the resident's room.On 8/13/2025 at 10:05 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #11 was alert and oriented and able to express their needs and wants. The CNA revealed that the resident did not report that someone was stealing soap and perfume to her however that the day before yesterday another CNA (CNA #2) was looking for the resident's missing soap. CNA #1 stated that she was not aware of any other complaints from the resident regarding missing items. On 08/13/2025 at 10:12 AM, the surveyor interviewed Resident #11's primary care Registered Nurse (RN) who stated that Resident #11 reported to her this morning that soap was missing and that someone stole it. The RN stated that the LNHA was in this morning to see the resident about the complaint. The RN revealed that in the past, the resident reported that perfume was stolen. The RN stated that the Social Worker (SW) and the LNHA were handling the issue. She stated that she was not sure if police were notified however the LNHA gave the resident a lock for the drawer after the resident reported that the perfume was missing. The RN stated that the resident was not consistently using the lock on the drawer because it was not convenient. She continued to add that if the resident complained of theft or missing personal items to her, she would report it to the administration, and they would handle the investigation. On 8/13/2025 at 10:24 AM, the surveyor interviewed the residents primary care CNA #2 who stated that Resident #11 reported that perfume was missing from the resident's drawer a couple months ago and she thought there was an investigation was being done by the Administrator. She stated that the LNHA was supposed to replace the perfume but was not replaced as far as she knew. She stated that after the resident reported that the perfume was missing, the administration put a lock on the resident's drawer. She confirmed that the resident did not consistently use the lock on the drawer and always needed someone to unlock it. She stated that she was not aware that the lock was broken at this time. She added that the resident reported to her on 8/11/25 that soap was now missing. CNA #2 stated that she reported the missing soap to an agency nurse and was not sure if the nurse told the administration. She stated Resident #11 called their RP and reported that their soap was stolen.On 8/13/2025 at 11:23 AM, the surveyor interviewed the Director of Nursing (DON) who stated that he was not aware and was not notified that the resident had complaints of missing or stolen items. He then added that he was made aware that Resident #11 stated that they had soap stolen from their room. He stated that the LNHA was investigating the complaint of stolen item that was reported this morning (8/13/25). The surveyor asked the DON if he was made aware about missing perfume a couple months ago. The DON stated that the missing perfume was not reported to him however was reported to the LNHA and that the LNHA was handling that investigation. The surveyor asked the DON what the process was for reporting misappropriation of resident property, and he stated that an investigation would be conducted which included completing an incident report, interviewing staff, obtaining written statements from resident and staff or any other witnesses. He stated that the staff were to contact family members and report the incident to the Department of Health (DOH) within 2 hours. On 8/13/2025 at 11:36 AM, the surveyor interviewed the Director of Maintenance (DOM) who stated that the LNHA usually instructed the DOM to put the locks on the resident's drawers if the resident requested. The MOD stated that the LNHA instructed the DOM to put the lock on Resident #11's drawer a couple months ago. The DOM spoke with the resident and the resident told him that the lock had to be put on because something about perfume. The DOM did not remember the date the lock was installed on the drawer. On 8/13/2025 at 11:54 AM, the LNHA stated that he did not investigate and did not report the allegation of missing perfume because he did not have a time frame. He stated that he should have reported the allegation to the NJDOH within two hours and called the police. He continued to admit that he should have obtained statements from the staff, resident and other alert and oriented residents in the area. He stated that he did not recall if the resident was reimbursed for the missing perfume. He stated that it would that been important to follow the process for investigating and reporting abuse/misappropriation of personal property to protect the resident and other residents. The LNHA stated that he was the abuse officer for the facility and was aware that he should have reported and investigated the residents compliant of missing personal items.The facility policy dated 9/2024 and titled, Abuse, Neglect, and Mistreatment of Residents Policy indicated that each resident had the right to be free from mistreatment, neglect and misappropriation of property. The policy indicated that misappropriation of property was defined as deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The policy indicated that the facility would ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown origin source and misappropriation of a resident's property would be reported immediately to the Administrator/designee or the facility and to other officials in accordance with state law including the state survey and certification agency.NJAC 8:39-4.1(a)5

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy and thoroughly and timely investigate an allegation of misappropriation of property by 1 of 1 resident (Resident #11) who reported missing property to the Licensed Nursing Home Administrator (LNHA). This deficient practice was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with the diagnoses which included but was not limited to end stage renal disease (kidney failure) and hypertension (high blood pressure). A review of the quarterly Minimum Date Set (MDS) and assessment that facilitates a resident's care dated 8/8/25, reflected that Resident #11 scored a 10 of 15 on the basic interview for mental status (BIMS) which indicated that the resident had moderate cognitive impairment and exhibited behaviors such as refusal of care. A review of the Care Plan (CP) did not reflect that the resident had accusatory behavior or fabricated stories.On 8/13/2025 at 8:45 AM, the surveyor interviewed Resident #11 who stated that agency Certified Nursing Assistances (CNAs) were breaking into the resident's locked drawer and stealing personal belongings such as perfume and soap. The resident stated that the administration and nurses were aware, but no one was doing anything about it. The surveyor observed the lock that was hanging on the drawer, and it was broken. The resident stated that they reported the missing soap the other morning (did not specify a date) to the nurse and the CNAs but did not know their last names. The resident stated that the police were not notified and the items that were stolen were not replaced. The resident stated that the missing perfume happened a couple months ago, and the perfume was not replaced by the administration at the facility. Stated that the family was aware of the missing items. On 8/13/2025 at 9:29 AM, the surveyor interviewed Resident #11's Resident Representative (RP) and asked the RP if they were aware of any issues that Resident #11 was having in the facility and the RP stated, What, the stealing that's going on. The RP stated that Resident #11 told her that an agency staff member was getting into the resident's locked drawer and stealing soap and perfume. She stated that the stealing started in May of 2025 and was reported to the Licensed Nursing Home Administrator (LNHA) in May. The RP stated that she bought Resident #11 a bottle of perfume that cost 100$ at Christmas and the perfume went missing. The RP stated that she had reported the missing perfume to the primary care nurse and to administration. She stated that the facility was supposed to replace the perfume but did not. The RP stated that the Administration did not have Resident #11 or RP fill out any paperwork or statements regarding the missing perfume. She stated that the police were not notified and that no one from the facility followed up with the RP with any conclusion of an investigation. She stated that Resident #11 was provided with a locked drawer after the perfume went missing but was not notified that the drawer lock was currently broken. She stated the on Monday 8/11/25, Resident #11 told the RP that soap was missing from the drawer in the resident's room.On 8/13/2025 at 10:05 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #11 was alert and oriented and able to express their needs and wants. The CNA revealed that the resident did not report that someone was stealing soap and perfume to her however that the day before yesterday another CNA (CNA #2) was looking for the resident's missing soap. CNA #1 stated that she was not aware of any other complaints from the resident regarding missing items. On 08/13/2025 at 10:12 AM, the surveyor interviewed Resident #11's primary care Registered Nurse (RN) who stated that Resident #11 reported to her this morning that soap was missing and that someone stole it. The RN stated that the LNHA was in this morning to see the resident about the complaint. The RN revealed that in the past, the resident reported that perfume was stolen. The RN stated that the Social Worker (SW) and the LNHA were handling the issue. She stated that she was not sure if police were notified however the LNHA gave the resident a lock for the drawer after the resident reported that the perfume was missing. The RN stated that the resident was not consistently using the lock on the drawer because it was not convenient. She continued to add that if the resident complained of theft or missing personal items to her, she would report it to the administration, and they would handle the investigation. On 8/13/2025 at 10:24 AM, the surveyor interviewed the residents primary care CNA #2 who stated that Resident #11 reported that perfume was missing from the resident's drawer a couple months ago and she thought there was an investigation was being done by the Administrator. She stated that the LNHA was supposed to replace the perfume but was not replaced as far as she knew. She stated that after the resident reported that the perfume was missing, the administration put a lock on the resident's drawer. She confirmed that the resident did not consistently use the lock on the drawer and always needed someone to unlock it. She stated that she was not aware that the lock was broken at this time. She added that the resident reported to her on 8/11/25 that soap was now missing. CNA #2 stated that she reported the missing soap to an agency nurse and was not sure if the nurse told the administration. She stated Resident #11 called their RP and reported that their soap was stolen.On 8/13/2025 at 11:23 AM, the surveyor interviewed the Director of Nursing (DON) who stated that he was not aware and was not notified that the resident had complaints of missing or stolen items. He then added that he was made aware that Resident #11 stated that they had soap stolen from their room. He stated that the LNHA was investigating the complaint of stolen item that was reported this morning (8/13/25). The surveyor asked the DON if he was made aware about missing perfume a couple months ago. The DON stated that the missing perfume was not reported to him however was reported to the LNHA and that the LNHA was handling that investigation. The surveyor asked the DON what the process was for reporting misappropriation of resident property, and he stated that an investigation would be conducted which included completing an incident report, interviewing staff, obtaining written statements from resident and staff or any other witnesses. He stated that the staff were to contact family members and report the incident to the Department of Health (DOH) within 2 hours. On 8/13/2025 at 11:36 AM, the surveyor interviewed the Director of Maintenance (DOM) who stated that the LNHA usually instructed the DOM to put the locks on the resident's drawers if the resident requested. The MOD stated that the LNHA instructed the DOM to put the lock on Resident #11's drawer a couple months ago. The DOM spoke with the resident and the resident told him that the lock had to be put on because something about perfume. The DOM did not remember the date the lock was installed on the drawer. On 8/13/2025 at 11:54 AM, the LNHA stated that he did not investigate and did not report the allegation of missing perfume because he did not have a time frame. He stated that he should have reported the allegation to the NJDOH within two hours and called the police. He continued to admit that he should have obtained statements from the staff, resident and other alert and oriented residents in the area. He stated that he did not recall if the resident was reimbursed for the missing perfume. He stated that it would that been important to follow the process for investigating and reporting abuse/misappropriation of personal property to protect the resident and other residents. The LNHA stated that he was the abuse officer for the facility and was aware that he should have reported and investigated the residents compliant of missing personal items.The facility policy dated 9/2024 and titled, Abuse, Neglect, and Mistreatment of Residents Policy indicated that the facility was to ensure timely and thorough investigation of abuse, neglect or mistreatment of residents. Observances, complaints or evidence of alleged abuse, neglect and or mistreatment are thoroughly investigated and reported to the appropriate parties. The policy describes misappropriation of property the deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. The policy indicated that an accident incident report form would be used for residents, witnesses if any would be documented on the report and an investigation would be conducted including but not limited to statements form staff in the area where alleged incident occurred, the resident and any other individual that may have information regarding the incident.NJAC 8:39-4.1(a)(5)

Based on observation, interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to provide the necessary care and services for one (1) of 1 resident (Resident #71) reviewed for respiratory care and was evidenced by the following:Review of the admission Record (admission summary) reflected that Resident #71 was admitted to the facility with the diagnoses that included but was not limited to; chronic obstructive pulmonary disease (COPD) (a chronic lung condition that makes breathing difficult) and depression.A review of the admission Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 6/25/2025, indicated that Resident #71 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS also indicated Resident #71 was dependent on staff for all activities of daily living (ADLs) and was not on continuous and intermittent oxygen (O2) treatments.On 8/13/2025 at 8:39 AM, Surveyor #1 observed Resident #71 in their room on oxygen (O2) via (by way of) nasal cannula (tubing that supplies O2) set at 3.5 liters/minute. On 8/13/2025 at 8:30 AM, Surveyor #2 observed Resident #71 in their room with the head of bed up and neck cushion on. The resident was pleasant and had no issues with breathing. The resident's respirations were even and unlabored. Surveyor #2 observed that the resident was on O2 via nasal cannula at 3.5 liters. The resident stated that she was not sure how much O2 should be administered. On 8/14/2025 at 10:38 AM, Surveyor #2 had a third observation that Resident #71 continued 3.5 liters of O2.A review of the physician order summary (POS) dated 7/1/25, reflected a physician's order for O2 at 2 liters/minute via nasal cannula continuously every shift for O2 therapy.A review of the Treatment Administration Record (TAR) dated 7/1/25, reflected an order for O2 at 2 liters via nasal cannula continuously. Review of the TAR dated 7/1/25 until 7/14/25 reflected that Resident #71's pulse Ox (measures the amount of oxygen in the blood) was within normal range.A review of the progress notes (PN) dated 6/20/2025 at 20:09 (9:09 PM) revealed that the resident was admitted on O2 at 2 liters via nasal cannula, however a physician's order was not obtained until 7/1/25.A review of the Care Plan (CP) dated 6/21/25, reflected that the resident was oxygen therapy with the settings at 2 liters/minute.On 8/14/2025 at 10:47 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN) who read the resident's physician orders in the presence of the surveyor and confirmed that the order read to administer O2 at 2 liters via nasal cannula continuously. The LPN accompanied the surveyor to the resident's room and confirmed that the resident's O2 concentrator was set to 3.5 liters of O2. The LPN stated that since the resident's pulse Ox's have been stable on 3.5 liters that he would reassess the resident and call the MD for a possible change in oxygen orders. The LPN did confirm that if the order indicated that the resident should have been given O2 at 2 liters then the resident should not be on O2 at 3.5 liters. He stated that 3.5 liters was the wrong dosage of oxygen. He also stated that the oxygen order should have been obtained on 6/20/25 when the resident was admitted to the facility.On 8/15/25 at 9:10 AM, the surveyor interviewed the MDS Coordinator Registered Nurse (MDSC/RN) who stated that he completed Resident #71's admission MDS dated [DATE]. The surveyor asked the MDSC/RN why the MDS did not indicate that the resident was on continuous O2. The MDSC/RN reviewed the resident's medical record in the presence of the surveyor and confirmed that the progress notes (PN) reflected that the resident was provided with O2 since 6/20/25, however the staff did not obtain a PO until 7/1/25. He stated that the resident was receiving O2 from 6/20/25 until 7/1/25 without a physician's order.The facility policy titled, Oxygen Administration and dated 12/2024 which indicated that it was the policy and procedure to provide oxygen to residents in compliance with their physician orders and upon receiving an order for oxygen from the resident's physician the nurse will place the order in (electronic medical record) to be carried out. NJAC 8:39-19.4(a)

Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 9 of 10 days reviewed. This deficient practice was evidenced by the following: Review of the PBJ Staffing Data Report for Quarter 1 2023 (October 1 - December 31) revealed the facility had no RN hours for the following dates: -10/01/23 (Saturday) -10/02/23 (Sunday) -10/09/23 (Sunday) -10/15/23 (Saturday) -10/16/23 (Sunday) -10/29/23 (Saturday) -10/30/23 (Sunday) -11/12/23 (Saturday) -11/13/23 (Sunday) -12/24/23 (Saturday) Review of the Employee Daily Schedule By Shift, provided by the facility, for the aforementioned dates, verified that there was no RN scheduled to work 8 consecutive hours on the following days: -10/01/22 -10/02/22 -10/09/22 -10/15/22 -10/16/22 -10/29/22 -10/30/22 -11/12/22 -12/24/22 During an interview with the surveyor on 02/23/24 at 10:32 AM, the Staffing Coordinator (SC) stated that they were to have staffed one RN within 24 hours, for a total of eight hours, and that they usually had two RNs, not including the Director of Nursing (DON). She stated that on the weekends now, they always had 1 RN in the morning and 1 RN at night and that the 3 PM to 11 PM shift had Licensed Practical Nurses. The SC further stated that on the weekends in question that she noticed there was no RN coverage on most of the dates and that the rest of the days should have had an RN for at least 8 hours. During an interview with the surveyor on 02/23/24 at 10:43 AM, the DON stated that they were to have staffed at least one RN for 8 hours each day and that on the weekends that they had an RN scheduled for every weekend clarifying that two RNs alternated weekends. The DON stated that if they were out of an RN that the Unit Manager, or the DON would have covered the weekend and that they should have had an RN scheduled for 8 hours during the days that were requested. Review of the facility's policy, Staffing, reviewed 08/2023, revealed, Policy: It is the policy and procedure of this facility to adequately staff the facility in accordance with the recommended guidelines. NJAC 8:39-25.2(h)

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to maintain a safe clean, comfortable, and homelike environment by a.) ensuring that the resident's wheelchairs were cleaned and repaired in a timely manner and b.) ensuring that each resident had their own waste receptacle (trash can) in their room. This deficient practice was observed for 8 out of 8 residents (Resident #2, #6, #25, #29, #44, #65, #72 and #78) and 3 out of 9 rooms (Rooms 106, 125 and 130) observed during environmental rounds. This deficient practice was evidenced by the following: 1.) On 02/16/24 at 09:14 AM, the surveyor observed Resident #65's wheelchair in the hallway folded but the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/16/24 at 09:16 AM, the surveyor observed Resident #72's wheelchair right arm rest was ripped, the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/16/24 at 11:52 AM, the surveyor observed Resident #44's wheelchair left arm rest was ripped and the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/20/24 at 11:20 AM, the surveyor observed Resident #6 sitting in their wheelchair in the dayroom area. At that time, the wheelchair appeared to be dusty. On 02/20/24 at 11:23 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that the housekeeping department was responsible for cleaning the wheelchair. She stated that the housekeepers had certain days that they took the wheelchair to be cleaned. She further stated that if the wheelchairs needed to be clean in between the housekeeping staff would. On 02/20/24 at 11:33 AM, the surveyor interviewed the Housekeeper (HK #1) who stated the housekeeping staff was responsible to clean the wheelchairs. She stated that she cleaned the wheelchair every one to two hours. HK #1 stated that while she was conducting her rounds she looked to see if any wheelchairs need cleaning. She explained she used disinfectant wipes to clean the wheelchairs. When asked if there was a cleaning log for the wheelchairs? HK #1 stated she was not sure if the housekeeping staff kept a log of cleaning the wheelchairs. On 02/20/24 at 11:42 AM, the surveyor interviewed the Registered Nurse (RN) who stated that the housekeeping department was responsible for cleaning the wheelchairs. She stated that the housekeeping department cleaned the wheelchairs periodically but was not sure of how often. The RN stated that the HK Director was very good with following thought with anything they needed. At that time, the surveyor and the RN observed a wheelchair in the hallway that appeared to have dust on the cushion. The RN lifted the seat cushion and observed debris underneath. The RN identified that the wheelchair belonged to Resident #78. She then stated that Resident #78 barely used the wheelchair. The RN explained that the housekeeping department would check the wheelchairs but that if nursing staff seen the wheelchair needed to be clean then they would notify housekeeping for the wheelchair to be cleaned. The RN stated she would expect the wheelchair to be cleaned. She then confirmed that the wheelchair was dusty and needed to be cleaned. She further stated that the wheelchair should be clean because of infection control and if the resident needed to use the wheelchair, they would want it to be cleaned. On 02/20/24 at 11:48 AM, the surveyor observed Resident #29's wheelchair and one (1) unidentified wheelchair in between rooms [ROOM NUMBERS] observed to have dust and debris on them. On 02/20/24 at 11:51 AM, the surveyor interviewed HK #2 who stated the CNAs were responsible for cleaning the wheelchair. She then stated that the CNAs cleaned them but that if it was an emergency and needed to be cleaned immediately then the housekeeping staff would clean them. On 02/20/24 at 11:53 AM, the surveyor interviewed CNA #2 who stated that the housekeeping staff was responsible for cleaning the wheelchairs. She stated she would let the housekeeping staff know that the wheelchairs needed to be cleaned. CNA #2 stated it was important for the wheelchairs to be cleaned for infection control. She explained because we do not want the residents to get sick from their wheelchairs being dirty as you never know what's on it. At that time, CNA #2 described the 2 wheelchairs in between rooms [ROOM NUMBERS] as rough and looked like they needed to be cleaned and disinfected. On 02/20/24 at 12:03 PM, the surveyor interviewed the Housekeeping Director (HKD) who stated that the housekeeping staff was responsible for cleaning the wheelchairs. She stated that the CNAs would also inform the housekeeping staff if a wheelchair needed to be cleaned. The HKD stated that she used to have a schedule for cleaning the wheelchairs, but it became a challenge because the residents were mainly in their chairs during the day. She explained that cleaning the wheelchairs was her hardest challenge because the wheelchairs have not been cleaned like they should be. The HKD stated that the evening shift 3 PM to 11 PM, there was only one HK staff that went around to clean the wheelchairs. She further stated that it became difficult because most of the residents were still in their wheelchairs during the evening shift. The HKD stated that she sometimes tried to clean the wheelchair while the resident was sitting in the wheelchair but only the handles. She then stated if they see the wheelchairs were ripped then they would report it to therapy. She indicated that she was working with therapy to see if they could replace them. The HKD emphasized about five to six months ago they had a really good system for cleaning the wheelchairs but that for the long-term care residents it became more difficult to keep a schedule for cleaning the wheelchairs. The HKD stated she had a schedule for staff to follow and explained the schedule was based off the room numbers and that a few were picked and cleaned that week. She again stated it has been months since they have been able to follow the schedule she created. On 02/20/24 at 12:13, the surveyor and the HKD conducted an environmental tour of all the wheelchairs in the hallway that the surveyor observed since 02/16/24 and revealed the following: At 12:13 PM, the HKD observed Resident #44's wheelchair and confirmed that the wheelchair needed to be cleaned. At 12:14 PM, the HKD observed Resident #72's wheelchair and stated that the resident was ambulatory. At the time, the HKD confirmed the wheelchair needed to be cleaned and the armrest needed to be replaced. At 12:15 PM, the HKD observed Resident #6's sitting in their wheelchair but confirmed the wheelchair needed to be cleaned. At 12:16 PM, the HKD observed Resident #78's wheelchair and confirmed it needed to be cleaned. At 12:17 PM, the HKD observed Resident #2's wheelchair and confirmed that it needed to be cleaned thoroughly and that the armrest needed to be replaced. She stated she would ask therapy to replace the seat cushion. At 12:18 PM, the HKD observed Resident #29's wheelchair and stated the resident was discharged . At that time, she confirmed that the wheelchair needed to be cleaned, the armrest needed to be replaced and then removed from the hallway since the resident was discharged . At 12:19 PM, the HKD stated she was not sure who the unidentified wheelchair was in the hallway but confirmed it needed to be clean, the arm rest needed to be replaced and then returned to therapy. At 12:21 PM, the HKD observed Resident #25's wheelchair and confirmed that it needed to be disinfected because it was dusty. On 02/20/24 at 12:22 PM, the HKD stated that it was important for the wheelchairs to be cleaned and disinfected because it was the resident's legs and their way of getting around. She further stated that the wheelchairs should be cleaned and disinfected to prevent infection control. On 02/20/24 at 01:25 PM, the surveyor and the Licensed Nursing Home Administrator (LNHA) observed Resident #65's wheelchair. At that time, the LNHA stated the wheelchair should have been cleaned and the arm rest needed to be changed. He then stated he was going to take the wheelchair right now to get cleaned. On 02/21/24 at 10:31 AM, the LHNA stated in the presence of the survey team that it was important to ensure the wheelchairs were cleaned and disinfected because of infection control. On 02/21/24 at 12:21 PM, the Director of Nursing (DON) stated the housekeeping staff was responsible for cleaning the wheelchairs and that they should be cleaned monthly. He further stated that it was important to ensure the wheelchairs were cleaned and disinfected because it was a dignity issue and infection control. The DON stated they did not want the resident sitting in a contaminated wheelchair and that the residents deserved to sit in a clean chair. A review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment reviewed 12/2023, included, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] for disinfection. 2.) On 02/21/24 at 12:45 PM, the surveyor toured Rooms 106, 110, 125, 127, 130, 132, 137, 139 and 152 that were increased in sized to meet the required square footage for double occupancy and revealed the following: -room [ROOM NUMBER] (Residents #9 and #22) only had one trash can in the room. -room [ROOM NUMBER] (Residents #44 and #70) only had one trash can in the room. -room [ROOM NUMBER] (Residents #23 and #61) only had one trash can in the room. On 02/22/24 at 10:41 AM, the surveyor interviewed the DON who stated that each resident should have a trash can in their room. He further stated that each resident should have one, so they could put their trash in it and not on the floor. The DON concluded that residents in a double occupancy room were not expected to share a trash can. On 02/22/24 at 10:44 AM, the surveyor observed there was still one trash can in the room for both Resident #9 and #22. On 02/22/24 at 10:45 AM, the surveyor observed there was still one trash can in the room for both Resident #44 and #70. On 02/22/24 at 10:46 AM, the surveyor observed there was still one trash can in the room for both Resident #23 and #61. At that time, the surveyor observed Resident #23 lying in bed listening to music from their phone while the TV was playing. Resident #23 stated that he/she did not realize that there was only one trash can in the room but that it was fine. On 02/22/24 at 11:13 AM, the surveyor interviewed the LNHA who stated that each resident should have a trash can in their room unless the resident moved it. He stated that each resident should have a trash can in their room for infection control and for cleanliness. When asked were residents expected to share a trash can? The LNHA stated that he did not have an answer but then stated that every resident should have one. He concluded that it was not ideal to have only one trash in the room for two residents. A review of the facility policy Clean/Homelike Environment reviewed 09/2023, included, Residents are provided a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 2. These characteristics include: d. personalized furniture and room arrangements. NJAC 8:39-27.1(a), 31.4(f), 31.8(c)(14)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include a resident's indwelling urinary catheter for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the bag was touching the floor. According to the Admission Record, Resident #75 had diagnoses which included, but were not limited to, acute kidney failure (sudden kidney damage), hemiplegia and hemiparesis (paralysis of one side of the body), chronic kidney disease stage 3, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/26/23, included the resident had a Brief Interview for Mental Status score of 13 which indicated the resident's cognition was intact. Further review of the MDS included the resident had an indwelling catheter. Review of the Order Summary Report, as of 02/21/24, included a physician's order to Change foley [urinary catheter] securement device and foley bag weekly, ordered 11/09/23. Review of the Medical Practitioner Note, dated 02/13/24, included, hospitalization S *10/20-10/30/2023: Patient sent to [hospital] for worsening kidney function . Foley catheter placed. Review of the resident's Care Plan did not include any focuses, goals, or interventions related to the resident's indwelling urinary catheter. During an interview with the surveyor on 02/21/24 at 9:49 AM, the Certified Nursing Assistant (CNA) stated that the CNAs empty the catheter bags and ensure the catheter drainage bags are positioned below the resident. The CNA further stated that the drainage bags should not be touching dirty surfaces to prevent infection. During an interview with the surveyor on 02/21/24 at 12:17 PM, the Licensed Practical Nurse (LPN) stated the Unit Manager (UM) was responsible for updating resident care plans. The LPN further stated that care plans should be updated as soon as there was a change in the resident's condition to promote the continuity of care. During an interview with the surveyor on 02/21/24 at 12:25 PM, the LPN/UM stated each department was responsible for updating the resident care plans. The LPN/UM further stated that care plans should be updated as soon as there was a change in the resident's condition to provide proper care for the resident. At that time, the LPN/UM reviewed Resident #75's care plan in the presence of the surveyor and acknowledged there was no care plan for the urinary catheter. The LPN/UM then stated that the urinary catheter should have been added to the care plan as soon as the resident had the catheter inserted. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that interventions for a urinary catheter included ensuring the drainage bag was secured below the bladder and not touching dirty surfaces. The DON further stated that the nurses were responsible for updating resident care plans and that they should be updated at the time the resident had any change in condition. Review of the facility's Care-Plans Comprehensive policy, dated 06/2023, included, Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; . Identify the interdisciplinary care team and professional services that are responsible for each element of care; . Reflect currently recognized standards of practice for problem areas and conditions. Further review of the policy included, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: When there has been a significant change in the resident's condition; When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and at least quarterly. NJAC8:39-11.2 (g)

Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses, and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On 02/15/24 from 09:45 AM until 10:45 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. At handwashing sink #1, there was a step lid trashcan that contained used paper towels, with no inner plastic bag. The FSD had no response when asked if the trashcan should have had a plastic bag to contain the trash. 2. In the walk-in refrigerator, there was one 2-inch half pan, that contained a ham sandwich, with clear plastic wrap partially covering the pan. The sandwich was visible and exposed to air. The FSD stated it was important that the pan should have been fully covered to prevent bacteria growth and threw the sandwich into the trash. 3. In the freezer there was one box marked Salisbury steaks, with a received sticker dated 2/7/24 and hand marked date 2/8/24, which the FSD stated was the date it was opened. The box contained an opened clear plastic bag with the steak patties exposed to air with visible ice crystals on the patties. The FSD acknowledged that the patties should not have been visible and exposed to air and stated that the bag should have been tied up and that ice crystals meant that the food was exposed to air. The FSD stated she would discard the patties and that if they were served that someone could have gotten sick. 4. There was one opened box marked chicken patties, with a received sticker dated 1/29/24, that contained one opened bag wrapped in clear plastic wrap with no open or use by date. The FSD acknowledged that the bag should have had an opened date and stated it was important to label the food correctly so staff would know how long a food item was stored. 5. There was one frozen eight-pound roast beef covered in ice crystals with no dates observed on the roast. The FSD acknowledged there was no label or date and stated that she usually put a received label on, but it must have come off. 6. On a table in the kitchen at the condiment section, there was one uncovered opened roll of foil that the FSD stated was used for food that went into the oven. The FSD acknowledged the roll of foil should have been covered so no food debris fell into the container. 7. There was a large free standing covered bin marked sugar, that was dated 1/10/24, with black specks observed. The FSD was unable to state what the black specks were and acknowledged that they should not have been there. The FSD stated that the sugar would be discarded, and the bin would be washed and sanitized. 8. On the pot/pan dry rack there was one large green cutting board with brown and black smudges and large gouges. There was one large yellow cutting board with large gouges. The FSD acknowledged the stains and gouges and stated that it was important for the prevention of bacteria that the cutting boards did not contain stains and gouges. 9. At the coffee station, there were large coffee filters, unbagged, resting on a shelf. The FSD acknowledged the coffee filters were stored incorrectly and stated that debris could have gotten on them or they could have fallen on the floor. 10. At handwashing sink #2, there was a step lid trashcan with a foot pedal that did not open the can. The FSD acknowledged it was important for the trashcan to open hands free so staff did not touch the can after washing their hands. On 02/15/24 at 12:37 PM, the FSD informed the surveyor that there was no cutting boards policy. On 02/16/24 at 10:02 AM, the surveyor toured the Nurse Station One locked pantry area with the Licensed Practical Nurse (LPN) who accessed the locked door. There was a refrigerator which the LPN stated was used for the resident's personal food items. The LPN stated that the nurse or certified nursing aide (CNA) would mark the items with the resident's name and date and that it was good for 2 to 3 days. The LPN stated that the staff would dispose of items if they were outdated. The surveyor observed a plastic bag that contained a disposable take out container. The bag was marked with a resident's name and room number; there were no dates on the bag. The LPN stated that she did not know how long the bag was in the refrigerator and that the bag should have had a date. She further stated that it was important to label and date all food items because spoiled food could have gotten a resident sick. On 02/20/24 at 10:45 AM, the surveyor interviewed the LPN Nurse Manager (LPN/NM) who stated the process when residents brought food into the facility was that the item was marked with the resident's name, date and room number and placed into the refrigerator in Nurse Station One, and that they were not left over 5 days. The LPN/NM stated that if there was no name or date noted that the food item would have been placed into the trash. The surveyor informed the LPN/NM of the undated personal food item that was observed on 02/16/24 and she stated that it was important to date the food correctly and that it should have been discarded. On 02/20/24 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the process when residents brought food into the facility was that the family or the nurse labeled the item with the resident's name and the date, and that it should be kept only a couple days. The surveyor informed the DON of the undated personal food item that was observed on 02/16/24 and he stated that it was important for the food item to have been dated so no one ate spoiled food. On 02/22/24 at 02:44 PM, the surveyors met with the administration team and made them aware of the kitchen concerns. A review of the facility's Labeling and Dating Policy, reviewed 07/2023, revealed, Policy: All food items must be labeled and dated. A review of the facility policy, Food from Outside Sources, updated 01/2024, revealed, Guidelines: 2. The food and beverages will be labeled with the resident's name, room number and date. A review of the undated facility policy, Proper Food Handling and Storage, revealed, Label food. (Name and discard date) A review of the facility policy, Solid Waste, updated 08/2023, revealed, Procedures: 1.and other solid wasted is stored in plastic bags which are sealed and placed in solidly constructed containers with plastic liners and tight fitting lids. NJAC 8:39-17.2(g)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately utilize an infection assessment tool for 5 of 5 residents (Resident #12, #53, #66, #139, and #286) reviewed that were prescribed antibiotic medications in the facility. This deficient practice was evidenced by the following: Review of the facility's Antibiotic Stewardship line list for January and February 2024, revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #12 was prescribed an antibiotic on 01/05/24 for five days for pneumonia. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria met. 2. Resident #66 was prescribed an antibiotic on 01/09/24 for five days for an upper respiratory infection. The line list did not indicate whether an infection assessment tool was completed. 3. Resident #139 was prescribed an antibiotic on 01/10/24 for three days for a urinary tract infection (UTI). The line list further indicated that an infection assessment tool was completed with antibiotic use criteria met. 4. Resident #53 was prescribed an antibiotic on 02/15/24 for five days for a UTI. The line list further indicated that an infection assessment tool was completed, but the criteria for antibiotic use was not met. 5. Resident #286 was prescribed an antibiotic on 02/16/24 for seven days for a left thigh wound infection. The line list did not indicate whether an infection assessment tool was completed. Review of the facility's Monthly Antibiotic Stewardship Report binder for 2024 included suspected infection Situation Background Assessment Request (SBAR) forms, an infection assessment tool, for the following residents: 1. Review of Resident #12's Suspected LRI (Lower Respiratory Infection) SBAR, dated 01/06/24, revealed that the resident did not meet the criteria in any of the four Assessment Input situations provided on the form, however, the nurse checked off the box below the section which indicated, Nursing home protocol criteria are met. Further review of the SBAR included the resident was started on an antibiotic treatment. 2. Resident #66's SBAR was missing from the binder. 3. Review of Resident #139's Suspected UTI SBAR, dated 01/10/24, revealed the resident did not meet the criteria in either of the Assessment Input situations provided on the form and the nurse did not check off a box to indicate whether or not the nursing home protocol was met. Further review of the SBAR included the resident was started on an antibiotic treatment. 4. Review of Resident #53's Suspected UTI SBAR, dated 02/15/24, revealed the resident did not meet the criteria in either of the Assessment Input situations provided on the form and the nurse did not check off a box to indicate whether or not the nursing home protocol was met. Further review of the SBAR included the resident was started on an antibiotic treatment. 5. Resident #286's SBAR was missing from the binder. During an interview with the surveyor on 02/22/24 at 11:08 AM, the Infection Preventionist (IP) stated that the infection assessment tool utilized by the facility was the SBAR forms. The IP further stated that she educated the nurses that when a resident is started on an antibiotic, the nurse must complete the SBAR form and give it to the IP to review. When asked what happened if the resident did not meet the criteria on the SBAR, the IP stated that the nurse would notify the doctor to discuss discontinuing the antibiotic treatment. The IP also stated that once the SBAR is completed, the information is input into the Antibiotic Stewardship line list and filed into the Monthly Antibiotic Stewardship Report binder for that year. The IP clarified that once the SBAR was completed, it was the IP's responsibility to ensure the form was completed in its entirety. During the same interview, the IP reviewed the Antibiotic Stewardship Report binder for 2024, in the presence of the surveyor, and stated the following: 1. Resident #12's SBAR should have been completed accurately and the nurse should not have checked off that the criteria was met based on what was filled out on the SBAR form. 2. Resident #66's SBAR was missing from the binder and that the IP was still waiting for the nurse to complete the form. 3. Resident #139's SBAR should have been completed accurately and the nurse should have checked off whether or not the criteria was met. 4. Resident #53's SBAR indicated the criteria was not met and the nurse should have checked off that the criteria was not met. 5. Resident #286's SBAR was missing from the binder and that the IP was still waiting for the nurse to complete the form. The IP further stated that the residents whose SBAR forms were missing had already completed their antibiotic treatment, and that the forms should have been returned to the IP within 24 to 48 hours for review to determine if antibiotic treatment was needed. When asked about the importance of the Antibiotic Stewardship program, the IP stated it was to prevent antibiotic resistance. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that if a nurse suspected that a resident had an infection, the nurse should complete an SBAR form and notify the physician. The DON further stated that the nurses should be completing the SBAR forms accurately and in their entirety, and submit the forms to the IP within 24 to 48 hours. The DON also stated that the importance of the SBAR forms were to meet the criteria for the Antibiotic Stewardship program and to prevent multi-drug resistant organisms. Review of the facility's Antibiotic Stewardship Program policy, dated 10/01/23, included, Review infections and monitor antibiotic usage patterns on a regular basis. NJAC 8:39-19.4(d)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for one (1) of 19 residents reviewed (Resident #78). This deficient practice was identified by the following: On 02/15/24 at 10:55 AM, during the initial tour the surveyor observed Resident #78 lying in bed watching TV. Resident #78 stated that he/she was fine and had no concerns at that time. The surveyor reviewed the medical record for Resident #78. A review of the Admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included, malignant neoplasm of prostate (prostate cancer), hypertension (high blood pressure, muscle weakness and dysphagia (difficulty swallowing). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 02/07/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. A review of the Order Summary Report (OSR) for February 2024 reflected a physician order Full Code (want resuscitation and all life saving measures during a medical emergency) discontinued 10/31/23 and Do Not Resuscitate and Do Not Intubate (DNR/DNI) active start date 11/1/23. A review of the individualized comprehensive care plan (ICCP) included a focus area for code status of Full Code. Interventions date initiated 10/26/23 included at any time, resident or legal representative may change the Full Code status. Upon this decision, the order will be changed and documented in the medical record. Ensure that code status is communicated to staff per facility protocol. On 02/16/24 at 11:44 AM, the surveyor interviewed Resident #78 who stated that he/she did not want anyone beating on their chest and confirmed their wishes were to be a DNR/DNI. On 02/21/24 at 12:05 PM, the surveyor interviewed the Registered Nurse (RN) who stated the resident's code status would be in the electronic medical record (EMR). She stated that it was a physician order (PO) as well as on the care plan (CP). The RN stated that all residents should have their code status on the CP and that the unit manager (UM) completed and updated the CP. She further stated that the nurses could update the CPs as well, but it was typically the UMs. On 02/21/24 at 12:10 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the long-term care unit. She stated that the code status was asked upon admission so they would know how to care for the resident in the event of an emergency. She further stated that the code status was also assessed quarterly. The LPN/UM stated that the code status was on the CP and that the UMs generally updated the CP but that each department head would also update their sections in the CP. The LPN/UM then clarified that the nurses or any licensed staff could update the CP. At 12:12, the LPN/UM stated to her knowledge the resident was a full code. She stated that in an emergency she would look in the EMR to confirm the resident's code status. At 12:16 PM, the surveyor and the LPN/UM reviewed the EMR together. At that time, the LPN/UM stated the resident had a PO for DNR/DNI and it was ordered on 11/01/23. She then reviewed the CP and stated that Resident #78 was a full code. The LPN/UM acknowledged the CP should have been updated and that she should have updated it. Upon further review, she stated that the 3 PM to 11 PM supervisor put the PO into the EMR but never updated the CP. At that time, in front of the surveyor the LPN/UM confirmed she was updating the CP in the EMR to reflect the resident's code status as DNR/DNI. A review of the updated ICCP after surveyor inquiry included a focus area for code status of DNR/DNI. Interventions date initiated 10/26/23 included at any time, resident or legal representative may change the DNR/DNI status. Upon this decision, the order will be changed and documented in the medical record. On 02/21/24 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses were responsible for updating the CP. At that time, the DON reviewed the EMR and stated that Resident #78 was a DNR/DNI. The DON then reviewed the CP for Resident #78 and stated that the focused area reflected DNR/DNI but was revised today 2/21/24. The DON stated that the CP should have been updated prior to surveyor inquiry. He then acknowledged that the CP should have been updated when the code status was changed. A review of the facility Care-Plans Comprehensive policy revised 06/2023, included, 7. Revisions a. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 8. Revising and Updating a. the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: i. when there has been a significant change in the resident's condition; iv. At least quarterly. NJAC 8:39-11.2(i)

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 6 residents (Residents #17, #35, #39, #63) observed for incontinence care on 1 of 4 units (B hall). This deficient practice was evidenced by the following: On 02/20/24 at 09:04 AM, the Long Term Care Unit Manager provided the surveyor with a list of incontinent residents in the facility. On 02/21/24 at 07:49 AM, the surveyor met with the Certified Nursing Assistant (CNA#1) on B hall to complete an incontinence tour. At that time, CNA#1 stated it was the previous CNA's responsibility to do incontinence rounds before they finished their shift. On 02/21/24 at 07:59 AM, the surveyor and CNA#1 greeted Resident #35 in their room and the resident was made aware of the incontinence rounds. Resident #35 was observed to have worn two diapers, with the inner diaper saturated with urine and the outer diaper dry. The resident was wearing a red tshirt with the back of the tshirt saturated from the neckline to the hem. The resident was lying on a dry quilted green pad, with a fitted sheet on the bed that had a large wet area. The resident was malodorous. CNA#1 acknowledged that the resident should not have been found wet with urine and stated that she did incontinence rounds on each resident every two hours. CNA#1 further stated that it was important to keep the residents dry for the prevention of urinary tract infections. A review of Resident #35's Admission Record (AR) reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (disease that cause air flow blockage in the lungs), diabetes, and supraventricular tachycardia (condition where your heart beats faster than normal). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/22/23, revealed Resident #35's Basic Interview for Mental Status (BIMS) was 11 out of 15 which meant the resident had moderate cognitive impairment. The MDS further assessed that the resident required extensive assistance from staff for personal hygiene and was frequently incontinent of bowel and bladder. On 02/21/24 at 08:12 AM, the surveyor met with CNA#2 on B hall to complete an incontinence tour. At that time, CNA#2 stated that incontinence rounds were done at morning rounds, after lunch and before the CNA left for the day. On 02/21/24 at 08:15 AM, the surveyor and CNA#2 greeted Resident #17 in their room and the resident was made aware of the incontinence rounds. Resident #17's diaper was observed to be soaked with urine. The resident was lying on a folded white blanket with a round tan stain, a dry quilted green pad, and a dry fitted sheet. CNA#2 acknowledged the stained blanket and stated that the urine soaked through and that it was important for the residents to be kept clean and dry to prevent sores. A review of Resident #17's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to diabetes, chronic atrial fibrillation (irregular, rapid heart rate), and hypertension (high blood pressure). The significant change MDS, dated [DATE], revealed Resident #17's BIMS score was 3 out of 15 which meant the resident had severe cognitive difficulties. The MDS further assessed that the resident was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. On 02/21/24 at 08:25 AM, the surveyor and CNA#2 greeted Resident #63 in their room and the resident was made aware of the incontinence rounds. Resident #63's diaper was observed to be soaked with urine. The resident was lying on a dry quilted green pad and a fitted sheet with a round tan stain. The resident was malodorous. CNA#2 stated that the urine had seeped through, and that the resident should not have been found that way. A review of Resident #63's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to senile degeneration of the brain, hypertension, and functional urinary incontinence. The annual MDS, dated [DATE], revealed Resident #63's BIMS score was 14 out of 15 which meant the resident was cognitively intact. The MDS further assessed that the resident required assistance from staff for personal hygiene and was frequently incontinent of bowel and bladder. On 02/21/24 at 08:32 AM, the surveyor and CNA#2 greeted Resident #39 in their room and the resident was made aware of the incontinence rounds. Resident #39's diaper was observed to be soaked with urine. The resident's hospital gown was wet, the folded sheet under the resident was wet with a tan stain, and the fitted sheet was wet with a tan stain. The resident was malodorous. CNA#2 stated the resident should not have been found that way. A review of Resident #39's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to traumatic subarachnoid hemorrhage (brain bleeding), pneumonitis (lung infection), and dementia. The annual MDS, dated [DATE], revealed Resident #39's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 02/21/24 at 08:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that CNAs were responsible for incontinence care and that it should have been done every two hours, and in between if needed. LPN#1 was informed of the surveyor's incontinence rounds observations. LPN#1 acknowledged the residents should not have been found wet and stated that it was important that the residents were dry with clean linen for the prevention of skin breakdown. On 02/21/24 at 08:45 AM, the surveyor interviewed LPN#2 who stated that the CNAs were responsible for incontinence care and that the nurses would help. She stated that incontinence care was done in the morning, afternoon and at the end of the shift, adding, we check them every two hours. LPN#2 was informed of the surveyor's incontinence rounds observations. LPN#2 acknowledged that the residents should not have been found wet nor double diapered, stating, that is a big no no. LPN#2 stated that wet linens or tan stains meant that it was there previously and was not changed. LPN#2 stated it was important to keep the residents clean and dry for the prevention of bed sores and to prevent complications. On 02/21/24 at 08:54 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that the CNAs were responsible for incontinence care and that the residents should have been changed every two hours. The LPN/UM stated that her expectation for her staff that found a resident wet was to not find them soaked and then to correct it. The LPN/UM was informed of the surveyor's incontinence rounds observations. The LPN/UM acknowledged that the residents should not have been found wet and stated, it's very embarrassing. The LPN/UM stated it was important for the prevention of sores, skin irritations, and wounds, that the residents were found clean and dry with dry draw sheets and no double diapers ever. On 02/21/24 at 09:01 AM, the surveyor interviewed the Director of Nursing (DON) who stated it was the CNAs responsibility for incontinence care and that they were to do rounds every two hours. The DON stated that his expectation for his staff that found a resident wet was to change them. The DON was informed of the surveyor's incontinence rounds observations. The DON acknowledged that the residents should not have been found the way you described it. The DON stated it was important for the prevention of skin breakdown that the residents were found clean and dry. A review of the facility policy titled, Incontinent Care, reviewed 09/2023, revealed, Policy: It is the policy of this facility to promote resident comfort by keeping residents clean and dry to prevent skin breakdown. Procedures: 3. Remove all soiled items and place them in plastic bags. Soiled linen or briefs are to be properly disposed of in the waste bin. A review of the facility policy titled, ADL Care Policy, updated 09/2023, revealed, Policy: It is the policy and procedure of this facility for the CNA's to adequately provide ADL care to the residents. Procedure: 1. ADL care, including assisting residents with .toileting. A review of the facility document titled, Position Title: Certified Nurse Aide, revealed Responsibilities/Accountabilities: 17. Collects and bags soiled linen. NJAC 8:39-27.1 (a), 27.2 (d, h, j)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag did not touch the floor or geriatric chair wheel, and b.) ensure the urinary catheter drainage bag was kept below the level of the bladder for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the drainage bag was touching the floor. On 02/16/24 at 12:39 PM, the surveyor observed Resident #75 in a Geri chair. The resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and was touching the wheel of the Geri chair. On 02/21/24 at 9:00 AM, the surveyor observed Resident #75 in a Geri chair. The resident's urinary catheter drainage bag was on the resident's lap, above the level of the resident's bladder. According to the Admission Record, Resident #75 had diagnoses which included, but were not limited to, acute kidney failure (sudden kidney damage), hemiplegia and hemiparesis (paralysis of one side of the body), chronic kidney disease stage 3, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/26/23, included the resident had a Brief Interview for Mental Status score of 13 which indicated the resident's cognition was intact. Further review of the MDS included the resident had an indwelling catheter. Review of the Order Summary Report, as of 02/21/24, included a physician's order to Change foley [urinary catheter] securement device and foley bag weekly, ordered 11/09/23. Review of the resident's Care Plan did not include the resident's indwelling urinary catheter. Review of the resident's Progress Notes, dated 02/01/24 through 02/21/24, did not include any resident behaviors. During an interview with the surveyor on 02/21/24 at 9:49 AM, the Certified Nursing Assistant (CNA) stated that the CNAs empty the urinary catheter drainage bags and ensure the drainage bags are positioned below the resident. The CNA further stated that the drainage bags should not be touching any dirty surfaces to prevent infection. During an interview with the surveyor on 02/21/24 at 9:58 AM, the Licensed Practical Nurse (LPN)/Unit Manager (UM) stated urinary catheter drainage bags should be secured below the level of the resident's bladder and not touching dirty surfaces to prevent infection. At that time, the LPN/UM accompanied the surveyor to Resident #75's room. The LPN/UM acknowledged that the drainage bag was in the resident's lap, above his/her bladder, and then secured the drainage bag to the Geri chair below the resident's bladder. During an interview with the surveyor on 02/22/24 at 12:46 PM, the Infection Preventionist (IP) stated urinary catheter drainage bags should be secured below the resident's bladder to prevent the urine backflowing into the resident. The IP further stated that the drainage bag should not be touching dirty surfaces to prevent infection. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that urinary catheter drainage bags should not be touching dirty surfaces because the catheter was a portal of entry for infectious organisms. The DON further stated that the drainage bag should be secured below the resident's bladder to prevent the backflow of urine which could cause discomfort or infection. Review of the facility's Urinary Catheter Care policy, dated 08/2023, included, It is the policy and procedure of this facility to minimize the risk of catheter-associated urinary tract infection and its related problems, minimize trauma to the urethra, and maintain cleanliness of the catheter and perineum. Further review of the policy did not include specifics on how the urinary catheter drainage bag should be secured to prevent infection. NJAC 8:39 - 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 1 resident (Resident #139) reviewed for respiratory care. The deficient practice was evidenced by the following: On 02/15/2024 at 10:04 AM, Surveyor #1 observed Resident #139 resting in bed, reading a book and was fully dressed for the day. Surveyor #1 observed that Resident #139 had oxygen (O2) being administered via (by way of) nasal cannula at three (3) liters/minute. The oxygen tubing was not labeled or dated. Resident #139 stated that he/she had pulmonary fibrosis (a condition in which the lungs are scarred, causing difficulty breathing) and required O2. Resident #139 further stated that he/she was not sure how often the staff changed the tubing. On 02/16/2024 at 12:34 PM and on 02/20/2024 at 10:24 AM, Surveyor #1 observed Resident #139 with O2 being administered via nasal cannula at 3 liters/minute and the oxygen tubing was not labeled or dated. On 02/22/2024 at 09:37 AM, Surveyor #2 conducted a review of the medical records which revealed that Resident #139 was admitted to the facility after hospitalization for influenza A (the flu). The resident's past medical history included but was not limited to pulmonary fibrosis. The admission Minimum Data Set (MDS), an assessment tool dated 01/11/2024 reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. The MDS also indicated that the resident had continuous oxygen was in use on admission and while a resident at the facility. On 02/22/24 at 09:37 AM, Surveyor #2 reviewed the physician orders dated 01/04/2024, which included but were not limited to Oxygen at 3 liters/minute via nasal cannula continuously and change oxygen tubing weekly on Wednesdays 11 PM to 7 AM shift and PRN (as needed) (label with date). A review of the Treatment Administration Record (TAR) for February 2024 revealed the Oxygen tubing was changed on Wednesdays 11 PM to 7 AM shift on 02/7/2024, 02/14/2024, and 02/21/2024. On 02/22/2024 at 09:22 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN) who stated the oxygen tubing was changed weekly on the night shift. The LPN also stated she thought the oxygen tubing was changed on Wednesday nights and the tubing should have been dated when changed. On 02/23/2024 at 10:16 AM, Surveyor #2 interviewed the Director of Nursing (DON) who stated the oxygen tubing should have been labeled and dated with each change. A review the facility policy Oxygen Administration indicated all oxygen tubing will be dated upon the first use and changed weekly. NJAC 8:39-27.1 (a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurate and consistent for 2 of 19 medical records reviewed (Resident #17 and #24). This deficient practice was evidenced by the following: 1). The surveyor reviewed Resident #17's Electronic Medical Record (EMR) which revealed the following: According to the Admission Record, Resident #17 had diagnoses which included, but were not limited to, Alzheimer's Disease. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/20/24, included the resident had a Brief Interview for Mental Status score of 03 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was receiving hospice care. Review of the Order Summary Report, as of 02/21/2024, included a physician's order for Do Not Resuscitate (DNR) dated 02/08/24. Review of the Care Plan, revised 02/06/24, included, [Resident #17] has a code status of DNR. Patient started on Hospice services 2/2/2024. Review of a progress note, dated 02/10/24, included, [Resident #17] is now on hospice services, and code status changed to DNR. Review of the miscellaneous tab in the EMR included a scanned copy of a Do Not Resuscitate form for Resident #17 which was signed by the resident's representative and the physician. The surveyor reviewed Resident #17's paper (physical) chart which revealed the following: Review of the first page in the resident's paper chart included a form which had FULL CODE (in the event a person's heart or breathing stopped, resuscitation would be provided) written in large letters and Resident #17's name and date of birth written below it. Further review of the paper chart did not include the resident's DNR code status. During an interview with the surveyor on 02/21/24 at 12:10 PM, Certified Nursing Assistant (CNA) #1 stated that if a resident was found unresponsive, the staff would look at the resident's EMR to find out the code status. During an interview with the surveyor on 02/21/24 at 12:17 PM, Licensed Practical Nurse (LPN) #1 stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The LPN further stated that it was important for the EMR and paper chart to match consistently because, if the resident is a DNR, you don't want to code the resident. During an interview with the surveyor on 02/21/24 at 12:25 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The LPN/UM further stated that it was important for the EMR and paper chart to match consistently, to ensure the resident's wishes are carried out. At that time, the LPN/UM reviewed Resident #17's EMR and paper chart in the presence of the surveyor and verified that the paper chart should not have included the resident was a full code. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The DON further stated that the EMR and paper chart should match consistently to prevent confusion in the event the staff needed to know the resident's code status. Review of the facility's Code Status policy, dated 10/2023, included, The resident's resuscitation status will be clearly indicated on his/her clinical record. 33106 2). On 02/15/24 at 10:12 AM, the surveyor observed that Resident #24 was out of the facility that day. The surveyor interviewed LPN #2 who stated that the resident was out of the facility on Tuesdays, Thursdays, and Saturdays for dialysis (process that cleans blood by removing it from the body and passing it through a dialyzer, or artificial kidney). The LPN also explained that the resident had an arteriovenous (AV) graft (a direct connection of an artery to a vein) in the left upper arm where he/she received dialysis. On 02/16/24 at 12:35 PM, the surveyor observed the Resident #24 in his/her room eating lunch. The resident stated that he/she goes to dialysis three times a week and had an AV fistula in the left upper arm. He/she stated that the nurses check the fistula to make sure that it's working correctly. He/she further stated that he/she had no issues regarding the care that was provided. The surveyor reviewed Resident #24's medical record which revealed the following information: According to the Admission Record, Resident #24 had diagnoses, which included but were not limited to, end stage renal failure and diabetes mellites. Review of the admission MDS dated [DATE], indicated that the resident was cognitively intact and received hemodialysis. Review of the Care Plan included an intervention that no blood pressures (BPs) or blood draws were to be done on the resident's left arm. Review of the Treatment Administration Record (TAR), dated 02/01/2024-2/29/2024, included a physician's order not to take blood pressures in Resident #24's left arm. Further review of the TAR revealed the nurses were signing that they were not taking BPs in the resident's left arm, however, the documentation in the Weights and Vital Signs Record of the EMR indicated nurses were documenting BPs in the left arm. The Weights and Vital Signs record for February indicated that following documentation: - On 02/19/24 at 05:44 AM, the BP was taken in the left arm. - On 02/18/24 at 21:06 (9:06 PM), the BP was taken in the left arm. - On 02/18/24 at 16:47 (4:47 PM), the BP was taken the left arm. - On 02/18/24 at 05:49 AM, the BP was taken in the left arm. - On 02/17/24 at 05:21 AM, the BP was taken in the left arm. - On 02/16/24 at 21:06 (9:06 PM), the BP was taken in the left arm. - On 02/16/24 at 18:48 (6:48 PM), the BP was taken in the left arm. - On 02/15/24 at 05:14 AM, the BP was taken in the left arm. - On 02/12/24 at 05:50 AM, the BP was taken in the left arm. - On 02/11/24 at 16:43 (4:43 PM), the BP was taken in the left arm. - On 02/11/24 at 05:53 AM, the BP was taken in the left arm. - On 02/10/24 at 23:10 (11:10 PM), the BP was taken in the left arm. - On 02/10/24 at 21:48 (9:48 PM), the BP was taken in the left arm. - On 02/10/24 at 20:23 (8:23 PM), the BP was taken in the left arm. - On 02/10/24 at 08:14 AM, the BP was taken in the left arm. - On 02/10/24 at 05:38 AM, the BP was taken in the left arm. - On 02/07/24 at 08:01 AM, the BP was taken in the left arm. - On 02/06/24 at 20:06 (8:06 AM), the BP was taken in the left arm. - On 02/04/24 at 05:47 AM, the BP was taken in the left arm. - On 02/03/24 at 05:41 AM, the BP was taken in the left arm. - On 02/02/24 at 21:04 (9:04 AM), the BP was taken in the left arm. - On 02/02/24 at 17:28 (05:28 PM), the BP was taken in the left arm. - On 02/02/24 at 06:00 AM, the BP was taken in the left arm. - On 02/01/24 at 05:20 AM, the BP was taken in the left arm. On 02/16/24 at 01:03 PM, the surveyor interviewed Resident #24 who stated that he/she knew that his/her left upper extremity had to be protected due to the AV fistula and that staff did not take and blood pressures or draw blood from the left arm. On 02/20/24 at 10:34 AM, the surveyor interviewed the CNA #2 who stated that Resident #24 required limited assistance with activities of daily living (ADLs). The CNA further stated that she thought that the resident had an AV fistula in the left upper arm, but she did not touch the AV site. She then added that she did not take vital signs in the facility and that the nurses were the only ones that could take resident vital signs. On 02/20/24 10:41 AM, the surveyor interviewed LPN #3 who explained that if a resident was admitted with an AV shunt, nurses would be responsible to check the AV site for functioning. She further stated the nurses would check the AV site for bruit and thrill every shift and would also monitor the site for infection, bleeding, bruising. She stated that the arm that had the AV shunt would have to be protected and the nurses should not take blood pressures or draw blood from the affected arm. At that time, the LPN reviewed Resident #24's vital sign record with the surveyor and confirmed that the nurses were documenting that they were taking the BP in the left arm. The LPN stated that she was not sure why some of the nurses were documenting on the VS record that they were taking the residents blood pressure in the left arm and that they documented in error. On 02/20/24 at 10:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who explained that if a resident was admitted to the facility with an AV shunt, the nurses were not to take BPs or perform blood draws on the affected arm. The RN/UM further stated that a physician's order would be obtained not to use that arm or take BPs in that arm. At that time, the RN/UM and the surveyor reviewed Resident #24's Vital Sign record and the RN/UM confirmed that the nurses were documenting that they were taking the residents blood pressure in the left arm. The RN/UM stated that the resident was alert and oriented and would notify the nurse not to use the left arm for blood pressures or blood draws. The RN/UM also confirmed that it was a multitude of different nurses that documented that they took the residents blood pressure in the left arm. On 02/20/24 at 11:21 AM, the surveyor interviewed the DON who confirmed that the nurses were documenting on the Vital Signs record that they took Resident #24's blood pressure in the left arm. The DON further stated that it was an error in documentation. The DON also stated that it could not be proven that they did not take the blood pressure in the affected arm because the nurses documented that they did. The DON added that the nurses should not be documenting that they took the residents blood pressure in the left arm, when they are also signing the physician's order in the TAR that they were not taking the resident's blood pressure in the left arm. The facility provided the surveyor with a signed, typed confirmation from Resident #24 on 02/22/24 that indicated that at no time did any nurse take his/her blood pressure in the left arm. Review of the facility's Medical Records and Confidentiality of Information and Personal Privacy policy, dated 08/2023, did not include any policy related to ensuring the medical record is accurate or consistent. NJAC 8:39-35.2 (d)

Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to a.) ensure the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing droplet precautions in accordance with facility policy and accepted national standards for 1 (one) of 1 (one) resident (Resident #140) reviewed for TBP, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during meal tray pass for 1 of 4 units (Cart 1 unit) observed. This deficient practice was evidenced by the following: 1.) On 02/15/24 at 10:09 AM, Surveyor #1 observed the outside of Resident #140's room and observed a sign posted on the resident's door that the resident was on Droplet Precautions [Infections transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing. Droplets are about 30 to 50 micrometers in size]. The sign also indicated that the proper personal protective equipment (PPE) to be worn in the room was an isolation gown, gloves, protective eye shield, and an N95 mask (a mask designed to have a tight seal and provide efficient filtration of airborne particles). There was also an isolation cart containing the necessary PPE set up outside the resident's door. On 02/15/24 at 10:40 AM, Surveyor #1 was in the hall outside of Resident #140's room and observed the housekeeper cleaning Resident #140's room. The housekeeper was not wearing a protective gown, protective eyewear, or N95 face mask and Resident #140 was present in the room. The housekeeper was observed wearing a regular mask and gloves. The surveyor observed the housekeeper exit the resident's room to rewet the mop and again enter the resident's room without wearing the proper PPE of eye protection, isolation gown, or an N95 mask. At that time, Surveyor #1 observed Licensed Practical Nurse (LPN) #1 walk down the hall and the surveyor asked the LPN what type to PPE was required in Resident # 140's room. The LPN explained to the surveyor that Resident #140 had the diagnosis of COVID-19 and that full PPE, such as N95 mask, protective gown, gloves, and protective eyewear, had to be worn in the room and removed upon leaving the room. The surveyor informed the LPN that the housekeeper was in Resident #140's room and did not don the appropriate PPE. The LPN observed the housekeeper in Resident #140's room not wearing the appropriate PPE and called the housekeeper out of the room to educate the housekeeper on the importance of wearing the proper PPE when in a COVID-19 positive room. The surveyor interviewed the housekeeper at that time, and the housekeeper explained what type of PPE she should have worn in Resident #140's room. The housekeeper explained to the surveyor that she should have worn a protective gown, N95 mask, gloves, and eye protection. She then stated that she had been employed by the facility since 2009 and had been educated multiple times on the contagious disease COVID-19 and wearing the appropriate PPE in COVID-19 positive rooms. The housekeeper further stated, that was my fault and I should have put on the appropriate PPE. The housekeeper admitted to not wearing the protective eyewear, gown or N95 mask and explained to the surveyor where all the PPE was located. The housekeeper showed the surveyor the isolation bin outside the resident's room which contained N95 masks, gowns, and protective eye shields. The surveyor reviewed Resident #140's medical record which revealed the following information: According to the Admission Record, Resident #140 was admitted to the facility with the diagnoses that included, but were not limited to, heart failure and major depression. The admission Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 12/27/23, indicated that Resident #140 was cognitively intact and was independent with self-care. The Physicians Order (PO) dated 02/13/24, indicated that Resident #140 was to remain on strict droplet isolation precautions until 02/21/24 for COVID-19. The Treatment Administration Record (TAR) dated 02/13/24 reflected the aforementioned physician's order for Resident #140 to be on strict droplet precautions every shift for the diagnosis of COVID-19 until 02/21/24. The Care Plan indicated that Resident #140 was to be on droplet/contact precautions due to diagnosis of COVID-19 until 02/21/24, with interventions that included: -Staff to wear proper PPE at all times when caring for the patient, initiated 02/15/2024. -Educate staff, therapy, family on the importance of maintaining single room isolation/contact precautions, initiated 02/15/2024. -Precaution signage on door of room and provide education to visitor and family member, initiated 02/15/2024 -Provide appropriate personal protective equipment for staff/visitor use. Infection Control Apron with PPE hanging on the door for easily access to facility staff/family On 02/21/24 at 09:49 AM, Surveyor #2 interviewed Certified Nursing Assistant (CNA) #1 who stated that when in a COVID-19 isolation room, the staff were required to wear gloves, gown, N95 mask, and a face shield. She further stated that the required PPE were located outside of the resident's room in bins and that it was important to wear the proper PPE to prevent the spread of infection. On 02/21/24 at 9:58 AM, Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that when in COVID-19 isolation rooms, the required PPE to be worn were gown, goggles/face shield, N95 face mask, and gloves. She further stated that the required PPE was located outside of the resident's room and it was important to wear the correct PPE to prevent the spread of infection. On 02/22/24 at 10:50 AM, Surveyor #2 interviewed the Housekeeping Director (HD) who stated that if a housekeeper was assigned a certain hallway that had COVID positive rooms, then they were responsible to clean those rooms. The HD stated that when the housekeeper entered the COVID positive room, they were required to wear an isolation gown, N95 mask, face shield, and gloves. The HD confirmed that it was important to wear the appropriate PPE to protect yourself from whatever infection the resident had. On 02/22/24 at 12:46 PM, Surveyor #2 interviewed the Infection Preventionist (IP) who confirmed that staff were required to wear faces shields, N95 mask, isolation gowns, and gloves in COVID positive rooms to protect themselves from a contagious infection. On 02/22/24 at 01:10 PM, Surveyor #2 interviewed the Director of Nursing (DON) who confirmed that when staff were in a COVID isolation room, staff were required to wear N95 face mask, face shield, isolation gown, and gloves. He stated that the purpose for wearing the PPE was to protect the staff member and to prevent the spread of infection. A review of the facility policy titled, Infection Control General Practices, with a review date of 10/01/23, indicated that staff must use appropriate PPE according to the transmission-based precaution guidelines such as gloves, mask, gowns, and eye protection when providing care to residents with an infectious disease. A review of the facility policy titled, Transmission Based Precautions (TBP), with a revised date of 07/2023, indicated that TBP are designed for patients documented or suspected to be infected with a highly transmissible pathogen for which additional precautions beyond standard/universal precautions were needed to interrupt transmission. Three types of TBP were identified as airborne, droplet and contact precautions. 43307 2.) On 02/16/24 at 12:15 PM, Surveyor #3 observed CNA #2 remove a food tray from the covered food cart and enter Resident #51's room. The CNA placed the tray on the bedside table (BST), moved the table closer to the resident, turned the light switch on, moved the BST over the resident, opened the cup lid, opened a sugar packet and poured it into the cup, handed the fork to the resident, opened the cardboard milk carton, removed the straw cover, and placed the straw into the milk carton. The CNA then moved some items on the tray, removed the plastic plate cover and exited the room where she then placed the plastic plate cover on top of the food cart in the hallway. The CNA then removed a meal tray from the covered food cart and entered Resident #44's room. The CNA placed the tray on the BST, moved the BST closer to the resident, touched the lotion container that on the BST, raised the BST, removed the plastic plate cover, used the bed control to adjust the head of the bed, moved the pillow, physically assisted the resident to move up in bed, used the bed control to adjust the head of the bed, and moved the BST over the resident. She then opened the cardboard milk carton, removed the straw cover, placed the straw into the milk carton, took the silverware out of the plastic bag, removed the plastic plate cover, and exited the room where she then placed the plastic plate cover on top of the food cart. The CNA then entered another room to speak with other staff members. No hand hygiene (HH) was observed during the meal tray pass. On 02/16/24 at 12:21 PM, Surveyor #3 interviewed CNA #2 who stated that the CNAs were responsible for delivering the meal trays and that HH was to be performed before touching the meal trays, and that once the tray pass was completed, she would have washed her hands with soap and water. The surveyor informed the CNA of the meal tray pass observation and that no HH was observed. The CNA acknowledged that she should have performed HH before touching the trays, in between trays, and that HH should have been done after touching resident belongings or adjusting the resident in the bed. The CNA stated she had been in-serviced on HH and that it was important to perform it correctly to prevent the transfer of bacteria. On 02/16/24 at 12:32 pm, Surveyor #3 interviewed LPN #2 who stated that it was the CNA's responsibility to pass the meal trays and that HH should have been done before and after giving each resident a tray. The surveyor informed the LPN of the meal tray pass observation and that no HH was observed. The LPN acknowledged that the CNA did not perform HH correctly and stated that it was important for infection control to perform HH before and after entering each resident's room. On 02/16/24 at 12:40 PM, Surveyor #3 interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that it was the CNA's responsibility to pass the meal trays out and that HH should have been done when they exit a resident room and before grabbing the next tray. The surveyor informed the RN/UM of the meal tray pass observation and that no HH was observed. The RN/UM acknowledged the CNA did not perform HH correctly and stated that HH should have been performed upon exiting a resident's room and upon touching anything else between residents. She added that it was important for infection control to perform HH correctly. On 02/16/24 at 12:52 PM, Surveyor #3 interviewed the Corporate RN Regional Infection Preventionist (CRN/RIP) who stated that HH should have been performed before removing a meal tray from the food cart and after delivering a tray to a resident. The surveyor informed the CRN/RIP of the meal tray pass observation and that no HH was observed. The CRN/RIP acknowledged that the CNA did not perform HH correctly and stated that HH was important to avoid contamination. On 02/16/24 at 12:59 PM, Surveyor #3 interviewed the DON who stated that it was the CNA's responsibility to pass out the meal trays and that he expected staff to perform HH before they started the tray pass and when they opened the resident's food items. The surveyor informed the DON of the meal tray pass observation and that no HH was observed. The DON acknowledged that the CNA did not perform HH correctly and stated that HH was important for infection control and prevention. A review of the facility policy, Handwashing/Hand Hygiene, dated 8/29/2023, revealed, Procedure: 4. In most situations, the preferred method is washing hands with soap and water. If hands are not visibly soiled, the use of an alcohol-based hand rub may be used for the following situations: a. Before and after direct contact with resident, f. After contact with a resident's intact skin, g. After contact with inanimate objects .,i. After contact with high touch surfaces . A review of the facility policy, Meal Pass Policy, reviewed 10/2023, revealed, Procedure: 2. Once the dietary staff member delivers the truck to the floor, staff will begin to pass out trays after performing appropriate hand hygiene. 3. Staff members will sanitize their hands in between each tray. A review of facility documentation titled, In-Service, Topic: Infection Control, 3. Handwashing, revealed the CNA's signature that she attended on 03/20/23. A review of facility documentation titled, Hand Hygiene Competency Validation, revealed the CNA's signature that she performed a return demonstration on 03/20/23 and on 11/29/23. NJAC 8:39-19.4 (m)(n), 27.1 (a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to complete a Significant Change in Status Assessment within 14 days for a resident who was admitted to hospice services. This deficient practice was identified for 1 of 1 resident (Resident #17) reviewed for hospice and was evidenced by the following: According to the Admission Record, Resident #17 had diagnoses which included, but were not limited to, Alzheimer's Disease. Review of the Long Term Care Facility - Change in [NAME] form, dated 02/02/24, revealed, This is to advise that, effective 02/02/24, [Resident #17] is: admitted to [hospice]. Review of the Care Plan, revised 02/06/24, included, Patient started on Hospice services 2/2/2024. Review of the Social Services progress note, dated 02/06/24, included, Family initiated referral for hospice services. [Resident #17] was picked up by [hospice company] effective 2/2/2024, care plan updated. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment used to facilitate the management of care, dated 02/20/24, revealed the Assessment Reference Date (ARD) was 02/20/2024, four days past the 14-day due date, and the MDS was signed as complete by the MDS Coordinator on 02/21/2024. During an interview with the surveyor on 02/21/24 at 10:20 AM, the MDS Coordinator explained the various scenarios in which a Significant Change in Status MDS would be triggered, including when a resident was admitted to hospice services. The MDS Coordinator further stated that MDS should be completed within 14 days of the resident starting hospice services. When asked about Resident #17, the MDS Coordinator stated the Significant Change in Status MDS should have been completed by 02/16/24. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated when a resident was admitted to hospice services, the Significant Change in Status MDS should be completed within 14 days. Review of the facility's MDS policy, dated 10/2023, included, Schedules Minimum Data Set (MDS) and Care Plan Meeting in accordance to existing regulations governing RAI [Resident Assessment Instrument] process. Review of the Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed that a Significant Change in Status Assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election. NJAC 8:39-11.2(i)

Based on observation, interview, and documentation review on 4/17/13 in the presence of the facility's Director of Maintenance, it was determined that the facility failed to ensure protection of the health and safety of residents, personnel, and the public by storing an extremely flammable product in an area where combustion and/or explosion could occur. This condition posed a serious and immediate threat to residents, personnel, and the public, as follows: This deficient practice was identified on 4/17/13 at 10:15 a.m. and corrected on the same day at 12:45 p.m. based on removal of the stored flammable product; notification of the Administrator; the receipt of an acceptable plan of correction; and verification of in-service to staff. On 4/17/13 at 10:15 a.m., the surveyor observed gasoline was being stored in the facility's boiler room. There was a gasoline-powered snow blower stored 3 feet from the hot water boiler. The snow blower's fuel tank was 1/2 full of gasoline and had a vented fuel tank cap. The facility's boiler was an open flame-tube, natural gas-fired boiler. This boiler was operating, and there were flames visible. The boiler room was an outside access room that backed up to the main kitchen that was attached to the main dining room. The boiler room also housed the main natural gas inlet line serving the kitchen and the emergency generator transfer switch. A fire or explosion in this room could result in damage to the main gas line allowing damage to continue past the 2-hour wall into the kitchen. With a breech in the wall due to an explosion, a water based fire sprinkler system on a ruptured natural gas line fire would prove to be ineffective. There was also the potential for damage to the main electrical equipment, resulting in a blackout condition in the facility with a fire emergency. In an interview at 10:15 a.m., the facility's Director of Maintenance (DM) stated that the snow blower was not normally stored in this room but he placed it there that morning after running it. The DM stated that he did not realize there was still fuel in the tank. The DM also stated that it was to be picked up to be stored off-site. A review of the facility's preventative maintenance records revealed that there was no documentation that the boiler room was observed on scheduled inspection rounds. However, at 11:45 a.m. the DM stated that Maintenance was in that room every day. The DM stated that Maintenance and the Administrator have a key to the boiler room and that the receptionist had a key if needed to allow service vendors access after hours. At 12 p.m., on 4/17/13, the Administrator was informed by the survey team that the storage of gasoline near open flames posed an immediate and serious threat, and that a plan of correction was required. On 4/17/13, at 12:50 p.m., a plan of correction was received, reviewed and accepted indicating the following action was taken: 1. The gas powered snow blower was immediately removed from the boiler room. 2. All areas of the facility were inspected to ensure that no hazardous materials were present including the boiler room, utility areas, and hallways. 3. The Administrator or designee would conduct daily inspections of the boiler room, utility rooms, and other utility areas for hazardous materials for 1 week, then weekly for 3 weeks, and then monthly for 2 months. The results of the audits would be forwarded to the Quality Assessment and Assurance Committee for review. 4. Department heads were in-serviced on storage of hazardous materials. 5. Signs were posted at the boiler room regarding the proper storage of hazardous material. The Immediate Jeopardy was lifted at 2:45 p.m. after survey team verification that in-services were performed with identified staff and that the subject of the in-service was understood by staff. NJAC 8:39-31.2(e)