Every finding on record at Careone at East Brunswick

Complaint number: NJ00172039 Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable on 1 of 2 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 6/23/25 at 11:30 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Director (FSD). At 11:59 AM, the surveyor and FSD observed the first food truck arrived on the Canterbury South 1st floor unit. The surveyor and FSD observed the first lunch tray being served at 12:00 PM, at that time a test tray of a regular diet and regular consistency was identified by the surveyor and FSD, this tray was removed from the food truck and placed in the dayroom by the FSD. After the last meal tray was delivered to a resident at 12:09 PM, the surveyor took the temperatures of the following items in the presence of FSD with calibrated thermometers and were as followed: Coffee 146.9 F Baked potato: 171 F Roast beef 152 F Carrots 146.4 F Ice cream 18.7 F Apple Juice 49.8 F Milk 59.8 F At 12:10 PM, following the food temperature recording, the FSD stated agreed the apple juice, milk and coffee were not in range for serving temperature. The FSD further stated corrective action would be taken immediately. On 6/23/25 at 12:45 PM, the FSD provided the surveyor with a facility policy titled, Food Preparation and Service, with a revised dated of July 2014. Under the policy interpretation and implementation section of the policy it states, 1. The danger zone for food temperatures is between 41 F and 135F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The FSD also provided a test tray audit sheet that states, Soup and hot beverages should be served at 150 F or higher. On 6/24/25 at 1:32 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The LHNA stated the kitchen concerns will be addressed immediately. On 6/26/25 at 11:15 AM, the surveyor met with the LHNA, DON, and Regional Clinical Nurse for the exit conference, no further pertinent information provided. NJAC 8:39-17.2(a) 2, (e)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/22/25 at 9:18 AM, the surveyor in the presence of the chef supervisor (CS) toured the kitchen and found the following: 1. On the chef preparatory table, the surveyor observed the can opener with a blackish color sticky debris. The CS stated the can opener was just used but should always be free of debris. 2. On a four-shelf storage rack, the CS stated on the pots, pans and serving trays were dry and ready for service. The surveyor observed wet nesting on 3, 1/4 size serving trays. 3. In the walk-in freezer the surveyor observed the ventilation fans with blackish dust-like debris on covers. The CS stated they would contact maintenance to have the covers clean immediately. 4. The surveyor observed the high temperature dish machine rinse cycle only reach 178 degrees Fahrenheit (F). The CS stated the rinse cycle should reach 180 degrees F. 5. The surveyor observed the outside dumpster area with latex gloves, empty water bottles, empty bag of chips, and plastic utensils on the ground around the dumpster. The CS stated the dumpster is shared between all departments and the garbage around the dumpster area was not from the dietary department. On 6/23/25 at 9:02 AM during the follow up tour of the kitchen the surveyor observed the following: 6. The surveyor observed the Regional Food Service Director (RFSD) wearing large dangling earrings as well as two other dietary aides wearing large, hooped earrings. The Food Service Director (FSD) stated earrings of that size should not be worn in the kitchen due to infection control practices. On 6/23/25 the FSD provided the surveyor with multiple facility policies related to the dietary department. The policy titled, Sanitization with an edited date of 4/12/2016, states under the policy interpretation and implementation section, All equipment's, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized by using hot water and/or chemical sanitizing solutions. The policy titled Cleaning with no created or revision date noted, states under the procedure section, Walk-in refrigerators and freezers must be cleaned bi-weekly. The policy titled, Dishwashing Machine Use with a revised date of March 2010, states under the policy interpretation and implementation, 3. Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degrees Fahrenheit (F), or less than: b. 180 degrees F for all other machines. The policy titled, Food-Related Garbage and Rubbish Disposal with a revision date of April 2006, states under the policy interpretation and implementation, 7. Outside dumpsters provided by garbage pick up services will be kept closed and free surrounding litter. The policy titled, Food Preparation and Service with a revised date of July 2014, states over the food service and distribution, 8. Dietary staff shall keep fingernails trimmed and clean. Jewelry shall be worn minimally, and hand jewelry shall be covered with gloves. On 6/24/25 at 1:32 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The LHNA stated the kitchen concerns will be addressed immediately. On 6/26/25 at 11:15 AM, the surveyor met with the LHNA, DON, and Regional Clinical Nurse for the exit conference, no further pertinent information provided. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to adhere to accepted standards of infection control practices for the ensure proper use of personal protective equipment (PPE) for 3 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: On 6/22/2025 at 9:03 AM, the surveyor entered the facility and observed the front desk receptionist wearing a surgical mask under their chin. The receptionist stated the building had an active Covid-19 outbreak, and all staff and visitors were required to wear a surgical mask when in the facility. On 6/22/2025 at 10:10 AM, during the tour of the Canterbury South 1st floor unit the surveyor observed a housekeeper (HK) wearing a surgical mask under their chin. The surveyor interviewed HK who stated they know how the surgical mask is supposed to be worn and is aware the facility is in a Covid outbreak. HK observed wearing the surgical mask correctly following interview. On 6/22/2025 at 10:16 PM, the surveyor observed a maintenance worker (MW) wearing the surgical mask with the mask below their nose. The MW stated the mask must have slipped off their nose while performing their duties. On 6/23/2025 at 11:00 AM, the surveyor interviewed the Infection Preventionist (IP), who stated the facility has been in Covid outbreak since 6/21/25 and all staff and employees should be wearing surgical masks and N95 mask when in the rooms with positive Covid patients. The IP further stated that 5 residents and 2 employees tested positive for Covid on Saturday. Sunday all residents and employees on that Canterbury South had been tested and 2 additional residents and 2 employees tested positive for a total of 8 positive resident and 4 employees. The IP stated all employees have been given in-services regarding proper wearing of PPE, unable to explain why some employees were not wearing the surgical masks correctly. On 6/23/2025 at 11:30 AM, the IP provided the surveyor with a facility policy titled, Personal Protective Equipment - Using Face Masks with a revision date of September 2010, staters under the procedure guidelines, Putting on the mask .5. Place the mask over the nose and mouth. On 6/24/25 at 1:32 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The DON stated all departments have been re-in serviced regarding PPE and surgical masks. On 6/26/25 at 11:15 AM, the surveyor met with the LHNA, DON, and Regional Clinical Nurse for the exit conference, no further pertinent information provided. NJAC 8:39-19.4 (a) (1) (n)

Repeat Deficiency Complaint #NJ00174978, and NJ00176742 Based on observation, interview and record review, it was determined that the facility failed to; a) clarify physician's admitting medication orders for 1 of 2 residents admitted for Hospice services (Resident #81); b) ensure a resident received their medications as prescribed by their physician for 1 of 24 residents sampled (Resident #88), in accordance with professional standards of practice. This deficient practice was as follows: 1. On 6/23/25 at 9:03 AM, the surveyor reviewed the closed medical record of discharged Resident #81. A review of the Resident admission Record (an admission summary) reflected the resident was admitted for Hospice respite to the facility with diagnoses which included multiple sclerosis, heart failure, and chronic kidney disease. A review of the Order Summary Report (OSR) with active orders as of 6/22/24 included physician orders (PO) for Farxiga oral tablet 10 mg (milligram) (Dapaglifozin propanediol); give one tablet by mouth for DM and an order for Jardiance 25 mg tablet; give one tablet by mouth one time a day for Diabetes Mellitus. A review of the June 2024 Medication Administration Record (MAR) revealed on 6/18/24, 6/19/24, 6/20/24, 6/21/24 and 6/22/24 at 9:00 AM, Resident #81 received both Jardiance and Farxiga. A review of the Consultant Pharmacist (CP) Comments report dated 6/18/24 revealed a recommendation concurrent use of Farxiga and Jardiance may be considered duplicate therapy. Please document clinical rationale if continuing present therapy. On 6/23/25 at 2:02 PM, the surveyor asked the Director of Nursing (DON) for any evidence the resident's physician had been notified of the potential duplication of therapy using Farxiga and Jardiance together. The DON was unable to provide documentation the orders had been clarified. On 6/24/25 at 1:44 PM, the survey team met with the facility Licensed Nursing Home Administrator and the DON. The DON explained the resident was a Hospice Respite admission and the resident's family would bring in the resident's medication list and medication bottles when he/she was admitted . The nurse would enter the medications into the computer after verifying with the physician and that's when the pharmacist would review the medications for irregularities including duplication of therapy. The surveyor asked for this report and the DON stated it was unavailable. On 6/25/25 at 1:12 PM, via telephone the surveyor interviewed the Regional CP for the facility, she was not the CP who made the recommendation on 6/18/24 to clarify the possible duplication of therapy. The CP was notable to confirm the physician had been contacted regarding the CP recommendations and stated the facility would have those records. When asked if in her professional opinion there was an indication to take Jardiance and Farxiga together she stated not that she was aware of. On 6/25/25 at 1:24 PM, the surveyor attempted to interview the resident's Nurse Practitioner (NP) via telephone. The surveyor left a message but did not receive a return phone call from the NP. On 6/25/25 at 2:25 PM, the DON and the LNHA acknowledged they were unable to locate the pharmacy reconciliation report. The DON further stated there was no documentation the CP recommendations were acted upon. The DON also acknowledged she was unaware of any indication for using both Farxiga and Jardiance together. The DON stated she believed the resident had used their own medications during their stay and that possibly the pharmacy substituted the Jardiance, but confirmed one of the medications should have been discontinued. 2. The surveyor reviewed the closed record for Resident #88. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included acute and chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, and pulmonary fibrosis (chronic lung disease when lung tissue becomes damaged and scarred) A review of the Order Summary Report (OSR) included the following physician's order (PO): Acetazolamide oral tablet 250 mg (milligram); give one tablet by mouth every 12 hours for diuretic, dated 8/25/24. A review of the corresponding September 2024 Medication Administration Record (MAR) revealed on three occasions the nurse documented 9. According to the key 9 indicated other- see nurses note. 9/5/24 6:00 AM 9, 9/5/24 6:00 PM 9, and 9/6/24 6:00 AM 9. A review of the corresponding Progress Notes revealed the following: On 9/5/24 at 6:31 AM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Medication not available, awaiting delivery from pharmacy. On 9/5/24 at 7:04 PM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Awaiting delivery from pharmacy. On 9/5/24 at 11:53 PM, acetazolamide 250 mg not available, a call was made to pharmacy, and I spoke to [redacted], and told me the medication is coming at midnight delivery. On 9/6/24 at 7:08 AM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Awaiting delivery from pharmacy. On 6/24/25 at 1:44 PM, the survey team met with the facility Licensed Nursing Home Administrator and the Director of Nursing (DON) stated the resident's records were reviewed and the nursing supervisor would enter the medication orders after reviewing them first with the attending physician. If a medication was not available, the nurse should have called the attending physician as to how to proceed. The DON further stated a medication could be considered stat and could be delivered within four hours. The DON reviewed the resident medical record and confirmed the nurse indicated the medication was not available and that the nurse should have documented the physician had been notified. On 6/25/25 at 2:39 PM, the surveyor interviewed the [NAME] President of special clinical projects who acknowledged the physician should have been notified the resident had not received their medication and they should have had medication delivered from the pharmacy stat. A review of the facility's Unavailable Medications policy with an effective date of February 2019, included .The facility must make every effort to ensure the medications are available to meet the needs of each resident .Nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies that are available . NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on long-term use of anticoagulant (type of medication that slows down the process of blood clotting) medication. This deficient practice was identified in 1 (one) of the 18 residents (Resident#18) reviewed for CP and was evidenced by the following: On 6/22/25 at 10:15 AM, the surveyor observed Resident #18 asleep in bed. On 6/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #18, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #18 was admitted with diagnoses that included but were not limited to atrial fibrillation (irregular heartbeat) and malignant neoplasm of the uterus (type of uterine cancer). A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) with an assessment reference date (ARD) (the last day of the observation period) of 4/11/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had an intact cognition. Further review of Q/MDS reflected in Section N- Injections - High-Risk Drug Classes: Use and Indication revealed that Resident #18 is taking anticoagulant medication. A review of the Order Summary Report (OSR) with the start date of 9/29/24, enoxaparin sodium injection solution 40 mg (milligram) subcutaneously (under the skin) in the morning for DVT (deep venous thrombosis, blood clot formation in the legs). A review of Resident #18's comprehensive CP review revealed no CP for anticoagulant use. On 6/25/25 at 9:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that there should be a CP for anticoagulants, as it can cause bleeding. On 6/25/25 at 9:20 AM, the surveyor interviewed the LPN/UM (Unit Manager), who stated that she had missed the CP for the anticoagulant for Resident #18 because it was a recent order. On 6/25/25 at 1:05 PM, the surveyor interviewed the Director of Nursing (DON) regarding the concern above. She stated that the anticoagulant should be in the CP. A review of the facility policy titled Care Plans, Comprehensive Person-Centered with the revised date of 3/2022 stated under Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. On 6/26/25 at 11:15 AM, the surveyor met with the Licensed Nursing Home Administrator, DON, and Regional Clinical Nurse for the exit conference; no further pertinent information provided. NJAC 8:39-11.2(d)

Complaint #NJ00175069 Based on interviews, medical record reviews, and a review of other pertinent facility documentation, it was determined that the facility failed to revise the comprehensive care plan (CP) interventions for 1 (one) of 18 residents (Resident #83) reviewed for a comprehensive CP. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #83 was admitted with diagnoses that included but were not limited to displaced bimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing disease, and dementia (loss of memory). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) on 6/18/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. Further review of A/MDS, as reflected in Section M - Skin Conditions, revealed that Resident #83 has a pressure reducing device for bed. A review of the June 2024 Order Summary Report (OSR) air mattress monitor for function and placement every shift, with a start date of 6/29/24. A review of the June 2024 Treatment Administration Record (TAR) revealed that the nurses documented that the air mattress was started on 6/29/24. A review of the form [Name Redacted] Wound Care dated 6/18/24 revealed a wound location to the coccyx to the buttock unstageable pressure ulcer (PU) with measurement of 5x7x0.1 with 100% necrotic material. Treatment recommendations include, but are not limited to, a low-air-loss mattress with measures in place for turning and positioning. A review of Resident #83's comprehensive CP review revealed actual skin breakdown related to coccyx PU initiated on 6/12/24. There are no interventions or tasks associated with a pressure-relieving air mattress. On 6/24/25 at 9:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that she would report the skin condition to her supervisor. The supervisor would then call the physician to inform them about the wound and request a treatment order, including an air mattress, and it should be added to the CP. On 6/24/25 at 9:14 AM, the surveyor interviewed the LPN/UM (Unit Manager), who stated that the CP should be updated if there is an additional order from the physician or wound doctor that includes a pressure relieving device. On 6/25/25 at 10:44 AM, the surveyor met with the Clinical Nurse/RN, who stated that the nurses failed to update the CP according to the physician's order. On 6/25/25 at 01:56 PM, the surveyor interviewed the Director of Nursing (DON) regarding the concern above but did not provide further information. A review of the facility policy titled Care Plans, Comprehensive Person-Centered with the revised date of 3/2022 stated under Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. On 6/26/25 at 11:15 AM, the surveyor met with the Licensed Nursing Home Administrator, DON, and Regional Clinical Nurse for the exit conference; no further pertinent information provided. NJAC 8:39-11.2(f)

Complaint #NJ00183311 Based on interview and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident abuse within two hours of being made aware of the allegation. The incident allegedly occurred on 11/23/24 when the Certified Nursing Assistant (CNA) allegedly inappropriately touched a resident during an initial skin evaluation (Resident #90). This deficient practice was identified for 1 of 3 investigations reviewed, and was evidenced by the following: On 6/24/25 at 9:49 AM, the surveyor reviewed the closed medical record for Resident #90 who was discharged from the facility. The surveyor reviewed the medical record for Resident #90. A review of the admission Record face sheet reflected the resident was admitted to the facility in November of 2024 with diagnoses which included acute cystitis (inflammation of the bladder caused by infection), other specified sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), diabetes and muscle weakness and difficulty in walking. A review of the most recent annual Minimum Data Set (MDS), and assessment tool dated 11/26/24, reflected a brief interview for mental status (BIMS) score of 14 out 15, which indicated an intact cognition and could understand others and make self-understood with clear speech. On 6/24/25 at 9:57 AM, the surveyor reviewed the facility provided Concern Form dated 11/27/24 the concern was reported to Assistant Director of Nursing (ADON) (now current Director of Nursing [DON]) reported by resident's family on day of discharge 11/27/24 was as follows: On 11/27/2024. received a report from patient's family member (redacted) that when the patient was admitted on [DATE] the family member thought they saw the CNA's hand on the residents private part. The family member stated they were in the room and both the nurse, and the CNA went in to do a skin assessment and after they turned the resident on their back this is when the family member thought they saw the incident happen. The family member however did not report this to any staff members. A review of the Nursing Progress notes revealed a resident evaluation dated 11/23/24 at 10:34 PM, which included the resident was oriented to time, place and person. Physical abilities were the resident required the assistance of one person for bed mobility, bathing and dressing. The resident was independent with eating but required total dependence with toileting (assistance of two persons), and transfers. At this time the resident's skin was assessed and revealed redness on the sacrum and a left flank opened blister. A further review of the resident's Progress Notes revealed the following: On 11/24/24 at 4:38 PM, the resident had a social service admission evaluation. There was no documentation the resident or family reported inappropriate touching. On 11/25/24 at 9:36 AM, the resident had an admission follow-up with the Nurse Practitioner (NP). There was no documentation the resident or family reported inappropriate touching. On 11/25/24 at 12:20 PM, the resident was seen by the Physician's Assistant (PA). There was no documentation the resident or family reported inappropriate touching. A review of the facility provided Investigation Report dated 11/27/24 completed by the DON which included a timeline of events. The events were as follows: On 11/27/24 at approximately 10:00 AM, Resident # 90's family met with the ADON and alleged while Resident # 90was having their skin assessed at the time pf admission on [DATE] the resident's family thought they witnessed the CNA place her hand on the resident's private part when turning them in bed. On 11/27/24 at approximately 10:15 AM, the DON and the ADON met Resident # 90 to discuss the allegation made by their family member. Resident # 90 was adamant and stated no one touched me inappropriately. The resident stated they did not know why their family member would say that. On 11/27/24 at approximately 10:30 AM. the DON left voicemails for the nurse and CNA who were accused for statements. On 11/27/24 at 3:00 PM, the DON and the ADON interviewed the CNA who stated she was with the nurse when Resident # 90 was admitted and assisted with turning and positioning the resident so the nurse could check their skin. The CNA denied the allegation of touching the resident's private part and stated her hand was on the resident's back while turning. On 11/27/24 at approximately 3:10 PM, the DON and ADON met with the Registered Nurse (RN) who stated nothing of that sort happened during the skin assessment. In addition, the report included that upon receiving the allegation from the resident's family member, the DON and ADON immediately went to speak with the resident. As per the resident the aide did not touch their private part. The DON reviewed the admission skin assessment dated [DATE] which included a left flank open blister and redness to the sacrum as well as that the resident was alert and oriented X 3 and denied any allegation of inappropriate touching. The investigation conclusion was After a thorough investigation including interviews with the staff and resident, the team has concluded that the allegation of inappropriate touching did not occur and was not substantiated. On 6/24/25 at 1:44 PM, the survey team met with the DON and the Licensed Nursing Home Administrator. The DON stated every staff member was responsible for reporting allegations of abuse, no matter the type of abuse. The LNHA and the DON both confirmed an allegation of sexual abuse should be reported to the NJDOH within two hours of when the allegation was reported. The LNHA stated he reviewed the reportable file from the previous LNHA and confirmed he could not find any additional documentation that this event was reported to the NJDOH as required. The LNHA stated he thought that if the facility could unsubstantiate an allegation before the two hours then the allegation did not have to be reported. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated revised September 2022, included . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours if an allegation that does not involve abuse or result in serious bodily injury . NJAC 8:39-9.4(f)

Complaint #NJ00175069 Based on the interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistently document an actual skin condition of the pressure ulcer (PU, damaged to the skin or underlying tissue) upon admission, b.) provide a necessary treatment and services consistent with professional standards of practice, to promote healing, and prevent worsening of a PU, c.) ensure pressure-relieving interventions according to the physician's order, and d.) consistently complete a weekly skin condition assessment. This deficient practice was identified in 1 (one) of 2 residents (Resident #83) reviewed for pressure ulcers/injuries. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #83 was admitted with diagnoses that included but were not limited to displaced bimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing disease, and dementia (loss of memory). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) on 6/18/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. Further review of A/MDS reflected in Section M - Skin Conditions revealed that Resident #83 has unstageable - slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) and/or eschar (a layer of dry, dead tissue that forms over a deep wound): known but not stageable due to coverage of wound bed by slough and/or eschar. A review of the Resident Evaluation assessment dated [DATE] revealed that the resident's Braden score (a tool used to predict risk for developing PU) is 14, which indicated moderate risk for developing pressure ulcers. Furthermore, there is no documentation of the site and description for the coccyx/buttocks PU. A review of the Progress Notes (PN), dated 6/11/24 at 7:53 PM, stated skin evaluation reveals current skin breakdown/skin conditions; refer to the completed evaluation and physicians' orders for type and location. A review of the PN dated 6/12/24 at 1:36 PM stated, second skin check findings include sacrum wound. A review of the June 2024 Order Summary Report (OSR) is as follows: 1. Phytoplex Z-Guard paste (petrolatum zinc oxide) applied to the sacral area topically every shift for a preventative measure for redness, with a start date of 6/11/24. 2. Cleanse the open area on the coccyx to the buttock with Dakin's 0.125% solution. Apply calcium alginate to the wound base, then cover it with a silicone foam dressing twice daily, starting on 6/20/24. 3. Bi-weekly skin observations every evening shift every Tuesday and Friday for 0- no skin breakdown, 1-previously identified wound, and 2-newly identified wounds with a start date on 6/14/24. 4. Braden scale on admission x 3weeks post admission, every evening shift, and every Tuesday for 3 weeks. Complete the Braden Scale in Forms. 5. Air mattress monitor for function and placement every shift, with a start date of 6/29/24. A review of the June 2024 Treatment Administration Record (TAR) stated that Bi-weekly skin observations every evening shift, every Tuesday and Friday, for 0- no skin breakdown, 1-previously identified wound, and 2-newly identified wounds with a start date on 6/14/24. The nurse documented 0 - no skin breakdown on the evening shifts of 6/14/24, 6/18/24, 6/21/24, and 6/25/24. There is no documentation for biweekly observations and Braden scale assessments for the 3 weeks following admission from the hybrid medical record. A review of the form [Name Redacted] Wound Care dated 6/18/24 revealed a wound location to the coccyx to the buttock unstageable PU with measurement of 5x7x0.1 with 100% necrotic material. Treatment recommendations include, but are not limited to, a low-air-loss mattress with measures in place for turning and positioning. A review of Resident #83's comprehensive CP review revealed actual skin breakdown related to coccyx PU initiated on 6/12/24 with a cancelled date on 7/30/24. There are no interventions or tasks associated with a pressure-relieving mattress. On 6/24/25 at 9:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that the process of admitting a new resident they check the skin condition, document it and if there is any pressure injury/wound she will report it to the supervisor then the supervisor will call the physician to inform about the wound to get a treatment order. She will inform the wound consult doctor who comes to the facility every Tuesday. On 6/24/25 at 9:14 AM, the surveyor interviewed the LPN/UM (Unit Manager), who stated that if the resident refused to be seen on the day of admission, she will go and meet the resident for a second skin assessment then document the PU in the Wound Assessment tab including the location, measurement, and the overall condition of the PU. On 6/24/25 at 10:01 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) who stated that there is a documented wound on 6/12/24, second skin check findings include sacrum wound and there is documentation from the wound doctor on 6/18/25 for unstageable PU. On 6/25/25 at 10:44 AM, the surveyor met with the Clinical Nurse/RN, who stated that the nurses failed to document or report the wound, may not have taken the measurement, and did not realize or recognize the need to complete the full assessment. The staff did order a treatment, but there should be an assessment or description of the wound, including the size and the location of the pressure sores. On 6/25/25 at 12:51 PM, the surveyor interviewed LPN#2 over the phone, who stated that she no longer works at the facility and has forgotten the resident, as the incident occurred in 2024. The LPN#2 added that she must have missed the documentation for the PU, and it should be documented, including the measurement and location of the wound. If the resident refused, she would report it to the nurse in charge. On 6/25/25 at 01:56 PM, the surveyor interviewed the Director of Nursing (DON) regarding the concern above and stated that the PU should be documented, including the measurement, and followed the physician's orders accordingly. A review of the facility policy title, Pressure Ulcer/Skin Breakdown-Clinical Protocol with the revised date of April 2018 stated under Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. On 6/26/25 at 11:15 AM, the surveyor met with the Licensed Nursing Home Administrator, DON, and Regional Clinical Nurse for the exit conference; no further pertinent information provided. NJAC 8:39-27.1(a,e)

Based on observation, interview, and record review, it was determined that the facility failed to follow a Physician's Order for an Oxygen (O2) dependent resident in accordance with professional standards of practice for 1 (one) of 2 residents, (Resident #45), reviewed for respiratory care. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 6/23/25 at 11:45 AM, the surveyor observed and interviewed Resident #45 awake in bed, with O2 via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 2.0 liters/minute (LPM), O2 running. Resident #45 stated they did not have any complaints of (c/o) shortness of breath (SOB) or breathing difficulty at that time. The surveyor reviewed the admission Record (AR; or face sheet; an admission summary) which revealed that the resident had been admitted to the facility with diagnosis that included chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia and chronic pulmonary hypertension. A review of the admission Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/22/25, revealed that the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident's cognition is intact. The MDS also reflected that the resident received continuous O2 therapy. A review of Resident #45's physician order (PO) revealed a PO, dated 6/10/2025, Oxygen at 3 LPM via N/C every shift for SOB. On 6/24/25 at 9:34 AM, in the presence of the Licensed Practical Nurse (LPN #1), the surveyor observed Resident #45 O2 machine set at 2.5 L/min. LPN #1 stated Resident #45's O2 should be set at 3 L/min, unable to state why the O2 was set at 2.5 L/min. On 6/24/25 at 10:30 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of a facility policy titled, Oxygen administration with a revision date of 10/2010. Under the preparation section of the policy it states, Verify there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Under the documentation section of the policy it states, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record .3. The rate of oxygen flow, route, and rationale. On 6/24/25 at 1:32 PM, the surveyor met with the Director of Nursing (DON) and LNHA to review concerns found during the survey. The DON stated any resident on O2 should receiving O2 as per the PO. On 6/26/26 at 11:15 AM, the surveyor met with the LNHA, DON and Regional Clinical Nurse for the exit conference. No further pertinent information provided. NJAC 8:39- 27.1 (a)

Based on record review, interview, review of facility grievances, and review of facility policy, the facility failed to implement their abuse policy when they did not identify an allegation of employee to resident abuse, failed to report the allegation in a timely manner, and failed to thoroughly investigate the allegation for one (Resident (R)48) of one residents reviewed for abuse allegations of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Reporting and Investigation dated July 2017 indicates that all reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by the facility management. The facility administrator is to suspend immediately all alleged perpetrators. Review of the electronic medical record (EMR) revealed R48 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA1 was removed from assignment. The final category or Resolution of Concern indicated CNA1 was removed from assignment. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized a complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over, and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. During an interview with the Director of Nursing (DON) and the Administrator on 11/30/23 at 10:00 AM, the DON said they did not see the report of concern as abuse. The Administrator revealed he was the abuse coordinator and responsible for making reports of abuse to the State Survey Agency (SSA). He confirmed the policy was not implemented as the allegation of abuse was not reported to the SSA in a timely manner, was not fully investigated, and CNA1 continued to work in the facility after the concern was reported on 11/07/23. NJAC 8:39-4.1(a)(5) NJAC 8:39-13.4(c)(i-vi)

Based on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of employee to resident abuse was reported immediately (within two hours) to the state survey agency (SSA) for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Prevention Program edited on 04/04/18 read in pertinent part, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility management. An alleged violation of abuse will be reported immediately but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Review of the electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category of a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA was removed from assignment. The final category or Resolution of Concern indicated CNA was removed from assignment. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. Review of the forms titled 7-3 Daily Assignment Sheet (5) dated 11/07/23 provided by the Director of Nursing (DON) revealed CNA1 was assigned to R48 on day shift. On 11/08/23 the 7-3 Daily Assignment Sheet (4) revealed CNA1 was assigned to R48 and then changed to another room on the same unit. Review of the Investigative Report provided by the facility revealed the allegation of employee to resident abuse was not sent to the SSA until 11/30/23, however R48 reported the allegation to staff on 11/07/23. During an interview with the Director of Nursing (DON) and the Administrator on 11/30/23 at 10:00 AM, the DON said they did not see the report of concern as abuse. The Administrator revealed he was the abuse coordinator and responsible for making reports of abuse to the State Survey Agency (SSA). He confirmed R48's allegation of abuse was not reported to the SSA until 11/30/23, 23 days after the allegation was made. During an interview with CNA1 on 11/30/23 at 10:20 AM she revealed she did not work with R48 the morning of the accusation, however, later indicated that she did take her off the bed pan and left room. She also acknowledged that she had worked with her as a CNA the two days prior to the allegation. She also verified that she was reassigned on 11/08/23 or after the allegation, however, was not suspended from the facility. Interview with R48 via phone on 11/30/23 at 12:00 PM confirmed CNA1 was always nasty. She took my legs off the pillow, took the sheets and blankets at my feet, and twisted them hurting my feet and ankle. R48 revealed she was wearing her hospital gown with a tie at the neck and CNA1 pulled the gown down on her neck. R48 revealed she told CNA1 she didn't want her in her room. R48 alleged that CNA1 knocked the phone out of her hand to the floor while she was trying to call for help. She hurt my foot, and it hurts now more than it did before. R48 revealed she did report the incident to facility staff on 11/07/23. NJAC 8:39-9.4(f)

Based on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of staff to resident abuse was thoroughly investigated in a timely manner for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Prevention Program edited on 04/04/18 read in pertinent part, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility management. Role of the investigator: The individual conducting the investigation will, at a minimum; interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (as medically appropriate); interview the roommate; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. Review of the electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA was removed from assignment. The final category or Resolution of Concern indicated CNA was removed from assignment. CNA1's statement indicated on 11/7/23 the nurse notified me and told me that the pt (patient) complained about the care that was given to her. At that time, I haven't given the pt (patient) any type of care. LPN2's statement included On 11/7/23 the Physical Therapist (actually the Occupational Therapist) came to me and brought some concerns regarding care of R48. At the time, the CNA had not provided care as of yet. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. Review of the forms titled 7-3 Daily Assignment Sheet (5) dated 11/07/23 provided by the Director of Nursing (DON) revealed CNA1 was assigned to R48 on day shift. On 11/08/23 the 7-3 Daily Assignment Sheet (4) describes CNA1 assigned to R48 and then changed to another room on the same unit. Review of the facility Investigation provided by the facility of the Concern reported regarding the allegation of employee to resident abuse on 11/07/23 failed to include interviews with residents on the unit that were being cared for by CNA1 on the day in question and preceding days, and failed to document such interviews, and failed to interview staff on the unit and document to determine if they were aware of any incidents between CNA1 and R48, or any other residents. Interview with the Director of Nursing (DON) and Administrator on 11/30/23 at 10:00 AM revealed we did not see this as abuse as R48 is unreliable and CNA1 indicated she was not in the room at the time of the allegation. The Administrator confirmed the resident was unreliable, and staff were not in the room. They both confirmed the internal investigation was completed as a Concern and was not thorough and lacked interviews from other residents who had been cared for by CNA1, and failed to interview staff on the unit to determine if they had knowledge of any incidents between CNA1 and R48. There was nothing noted in R48's Care Plan related to her being unreliable. Interview with CNA1 on 11/30/23 at 10:20 AM revealed she did not work with R48 the morning of the accusation, however, later indicated that she did take her off the bed pan that day and left room. She also acknowledged that she had worked with her as a CNA the two days prior to the allegation. She also verified that she was reassigned on 11/08/23 or after the allegation, however, was not suspended from the facility. A further interview with the DON 11/30/23 at 11:00 AM revealed that CNA1 has now been suspended. The DON confirmed R48 did not have a Care Plan related to being unreliable. Interview with R48 via phone call on 11/30/23 at 12:00 PM confirmed CNA1 was always nasty. She took my legs on the pillow, took the sheets and blankets at my feet, and twisted them hurting my feet and ankle. R48 revealed she was wearing her hospital gown with a tie at the neck and CNA1 pulled the gown down on her neck. R48 revealed she told CNA1 she didn't want her in her room. R48 alleged that CNA1 knocked the phone out of her hand to the floor while she was trying to call for help. She hurt my foot, and it hurts now more than it did before. R48 revealed she did report the incident to facility staff on 11/07/23. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f) NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and failed to store food in accordance with the professional standards for food service safety to prevent the development of food borne illness. This deficient practice was evidenced by the following: On [DATE] at 10:50 AM, the surveyor toured the kitchen along with Director of Culinary Services (DCS). During the tour, the surveyor observed the following: 1.) The high temperature dishwasher was observed with a temperature of 177 degrees Fahrenheit (F) during the rinse cycle. The surveyor instructed the DCS to run the dishwasher for a second rinse cycle which displayed a temperature of 176 degrees F. The DCS ran the dishwasher for a third rinse cycle that showed a temperature of 177 degrees F. The DCS stated that the temperature should have reached 180 degrees F during the rinse cycle as recommended by the Food and Drug Administration food code. 2.) In the walk-in refrigerator the surveyor observed 26 small milk cartons containing 4 ounces (118 mL) fat free milk in each carton that had expired. The surveyor interviewed the DCS who stated that the milk should have been discarded since it had passed it's expiration date. On [DATE] at 11:30 AM, the surveyor discussed the above concern to the Administrator, Assistant Director of Nursing and the Regional Registered Nurse. No further information was presented. NJAC 8:,d+[DATE].1(a);17.2(g)

Based on record review, interviews, facility policy review, and Centers for Disease Control (CDC) publication, the facility failed to: 1. Obtain written consent for the administration of an influenza immunization for one (Resident #2) of five sampled residents reviewed for influenza and pneumonia immunizations; 2. Offer a PPSV23 pneumonia vaccine per CDC guidelines to two (Residents #2 and #3) of five sampled residents reviewed for influenza and pneumonia immunizations. These deficient practices had the potential to affect all 89 residents who resided in the facility. Findings included: Reference: The CDC's Pneumococcal Vaccine Timing for Adults information sheet, dated 06/25/2020, (www.cdc.gov/pneumoccal/vaccination.html) indicated: Adults [AGE] years without an immunocompromising condition .For those who have not received any pneumococcal vaccines, or those with unknown vaccination history - If patient and provider decide PCV13 is not to be given: Administer 1 dose of PPSV23. - If patient and provider decide PCV13 is to be given: Administer 1 dose of PCV13. Administer 1 dose of PPSV23 at least 1 year later .For those who have previously received 1 dose of PPSV23 at (or above) [AGE] years and no doses of PCV13 - If patient and provider decide PCV13 is not to be given: Series is complete. No additional doses indicated. If patient and provider decide PCV13 is to be given: Administer 1 dose of PCV13 at least 1 year after the dose of PPSV23 for all adults, regardless of medical conditions . 1. Resident #2's admitted was 06/01/2018. Documentation in the Immunization tab of the electronic health record (EHR) indicated the resident had been administered the influenza vaccine on 10/01/2020. There was no evidence in the electronic health record (EHR) which indicated the resident/resident's representative had given consent for the influenza vaccine. Documentation in the Immunization tab of the EHR indicated the resident had been administered the PCV13 pneumonia vaccine on 01/20/2016. There was no evidence in the EHR which indicated the resident/resident's representative had been offered the PPSV23 pneumonia vaccine per CDC guidelines. On 01/06/2021 at 4:22 PM, the Administrator, Director of Nursing (DON), and the Infection Control Preventionist (ICP) were interviewed. When asked if consent for the administration of the influenza vaccine had been obtained prior to administration, the DON stated, No. When asked if the PPSV23 pneumonia vaccine had been offered to the resident/resident's representative, the DON stated, No. 2. Resident #3's admitted was 04/01/2017. Documentation in the Immunization tab of the EHR indicated the resident had been administered the PCV13 pneumonia vaccine on 03/29/2017. There was no evidence in the EHR which indicated the resident/resident's representative had been offered the PPSV23 pneumonia vaccine per CDC guidelines. On 01/06/2021 at 4:23 PM, the Director of Nursing (DON) was asked if the PPSV23 pneumonia vaccine had been offered to the resident/resident's representative per CDC guidelines. The DON stated, No. The facility's Influenza Vaccine policy and procedure, reviewed/revised 10/2019, indicated: .A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. The policy did not address obtaining a consent for the administration of the influenza vaccine prior to administration. The facility's Pneumonia Vaccine policy and procedure, revised 10/2019, indicated: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . N.J.A.C. § 8:39-19.4(h) N.J.A.C. § 8:39-19.4(i)

Based on observation, interview and record review, it was determined that the facility failed to ensure a fast-acting insulin was administered with a breakfast meal in accordance with professional standards of nursing practice and physician orders. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #76). The evidence was as follows: The surveyor reviewed the medical record for Resident #76 on 9/18/19. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/28/19 reflected that Resident #76 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS assessment further reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating fully intact cognition. It further reflected that the resident required an extensive one-person assistance with eating. A review of the resident's individualized, comprehensive care plan initiated on 8/22/19 documented that the resident was dependent on insulin, an injectable medication used to lower blood sugar levels. The goal included that the resident will be free from complications related to his/her disease process. Interventions included, Administer medications per physician orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. The order specified to inject four (4) units subcutaneously (under the skin) with meals for diabetes mellitus. The eMAR noted the insulin was scheduled to be administered at 8:00 AM, 12:00 PM and 5:00 PM. On 9/19/19 at 9:08 AM, the surveyor observed Resident #76 in bed with his/her legs dangling off the edge of the bed. There was a covered breakfast tray on the resident's bedside table positioned against the wall. The breakfast tray had not been touched. The resident stated that he/she did not eat breakfast yet. At that time, the resident's assigned Licensed Practical Nurse (LPN) entered the resident's room. The surveyor observed the LPN assist the resident to sit up on the edge of the bed, and the LPN opened the resident's breakfast meal. The breakfast tray included two mini-muffins, hot oatmeal, and apple juice. The LPN began pouring the hot oatmeal onto the open space on the resident's plate. The LPN stated she was setting up the breakfast meal to speed up the process, so it would be easier for the resident to eat. The resident stated that he/she had some nausea and the LPN encouraged the resident to try and eat because she had administered insulin to the resident that morning. The resident took the first bite of breakfast at 9:10 AM. At 9:12 AM, the surveyor interviewed the LPN who stated that she checked the resident's fasting blood sugar that morning, and the result was 114 (normal fasting glucose range is typically 65-99). The LPN stated that she administered [MEDICATION NAME]this morning, guessing that she administered it around 8:30 AM. The surveyor inquired about how quickly fast-acting [MEDICATION NAME]began to work, and the LPN replied within 15 to 30 minutes, and that it was supposed to be given with the meal so the blood sugar doesn't drop too low. The LPN stated that she gave the insulin when the cart of trays were delivered to the unit. She stated that she did not offer/assist the resident in setting up the breakfast tray until 9:08 AM this morning, because she believed the resident was able to do it independently. She acknowledged that the resident had not eaten food since she administered the insulin. At 9:14 AM, the surveyor interviewed the Registered Nurse (RN) at the desk. The RN stated that [MEDICATION NAME] was a fast-acting insulin and that the resident needed to eat within an hour of giving the insulin. At 9:36 AM, the surveyor interviewed Resident #76 a second time. The surveyor observed that the resident had consumed 100% of the breakfast meal. The resident stated that the nurses check the blood sugar before every meal and that the blood sugars were always above 70. The surveyor inquired if the resident was able to decipher if he/she had a low or high blood sugar based on how he/she felt, and the resident stated that he/she only felt symptoms if the blood sugar was low. The surveyor asked what he/she would feel when it would be low, and the resident stated, I would feel weird. The surveyor asked the resident what he/she meant by weird and the resident replied, I don't know, just weird. The resident denied having any symptoms of low blood sugar while a resident at the facility, adding that the nurses were on top of all that. The surveyor asked if the resident had a preferred time he/she liked to be served breakfast, and the resident denied having a preference. At 9:39 AM, the surveyor interviewed a second LPN (LPN #2), regarding the fast-acting [MEDICATION NAME] insulin. LPN #2 stated that [MEDICATION NAME] worked within 15 minutes of injecting it, and that the resident should have the insulin with a meal. At 9:49 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM stated that [MEDICATION NAME] was a fast-acting insulin that worked within 15 minutes. The RN/UM acknowledged that if the order specified to administer the insulin with a meal, the resident should be set up with the tray and ready to eat at the time the insulin was administered. The surveyor reviewed the Location of Administration Report for (MONTH) 2019 that accompanied the eMAR for (MONTH) 2019. The report reflected that the [MEDICATION NAME]was administered to the right lower quadrant of the abdomen on 9/19/19 at 7:51 AM that morning. On 9/23/19 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the LPN had seen the breakfast trays delivered to the unit that morning and she assumed the resident would be eating soon. The DON stated that [MEDICATION NAME] was a fast-acting insulin and worked within 15 minutes of administration. She acknowledged that if the physician order [REDACTED]. She stated that the resident was asymptomatic and that the HBA1C (blood test used to determine blood sugar levels over a period of time) was within a normal range. A review of the manufacturer specifications revised 1/2015 for [MEDICATION NAME]included, [MEDICATION NAME] has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal . NJAC 8:39-29.1; 29.2

Based on observation, interview, and record review, it was determined that the facility failed to a.) complete the required documentation on the Controlled Drug Administration Record, and b.) document Nurse signatures on the Controlled Drugs-Count Record. This deficient practice was evidenced by the following: 1. On 8/7/18 at 11:05 AM on the Lexington Unit in the presence of the Licensed Practical Nurse (LPN), the surveyor reviewed the Controlled Drug Administration Record (CDAR) (a narcotic medication sheet used to document the date a medication was used, the nurse's signature and a declining count of the medication)for Medication Cart #2. The CDAR revealed the count-down medication documentation for 30 tablets of [MEDICATION NAME] 1 mg (milligram) (an anti-anxiety medication) for Resident #12. The surveyor further observed, in the upper right-hand corner of the CDAR, the facility would document the Amount Received, the Date Received, and the Nurse Signature when the medication was received from the pharmacy. The surveyor observed the Nurse Signature was blank. At that time, the surveyor interviewed the LPN. The LPN confirmed the missing signature and was unable to provide further information. On 8/7/18 at 11:25 AM on the Canterbury Unit in the presence of a Licensed Practical Nurse (LPN), the surveyor reviewed the following CDAR forms for Medication Cart #2: One CDAR sheet for 30 tablets of [MEDICATION NAME] 5 mg (a pain medication) for Resident #29. One CDAR sheet for 30 tablets of [MEDICATION NAME] 5 mg for Resident #112. One CDAR sheet for 18 tablets of [MEDICATION NAME] 5 mg for Resident #112. The surveyor observed the Amount Received, Date Received and Nurse Signature on the upper right-hand corner of each CDAR sheet was blank. At that time, the surveyor interviewed the LPN. The LPN confirmed the missing documentation and was unable to provide further information. 2. On 8/7/18 at 11:25 AM on the Canterbury Unit for Medication Carts #2 and #4, the surveyor reviewed the Controlled Drugs-Count Record (a sheet used to document the shift-to-shift count of narcotic medications in the medication cart) sheets for the months of June, (MONTH) and (MONTH) (YEAR). The surveyor identified nurse signature blanks on the shift-to-shift Controlled Drugs-Count Records as follows: On the Canterbury Unit Medication Cart #2: 6/18/18 (7-3 shift Nurse Off ), 6/25/18 (11-7 shift Nurse On), 6/27/18 (7-3 shift Nurse Off), 6/29/18 (7-3 Shift Nurse Off), 7/11/18 (7-3 Shift Nurse Off), and 8/5/18 (11-7 Nurse On). On the Canterbury Unit Medication Cart #4: 7/29/18 (7-3 Shift Nurse Off). The surveyor reviewed the facility's Controlled Drugs Count Record (CDCR) / Controlled Drug Index (CDI) - New Jersey policy with an effective date of 8/1/10. The policy revealed, Maintaining an accurate inventory of controlled drugs must occur. The policy further revealed, Purpose: To ensure that all controlled substances are accounted in the center in manner that promotes proper security and accountability. The policy stipulated a process that included, 1. At the change of each shift and/or at any time in which the narcotic keys are surrendered to another responsible party, the outgoing responsible party will count all controlled drugs with the incoming responsible party. 2. Accounting will be documented on the Controlled Drug Count Record (CDCR) form. 3. Both responsible parties will count the number of bingo cards, packs/boxes, and bottles and document the count on the designated spaces. The outgoing responsible party fills out the first column and the incoming responsible party completes the second column on each shift and signs on the designated line to acknowledge that the count was correct on the CDCR form. On 8/9/18 at 1:30 p.m., the surveyor met with the facility's Administrator and the Director of Nursing. The Director of Nursing confirmed the findings and stated that the Controlled Drugs Administration Record and Controlled Drugs-Count forms should have been completed. NJAC 8:39-29.7

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure medications were labeled appropriately in 1 of 3 medication carts reviewed, and b.) ensure a multi-dose Mantoux vial was appropriately dated when opened in 1 of 1 medication storage units reviewed. This deficient practice was evidenced by the following: 1. On 8/7/18 at 11:45 AM on the Canterbury Unit, in the presence of a Licensed Practical Nurse (LPN), the surveyor reviewed the medication inventory of Medication Cart #4. The surveyor observed ten (10) multi-dose [MEDICATION NAME] Sodium 1 ml (milliliter) (an anticoagulant medication) vials for Resident #55. The surveyor observed the [MEDICATION NAME] vials were unopened and stored in a resealable plastic bag with the resident's name, room number, and [MEDICATION NAME] written on the plastic bag with a black marker. The surveyor observed the resealable plastic bag did not reveal a label from the pharmacy. At that time, the surveyor interviewed the LPN. The LPN confirmed the surveyor's findings and stated that the resealable plastic bag that contained the resident's [MEDICATION NAME] vials should have had pharmacy label. The surveyor reviewed the facility's Labeling of Medication Containers policy with a revision date of (MONTH) 2007. The policy revealed, All medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations. 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drugs containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Direction for use. The surveyor reviewed the facility's Storage of Medications policy with a revision date of (MONTH) 2007. The policy revealed, 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 2. On 8/8/18 at 11:47 AM, in the presence of the Assistant Director of Nursing (ADON), the surveyor inspected the medication storage room on the Canterbury Unit. The surveyor inspected the medication refrigerator and identified one Mantoux vial (screening test for [MEDICAL CONDITION]) with an expiration date of (MONTH) 16, 2020. The surveyor observed the vial was in the original box with a broken seal and the rubber [MEDICATION NAME] (location to insert a needle) was not covered with a cap and exposed to air. The surveyor observed the vial was not dated. At that time, the surveyor interviewed the ADON. The ADON confirmed that the vial was opened and undated. The ADON further stated the vial should have been dated when opened. On 8/9/18 at 1:30 PM, the surveyor interviewed the Administrator and Director of Nursing (DON). The DON stated the vial should have been dated when opened. NJAC 8:39-29.4

Based on observation, interview and record review it was determined that the facility failed to provide personal privacy to a resident during care. This deficient practice was identified for 1 of 22 residents, Resident #22, reviewed for privacy/dignity as evidenced by the following: On 6/8/17 at 10:00 a.m., the UM stated that Resident #22 was interviewable, on medication for [MEDICAL CONDITION] and paranoid delusions and was currently receiving therapy for generalized weakness. On 6/14/17 at 09:06 a.m., the surveyor was walking down the hall past the shower suite and observed Resident#22 through a doorway in one of the shower room stalls. The resident was in a sitting position and unclothed. At that time the UM observed the surveyor stopped in front of the shower suite and got up from the nurses' station (located directly in front of the shower suite) to investigate. The UM immediately walked into the shower room and closed the main door of the shower suite behind her. At 9:30 a.m., on the above date, the surveyor interviewed the CNA who stated multiple people could utilize the shower room simultaneously and that was why he did not close the main door. He further stated that he pulled the shower curtain while providing the shower but he may have shifted the curtain with his body while providing care to the resident. The resident declined an interview with the surveyor at 10:25 a.m., that day. At 10:39 a.m., the surveyor toured the shower room while it was not in use. The surveyor observed that there were two doors, which were not closed, between the surveyor's line of sight and where the resident was seated at the time of the observation. At 12:30 p.m., during a meeting with the Administrator and the Director of Nursing (DON), the surveyor reviewed the policy provided by the DON regarding quality of life and dignity. The policy stated that residents should be cared for in a manner that promoted and enhanced dignity and respect. Under section #10, the policy further stated that the staff should promote, maintain and protect residents privacy, including bodily privacy during assistance with personal care. The Administrator stated that the resident should have had privacy while in the shower suite. On 6/14/17 at 1:00 p.m., the Director of Nurses' provided evidence of inservice training that was conducted with staff after the above incident. The training session was titled Resident Privacy, shower doors will be closed at all times when residents are being showered. NJAC 8:39-4.1(a)12 NJAC 8:39-4.1(a)16

Based on observation, interview and record review, it was determined that the facility failed to consistently document administration of enteral protocol to a resident receiving nourishment and hydration through a feeding tube. This deficient practice was identified for Resident #3, 1 of 2 residents reviewed for enteral feeding, as evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a Licensed Practical Nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/8/17 at 10:00 a.m., the surveyor toured the unit with the Unit Manager (UM). Resident #3 was observed in the bed with the curtain pulled closed, receiving care. The UM stated that the resident received enteral nutrition through a gastrostomy tube (G tube). The surveyor reviewed the resident's medical record on 6/09/17 at 9:05 a.m., which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the June 2017 physician's orders [REDACTED]. On 6/9/17 at 11:20 a.m., the surveyor reviewed the June 2017 Medication Administration Record (MAR) and observed multiple blank spaces, where nurses initials would verify administration of the nutrition and hydration. Further review revealed blank spaces on the May 2017 and April 2017 MAR. The surveyor spoke to the nurse who stated the 8:00 a.m. bolus feed and flush had been provided but not signed for. The nurse further stated there are a lot of distractions, sometimes you end up missing things. On 6/14/17 at 11:15 a.m., the surveyor reviewed the facility's Policy and Procedure for Enteral Nutrition Feedings. Under Process, #22 revealed that a signature documenting the procedure was required after the procedure was completed. At 11:25 a.m., the surveyor interviewed the medication nurse, who stated enteral feeding and flushes documentation were only written on the MAR and there was no other place where administration would have been documented. NJAC 8:39- 29.2(d)

Based on observation, interview and record review, it was determined that the facility failed to discard used indwelling catheter bags in a manner consistent with infection control practices, to prevent disease and infection. This deficient practice was identified for 1 of 3 residents reviewed with indwelling catheters, Resident #10, as evidenced by the following: On 6/8/17 at 10:00 a.m., the surveyor observed Resident #10 in bed. The resident had an indwelling urinary catheter (in a dignity bag) to overside drainage fastened to the left side of the bed. Clear amber colored urine was observed in the catheter tubing. The surveyor reviewed the medical record of Resident #10 on 6/9/17 at 9:30 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. On 6/9/17 at 9:55 a.m., the CNA caring for the resident told the surveyor that the resident uses a leg bag for urinary drainage when out of bed. At that time the surveyor observed a used leg bag in the resident's bathroom in a plastic bag. The tubing was noted to be uncapped. On 6/12/17 at 10:00 a.m., the surveyor observed two urinary catheter leg bags hanging from a rail in the resident's bathroom. Both bags were noted to have traces of urine in them. On 6/12/17 at 1:00 p.m., the surveyor reviewed the facility policy titled Urinary Leg Drainage Bags. Under the section Steps in the Procedure, #14, the policy indicated to Discard used urinary leg drainage bag into designated container. The Director of Nurses' (DON) confirmed to the surveyor at that time, that a new leg drainage bag should be used each time. On 6/13/17 at 10:00 a.m., the DON provided evidence of staff education on 6/12/17, on all shifts, titled Disposal of drainage bags, Immediate disposal of both drainage leg bags and drainage storage bags. NJAC 8:30-19.4 (a)