Every finding on record at Careone at Valley

Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 4/23/26 and 4/24/26, it was determined that the facility failed to provide a safe environment for its residents. The facility failed to ensure that a resident (Resident #2) who was an elopement risk upon admission, remained in the facility. The facility failed to provide adequate supervision to prevent residents from eloping from the facility. This deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #2).A review of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) was dated 4/17/26 and contained information regarding Resident #2's elopement. Resident #2 eloped from the facility which led the facility initiate a Code grey for a missing resident. Resident #2 was located at home after answering the facility's phone call to them and was escorted back to the facility with a staff member from the facility who lived in Resident #2's vicinity. Resident #2 did not suffer any harm from this elopement.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: cellulitis of the abdominal wall (a bacterial skin infection characterized by red, hot, swollen, and tender skin), atelectasis (a condition resulting from airway blockages which can cause breathing difficulties), and muscle weakness.According to the Minimum Data Set (MDS), an assessment tool dated 4/17/26, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired.A review of Resident #2's Care Plan (CP) revealed that the CP had been initiated on 3/19/26 under Focus, Elopement risk related to New admission/change of environment -Wanderguard to left wrist. Under Interventions, Accompany to meals and scheduled activities, allowed to vent feelings and/or frustration as needed, ask family/visitors to notify staff when leaving following patient visit, check for placement and function of security bracelet as indicated, elicit family input into former customary routine which might explain attempts to leave unescorted, engage in activities/tasks to keep occupied.A review of the facility's summary and conclusion for this FRE stated that: An immediate review of surveillance footage by the Administrator and Environment Services Director (JV), confirmed that the wander-guard alarm system engaged and a manual reset was entered by the receptionist, as no one was in the immediate lobby area when the receptionist disengaged the alarm. As per review of this event, the resident appeared from behind the receptionist after the code was entered and exited through the door. (Resident #2) was dressed in a jacket and carrying large envelopes, presenting as a visitor.On 4/23/26 at 9:16 AM, Resident #2 refused an interview with the surveyor stating that they were eating breakfast and the surveyor was instructed to speak to their roommate until they were done with breakfast.On 4/23/26 at 09:24 AM, Resident #2 finished their breakfast and when asked regarding when they left the facility, Resident #2 stated, I escaped from this place. I couldn't tell you when. I think everyone wants to go home. You don't have freedom. I want to get up and go. I feel like this is confinement. When asked how they left the facility Resident #2 stated, I walked out and I walked home and made sure not to get caught. No one helped me. I had to be careful. I don't remember the details.On 4/23/26 at 9:57 AM, the surveyor interviewed a Certified Nursing Assistant (CNA) from the facility regarding Resident #2 and Wanderguards. The CNA stated that Resident #2 is a wanderer who does not need assistance walking. The CNA also reported that Resident #2's picture is around the facility so that everyone knows to keep an eye out for Resident #2. She further stated that if she sees Resident #2 wandering or activating the Wanderguard alarm she will engage with Resident #2 and redirect them back towards their room or away from the doors. When asked about the Wanderguard system, the CNA said that the Wanderguard alarm system is very loud and comes from the door themselves. She said that if the resident or the Wanderguard that is activating the alarm is moved away and 10 seconds pass the alarm will turn itself off. The CNA said that even if a resident with a Wanderguard were to reach the exit doors, the doors would not open.On 4/23/26 at 10:29 AM, the surveyor interviewed a Licensed Practical nurse from the facility who was familiar with Resident #2. The LPN stated that Resident #2 was an elopement risk which is why Resident #2 has a Wanderguard. She said that Resident #2 walks around the facility a lot and if Resident #2 ends up setting the Wanderguard alarm off Resident #2 will walk themselves away from the alarm. The LPN also stated that Resident #2's picture is posted at the timeclock for employee as well as the nurses station and throughout the facility so that everyone can keep an eye out for Resident #2. The LPN revealed that Resident #2 is the only elopement risk for the long-term care portion of the facility as the other elopement risk for the facility resides in the assisted living memory center. The LPN also stated that Wanderguards are checked every shift by the primary nurse who has the resident with the Wanderguard in their assignment. When asked how she would respond to a Wanderguard alarm, the LPN replied: If a Wanderguard alarm goes off I will look around to see what is causing the alarm to go off because anything can happen. We have to make sure we can visualize the patient and make sure the patient is safe and able to be located.On 4/23/26 at 10:51 AM, the surveyor interviewed a Registered Nurse (RN) from the facility who was familiar with Resident #2. When asked about Resident #2 the RN said that Resident #2 likes to wander all over the place which is why they have a Wanderguard. The RN stated that Resident #2 typically doesn't set the Wanderguard alarm frequently and that Resident #2 is frequently rounded on to prevent Resident #2 from going towards the front entrance. When asked about what interventions are used when Resident #2 is wandering, the RN replied that Resident #2 is engaged in conversation for redirection. When asked about staff members response to a Wanderguard alarm the RN stated that the staff will get up and physically go check to see who is setting the alarm off. She further stated that the doors will automatically lock so that the resident can be located. She also stated that if the Wanderguard alarm is going off and a resident can't be located a Code Grey is started and administration and the resident's family are automatically notified.On 4/23/26 at 11:03 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON stated that in regards to Resident #2's elopement, the primary nurse from the 3pm-11pm shift realized Resident #2 was missing and a Code Grey was initiated. She stated that being able to locate a resident is important for safety and that there is a major highway right outside the facility doors so there is potential for a resident to get hit. The ADON stated that Resident #2's narrative of the elopement is inconsistent but that it would not be feasible for Resident #2 to have walked home because Resident #2's home was located about 35-40 minutes away by car with no traffic. The ADON also stated that Resident #2 is aware of their Wanderguard and the alarm system and stated that Resident #2 will often redirect themself away from the door when the Wanderguard alarm is activated. When asked if it was policy for the Wanderguard alarm to be manually turned off before the resident causing the alarm is located, the ADON stated no.On 4/23/26 at 11:26 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that if a resident is an elopement risk, the facility will identify that the resident is a wanderer and put interventions in place to prevent elopement such as a Wanderguard. The DON further stated that to her knowledge, when a Wanderguard alarm is activated, the alarm will not shut off unless it is de-activated. When asked about what staff is supposed to do when a Wanderguard alarm goes off the DON replied: If the alarm is going off staff are supposed to locate what is causing the alarm to go off. You typically search the area and once you locate what is causing the alarm to go off you enter the code.On 4/23/26 at 11:46 AM, the surveyor interviewed the receptionist who was working. The receptionist was questioned as to what she would do if a Wanderguard alarm went off. The receptionist replied: If I hear a Wanderguard alarm going off I look around to see who is setting the alarm off. I type in the code to stop the alarm. I check outside to see if anyone is outside but this is only if I can't locate who is setting the alarm off and then I will inform the Licensed Nursing Home Administrator (LNHA) and DON if I can't locate the resident. I can't leave the front desk. This is how I have been trained since I started here. I am able to text the LNHA and DON if they are not in the office immediately. We will also contact maintenance to make sure nothing is faulty with the system.On 4/23/26 at 11:59 AM, the surveyor interviewed the LNHA who summarized Resident #2's elopement and it correlated with the FRE submitted to the NJDOH. The LNHA stated that when Resident #2 entered the facility after being located the Wanderguard beeped. The LNHA was questioned on the Wanderguard system and how it worked. She replied that the Wanderguard works as sa radiofrequency and the sensor for the Wanderguard is at the Exit doors for the facility. When asked about how she expects staff to react to a Wanderguard alarm she stated that staff are trained to locate what is causing the alarm and that staff are aware who the elopement risks are for the building and emphasized that elopement risk resident pictures are everywhere throughout the facility. She also stated that the facility checks placement and function of a Wanderguard every shift. The LNHA also stated that the receptionists know not to deactivate the code manually if the source of the Wanderguard alarm is not located and how to handle other residents and visitors if they are upset by the alarm not being turned off. When asked how Resident #2 was able to leave the facility if the Wanderguard and alarm system were functioning properly, the LNHA stated that review of the surveillance footage revealed that because the receptionist did not see anyone in the lobby, she entered the code to disengage the alarm. She also stated that Resident #2 often likes to sit in the Magnolia lounge of the facility which is close to sensors in the Lobby exit doors and can trigger the Wanderguard alarm system. The LNHA stated that the receptionist enters the code, Resident #2 goes behind the receptionist fully dressed with papers and leaves the facility. The LNHA stated that Resident #2 was quick and looked different, however, that the receptionist should have questioned why the alarm was going off and done a better job to look around.On 4/23/26 at 12:43 PM the surveyor interviewed DON and LNHA together. The LNHA stated that believes the receptionist believed Resident #2 was a visitor leaving when Resident #2 walked behind her. The LNHA stated that the process is that if the Wanderguard alarm is going off, the supervisors are notified, and the supervisors will do a headcount of the residents. The surveyor asked if that is what occurred the night of Resident #2's elopement and the LNHA and DON both did not respond.On 4/24/26 at 9:00 AM, the surveyor requested a Wanderguard and sat in the Magnolia lounge. The surveyor could not hear the alarm system alarming, however once exiting nursing station 3 and entering the lobby the alarm could be hear. The receptionist was requested to disengage the alarm after the LNHA confirmed the Wanderguard was with the surveyor.On 4/24/26 at 10:12 AM, the surveyor interviewed the LNHA regarding the receptionist's statement related to Resident #2 eloping. The surveyor questioned if the receptionist notified the facility about an elderly woman leaving the facility after the Code Grey was initiated. The LNHA stated that the receptionist reported that she had not seen Resident #2 and that Resident #2 looked different dressed up and holding papers.On 4/24/26 at 10:45 AM, the surveyor and LNHA activated the Wanderguard together to observe if the exit doors automatically lock and if the alarm would shut off when the Wanderguard was moved away from the sensor. The alarm did not go off until a manual code was entered.On 4/24/26 at 10:54 AM, the surveyor heard the Wanderguard alarm and went to observe what was happening as the lobby was empty. Resident #2 was sitting in the Magnolia lounge causing the Wanderguard alarm to go off and when Resident #2 was redirected, the alarm disengaged.A review of the facility's policy titled, Wandering and Elopements, with a revision date of March 2019 included the following information under Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.N.J.A.C. 8:39-27.1 (a)

Based on observations, document review, interviews, and policy review, the facility failed to ensure that temperatures were obtained for all altered food prior to serving. This had the potential to negatively impact seven residents (Residents (R)16, R22, R8, R48, R52, R102, R86) who received Pureed food, seven residents (R18, R28, R46, R58, R104, R74, R90) who received Soft & Bite sized prepared foods, and two residents (R31, R1) who received Minced & Moist prepared food out of 85 residents reviewed for diet texture. Finding included: Review of the facility's policy titled, Food Preparation and Services dated 2001 revealed, .Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees F (Fahrenheit) during preparation or they are reheated to 165 degrees F for holding for hot service. During an observation and interview on 09/24/25 at 11:35 AM, the regular textured food was on the steam table and food temperatures were taken with the Dietary Manager (DM) present. The foods included plain pasta, vegetable medley, meatballs, shrimp scampi, and gravy. All temperatures were in the safe temperature range. The DM provided the Food Temperature/Sanitation Records dated 09/01/25 through 09/23/25. Review of 23 of 23 records revealed dietary staff had not obtained the temperature for the Small & Bite Sized, the Minced & Moist and the Pureed food. The DM stated they do not take the temperature of the altered food. He stated they would use the regular textured food temperatures for the altered food also. He confirmed altered food included Small & Bite Sized, Minced & Moist and Pureed. During an interview on 09/24/25 at 11:40 AM, the Administrator stated that the dietary staff did not need to take the temperature of the altered food because the temperature had been taken for the regular texture food which was satisfactory. During an interview on 09/24/25 at 2:34 PM, the Registered Dietician (RD) stated all food, regardless of texture, should be in the correct temperature range. During an interview on 09/25/25 at 3:01 PM, the Director of Nursing (DON) said it was important to have altered food at a safe temperature, and all food should be verified as it is in the correct temperature range prior to serving. NJAC 8:39-17.2(g)

Based on record review, interview, review of the McGeer's Infection Symptom Tracking criteria, and policy review, the facility failed to ensure one of two residents (Resident (R)71) reviewed for antibiotic use out of a sample of 24 residents received an antibiotic with justification for its use. This had the potential for R71 to receive an antibiotic unnecessarily and could potentially contribute to the development of antibiotic-resistant bacteria.Findings include:Review of the facility's policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated 12/2016revealed, The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.Review of the McGeer Criteria for Infection Surveillance Checklist revealed, .Clostridium Difficile Must fulfill 1 and 2, At least one of the following criteria: 1a. Diarrhea: (greater than) 3 liquid or watery stools above what is normal for the resident within 24h[hour], b. Presence of toxic megacolon (radiologic finding of abnormal large bowel dilatation) 2. At least one of the following diagnostic criteria: a. Stool sample positive for C difficile toxin A or B, or detection of toxin-producing C difficile by culture or PCR in stool sample, b. Pseudomembranous colitis identified in endoscopic exam, surgery, or histopathologic exam of biopsy specimen.Review of R71's admission Record from the electronic medical record (EMR) Profile tab showed an admission date of 09/04/25, with medical diagnoses that included chronic kidney disease, dementia, and congestive heart failure.Review of R71's Lab Report from the EMR under the Results tab, dated 09/16/25 revealed C. difficile PCR (Clostridium difficile, Polymerase Chain Reaction) Result Negative.Review of R71's Clinical Physician Orders from the EMR under the Orders tab revealed R71 received Vancomycin HCL (antibiotic medication) Solution 250 MG (milligram)/5 ML [milliliters] Give 2.5 ml by mouth every 6 hours for PPX (prophylaxis) for c-diff for 10 days. Start date 09/16/25. During an interview on 09/22/25 at 2:45 PM, Registered Nurse (RN) 3 stated R71 did not have C. difficile, and staff did not need to use any precautions when working with R71. She stated R71 had negative lab results for C. difficile but is taking Vancomycin prophylactic because of loose stools. During an interview on 09/24/25 at 2:00 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated R71 was started on Vancomycin prophylactic because she had C. difficile in the past. She stated they follow the McGeer's Infection Symptom Tracking criteria for Antibiotic Stewardship. During an interview on 09/25/25 at 2:14 PM, the ADON/IP stated she had talked to the doctor who said, he wanted to finish the course of antibiotics. She stated R71 did not have active Cdifficile but it was suspected because of her loose stools. She stated there were references of two loose stools in the progress notes. During an interview on 09/25/25 at 3:01 PM, the Director of Nursing (DON) stated it was important to follow the McGeer's Infection Symptom Tracking Criteria for Antibiotic Stewardship. NJAC 8:39-19.4(d)

Based on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R) 66) of 24 residents reviewed was invited to their scheduled care plan conference. Specifically, the facility failed to invite R66 to her care conference to discuss discharge plans. This had to potential to cause R66 uncertainty about her plan of care. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team dated 03/2022 revealed, Care plan meetings are scheduled at the best time of the day for the resident and family when possible.If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. Review of R66's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 09/11/25 with medical diagnosis of chronic obstructive pulmonary disease with exacerbation. Review of R66's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an assessment reference date (ARD) of 09/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R66 was cognitively intact. Review of the Care Conference Progress Note dated 09/18/25 located in the EMR under the Progress Note tab revealed, Family meeting held on 09/18/25 via phone. Department and individuals present are Social Services; Rehab; Nursing; Nutrition; Family participated in assessment and goal setting. Names of active participants: In attendance was the resident's cousin [cousin name] via phone call. Resident's overall goal is to be discharged to the community. (Apartment). During an interview on 09/22/25 at 10:15 AM, R66 stated, they don't tell me what is going on, I'd like to know when I'm going home. During an interview 9/24/25 at 9:16 AM, the Social Services Assistant (SSA) stated on the first day a resident admits to the facility she will complete the initial assessment and discuss the care conference. She stated at this time she will determine a date for the conference. She said if the resident is alert and oriented, she will ask the resident and ask if they had family they would like to invite to the conference. The SSA stated that when they held conference, R66 did not attend only R66's cousin. She stated she would document if the resident was asked and refused or if the resident attended. During an interview on 09/24/25 at 10:47 AM, the Director of Nursing (DON) stated residents should always be invited to their care conference. She stated if a resident refuses the SSA should document the refusal and document the reason for not going to the care conference. She stated the facility should always follow the policy. NJAC 8:39-11.2(e)

Based on observation, interview, and record review, it was determined that the facility failed to properly store a controlled and noncontrolled medications in a secure manner. This deficient practice was identified for one (1) of 3 units inspected and involved two Residents, Resident #123 and #122. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 6/4/24 at 11:55 AM, the surveyor inspected the medication cart located on Unit 2 of the facility in the presence of the Licensed Practical Nurse (LPN). The surveyor opened the top drawer of the medication cart and noted that there was a medication cup that contained 2 pharmacy wrapped unit dose medications. The surveyor inspected the 2 medications which were found to be Doxycycline 100mg Capsule (an antibiotic) and Oxycodone IR 5 mg tablet (Schedule II Opioid analgesic). The surveyor discussed the storage of the two medications, Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet in the medication cup with the LPN, who stated that he was not made aware by the previous shift that the unit dose Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet were in his cart. The LPN stated that he did not know which resident this belonged to. The LPN explained that if he was aware he would have questioned why they were there because the Oxycodone 5 mg should be stored in the locked narcotic box of the medication cart. On 6/4/24 at 12:00 PM, the Assistant Director of Nursing (ADON) joined the surveyor in investigating the Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet found in a medication cup in the top drawer of the medication cart. The ADON could not identify which resident the medications belonged to and The ADON stated that she was not aware of the medication left in the top drawer. The ADON added that she needed to investigate how and why these medications were left not properly secured in the medication cart, especially a Class II control substance. On 6/4/24 at 12:09 PM, the surveyor and ADON reviewed the medication back up System (Omnicell) printout for history of Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet activity. The Omnicell printout showed that on 6/1/24 at 16:11 (4:11 PM), 1 capsule of Doxycycline 100mg was removed for the Resident #123 as well as on 6/3/24 at 17:21 (5:21 PM), the printout showed that 2 tablets of Oxycodone IR 5 mg tablets were removed for Resident #122. The physical count for the Class II Controlled Substance Oxycodone IR 5 mg was shown to be correct in the Omnicell. On 6/4/24 at 12:15 PM, the surveyor interviewed the ADON who stated that when a medication is not administered, it needs to be destroyed, relating to the Doxycylcine 100mg and the Oxycodone 5 mg. She added that a control substance (Oxycodone 5 mg) should be stored separated in a double locked area and that the destruction of a control substance should be carried out by two nurses. The surveyor reviewed the medical record for Resident #123. A review of the Admission Record for Resident #123 reveals that the resident was admitted with diagnosis that include but are not limited to Fracture of Superior Rim of Left Pubis, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, and Primary Generalized Osteoarthritis. Review of the June 2024 electronic medication administration record (eMAR) documents a physician's order dated 6/1/24 for Doxycycline Hydrate 100 mg to be administered twice daily for skin/soft tissue infection for 10 days. The June eMAR documents the administration of the Doxycycline 100mg twice daily with no missed doses. Review of the Admission Record for Resident #122 reveals that the resident was admitted with diagnosis that include but are not limited to Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Type 1 Diabetes Mellitus and Anxiety Disorder. Review of the June 2024 eMAR documents a physician's order dated 5/31/24 for Oxycodone 10 mg every 6 hours as needed for severe pain (8-10) and Oxycodone 5 mg every 6 hours as needed for moderate pain (5-7). Documentation for administration for the Oxycodone 5 mg reveals that it was administered as (1) tablet on 6/3/24 at 17:35 (5:35 PM) even though (2) tablets were removed from the Omnicell at 17:21 (5:21 PM). The Director of Nursing presented an interview with LPN#2 who administered the Oxycodone 5 mg to Resident #122 on 6/3/24. This interview revealed that Resident #123 was going to therapy and requested pain medication. LPN#2 continued that the nursing supervisor went to the Omnicell and removed 2 tablets of Oxycodone 5 mg (logged into the Omnicell) but that Resident #122 only requested 1 tablet of Oxycodone 5 mg. LPN#2 stated that she forgot to destroy the extra Oxycodone 5 mg that was not administered. On 6/6/24 at 1:30 PM, the surveyor telephoned the Provider Pharmacy and spoke to a Pharmacy Technician who revealed that #30 tablets of Oxycodone IR 5 mg and #30 tablets of Oxycodone IR 10 mg were delivered to the facility for Resident #123 on 6/4/24 at 3:50 PM. The Pharmacy Technician explained that a Class II control substance does not automatically get transmitted, the pharmacy needs a physician's written and signed order. The Pharmacy Technician continued by stating that this is the reason that the facility has a back up medication unit, Omnicell so that there is no delay in treatment if medication is needed prior to the pharmacy delivery. The Pharmacy Technician stated that the order was received from the facility on 6/4/24 at 7:00 AM. The Pharmacy Technician stated that the Doxycycline 100mg was ordered and delivered on 6/1/24. Review of the Controlled Substances policy section Storing Controlled Substances, 1. Controlled substances are separately locked in permanently affixed compartments,. Documented under Dispensing and Reconciling Controlled Substances, 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. And 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. On 6/6/24 at 1:51 PM, the surveyor met with facility staff Clinical Reimbursement Coordinator, ADON, Director of Nursing, and [NAME] President of Special Clinical Projects who did not provide any further information. NJAC 8:39-11.2(b), 29.2 (a)(d)

Based on observation, interview, and review of pertinent medical records, it was determined that the facility failed to follow physician orders related to the use of continuous oxygen (O2) for 1 of 1 resident, Resident #3. This deficient practice was evidenced by the following: On 6/4/24 at 10:45 AM, the surveyor observed Resident #3, who was laying in bed in their room. Resident #3 was receiving O2 delivered through a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) utilizing a concentrator (an oxygen delivery system) at 3.5 Liters per minute (LPM). Resident #3 stated their O2 should be running at 4 LPM. The surveyor reviewed the resident's medical chart which included a review of a paper as well as computerized medical chart. A review of the Admission Record (a summary of important information about the resident) documented the resident was admitted to the facility on [DATE] with diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, Essential Hypertension, Morbid Obesity, and Obstructive Sleep Apnea. A review of an Annual Minimum Data Set (AMDS, an assessment tool to facilitate care), dated 5/7/24, documented the resident had a Brief Interview for Mental Status (BIMS) and scored a 15 out of 15, indicating that Resident #3 was cognitively intact. The AMDS further revealed Resident #3 is receiving continuous oxygen therapy. A review of the Physician's Orders (PO) and electronic treatment administration record (eTAR) documented a physician's order for, Oxygen at 4 Liters/minute with Humidification VIA: Nasal Cannula (NC) every shift for Acute Respiratory Failure with a start date of 5/20/24. A review of Resident #3's Care Plan (CP) with a revision date of 5/10/24 read, .At risk for respiratory impairment related to Asthma, COPD, morbid obesity, OSA. An intervention for the CP read, Administer oxygen per physician order. On 6/5/24 at 9:42 AM, the surveyor observed Resident #3's O2 concentrator, set at 3 1/2 L/min, second observation of O2 concentrator. On 6/5/24 at 9:45 AM, the surveyor interviewed Licensed Practical Nurse (LPN) caring for Resident #3. The LPN reviewed with the surveyor the PO for the resident's O2 settings. The surveyor informed the LPN of the two observations on 6/4/24 and 6/5/24 in which the resident's O2 setting was at 3 1/2 LPM. The surveyor accompanied the LPN to Resident #3's room to check the O2 settings. The LPN acknowledged the O2 was not set at 4 LPM as ordered by the physician. The LPN could not explain why the resident's O2 setting was at 3 1/2 LPM and adjusted the resident's O2 setting to 4 LPM. On 6/5/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Oxygen Administration, which had a revised date of October 2010. Under the Preparation portion of the policy it read, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the Documentation section of the policy it read, 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 6/6/24 at 1:42 PM, the survey team met with the LNHA, Director of Nursing (DON), Assistant Director of Nursing (ADON), [NAME] President of Special Clinical Project (VPSCP), and Clinical Reimbursement coordinator (CRC) The surveyor informed the facility about the concerns of the O2 setting for Resident #3. The DON stated the O2 should be administered according to physicians' orders. There was no further information provided. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 21 residents, Resident #69 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: Reference: According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023). This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. Code 99, Not Listed 1. On 6/06/24 at 9:36 AM, the surveyor reviewed the closed medical record for Resident #69 whose discharge MDS was coded for discharge to an acute hospital. The surveyor reviewed the 3/06/24 progress notes which indicated that Resident #69 was discharged home. Review of Resident #69's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to metabolic encephalopathy, acute kidney failure and diabetes mellitus. Review of the A section of the Discharge MDS for Resident #69 revealed that section A2105 Discharge Status documented, 04. Short-Term General Hospital. On 6/06/24 at 11:10 AM, the surveyor interviewed the Clinical Reimbursement Coordinator/MDS Coordinator (MDSC) regarding where Resident #69 was discharged to. The MDSC stated that she believed that Resident #69 went home. The surveyor asked the MDSC about Resident #69's Discharge MDS which was coded for discharge to the hospital. The MDSC stated that she thought it was an error in the coding and that she was going to check the medical record. The MDSC then confirmed that the Discharge MDS was coded incorrectly and that Resident #69 was discharged to home and not to a hospital. On 6/06/24 at 01:43 PM, in the presence of the survey team, the surveyor told the Licensed Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, VP of Special Clinical Projects and the Clinical Reimbursement Coordinator (CRC #2) the concern that Resident #69's Discharge MDS was coded incorrectly. CRC #2 confirmed that Resident #69's Discharge MDS was coded incorrectly and added that the facility modified the MDS. The facility did not provide any additional information. A review of the facility provided policy titled, Comprehensive Assessments with a revised date of March 2022 included the following: Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. N.J.A.C. 8:39-11.1, 11.2

Based on observation, interview, and record review, it was identified that the facility's housekeeper failed to practice appropriate hand hygiene in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19 and other infections. The deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a clean towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. On 12/16/22 at 12:22 PM, the surveyor observed a housekeeping staff member wearing disposable gloves in the COVID 19 unit emptying the used room gown bin (contaminated bin) from room [ROOM NUMBER] into a covered rolling container. The housekeeper proceeded to room [ROOM NUMBER], wearing the same dirty gloves and touching the doorknob to open the door. The surveyor further observed that same housekeeper empty the used gown bin (contaminated bin) from room [ROOM NUMBER] again, into the covered rolling container. The surveyor observed another facility staff member from the same COVID 19 unit instruct the housekeeper to stop emptying the dirty gown bins into the covered rolling container because the lunch trays were being served to the residents. The surveyor observed that the housekeeper removed his dirty gloves and continued holding onto and pushing the covered rolling container used to collect the dirty gowns from the unit. The housekeeper pushed the covered rolling cart containing the contaminated collected gowns with his bare hands while exiting the COVID 19 unit. The housekeeper was then observed discarding the used dirty gloves prior to exiting the COVID 19 unit and entering the laundry room, without sanitizing with Alcohol based hand rub gel (ABHR) or washing his hands. The surveyor interviewed the housekeeper who acknowledged that he did not apply ABHR gel nor washed his hands after removing his dirty gloves. The housekeeper acknowledged that he should have sanitized or washed his hands after leaving room [ROOM NUMBER] and prior to entering room [ROOM NUMBER]. The housekeeper added that he should have also washed his hands after removing his gloves and leaving the COVID 19 Unit. A review of the facility's policy titled Laundry and Linen under General Guidelines Standard Precautions explains, 2.) Wash hands after handling soiled linen and before handling clean linen. 3.) Consider all soiled linen to be potentially infectious and handle with standard precautions. On 12/16/22 at 1:30 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator, the Director of Nursing and Infection Preventionist who did not provide any further information. NJAC 8:39-19.4(a)(1) (2) (n)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to 1.) appropriately put on personal protective equipment (PPE) while in the rooms of residents on transmission-based precautions (TBP). This was observed for1 of 1 housekeepers on the unit, and 2.) failed to appropriately handle potentially contaminated items coming from TBP rooms for 2 of 2 Certified Nursing Assistants (CNA) observed and evidenced by the following: 1. On 8/4/22 at 10:45 AM, the surveyor observed a sign on the door to resident room [ROOM NUMBER]-46 which indicated that the residents were on Isolation Droplet/ Contact Precautions and that PPE including a gown, N-95 respirator, eye protection, and gloves should be worn while in the room. At the same time the surveyor observed the housekeeper inside room [ROOM NUMBER]-46 mopping the floor. The surveyor observed that the housekeeper wore a gown, N-95 respirator, and eye protection but did not have gloves on and mopped with bare hands. On 8/4/22 at 10:46 AM, the surveyor interviewed the Housekeeper. The surveyor asked what type of unit this was. The housekeeper stated that it was a COVID-19 unit. The surveyor asked if he was in a COVID-19 room. The housekeeper stated, this is a COVID room. The surveyor asked what kind of PPE he needed to wear in a COVID-19 room. The housekeeper stated that he wore goggles, a face mask, and a gown. The surveyor asked if the housekeeper needed to wear gloves while in the room. The housekeeper gestured to the housekeeping cart outside of the room which held his cleaning supplies and stated that he had gloves but that he took the gloves off after he changed the mop head. The surveyor asked if the Housekeeper should have put new gloves on after changing his gloves. The housekeeper did not respond. On 8/4/22 at 10:56 AM, the surveyor observed that the housekeeper's cart was still outside of room [ROOM NUMBER]-46 and that two plastic meal trays were positioned on top of the cart. The surveyor observed that each meal tray had several items on it including utensils, plates, and cups. At this time the surveyor observed CNA #1 and CNA #2 each pick up one of the meal trays. The surveyor followed CNA #1 and CNA #2 as they walked through three doors and several hallways carrying the meal trays. CNA #1 and CNA #2 brought the meal trays to the kitchen and left the trays on a metal tray truck which held several meal trays. On 8/4/22 at 10:58 AM, the surveyor interviewed CNA #1 and CNA #2. The surveyor asked why they were carrying meal trays from a COVID-19 room to the kitchen. CNA #1 stated that kitchen staff took the tray truck before the residents in room [ROOM NUMBER]-46 were finished eating. The surveyor asked if this was normally the way that they would bring meal trays that were in a COVID-19 room back to the kitchen. CNA #1 stated that normally they would go on the tray truck but that it was not on the nursing unit. The surveyor asked if it was alright to transport meal trays from COVID-19 rooms to the kitchen in this way. CNA #1 stated that the housekeeper used wipes on the trays and sanitized them and that the trays were clean. The surveyor stated that there were several items on the tray and how were they sure all items were sanitized. CNA #1 restated that the trays were clean. On 8/4/22 at 11:30 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The surveyor described her observation, that CNA #1 and CNA #2 carried meal trays from a COVID-19 room into the kitchen. The LPN/UM stated that this was not an acceptable way to transport meal trays that were in a COVID-19 room. The surveyor asked what the proper way to transport the meal trays from the COVID-19 room was. The LPN/UM stated that the meal trays should be in the closed meal tray truck. On 8/4/22 at 11:57 AM, the surveyor interviewed the Regional Environmental Services Director (RESD). The surveyor described how she observed the housekeeper in a COVID-19 room mopping without gloves. The RESD stated that the housekeeper should have been wearing gloves in the COVID-19 room. The surveyor also stated that the housekeeper had meal trays from a COVID-19 room on top of his housekeeping cart. The RESD stated that the housekeeper should not take meal trays out of resident rooms and should not have touched the meal trays. On 8/4/22 at 12:02 PM, the surveyor interviewed the housekeeper. The surveyor asked if the housekeeper took the trays out of room [ROOM NUMBER]-46 and put them on the housekeeping cart. The housekeeper acknowledged that he did. The surveyor asked if he sanitized the meal trays when he took them out of the COVID-19 room. The housekeeping aide stated, how would I clean the tray, there's food on it?. The surveyor reviewed the facility's policy titled, Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents with a revised date of 8/22 indicated that residents who test positive for COVID-19 are cared for by staff using a NIOSH approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and a gown. The surveyor reviewed the facility's policy titled, Coronavirus Disease (COVID-19)- Cleaning and Disinfecting reviewed 12/21, indicated to clean and disinfect areas, material and equipment that have likely been contaminated by a person with COVID-19 in the last 24 hours using a disinfectant found on the EPA's List N (disinfectants effective against COVID-19). 2. On 8/5/22 at 11:00 AM, the surveyor observed a housekeeper don (put on) PPE appropriately, outside the room of a resident who was on contact and droplet precautions due to a Covid-19 infection (red room) as evidenced by a red sign posted on the door that read: Isolation Droplet/Contact Precautions. When the housekeeper came out of the room the surveyor asked the housekeeper how he doffed (removed) PPE and what order he cleaned the resident rooms. He described appropriately how he doffed PPE but when describing the order in which he cleaned the rooms he said he cleaned the red rooms first. On 8/5/22 at 11:20 AM the surveyor observed the housekeeper in the hallway outside of the shower room next to the Covid-19 positive room he had just cleaned. He said he already cleaned the red room and the shower room next to it. He said he cleaned the red rooms first and then the yellow rooms (residents who were on contact and droplet precautions due to exposure to Covid-19, or new admissions), and then the green rooms (residents who had no known exposure to Covid-19). The surveyor asked the Infection Preventionist (IP) what order the housekeeper should have cleaned the resident rooms, the IP said green rooms first, then yellow rooms, then red rooms last, using a well to ill flow in accordance with guidance from Centers for Disease Control and Prevention. The surveyor confirmed with the IP that the rooms in question were rooms of residents who were on isolation due to a confirmed positive test result for Covid-19 infection. She further confirmed that there were two rooms that were coded as red for having residents in them who had Covid-19, and she pointed out those rooms. On 8/5/22 at 11:25 AM the surveyor asked the RESD what order the housekeeper should have been cleaning the rooms with respect to different cohorts, red, yellow, and green. He said the housekeepers should clean the green rooms first, then the yellow rooms, then the red rooms last. The surveyor joined the RESD when he went to speak with the housekeeper. When the surveyor and RESD approached the housekeeper he was donning PPE outside of a red room. The RESD explained to him what order to clean the rooms. The housekeeper did confirm that he had finished cleaning a red room and was going to clean the second red room then he would clean the yellow and the green rooms. The RESD said he was going to get an interpreter and explain to the housekeeper in his own language. As the surveyor and the [CONDITION(S)] were walking away the housekeeper, who was wearing full PPE (N95 mask, goggles, gown, gloves), started to enter the red room. The [CONDITION(S)] stopped the housekeeper from entering the red room and said to wait there and he would be right back. The housekeeper waited outside the red room. The [CONDITION(S)] came back within a few minutes and asked the housekeeper to go with him for training with an interpreter and they left the unit. On 8/5/22 at 1:20 PM, the surveyors discussed the above concerns to the Administrator and Director of Nursing. No additional information was provided. The surveyor reviewed the policy and procedure titled General Cohort Guidelines. The guidelines described the different cohorts as follows: Red (Confirmed Covid Positive), Yellow (Potentially Incubating, not up to date with vaccinations and exposed or newly admitted ), Green (Naive, negative, recovered, vaccinated, asymptomatic, no known exposure, admits/readmits post quarantine, Covid recovered/released from transmission based precautions). 08/17/22 10:26 AM, the surveyor asked the DON for the policy and procedure the housekeeper or nursing would follow to address the well to ill flow when entering rooms for care or cleaning. She said they didn't have a policy but that was their practice. NJAC 8:39-19.4 (a)

Based on observation, interview, and review of records, it was determined that the facility failed to practice appropriate hand hygiene for 3 of 7 staff observed in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a clean towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. 1.) On 5/3/22 at 11:52 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) perform handwashing for 10 seconds. The LPN/UM did not wet her hands before applying soap. The surveyor also observed that the LPN/UM did not use a clean towel to turn off the faucet. 2.) On 5/3/22 at 11:57 AM, the surveyor observed Certified Nursing Assistant (CNA) #1, assigned in a non-COVID unit perform handwashing for 8 seconds. CNA #1 did not wet her hands before applying soap. CNA #1 was observed scrubbing her hands with soap for 3 seconds then continued to scrub her hands under the running water for 5 seconds. The surveyor also observed that the CNA #1 did not use a clean towel to turn off the faucet. 3.) On 5/3/22 at 12:50 PM, The surveyor observed CNA #2, who was assigned in the COVID unit perform handwashing. The surveyor observed CNA #2 scrub their hands with soap for 17 seconds. A review of the facility's Policy and Procedure titled, Handwashing/Hand Hygiene that was provided by the facility revealed under procedure Washing Hands 1. Wet hands first with water, apply soap and vigorously rub hands together creating friction to all surfaces for a minimum of 20 seconds (or longer). 2. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. On 5/4/22 at 12:05 PM, the surveyors met with the Administrator, Regional Administrator, and Director of Nursing and were made aware of the above concerns. They all responded and specified that handwashing should be at least 20 seconds. NJAC 8:39-19.4 (a) (1) (n)

Based on observation, interviews, and record review, it was determined that the facility failed to identify and address weight loss in a timely manner for 1 of 7 residents reviewed for nutrition (Resident #21). This deficient practice was evidenced by the following: According to the Admission Record, Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), an assessment tool dated 12/03/19, reflected the resident had a Brief Interview for Mental Status (BI[CONDITION]) of 14, which indicated that the resident's cognition was intact. The Annual MDS also reflected Resident #21 was on a therapeutic diet with a weight of 2[AGE] pounds (lb). On 02/25/20 at 10:17 AM, the surveyor observed Resident #21 sitting up in bed with a breakfast tray in front of him/her. At that time, Resident #21 stated he/she had one egg and one muffin for breakfast. Resident #21 stated he/she had diabetes and was making an effort to eat healthier by eating less but was not actually on a diet to lose weight, but would welcome the weight-loss. The resident stated he/she would eat more carbohydrates in the morning and protein in the afternoon. Review of the Order Summary Report, printed on 02/25/20, revealed an order dated 11/10/19, for house carbohydrate consistency/consistent carbohydrate diet (HCC/CCHO) with regular texture and regular, thin liquid consistency, for diabetes. Review of the Clinical Physician order [REDACTED]. Review of the Weight Summary sheet, revealed the following recorded weights for Resident #21: On 12/02/19, the weight was 2[AGE].6 lb; On 01/13/20, the weight was 263.8 lb; On 0[DATE], the weight was 240.7 lb. The Weight Summary sheet did not reflect any re-weights noted after the 01/13/20 weight loss of 20.8 lb = 7% and did not reflect any re-weights noted after the 0[DATE] weight loss of 23.1 lb = 9%. Review of the Progress Notes (PNs), from 01/13/20 through 02/03/20, revealed that the facility did not address the 7% weight loss. Review of the PNs, dated from 01/13/20 to 02/24/20, revealed that there was no documentation that the physician or nurse practitioner was made aware of the 20.8 lb weight loss between 12/02/19 and 01/13/20 or the 23.1 lb weight loss between 01/13/20 and 0[DATE]. The PNs did not reveal Registered Dietitian (RD) documentation that addressed the weight changes within [AGE] hours. Additionally, the PNs did not reveal an assessment, analysis and conclusion by the multidisciplinary team regarding the weight changes for Resident #21. Review of Resident #21's Care Plan (CP), date initiated [DATE], revealed a focus of nutritional status as evidenced by actual/potential weight loss/gain related to therapeutic diet, and chronic wounds. The CP goals included to tolerate diet and textures/consistency, consume appropriate amounts of food and fluids, and maintain nutritional status. The CP interventions included, but were not limited to, notify physician and responsible party of significant weight changes. During an interview with the surveyor on 0[DATE] at 9:50 AM, the RD stated all resident notes were in the electronic medical record. The RD stated the Certified Nursing Assistants (CNA) would obtain the weights as ordered and that she would review weekly weights on Tuesday and monthly weights every month. The RD stated the nurses and CNAs should re-weigh a resident if there was a 3-5 lb change or if the weight was outside the ordered parameter. During an interview with the surveyor on 0[DATE] at 12:34 PM, the Registered Nurse Unit Manager (RN/UM) stated she would be responsible to review resident weights also and, if there was a discrepancy, she would either observe or re-weigh the resident herself. The RN/UM stated the CNAs could see the previous weights and should report any discrepancy to the nurse. The RN/UM stated that she would expect a change of 4-5 lb to be re-weighed and reported. In the presence of the surveyor, the RN/UM accessed the electronic medical record and acknowledged there had been no re-weights for Resident #21 in January or February. During an interview with the surveyor on 02/24/20 at 10:16 AM, CNA #1 stated the CNAs would get a list of the residents that needed to be weighed. The CNAs would enter the weight into the computer and were able to see the previous weight. CNA #1 stated if the resident's weight was 3-4 lb different, they would verbally communicate to the nurse and the nursing supervisor, and re-weigh the resident. During an interview with the surveyor on 02/24/20 at 10:53 AM, RN #1 stated the process was for the CNA to obtain the weight and tell the nurses verbally if there was a big change. RN #1 stated the nurses entered the weights on the Medication or Treatment Administration Record (MAR) in accordance with the physician's orders [REDACTED].#1 add that if the nurses see a weight change, they should report it to the physician. During an interview with the surveyor on 02/24/20 at 11:12 AM, the Director of Nursing (DON), stated the CNAs would get a weight list and weigh the resident. If the resident's weighed was under a 100 lb and the weight was up or down by 2 lb or if the resident was over 100 pounds and the weight was up or down 5 lb, the staff would re-weigh the resident and notify the physician. The resident would be re-weighed by the CNA and nurse to see if it was accurate. The DON stated the re-weights would be listed in the electronic medical record weight summary. During an interview with one of the surveyors on 02/25/20 at 10:14 AM, CNA #2 stated CNAs would take a residents weight, compare it to the last one and, if the weights did not match, the CNA should re-weigh the resident and inform the nurses. CNA #2 stated it was important to re-weigh, especially if the resident had a weight loss so they can tell the nurse and the nurse could call the physician. During an interview with one of the surveyors on 02/25/20 at 10:25 AM, RN #2 stated the CNAs would get a list in their computer tasks of which residents needed to be weighed. RN #2 stated it would be the nurses responsibility to look at the weights when they are logged into the computer and that the nurses were able to see the last two or three weights. RN #2 stated a weight change of 2 lb in a day or maybe 5 lb would indicate the staff needed to re-weigh the resident to ensure it was accurate and that the re-weigh should be done within the day because if there was a problem, the staff could catch it. RN #2 stated weight loss would be reported to the nursing supervisor and RD. During an interview with one of the surveyors on 02/25/20 at 10:26 AM, RN #3 stated if there was a discrepancy in weights, the staff would obtain a re-weight and if it was a true discrepancy, the nurses would report it to the nursing supervisor and RD. During an interview with the surveyors on 02/25/20 at 12:13 PM, the RD stated Resident #21 should have had a re-weight and that she had requested a re-weight but it was never done. The RD stated if she had a hard time getting the staff to re-weigh a resident, that she would have gone to the DON but there was no record of this communication. The RD acknowledged there had been no re-weight for Resident #21 in the medical record and documentation that a re-weight was discussed with staff. During an interview with the surveyor on 02/26/20 at 10:51 AM, Resident #21 stated he/she always tried to eat healthy but had been in the hospital a few times, which could have resulted in a weight loss, but was unaware of how much weight he/she had lost. Resident #21 stated none of the staff, including the physician and the RD had ever discussed any weight loss plans but that the RD discussed it with him/her on 02/25/20. During an interview with the surveyor on 02/26/20 at 10:55 AM, RN #2 stated Resident #21's normal intake for breakfast was one or two eggs, a bagel or sometimes cereal, coffee or tea. For lunch, the resident ate chicken and one or two bites of dessert. RN #2 stated the resident had been trying to eat more protein in the evening and was cutting down on carbohydrates. RN #2 stated she had a discussion in passing with the resident regarding healthy eating. RN #2 stated there was no formal discussion or weight loss plan documented in the resident's medical record and that she should have documented the conversation. Review of the facility's Weighing and Measuring the Resident policy and procedure, dated 08/16, revealed to note and record the weight and report significant weight loss/weight gain to the nurse supervisor: 1 month=5%; 3 months=7.5%, and 6 month=10%. Review of facility's Weight Assessment and Intervention Policy, dated 01/20, revealed weights would be recorded in each resident's medical record; a change of 5 lb or more in a resident weighing more than 100 lb or 2 lb in a resident weighing less than 100 lb, will be retaken for validation. If weight was verified, nursing would notify the Dietitian. The Dietitian will respond within [AGE] hours. Assessment information shall be analyzed by the multidisciplinary team and conclusion shall be made regarding the resident's target weight range; calorie, protein and nutrient needs, the relationship between current medical condition or clinical situation and recent fluctuations in weight and whether and to what extent weight stabilization or improvement can be anticipated. Review of the the provided Monthly Weight Meetings, dated 01/06/20, 01/14/20, 01/22/20, 01/29/20, 02/05/20, and 02/12/20, revealed Resident #21 had not been included or listed in the meeting notes and the attached Monthly Weight Report, dated from March 2019 to February 2020, did not have Resident #21 listed on the report at all. Review of the facility's Change in a Resident's Condition or Status policy, dated 05/17, revealed the facility shall promptly notify the resident, Physician and representative of changes in the medical/mental condition. The nurse will notify the resident's Physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. The nurse will record in the resident's medical record, information relative to changes in the resident's medical/mental condition or status. If significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition would be conducted. Review of the Dietitian Job Description, dated revised 01/19, revealed the dietitian was responsible for the nutritional oversight of all residents, which included review of weekly weights, as applicable, and completion of reassessments and care plan revisions on all residents that display a significant weight change. A review of monthly weights and completion of reassessments and care plan revisions on all residents that display a significant weight change of greater than or equal to 5% in one month. During an interview with the survey team on 02/26/20 at 11:50 AM, the Administrator stated the facility did not have the signed RD job description there so they could not provide it, but that the Job Description-Dietitian that was provided to the surveyors was the same one signed by the RD. NJAC 8:39-17.1(c); 27.2(a)

Based on interview and record review, it was determined that the facility failed to consistently document the Peritoneal [MEDICAL TREATMENT] (PD) exit site care and condition. PD is a treatment for [REDACTED]. This deficient practice was identified for Resident #12, 1 of 1 residents reviewed for PD and was evidenced by the following: According to the Admission Record, Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12 had a Physician Order, dated 02/28/19, for PD every evening shift for [MEDICAL CONDITION]. A review of Resident #12's Care Plan, dated 02/13/19, included that the resident had [MEDICAL CONDITION] related to [MEDICAL CONDITION] (kidney failure) and was on PD. The goal of the Care Plan indicated that the resident would be free from signs and symptoms of infection. The Care Plan interventions included PD [MEDICAL TREATMENT] catheter (tube used during the treatment) care and site (area that the tube exits the abdomen) care per physicians orders. Review of Resident #12's (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019 Treatment Administration Records (TAR) revealed that there was no documentation that the PD exit site care was done. There was also documentation that addressed the condition of the exit site. On 3/01/2019 at 11:21 AM, the Administrator provided the surveyor with the PD- Continuous Ambulatory-CAPD policy and procedure (2001 MED-PASS, Inc.) (Revised 2010), which revealed to document the condition of the catheter, insertion site and surrounding skin. During an interview conducted by the surveyor on 3/05/19 at 09:49 AM, the facility Registered Nurse (RN) Staff Educator stated that the facility's PD policy and procedure should be followed. She also stated that she could not recall if the nurses were instructed to document the PD exit site care and condition of the site. During an interview conducted by the surveyor on 3/05/19 at 10:05 AM, the corporate Director of Nursing (DON) stated that the nursing staff should be following the corporate facility's PD policy and procedure. On 3/06/19 at 09:50 AM, the Station 3 RN/Unit Manager (RN/UM) provided the surveyor with a different PD policy and procedure and stated the corporate DON found the policy in the [MEDICAL TREATMENT] Manual (a manual provided by the outside facility contracted [MEDICAL TREATMENT] company). The RN/UM stated that the PD exit site care and the condition of the exit site should have been documented each time it was done and that PD exit site care and condition should have been on the TAR, as it was on the Care Plan. Review of the above undated PD policy and procedure from the [MEDICAL TREATMENT] Manual revealed, Documentation #2: Exit site care given, and condition of exit site. On 03/06/19 at 11:29 AM, the surveyor conducted a telephone interview with the RN Clinical Educator, from the contracted [MEDICAL TREATMENT] company, who stated that she and the facility's RN Staff Educator did a PD in-service to the nursing staff on 01/04/19 that included PD exit site care. The RN Clinical Educator further stated that she educated the staff based on the PD policy and procedure in the [MEDICAL TREATMENT] Manual when she in-serviced the facility nurses on the PD process. During an interview conducted by the surveyor on 3/06/19 at 11:53 AM, the facility DON stated the PD exit site care and condition should be documented in the TAR. She further stated that if the PD exit care and condition was not on the TAR, then she would expect the nurses to document in the Progress Notes. She also stated that the RN/UM was responsible to monitor Resident #12's TAR and assure that the PD exit site care and condition was being documented. During a telephone interview conducted by the surveyor on 3/06/19 at 12:10 PM, the Station 3, 3 PM-11 PM shift Licensed Practical Nurse (LPN) stated that she provided PD to Resident #12 on a daily basis when she worked her shift. She further stated that she had not documented the PD exit site care and condition. She also stated that she only would document the PD exit site care and condition if there was an issue. During an interview conducted by the surveyor on 03/06/19 at 12:18 PM, the facility DON stated that she was able to find two dates in the Progress Notes (PN) dated 12/30/18 through 02/15/19 where the PD exit site condition was documented. The DON further stated that she was unable to find any Progress Notes that documented that the PD exit site care was done. Review of the PN dated 11/29/18 through 03/02/19 revealed the following dates the condition of the site was documented: 12/30/18 at 6:56 PM revealed, Site clean and no redness noted and on 02/15/19 at 11:24 AM revealed, Site clean, no signs and symptoms of infection noted. During an interview conducted by the surveyor on 03/06/19 at 12:23 PM, the Administrator stated that all of the facility's policies were located on a corporate portal. She stated she was made aware that the corporate DON had found the additional PD policies and procedures in the [MEDICAL TREATMENT] Manual. She stated that she had not been aware that the additional PD policies and procedures existed in a [MEDICAL TREATMENT] Manual. The Administrator further stated that if a facility nurse needed a facility policy and procedure, they would retrieve it from the corporate portal. During an interview conducted by the surveyor on 03/08/19 at 10:24 AM, the facility DON stated that the nurses are to use the PD policy and procedure located in the [MEDICAL TREATMENT] Manual and not the corporate PD policy and procedure. During an interview conducted by the surveyor on 03/08/19 at 10:31 AM, the Administrator stated that the facility should have it's own PD policies and procedures based on the contracted [MEDICAL TREATMENT] company's PD policies and procedures in the [MEDICAL TREATMENT] Manual. Lastly, she stated that she was aware of the confusion created with having the two different PD policy and procedure guidance's. NJAC: 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to implement posted isolation precautions. This deficient practice was identified for Resident #96 and #98, 2 of 2 residents reviewed for isolation precautions and was evidenced by the following: 1. According to the Admission Record, Resident #96 was re-admitted to the facility on [DATE]. Resident #96 had medical [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) physician order [REDACTED].#96's medical record did not reveal a physician order [REDACTED]. The nurse progress note, dated 02/25/19 and timed 22:21 (10:21 PM), revealed, isolation precaution in place [MEDICAL CONDITION]. Will continue to monitor. The nurse progress note, dated 02/27/19 and timed 10:50 AM, revealed, As per (physician name) D/C (discontinue) isolation when ABT (antibiotics) are completed. On 02/27/19 at 10:19 AM, the surveyor observed that there was an isolation caddy on Resident #96's room door. The door also contained a sign that indicated to stop and see the nurse before entering. At that time, the surveyor observed a Physical Therapist (PT) enter Resident #96's room with a portable, multi-patient use blood pressure machine. The PT did not stop and don (put on) any Personal Protective Equipment (PPE). The PT applied the blood pressure cuff to Resident #96's are and obtained a blood pressure. As the PT began to leave the room, the surveyor intervened. During an interview at the time, the PT stated he wasn't sure what type of isolation Resident #96 resident was on isolation for contact I think and that he could have just wiped down the portable BP machine. In addition, the PT stated, I guess I should have had a gown on. During an interview conducted by the surveyor on 02/27/19 at 10:25 AM, the facility educator stated that the physical therapy staff all had been educated on PPE and isolation. The educator stated this PT had been newly hired and had the training recently. The director of PT stated all the physical therapy staff should have known what isolation precautions were and how to use PPE. The facility educator left the portable BP machine as dedicated equipment in the isolation room. 2. According to the Admission Record, Resident #98 was admitted to the facility on [DATE]. Resident #98 had medical [DIAGNOSES REDACTED]. Resident #98 had a physician's orders [REDACTED]. A physician note, dated 02/25/19, revealed the resident had tested positive for influenza. A nursing note, dated 02/25/19, revealed droplet precautions upheld and another nursing note dated 02/25/19 that isolation precautions had been maintained. The medical record also revealed a physician's orders [REDACTED]. On 03/01/19 at 09:28 AM, the surveyor observed that there was an isolation caddy on Resident #98's room door. The door also contained a sign that indicated to stop and see the nurse before entering. At that time, the surveyor observed a therapy rehabilitation aide enter Resident #98's room without donning (putting on) any PPE. The surveyor stopped the rehabilitation aide as she began to leave the room. The therapy aide stated the resident had been on isolation for the flu. The therapy aide stated she had worked at the facility for five years and knew what the isolation set up had been for. The therapy aide acknowledged she should have applied the PPE as per facility policy. The facility educator provided the surveyor with the facility Isolation-Initiating Transmission-Based Precautions policy, dated 01/2012 that revealed, Transmission-Based Precautions shall be used when the spread of infection cannot be reasonable prevented by less restrictive measures. The facility educator provided the surveyor with the facility Equipment and Supplies Used During Isolation policy, dated (MONTH) 2012 that revealed, appropriate equipment and supplies will be used to maintain sanitary conditions while isolation precautions are in effect. On 02/27/19 at 12:02 PM, the facility educator provided the surveyor with the facility General Orientation Checklist document, dated 11/13/18, that revealed the PT had received initial education and training on PPE, Standard precautions, transmission-based precautions, infection control, and breaking the chain of infection. On 03/01/19 at 10:38 AM, the facility educator provided the surveyor with the facility Employee Education Attendance Record, dated 02/27/19, that revealed the rehabilitation therapy aide had been re-educated on PPE, standard precautions and handwashing. NJAC 8:39-19.4(a)(2,4)

Based on observation, interview and record review, it was determined that the facility failed to initiate and implement an initial baseline care plan upon a resident's admission. This deficient practice was identified for Resident #96 and #86, 2 of 19 residents reviewed for care plans and was evidenced by the following: 1. On 02/27/19 at 10:19 AM, the surveyor observed that there was an isolation caddy on Resident #96's room door. The door also contained a posted sign that indicated to stop and see the nurse before entering. According to the Admission Record, Resident #96's was re-admitted to the facility on [DATE]. Resident #96 had a medical [DIAGNOSES REDACTED]. The surveyor reviewed the on-going care plan which included resolved issues. The care plan did not reveal any focus area, goal or interventions that addressed Resident #96 being on isolation precautions. The medical record did not reveal a physician order [REDACTED]. During an interview conducted by the surveyor on 03/06/19 at 11:28 AM, the Licensed Practical Nurse/Minimum Data Set (an assessment tool) (LPN/MDS) Coordinator stated the isolation had not been initiated on the care plan but should have been added. The LPN/MDS Coordinator stated the nurse unit manager should have initiated the isolation on the care plan upon admission. The nurse unit manager had been on vacation prior to the start of the survey and had been unavailable for interview the entire survey. During an interview conducted by the surveyor on 03/06/19 at 11:31 AM, the Assistant Director of Nursing (ADON) stated the nurse unit manager would have been responsible to have care planned the isolation. The ADON stated one of the MDS coordinators would have followed up to ensure the care plan had been accurate. During an interview conducted by the surveyor on 03/06/19 at 11:35 AM, the Director of Nursing (DON) stated Resident #96 had an existing order from the hospital for isolation. The DON acknowledged the isolation should have been on the initial care plan. 2. According to the Admission Record, Resident#86 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #86 had a medical [DIAGNOSES REDACTED]. Resident #86's MDS dated [DATE] that revealed, Medication received: Days: Antidepressant - 7. Resident #86 had a physician's orders [REDACTED]. According to the Care Conference Note, dated 02/26/19, an introductory care conference was held on 02/26/19. The Care Conference Note indicated that nursing reviewed medications with resident and family all were familiar with all medications. During an interview conducted by the surveyor on 03/05/19 at 11:10 AM, the DON acknowledged that the [DIAGNOSES REDACTED]. The DON stated the MDS coordinators and nurse unit manager would have been responsible to verify the care plan had been accurate and correct. The DON stated the facility also had care plan meetings but the depression and antidepressant being added to the care plan must have been missed. On 03/05/19 at 11:15 AM, the surveyor and the LPN/MDS Coordinator reviewed Resident #86's care plan, dated 02/21/19. The LPN/MDS Coordinator acknowledged the [DIAGNOSES REDACTED]. The LPN/MDS coordinator acknowledged the depression and antidepressant had not been initiated on the care plan but should have been. During an interview conducted by the surveyor on 03/05/19 at 11:28 AM, the Registered Nurse/ MDS (RN/MDS) Coordinator stated she had worked at the facility for [AGE] years. The RN/MDS coordinator stated she did not know why the depression or antidepressant had not been on the care plan but that both should have been. On 03/05/19 at 11:10 AM, the DON provided the surveyor with the facility, Care Plans, Comprehensive Person-Centered policy, dated 12/2016, that revealed, the care plan should include measurable objectives and timetables to meet physical, psychosocial and functional needs and would be developed and implemented for each resident; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and to include the resident's goals upon admission and desired outcomes. The policy also revealed that the interdisciplinary team must review and update the care pan when the resident had been readmitted to the facility from a hospital stay. NJAC 8:39-11.2(d); 11.2(e)(1-2)

Based on interview and record review, it was determined that the facility failed to document an indicated [DIAGNOSES REDACTED]. This deficient practice was identified for Resident #77, 1 of 5 residents reviewed for unnecessary medications and was evidenced by the following: According to the Admission Record, Resident #77 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #77's physician orders [REDACTED]. Review of the Consultant Pharmacist Review, dated 02/25/19 revealed that [MEDICATION NAME] (Quetiapine [MEDICATION NAME]) [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist Medication Regimen Review, dated 02/25/19, revealed, [MEDICATION NAME] (quetiapine) is indicated for the treatment of [REDACTED]. Please update this resident's [DIAGNOSES REDACTED]. If not please have the physician document in the residents chart the benefit of continuing the treatment. Review of a Social Services note, dated 02/05/19, revealed Resident #77 was admitted on [DATE] from the hospital and that the resident presented with no mood or behavior concerns. Review of Resident #77's Minimum Data Set (MDS), an an assessment tool dated 01/29/19, revealed no when assessed for depression and no when assessed for [MEDICAL CONDITION]/[MEDICAL CONDITION] disease. Review of the facility's History and Physical document, dated 01/30/19, revealed a present illness of but not limited, to dementia. Review of the Electronic Medication Administration Record [REDACTED]. Review of Resident #77's progress notes, dated from admission on 01/29/19 through 03/06/19, revealed no documented behaviors from the resident during that time frame on any shift. Review of the resident's Pre-Admission Screening and Resident Review (PASRR), a screening tool for mental illness dated 01/29/19, revealed no significant impairment or known [DIAGNOSES REDACTED]. During an interview conducted by the surveyor on 03/07/19 at 11:25 AM, the Assistant Director of Nursing (ADON) stated she had missed the pharmacy consultants recommendation upon admission and had not addressed it with the physician. The ADON stated there had been no documentation from the physician because she went ahead and changed the [DIAGNOSES REDACTED]. The ADON stated there had been no documentation that supported the initial [DIAGNOSES REDACTED]. During an interview conducted by the surveyor on 03/08/19 at 08:56 AM, the Director of Nursing (DON) stated she would have received the consultant pharmacy reports and they would be given to the unit managers. The unit manager for Resident #77 had been on vacation and unavailable for interview. The DON stated the ADON would have been responsible to follow up on the consultant pharmacy review reports. During an interview conducted by the surveyor on 03/08/19 at 09:10 AM, the medication nurse on Resident #77's unit stated he would always check the [DIAGNOSES REDACTED].#77. The medication nurse who had administered medications to Resident #77 stated she had noticed the [DIAGNOSES REDACTED]. On 03/07/19 at 11:53 AM, the DON provided the Consultant Pharmacist's Medication Regiment Review, dated 01/29/19, that revealed, [MEDICATION NAME] is indicated for the treatment of [REDACTED]. Please update this resident's [DIAGNOSES REDACTED]. If not please have the physician document in the residents chart the benefit of continuing the treatment. The DON stated that the 01/29/19 Consultant Pharmacist Medication Regiment Review had not been in the Resident #77's medical record and that it had not been addressed. The Administrator provided the facility, Medication Regiment Reviews policy, dated 10/24/17, that revealed the consultant pharmacist will perform a medication regimen review for every resident; the consultant pharmacist will identify medication errors included those related to documentation; the medication regime review will be maintained as part of the permanent record; the consultant pharmacist will provide a written report to physicians for each resident and if the physician does not respond, the report will be addressed with the medical director and Administrator. The Administrator provided the facility, Psychopharmacologic Medication Policy, dated 09/06/18, that revealed residents who are transferred from a hospital and who are already receiving anti-psychotic medications will be evaluated for the appropriateness and indications for use; The interdisciplinary team will complete the PASRR screening if appropriate, re-evaluate the use of the anti-psychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered or discontinued; based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust or stop the anti-psychotic medication; diagnoses alone do not warrant the use of anti-psychotic medication; anti-psychotic medications will generally only be considered if the following conditions are also met: behavioral symptoms present a danger to the resident or others, the symptoms are identified as being due [MEDICAL CONDITIONS] and behavioral interventions have been attempted and included in the plan of care. NJAC 8:39-11.2(a); 27.1(a)

Based on interview and record review, it was determined that the facility failed to obtain a physician's order for the daily care of a resident's Pertioneal [MEDICAL TREATMENT] (PD) catheter exit site, in accordance with professional standards of practice. PD is a treatment for [REDACTED]. This deficient practice was identified for Resident #12, 1 of 1 residents reviewed for PD and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the Admission Record, Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12's Physician Order (PO), dated 02/28/19, reflected an order for [REDACTED]. A review of Resident #12's Care Plan, dated 02/13/19, reflected that Resident #12 had [MEDICAL CONDITION] related to [MEDICAL CONDITION] (kidney failure) and was on PD. The Care Plan goal indicated the resident would be free from signs and symptoms of infection. The Care Plan interventions included PD [MEDICAL TREATMENT] catheter (tube used during the treatment) care and site (area that the tube exits the abdomen) care per physicians orders. During an interview conducted by the surveyor on 03/05/19 at 9:05 AM, the Director of Nursing (DON) stated that the PD exit site care was part of the PD policy and procedure, but that there should have been a PO for the daily PD exit site care. The DON also stated that the Registered Nurse Unit Manager (RN/UM) is responsible to make sure that the PD exit site care had a PO. During an interview conducted by the surveyor on 03/06/19 at 9:50 AM, the Station 3 RN/UM stated that there should have been a PO for the PD exit cite care as written on the Resident #12's Care Plan. During an interview conducted by the surveyor on 03/06/2019 at 12:15 PM, the Assistant Director of Nursing (ADON) stated Resident #12's Care Plan should not have indicated per physician's order if there was not an actual order. The ADON explained that the nurse who completed Resident #12's Care Plan does not always know the PO when actually writing the Care Plan, but usually indicates as per physician orders. Lastly, the ADON stated that the daily care of the PD exit site is part of the PD policy and procedure, but going forward there should be a PO for the exit site care. NJAC: 8:39-27.1(a)

Based on observation, interview and medical record review, it was determined that the facility failed to a.) provide a dignified dining experience and b.) ensure a resident was assisted with toileting needs in a timely manner for 1 of 19 sampled residents, Resident #26. This deficient practice was evidenced by the following: According to the facility Admission Record, Resident #26 was admitted to the facility in 9/2017 and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 12/25/2018, revealed that Resident #26 had a Brief Interview for Mental Status of 3 which indicated that the resident had severe cognitive impairment. Additionally, the MDS revealed that the resident required extensive assistance of one person for eating and was dependent on staff for toileting. A review of Resident #26's Care Plan (CP) revealed a focus that the resident had an Activities of Daily Living (ADL) deficit related to dementia and impaired mobility. The CP goal indicated that the resident would receive assistance necessary to meet ADL needs. The CP interventions included, but were not limited to, assist with 1-2 persons with ADLs, and assist with daily hygiene, grooming, dressing, oral care and eating as needed. An additional CP addressed that the resident had urinary incontinence with an intervention to provide assistance with incontinent care as needed. On 2/27/2019 at 11:25 AM, the surveyor observed Resident #26 in bed with a breakfast tray on a bed side table in front of the resident. The resident's left arm and hand was sitting on the plate of the tray. The following was observed on the breakfast tray: scrambled eggs, cut up banana, full bowl of oatmeal, full cup of cranberry juice, full cup of milk, and a chocolate shake which was spilled on the tray. The resident stated, I need help, hoping to go home. During an interview conducted by the surveyor on 02/27/2019 at 11:27 AM, the unit Registered Nurse (RN) stated that breakfast trays were delivered to the unit at 08:30 AM and that Resident #26 was alert with confusion and able to feed him/herself. The surveyor then brought the RN into Resident #26's room. The RN stated that Resident #26 was a slow eater and would take away the tray. When the RN went to remove the tray, the RN picked up a coffee cup off of the resident's lap which revealed spilled coffee on the resident's gown. The RN stated, coffee spilled, this upsets me. The RN cleaned the resident, and dressed the resident with a clean shirt. The RN stated that the coffee was cold, and the food on the tray was room temperature. Additionally, the RN stated the resident was not washed or dressed yet, because there were clean towels, and a brief at the edge of the bed. The RN did not ask the resident if he/she wanted another tray or provide another tray. The surveyor requested to Resident #26's Certified Nurses Aide (CNA) to come to the resident's room. On 2/27/2019 at 12:06 PM, the RN Unit Manager (UM) and Resident #26's CNA entered Resident #26's room. The CNA stated she delivered the breakfast tray between 08:30 and 09:00 AM and Resident #26 didn't want to be fed, so she left the tray with the resident. The CNA stated that the breakfast tray should not have been left with the resident that long, but the resident was yelling when she attempted to remove the tray. The surveyor asked the CNA when she last checked the resident for incontinent care, and the CNA stated she checked her in the morning, but she did not remember what time. The surveyor asked the UM and CNA to check the resident's incontinence brief. The UM and CNA unfastened the resident's brief, the UM stated, the brief is wet. The surveyor observed the wet brief and urine odor. The UM and CNA refastened the brief, and told the resident that they would come back and wash the resident after they tended to another resident. The CNA left the room. At 12:15 PM, the RN stated, that it was not okay to leave the resident incontinent, but there was another resident who needed to go to the dining room, and she was unable to provide care to Resident #26 herself. At 12:23 PM, 8 minutes later, the surveyor observed the UM and a CNA enter Resident #26's room with clean towels to provide care to Resident #26. During an interview conducted by the surveyor on 03/05/2019 at 10:34 AM, the UM stated that if the resident's food is cold, the staff would call the kitchen for a new tray. The UM stated that Resident #26 may need assistance with feeding depending on his/her mental status, and staff will assist the resident if the resident isn't feeding him/herself. The UM stated on 02/27/19, the resident was checked by three staff during breakfast, and did not want assistance from staff. The UM stated, we are told it's patient centered care and it's (the resident's name) right. The UM stated she did not provide the resident with an additional tray. During an interview with the surveyor on 03/05/2019 at 12:30 PM, the Director of Nursing (DON) stated that Resident #26 required cueing for eating and during meals, staff check the residents every thirty to forty five minutes. Additionally, the DON stated Resident #26's breakfast tray should not have been sitting for three hours and that the resident should have received another breakfast tray. The DON also stated the staff should have provided incontinent care at the time the staff noticed the resident was incontinent. 8:39-4.1(a)(12)

Based on interview and review of the medical records, it was determined that the facility failed to accurately asses the resident's status upon discharge. This deficient practice was identified for Resident #22, 1 of 3 residents reviewed for discharge documentation and was evidenced by the following: On [DATE] , the surveyor reviewed the discharged record for Resident #22. The surveyor then reviewed the Physicians Discharge Summary (PDS) dated [DATE] that revealed Resident #22 had expired on [DATE] and was discharged to a funeral home. The surveyor reviewed the Progress Notes and the Patient Discharge Summary/ Instructions dated [DATE] which indicated that Resident #22 was discharged home on the care of Hospice. On [DATE] at 10:45 a.m., the surveyor interviewed the Director of Nursing (DON) who stated that the physician incorrectly documented on the PDS that Resident #22 had expired on [DATE] and was discharged to a funeral home. NJAC 8:,[DATE].1(d) 15

Based on observation, interview and record review it was determined that the facility failed to implement a fall intervention as listed in the Care Plan. This deficiency was identified for Resident #9; 1 of 23 residents reviewed for care plans and was evidenced by the following: The Admission Record reflected Resident #9 was admitted to the facility with medical [DIAGNOSES REDACTED]. The surveyor observed Resident #9 in bed with the bed in the high position and no mats on the floor, which were listed as interventions in the Care Plan and Kardex, The surveyor observations occurred on the following dates and times: 11/13/17 at 11:45 a.m.; 11/14/17 at 10:50 a.m.; 11/16/17 at 9:20 a.m.; 11/161/7 at 12:15 p.m.; and on 11/17/17 at 8:45 a.m. On 11/17/17 at 9:25 a.m., the surveyor interviewed the Registered Nurse (RN) who stated Resident #9 had floor mats as a Care Plan intervention and the floor mats should have been down during the day because the resident is bed bound and the roommate doesn't get out of bed or move around the room. On 11/17/17 at 9:10 a.m., the surveyor reviewed Resident #9's Care Plan initiated on 9/15/17 that indicated Resident #9 was at risk for falls and floor mats on the left side of the bed were to be utilized. On 11/17/17 at 9:15 a.m., the surveyor reviewed Resident #9's Kardex (a summary of care for staff to give to a resident) that revealed fall mat(s): specify left side of bed. NJAC 8:39-11.2(b)

Based on observation, interview and record review it was determined that the facility failed to date medications and Diabetic supplies when opened and properly store an opened medication. This deficient practice was present in 6 of 6 medication carts inspected for proper storage and labeling of medication and evidenced by the following: On 09/29/16 beginning at 10:25 a.m. the surveyor inspected the medication carts in the presence of each nurse assigned to the cart. Each nurse agreed with the surveyor's findings. 1. The surveyor inspected the Station 1 medication cart and observed 2 single dose vials of Duoneb in an opened foil pouch. The pouch did not have the date it was opened. Once opened the Duoneb should be used in 7 days or discarded per manufacturers recommendation. 2. The surveyor inspected the Station 2 medication cart and observed a bottle of Latanoprost eye drops opened 08/05/16. Once opened the Latanoprost eye drops must be used within 42 days or discarded. 3. The surveyor inspected the Station 3-1 medication cart and observed 4 single dose vials of Duoneb in opened foil pouches for 2 different residents. The pouches did not have the date each was opened. 4. The surveyor inspected the Station 3-2 medication cart and observed a bottle of glucometer strips and a Humalog Insulin flex pen that were opened but not dated. The surveyor also observed 3 single dose vials of Duoneb in an opened foil pouch that was not dated when opened. 5. The surveyor inspected the Station 4-2 medication cart and observed a Lantus Insulin flex pen that was opened but not dated. On 09/29/16 at 12:05 p.m. the surveyor brought these findings to the attention of the Director of Nursing and Administrator. No additional information was provided. NJAC 8:39-27.1 (a)