Every finding on record at CareOne At Wall

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident #15) reviewed for medication administration times.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 3/19/26 at 11:01 AM, during an initial tour, the surveyor observed Resident #15 awake and alert sitting in their wheelchair. Resident #15 informed the surveyor that they had returned from their doctor's appointment and were waiting for their medications. The resident further stated that it was not the first time they had to wait for their morning meds.The surveyor reviewed the electric medical record (EMR) for Resident #15.A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; Rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints), Atrial Fibrillation (A-fib; a common heart condition causing an irregular, often fast, heart rate) and essential (primary) hypertension (htn; high blood pressure that is not due to another medical condition).A review of the comprehensive Minimum Data Set, an assessment tool dated 12/20/25, revealed that the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating cognitively intact cognition.A review of the individualized comprehensive care plan (ICCP) revealed a focus area created on 12/30/25, included pain related to fracture, pressure points/ulcers; right shoulder pain/arthritic. The ICCP Interventions included but were not limited to: administer analgesia (medicines that relieve pain) per physician orders. A further review of the ICCP included a focus area: anticoagulant therapy (blood thinners to prevent, treat, or stop the growth of blood clots) to treat A-fib: At risk for adverse effects, date initiated 3/22/26. The interventions included to administer medication per physician orders. A further review of the ICCP reflected another focus area date initiated 3/22/26: cardiac disease related to arrhythmia (an abnormal or irregular heartbeat where the heart beats too fast (tachycardia), too slow (bradycardia), or with an irregular rhythm), hypertension. The interventions included administer medication per physician orders.A review of Resident #15's Order Summary Record (OSR) included the following physician orders (POs): A PO dated 12/24/25 for enalapril maleate 20 mg - give one tablet by mouth one time a day for htn.A PO dated 12/24/25 for Eliquis 2.5 mg- give one tablet by mouth every 12 hours for A-fib. Monitor for bleeding, bruising and black tarry stools.A PO dated 12/25/25 for prednisone 5 milligram (mg) - give one tablet by mouth one time a day for rashes.A PO dated 12/25/25 for nifedipine extended release (ER) 24 Hour 30 mg - give one tablet by mouth two times a day for htn.A PO dated 3/9/26 for acetaminophen 500 mg - give two tablets orally every 12 hours for shoulder pain for 5 days, Stop date 3/14/26A PO dated 3/9/26 for lidocaine patch 4%- apply to right shoulder one time a day for pain management, apply for 12 hours in a 24-hour period and remove per schedule.A review of the March 2026 progress notes (PNs) revealed no documentation regarding Resident #15's medications not being administered as scheduled according to the PO's.A review of the facility Medication Admin Audit Report, dated 3/1/26 through 3/20/26, revealed the following:On 3/1/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:49 AM.On 3/2/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:19 AM.On 3/3/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:13 AM.On 3/5/26:1.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 10:53 AM.On 3/7/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 11:02 AM2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 11:02 AM.3.Eliquis 2.5 mg one tablet, scheduled for 9:00 AM was administered at 11:02 AM.4.nifedipine ER 30 mg one tablet, scheduled for 9:00 AM was administered at 11:02 AM.On 3/8/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:58 AM.2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 10:03 AM.On 3/10/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 10:35 AM2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 10:34 AM.3.Eliquis 2.5 mg one tablet, scheduled for 9:00 AM was administered at 10:35 AM.4.nifedipine ER 30 mg one tablet, scheduled for 9:00 AM was administered at 10:35 AM.5.acetaminophen 500 mg two tablets, scheduled for 9:00 AM were administered at 10:35 AM.6.lidocaine patch 4% to right shoulder, scheduled for 9:00 AM was applied at 10:39 AM.On 3/11/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 12:41 PM2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 12:41 PM. 3.Eliquis 2.5 mg one tablet, scheduled for 9:00 AM was administered at 12:41 PM.4.nifedipine ER 30 mg one tablet, scheduled for 9:00 AM was administered at 12:41 PM.5.acetaminophen 500 mg two tablets, scheduled for 9:00 AM were administered at 12:42 PM.6.lidocaine patch 4% to right shoulder, scheduled for 9:00 AM was applied at 12:43 PM.On 3/12/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 10:14 AM2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 10:14 AM.3.Eliquis 2.5 mg one tablet, scheduled for 9:00 AM was administered at 10:14 AM.4.nifedipine ER 30 mg one tablet, scheduled for 9:00 AM was administered at 10:14 AM.5.acetaminophen 500 mg two tablets, scheduled for 9:00 AM were administered at 10:14 AM.6.lidocaine patch 4% to right shoulder, scheduled for 9:00 AM was applied at 10:14 AM.On 3/13/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:09 AM.On 3/14/26:1.acetaminophen 500 mg two tablets, scheduled for 9:00 AM were administered at 10:07 AM.On 3/15/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:12 AM.On 3/16/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:43 AM.On 3/17/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:56 AM.2.enalapril maleate 20 mg one tablet, scheduled for 9:00 AM was administered at 10:10 AM.On 3/18/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:46 AM.On 3/19/26:1.prednisone 5 mg one tablet, scheduled for 8:00 AM was administered at 9:31 AM.On 3/20/26 at 12:51 PM, during an interview with the surveyor, the Registered Nurse (RN) stated that medications could be administered one hour before and one hour after the physician order scheduled administration time. The RN stated the electronic Med Administration Record (eMAR) gives you the time and that's how she knew what time the resident's meds were due at. The RN further stated she would administer meds as per physician orders. The RN further stated she would let the physician know if the meds were administered late. The surveyor inquired if the RN would document that she notified the physician about late med administration. The RN stated, not for that, they would document only if meds were not available and if the physician was made aware. The surveyor showed the Med Audit Report where the RN had signed for 3/12/26 9 AM, scheduled meds were administered at 10:14 AM, the RN stated, Yes, meds can be given late. In a perfect world, we cannot give all 12 patients their meds at 9 AM. I just do the best I can and try to get it done.On 3/23/26 at 12:04 PM, during an interview with the surveyor, the RN/Unit Manager (UM) stated the meds could be administered one hour before and one hour after the scheduled time. The RN/UM stated the nurses should follow the five rights during med administration which include: right patient, right time, right dose, right drug and right route. The RN/UM stated the expectation from the nurses was to make the physician aware if the meds were being administered late, either get a separate order if the meds were delayed for over an hour or if it was okay with the physician then write a progress note stating, MD (doctor) was made aware and okay to administer meds. The surveyor reviewed the Med Audit Report with the RN/UM, and she acknowledged that meds were administered after the hour window. The RN/UM stated once again that the nurses should notify the doctor and document it.On 3/23/26 at 12:21 PM, the Licensed Practical Nurse (LPN/UM) informed the surveyor that she did not see any documentation for Resident #15 where the physician was notified for late med administration.On 3/24/26 at 10:17 AM, during an interview with the Director of Nursing (DON) she stated the expectation from the nurses was to give the meds timely. The DON further stated the nurses should sign off meds as soon as they administer them. The surveyor made the DON aware of the above-mentioned concerns for Resident #15 and the DON acknowledged, I think there is an issue with the late meds and I will speak with them (the nurses) and further stated the nurses should be notifying the physician if it was a true late med administration.On 3/24/26 at 1:58 PM, the survey team met with the DON, and the Licensed Nursing Home Administrator (LNHA). The surveyor made the facility administration aware of the above-mentioned concerns for Resident #15. A review of the facility's Administering Medications policy with revision date 4/19 and CO Edited 2/26/25 revealed Policy statement: Medications are administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; c. honoring resident choices and preferences. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident.right time . of administration before giving the medication. 21.If a drug is withheld, refused, or given at a time other than the scheduled time, . using electronic documentation (e.g. eMAR), enter the appropriate documentation code.A review of the facility provided, Job Description - Staff Nurse included but was not limited to; Under Staff Nurse Essential Duties and Responsibilities: 10. Ensures timely and accurate medication.N.J.A.C. 8: 39-27.1

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to treat a resident in a dignified manner that promotes their quality of life. This deficient practice was identified for 1 of 1 residents (Resident #106) reviewed for resident rights and was evidenced by the following:On 3/19/26 at 11:15 AM, during the initial tour, the surveyor noted Resident #106 lying in bed with a tracheostomy (a hole in the neck to help breathing), a feeding tube (tubing that attaches to a pump and delivers liquid nutrition to the stomach/intestines), and a biliary drain (tubing that drains liquid from the bile duct). The resident was unable to respond to surveyor questions.On 3/20/26 at 9:43 AM, the surveyor observed Resident #106 from their open door, in bed, uncovered, with their body exposed. The door to the resident's room was open and the curtain was not drawn. Upon entering the room, the surveyor observed that the resident was wearing an adult incontinence brief; a hospital gown was observed underneath the resident's body. The resident's feeding tube was attached to the pump and running; the biliary drain tubing was observed going under the resident's right arm under their twisted hospital gown. Sputum was noted on the resident's chest just below the tracheostomy site. The resident did not respond to surveyor questions. Non-slip socks were noted lying at the foot of the bed. At that time the Unit Manager (UM) and Licensed Practical Nurse (LPN) entered the room and stated that the resident was due for care. The surveyor left the room.On 3/23/26 at 9:41 AM, the surveyor observed the resident lying in bed covered with a sheet. The resident acknowledged the surveyor and attempted to provide answers to some yes/no questions at that time, the resident denied being in pain or having discomfort.On 3/24/26 at 9:02 AM, the surveyor observed Resident #106 from their open door, in bed, uncovered, with their body exposed. A drainage bag was observed hanging from the resident's bed sheet from the hallway; the surveyor entered the room. Resident #106 was observed with their tracheostomy collar (an oxygen delivery device) rotated to the resident's right side and a small amount of sputum at the site. The resident's left arm was out of their hospital gown, leaving only the right arm and shoulder area covered. An abdominal binder (a hook and loop fastener used to keep medical lines in place by wrapping around the torso/abdomen) was noted on the resident and what appeared to be a blue mechanical lift pad (used to lift/lower residents that are unable to get out of bed or roll over on their own) was noted under the resident. The resident appeared to be sleeping at that time.On 3/24/26 at 12:27 PM, the surveyor observed Resident #106 from the hallway resting in bed with their exposed legs toward the left side of the bed, close to the edge. The surveyor entered the resident's room and observed that the resident had a bed sheet bundled around their thighs and midsection; the resident's legs were bare, and the resident was wearing one sock on the right foot, with nothing on the left. Noted lying on top of the resident's chest was a blue pad, the resident had a hospital gown covering their chest underneath it.The surveyor reviewed the medical record for Resident #106.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to, fracture of unspecified part of the neck of left femur (top of the thigh bone) with subsequent encounter for closed fracture with routine healing, encounter for surgical aftercare following surgery on the digestive system, encounter for surgical aftercare following surgery on the respiratory system, acute cholecystitis (gallbladder inflammation), acute respiratory failure with hypoxia (low oxygen levels), severe sepsis with septic shock (bloodstream infection with extreme immune response), and unspecified dementia without behavioral, psychotic, or mood disturbance. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that the MDS was still in progress as Resident #106 was newly admitted . A review of social services' assessments was completed instead. A Brief Interview/Assessment for Mental Status (BIMS) was completed on 3/18/26 and revealed that the resident was severely cognitively impaired. A review of social services Activity Evaluation V2 form revealed that the Resident was alert and oriented and required one-to-one needs. A review of the Social Service admission Evaluation V5 form revealed that the resident's verbal ability was poor, could understand and respond at times, with a communication note difficulty communicating due to trach, cognitive impairment, physical debility and a check mark under confused was noted. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, dated 3/17/26, that the resident had difficulty understanding/communicating related to Dementia with a goal of making needs known to staff. A focus area, dated 3/17/26, revised on 3/20/26, revealed a potential for complications related to cholecystostomy (bile duct) drain site, the goal was to be free from signs and symptoms of infection. An intervention dated 3/17/26 included: monitor placement of chole drain; an intervention dated 3/21/26 added: abdominal binder on at all times, remove for hygiene and skin checks every shift. An intervention from 3/23/26 included: pin the tube to clothing to anchor. The following focus areas, goals and interventions were added after surveyor inquiry. An intervention dated 3/22/26 included anticipating and meeting resident needs and communicating with yes/no questions when able. The ICCP also revealed a focus area, dated 3/22/26, that the resident's tracheostomy was at risk of becoming dislodged/removed related to cognitive impairment and history of self-decannulation; with a goal of the tracheostomy remaining in place. Interventions, dated 3/22/26, included frequent rounding (seeing the resident), providing a busy mat to hold and use, a second intervention for increased frequent rounding, and another for staff to continue with increased rounding, and if [resident] becomes agitated or restless, staff to stay with [resident] until calm. A focus area, dated 3/23/26, for inappropriate dressing/undressing such as removing clothing and sheets, often having skin exposed related to cognitive impairment and dementia; the goal was to maintain a neat and dignified appearance through daily routine. Interventions included a busy mat, elicit family input for best approaches, and to notify family and make arrangements to obtain adaptive clothing if needed. A focus area, dated 3/20/26, included: ADL (Activities of Daily Living) Self care deficit related to physical limitations. Goals for that focus included that the resident: will be clean, dressed and well groomed daily to promote dignity and psychosocial well-being; will not develop complications related to decreased mobility, and will receive assistance necessary to meet ADL needs. Interventions included: assist of 1 person with ADLs, assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed.A review of the Order Summary Report (OSR), included the following physician orders (PO):A PO, dated 3/17/26, to cleanse biliary (bile duct) drainage tube site with normal saline and cover with CDD (clean dry dressing), every day shift.A PO, dated 3/16/26, to document right chole (bile duct) drain output, every shift.A PO, dated 3/21/26, after surveyor inquiry, for an abdominal binder on at all times, may remove for hygiene, every shift.On 3/24/26 at 12:44 PM the surveyor interviewed a Licensed Practical Nurse (LPN) regarding privacy and dignity for residents. When asked what the staff/facility did to provide privacy for residents, the LPN stated that staff would knock on the door before entering, close the door or curtain during care or sensitive procedures, and to only uncover the bare minimum while providing care. When asked how privacy and dignity are ensured for confused or incontinent residents the LPN responded that staff would do rounds and see the residents every two hours. The LPN stated that staff would look for any drinks that needed refilling, make sure the residents are covered, can reach their call bell and personal items, and to ensure their safety, she stated that nurses do not document the rounds. The surveyor then asked the LPN what they would do if they saw a resident uncovered from the hallway; she responded that she would immediately go into the resident's room to cover them, for their dignity and privacy. When asked if someone in the hallway should be able to see a resident's drainage bag, the LPN responded that drainage bags should always be placed into privacy bags to ensure resident privacy and dignity is maintained. The surveyor then asked the LPN whose job it was to maintain a resident's privacy and dignity in a care setting, the LPN responded that it is all of the staff's responsibility.On 3/24/26 at 12:59 PM the surveyor interviewed the Director of Nursing (DON) regarding resident rights and dignity. The DON responded that it is every staff member's responsibility to ensure resident rights and safety at the facility. The DON also stated that the facility provides privacy for residents by closing doors or curtains depending on resident preference while performing sensitive care procedures such as incontinence care, and that it was her expectation that staff does rounding to check on residents frequently. When asked what staff looks for during rounds, the DON responded that staff would look at the resident's appearance, to see if they look clean and smell clean; that they were expected to do a diaper/brief check on incontinent residents, and to make sure the residents are safe in their room with their equipment. The DON stated that rounds and checks are documented in the electronic medical records under the tasks for nursing aides. When asked about seeing an uncovered resident from the hallways or a drainage bag, the DON stated that it was her expectation that staff would immediately go and assist an uncovered resident to get them covered and provide any care needed at that time. She then stated that any resident drainage bags should be always covered with privacy bags to ensure resident privacy and dignity.On 3/24/26 at 2:14 PM the above concerns and observations were presented to the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and survey team and acknowledged.A review of the facility's policy Resident Rights, revised October 2025, revealed the following: Employees shall treat all residents with kindness, respect, and dignity.federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.a dignified experience.self-determination.privacy and confidentiality.wear or be dressed in clothing, accessories, or cosmetics or to engage in grooming practices that are permitted to any other resident.A review of the facility's Confidentiality of Information and Personal Privacy policy, revised February 2021, revealed the following: Our facility will protect and safeguard resident confidentiality and personal privacy.the facility will strive to protect the resident's privacy regarding his or her: accommodations, personal care, medical treatments.A review of the facility's Dignity policy, revised October 2025, revealed the following: Residents are treated with dignity and respect at all times.each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident keep urinary catheter bags covered.staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements.NJAC 8:39-4.1(a)(12)

COMPLAINT #2715780 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/28/26, it was determined that the facility failed to revise care plan interventions for Resident #3 after the resident pushed a bedside table into the abdomen of their roommate (Resident #1). This deficient practice was identified for 1 of 3 residents reviewed (Resident #3) and was evidenced by the following:A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction, aphasia (a language disorder that affects the ability to speak and understand what others say), apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), and speech disturbances. A review of the Facility Reported Event (FRE) dated 1/13/26, revealed that Resident #3 had a Brief Interview of Mental Status (BIMS) of 7 out of 15, which indicated that the resident had severe cognitive impairment. The FRE further stated that an incident of resident-to-resident abuse occurred on 1/10/26 when a verbal argument was overheard in the room of Resident #1 and Resident #3. Registered Nurse (RN #1) stated that she entered the residents' room and observed Resident #3 waving the television remote, and appeared frustrated and 'pushed [their] bedside table towards [Resident #1] bumping [Resident #1] in the abdomen with the table.' A review of Resident #3's Progress Notes (PN) for January 2026 revealed a change in condition note dated 1/10/26 at 10 AM, created by the Unit Manager (UM #1) which indicated that Resident #3 had a verbal argument with their roommate related to television remote control and that the Resident #3 pushed a bedside table into the abdomen of Resident #1. Another nursing note created by UM #1 on 1/10/26 at 4:58 PM, stated that, .[Resident #3] became frustrated and pushed table at their roommate (Resident #1). A review of Resident #3's care plan (CP) revealed a focus which indicated that Resident #3 had difficulty expressing themselves due to expressive aphasia (difficulty getting their words out). A review of interventions initiated on 1/10/26 included the following: Emotional Support provided, time given to express feelings. There was no information on the care plan regarding how they facility would ensure the resident's roommate would be protected when resident #3 gets frustrated again and staff are not in the room to provide emotional support and allow time for resident to express their feelings. The care plan failed to include adequate interventions to ensure other residents are protected from Resident #3, given their risk to physically act out towards others. On 1/23/26 at 11:43 AM, surveyor attempted to contact RN #1 via telephone without success. On 1/23/26 at 12:57 PM, surveyor attempted to contact UM #1 via telephone without success. During a joint interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator on 1/23/26 at 5:14 PM, the surveyor asked if Resident #3's CP had been updated after the incident to which they stated that Resident #3's CP was updated and referenced the above intervention. When asked how this intervention would prevent Resident #3 from becoming frustrated and physically acting out towards another resident again when staff were not around, both the DON and the LNHA stated that their updated interventions would not stop Resident #3 from another altercation with another resident. A review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 revealed that the purpose was to include person-centered measures that would meet a resident's physical, psychosocial and functional needs that would be developed and implemented. The policy further indicated that interventions were to address the underlying source of a problem. N.J.A.C. 8:39-11.2(e)2, 27.1(a)

COMPLAINT #2720500 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/26/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1) and was evidenced by the following:A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction, aphasia (a language disorder that affects the ability to speak and understand what others say), apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), and speech disturbances. The comprehensive Minimum Data Set (MDS), an assessment tool, dated 1/12/26, revealed a Brief Interview of Mental Status (BIMS) of 14 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS indicated that Resident #1 required substantial assistance with toileting and bathing, and that the resident was at risk of developing pressure ulcers/injuries. A review of Resident #1's care plan (CP), revealed a focus related to the resident being at risk of having alteration in skin integrity. Further review revealed an intervention, initiated on 1/6/26, that indicated that the resident's skin was to be observed during daily [Activities of Daily Living] (ADL) care and that abnormalities were to be reported. A review of Resident #1's Task list for January 2026 included the following areas facility stated should be documented during each shift. There was no evidence of documentation on the following dates and shifts: -Bladder continence and toilet use:1/6 Night1/7 Day, Evening & Night1/8 Day, Evening & Night1/9 Day, Evening & Night1/10 Day & Night1/11 Evening & Night1/12 Day, Evening & Night -Bowel movement and toilet use1/7 Evening & Night1/8 Day, Evening & Night1/9 Day, Evening & Night1/10 Day1/11 Evening & Night1/12 Day, Evening & Night -Hygiene1/6 Evening and Night1/7 Day & Night1/8 Day, Evening & Night1/9 Day, Evening & Night1/10 Day & Night1/11 Evening & Night1/12 Day, Evening & Night A review of Resident #1's Progress Notes (PN) for the corresponding dates did not reveal any documentation related to the above tasks on the stated dates. During an interview with the Certified Nursing Assistant (CNA #1) on 1/28/26 at 10:47 AM, CNA #1 stated that CNA's were primarily responsible for assisting residents with Activities of Daily Living (ADL) care. CNA #1 further stated that all care provided was to be documented in each resident's electronic medical record (EMR). CNA #1 further stated that documentation was important because it verified that residents were being monitored and that care was provided. During a joint interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 1/28/26 at 2:10 PM, they both stated that CNAs were responsible for providing ADL care and that they were expected to enter all care provided into each residents EMR. They further stated that documentation was important to prove that that care was provided. They further stated that nurses and unit managers were responsible for not only ensuring that the appropriate care was provided, but that the CNAs are documented the care they provided. A review of the facility's Charting and Documentation policy dated July 2017 revealed that all services provided to residents should be documented and that documentation would be complete and accurate. The policy listed what information was to be documented and included, .Treatment or services performed. N.J.A.C. 8:39-27.1(a)

COMPLAINT #2720500 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/28/26, it was determined that the facility failed to notify a resident's representative (RR) regarding a change in the resident's medical condition and or status. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1) and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: type II diabetes, cerebral infarction, chronic obstructive pulmonary disease, and hypertension. A review of Resident #1's Progress Notes (PN) for January 2026 revealed a nursing note dated 1/11/26 at 11:39 PM, created by Registered Nurse (RN #1) which state: [Physician] notified of excoriation to bilateral groins and scrotum, (scraped skin). There was no documented evidence to show that the facility notified the resident's representative about the newly identified scraped areas on the resident's skin. During an interview with RN #1 on 1/23/26 at 4:17 PM, RN #1 stated that a RR was to be notified of any change in a resident's medical condition and that the notification should be documented. In the presence of the surveyor RN #1 reviewed the above-mentioned PN and stated that if the family was notified, they would have documented it. RN #1 further stated that they should have informed the RR. During a joint interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 1/28/26 at 2:10 PM, they both stated that the expectation was for staff to notify the RR of any new conditions, including excoriation of the skin. They further stated that RN #1 should have informed Resident #1's RR of their change in the resident's skin condition. A review of the facility's Change in a Resident's Condition or Status policy dated February 2021 revealed that the facility would promptly notify an RR of a change in a resident's medical condition. The policy further indicated that notification would occur within twenty-four hours of the change. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows: On 10/11/24 at 10:11 AM, the surveyor in the presence of the Director of Culinary Management (DCM), toured the kitchen and observed the following: 1. In the walk-in freezer, a box of chocolate chip premade dough cookies, a box of beef patties, and a box of vegetable burgers. The boxes were open, there were no dates when to use by, and the the bags inside the boxes were unsealed and the products were covered in ice crystals. The DCM could not speak to when the boxes were opened. 2. In the kitchen, the ice machine had black sediment on the output flap in the interior of the machine. The DCM wiped the flap with a white paper towel revealing it had a wipeable black colored sediment. When the surveyor asked the DCM what it was, the DCM responded it was black mold, and it needed to be cleaned immediately. On 10/11/24 at 10:20 AM, the surveyor interviewed the DCM, who stated that the freezer items should have been labeled with an opened date, and if only part of the bag was used, the bag should be resealed and labeled. The DCM stated that labeling ensured that it was used in a timely fashion to prevent waste, and sealing it prevented contamination, ice crystals, and food borne illness. On 10/17/24 at 12:34 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON) and survey team acknowledged the concerns. The LNHA provided no additional information. A review of the facility provided Refrigerators and Freezers policy dated revised November 2022, included this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .6. Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference. 7. All food is appropriately dated to ensure proper rotation by expiration dates. received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated on food that are open .9. Supervisors are responsible for ensuring food items in pantry, refrigerators and freezers are not past use by or expiration dates . A review of the facility provided Ice Machines and Ice Storage Chests dated revised January 2012, included ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .ice making machines, ice storage chests/containers, and ice can all become contaminated by [ .] c. colonization by microorganisms .to help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions [ .] f. clean and sanitize the tray and the scoop daily . NJAC 8:39-17.2(G)

Based on observation, interview, and pertinent facility documents, it was determined that the facility failed to ensure narcotic medications were secured under double lock. This deficient practice was identified in 1 of 2 medication storage rooms observed (Cove nursing unit), and was evidenced by the following: On 10/15/24 at 11:11 AM, the surveyor, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN) observed the Cove nursing unit's medication storage room. Upon entering, the surveyor opened the unlocked medication refrigerator (med fridge), and inside was the unlocked narcotic medication lock box. The narcotic medication lock box contained 57 dronabinol 5 milligram capsules (a controlled medication used to treat weight loss). At that time, UM/LPN confirmed that the controlled medications should be stored under two secured locks. On 10/15/24 at 12:18 PM, the surveyor interviewed the Director of Nursing (DON), who stated narcotic medications should be stored under two secured locks to prevent drug diversion. The DON confirmed that the dronabinol in the Cove nursing unit medication storage room should have been stored with two secure locks. On 10/17/24 at 12:34 PM, the surveyor, in the presence of the DON and the survey team, interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed that the narcotic medication stored in the Cove nursing unit's med fridge were not considered stored under double lock. A review of the facility's Controlled Substance Storage policy with effective date of February 2019, Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment separate from all other medication or per state regulation. The access system to controlled medication is not the same as the system giving access to other medications (the key that opens the compartment is different from the key that opens the medication cart.) If a key system us used, the medication nurse on duty maintains possession of the key to controlled substance storage areas .Controlled-substances that require refrigeration are stored within a locked box within the refrigerator, this box must be attached to the inside of the refrigerator in such manner that prevents its removal from the medication room . NJAC 8:39-29.7(c)

Based on interview, record review and review of facility provided documentation, it was determined that the facility failed to: a) follow their Accident/Incident Policy and complete an investigation when a resident was found with a dislodged hemodialysis [the clinical purification of blood by dialysis, a substitute for the normal function of the kidney] perma-catheter on [DATE], and required emergency transport to the hospital, and b) document and consistently implement interventions to prevent recurrence. This deficient practice occurred for 1 of 5 residents reviewed for accidents/incidents (Resident #76), when on [DATE] Resident #76 was observed by staff trying to remove the hemodialysis perma-catheter, and on [DATE] Resident #76 was found unresponsive, profusely bleeding with the hemodialysis perma-catheter dislodged and was pronounced deceased . Resident #76 had diagnoses which included but were not limited to: dependence on renal dialysis, anxiety disorder, and vascular dementia with other behavioral disturbances. A review of the Progress Notes (PN) revealed a Licensed Practical Nurse (LPN) #1 documented on [DATE], that Resident #76 dislodged his/her dialysis access to the right chest wall, was bleeding profusely and was sent to the emergency room (ER). A PN by LPN #1 dated [DATE], documented that Resident #76 was trying to remove his/her perma-catheter located to the right chest wall. A PN by LPN #2 dated [DATE], revealed Resident #76 was again found with his/her perma-catheter dislodged, was bleeding a significant amount, required cardiovascular pulmonary resuscitation (CPR), and was pronounced deceased by the emergency response physician. The facility's failure to follow their Accident/Incident policy, complete an investigation and implement interventions resulted in an Immediate Jeopardy (IJ) situation. The IJ situation began on [DATE], and was identified on [DATE] at 2:42 PM, and the Licensed Nursing Home Administrator (LNHA) was notified of the IJ situation. An acceptable removal plan was received on [DATE] at 3:20 PM and was verified as implemented on [DATE] at 11:42 AM. The evidence was as follows: On [DATE] at 12:05 PM, Surveyor #1 requested and reviewed Accident/Incident reports for Resident #76. The facility provided two Accident/Incident reports dated [DATE] and [DATE]. A review of additional PNs revealed documentation dated [DATE] by the Social Worker (SW). The SW documented a phone call with the resident's family about the resident's expressed feelings towards dialysis, but that the resident would continue with dialysis. Surveyor #1 reviewed the electronic medical records (EMR) for Resident #76. Resident #76's most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate care, dated [DATE], which included but was not limited to; a Brief Interview of Mental Status (BIMS) of 08 out of 15 which indicated the resident was moderately cognitively impaired. Section E0200 documented the resident had no behaviors. Resident #76 required extensive assistance for Activities of Daily Living (ADLs) except eating which was supervision only. Section O documented that the resident received dialysis while a resident. The Order Listing Report dated [DATE] through [DATE], included but was not limited to; an order to assess dialysis site for signs and symptoms of infection/bleeding every shift. A notation was documented that the resident was socially inappropriate yelling to exhaustion. A review of the on-going patient centered Care Plan (CP) included but was not limited to; a focus area of at risk for adverse effects related to the use of antianxiety medication dated [DATE], with interventions including notify physician of decline in ADL or mood/behavior, psychiatric consult and follow-up as needed, and both initiated on [DATE] with no revisions. A focus area of at risk for behavior symptoms related to dementia-restlessness initiated [DATE], with no revisions. A focus area of renal insufficiency initiated [DATE], with interventions which included check access site for evidence of infection, swelling or excessive bleeding. There were no revisions to include the dislodged perma-catheter on [DATE] or [DATE], nor interventions to prevent recurrence. The CP did not contain focus area or interventions regarding the documentation of the event that occurred when Resident #76's hemodialysis perma-catheter was dislodged on [DATE], and when the resident was observed trying to pull the hemodialysis perma-catheter out on [DATE]. In addition, there were no focus areas, goals or interventions regarding the documentation of Resident #76's expressed feelings towards dialysis. A review of the PN Situation Background Appearance and Review (SBAR - a summary) dated [DATE], included but was not limited to; Situation: 1. patient perma-cath to right chest wall was dislodged. 4. Has this condition, symptom or sign occurred before? yes. 4a. If yes, treatment for last episode: [DATE]. Resident was sent out to [name redacted] for insertion. Appearance: Mental Status Evaluation: 8. Compared to baseline; b. increased confusion or disorientation. 10. Are there any behavioral issues noted? a. Yes. 10b. Describe symptoms or signs: occasional yelling/screaming. Call for 911, Emergency medical transport. On [DATE] at 12:17 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that she only had two Accident/Incident reports for Resident #76. The DON stated that the process was to do Accident/Incident reports for situations such as falls, bruising, injuries, unusual occurrences, skin breakdown, and new wounds. The DON stated Resident #76 had a perma-catheter and had been sent to the hospital a few times because he/she pulled out the perma-catheter. The DON clarified that, well the staff found it [the dislodged hemodialysis perma-catheter] but nobody actually saw him/her pull it out. It was possible it could have come out some other way. The DON stated that Resident #76 was not alert but could say that he/she doesn't want hemodialysis. The DON stated that she had spoken to the nurse regarding the [DATE] incident, but did not document the conversation. The DON further stated she had no documented statements from any of the staff. She acknowledged, that's not the normal procedure when there was an incident. The DON stated there should have been an investigation, but it was not done. The DON further stated, I did ask staff to provide statements, but I was not given anything. She stated the dislodged perma-catheter was not considered a usual occurrence and she should have requested an investigation. She stated the supervisor on duty documented in the EMR and in the communication report. When asked about a review of the CP, the DON stated, I don't remember, but I would expect that [the dislodged hemodialysis perma-catheter] to be on the care plan since there was a history of the resident pulling out the perma-catheter. The DON further stated the incident had not been reported to the New Jersey Department of Health (NJDOH). The DON stated, I don't remember if this was discussed in morning meeting. We would usually review the incidents. On [DATE] at 11:34 AM, during an interview with Surveyor #2, the Certified Nursing Assistant (CNA) #1 revealed that the resident was not on her assignment. CNA #1 stated she was aware that Resident #76 was a hemodialysis patient and had a privately hired aide for companionship that would sit with him/her. She stated that when the private aide was not at the facility, the resident would be placed by the nursing station for monitoring. On [DATE] at 11:38 AM, during an interview with Surveyor #2, the LPN Unit Manager (UM) stated that the resident had a private aide hired by the family for 7 days a week from 8:00 AM to 8:00 PM. She stated Resident #76 had a behavior of yelling out, would try to ambulate unassisted, was very confused, and attended hemodialysis three times weekly. She stated that the hemodialysis center reported a behavior of the resident screaming, had attempted to remove his/her colostomy [a surgically created opening to empty fecal matter into a bag], was very restless and difficult to redirect. The LPN UM stated that the resident was scheduled to receive an anti-anxiety medication prior to receiving hemodialysis. On [DATE] at 11:39 AM, during an interview with Surveyor #3, CNA #2 stated that the resident went back and forth to dialysis, his/her behaviors included lashing out and yelling. CNA # 2 stated, If I noticed anything with his/her dialysis site, I would go directly to his/her nurse and let them be aware. About a few weeks before he/she passed, he/she would try to pull out his/her dialysis catheter. I would tell him/her not to touch it. In the morning before his/her private aide would come in, I would place him/her by the nurse's station at the front desk so the Unit manager or unit clerk could watch him/her until the aide got here. His/her aide was more of a companion so we would do his/her physical care. When I would bring him/her to the front desk, I would tell the UM why and that he/she was trying to pull at his/her dialysis catheter. I don't remember seeing the dialysis site bleeding on my shifts. I heard he/she had pulled out his/her catheter on other shifts and had to be sent out to the hospital. I would check on him/her frequently on my shift. On [DATE] at 11:45 AM, during an interview with Surveyor #3, the Unit Secretary stated that she was familiar with Resident #76 and that the resident received dialysis. The Unit Secretary further stated that when he/she first came to the facility, the CNAs would bring him/her to the nurses desk because the resident would try to get out of the bed. On [DATE] at 11:38 AM, during an interview with Surveyor #1, the SW stated she had recalled the resident. The SW stated there were, a lot of complex things going on. The resident had an aide for companionship because the resident didn't do his/her own care. The SW was asked about the [DATE] PN. The SW stated that the resident wasn't oriented and at times he/she would state they didn't want to go to dialysis, but he/she did not say it every day or consistently. The SW stated at the time of the PN, the resident verbalized only once or twice that he/she didn't want to go to dialysis. The SW stated she reached out to the family to make them aware. The SW stated that was the last time Resident #76 had ever said that he/she did not want to go to dialysis. The SW stated she was not aware if the resident ever pulled out his/her hemodialysis perma-catheter. The SW stated if the resident had pulled out their hemodialysis perma-catheter, she would expect to have been made aware and there would be an Interdisciplinary Team meeting. On [DATE] at 12:02 PM, the LNHA stated she was familiar with Resident #76 and that the resident had a private duty aide from 8:00 AM to 8:00 PM just for companionship. She stated the resident was a hemodialysis resident and had gone out on [DATE] for the dialysis perma-catheter being dislodged. The LNHA stated he/she passed away here [at the facility] because his/her [hemodialysis] perma-catheter was out on [DATE]. The LNHA further stated, I don't remember if I was in am [morning] meeting for clinical for [DATE]. I would expect for it [dislodged hemodialysis perma-catheter] to be discussed especially since we sent him/her out. We definitely would discuss why we sent out a resident and if there was anything we could have done in-house. The LNHA stated she did not know that the resident had stated he/she did not want to go to dialysis. The LNHA further stated that maybe Resident #76 did not want to go to dialysis because of the late appointment time. The LNHA stated that should have been discussed in a meeting or care conference. The LNHA stated she was only aware of two times the resident pulled out their perma-catheter. She stated on [DATE], the DON had spoken to the staff who would have called the DON about Resident #76. The LNHA stated that after thinking about the incident, she realized it was an unusual occurrence and should have been reported to the NJDOH. The LNHA stated there was no investigation or statements done at the time of Resident #76's dialysis perma-catheter being dislodged. She stated the DON started an investigation after the surveyors made the facility aware. The LNHA reviewed the facility Accident/Incident policy and acknowledged that the incident on [DATE] also should have warranted an investigation. The LNHA stated if the resident had a behavior of dislodging their perma-catheter, interventions should have been implemented. The LNHA further stated there would be targeted behaviors documented if there was a specific behavior exhibited by the resident. On [DATE] at 1:11 PM, LPN #1 was interviewed via telephone. LPN #1 stated that on [DATE], he found Resident #76 with his/her perma-catheter already dislodged. LPN #1 stated he had not witnessed the resident pulling it [the perma-catheter] out. He stated he applied pressure to the bleeding dialysis site and called 911. LPN #1 stated the resident was sent out to the hospital and returned on [DATE]. LPN #1 stated that on [DATE], he had witnessed Resident #76 trying to remove the perma-catheter and was able to stop him/her and reinforce the dressing. LPN #1 stated he reported the incident to his supervisor. On [DATE] at 1:35 PM, the DON and the LPN UM were interviewed by the surveyors. The DON stated that the surveyors, opened her eyes and she should have investigated but did not. I take ownership. The DON stated she read that the resident coded and when a resident codes, it must be discussed in the morning meeting. The DON stated, I should have investigated, and I should have reported [to NJDOH]. There would be a clinical discussion but there wasn't for this one. I don't know. It wasn't done. The DON further stated she was doing the investigation now that the surveyors brought it to the attention of the facility. The LPN UM stated that there was documentation in the EMR that Resident #76 would pull at his/her perma-catheter. The LPN UM stated pulling at his/her perma-catheter was like a behavior. When asked about interventions for Resident #76's behavior of pulling at their perma-catheter, the DON stated there was a talk of an ace wrap, but it was not documented. The DON acknowledged that with no causal factor documented and no interventions documented, we don't know that anything had been done and there is nothing else we can tell you. On [DATE] at 2:26 PM, the DON was in the conference room with the surveyors. The DON had provided statements that she acknowledged were just gathered and are all back dated. The DON stated, I know the staff and I asked them Friday ,d+[DATE] [23] and I noticed they were all backdated. I noticed but did not want to change anything. I know it's not the right date. On [DATE] at 10:31 AM, the Registered Nurse (RN) supervisor stated that on [DATE], she was called into Resident #76's room, CPR was in progress, the perma-catheter was dislodged and there was blood all over. She stated 911 [Emergency Medical Services - EMS] was called, the family was called, EMS arrived, and the EMS physician pronounced the resident as deceased . The RN stated she notified the doctor's Nurse Practioner and the DON. When asked how the DON was notified, the RN stated a text message was sent to the DON and I thought it was taken care of by the next shift. The RN stated, it was a company text so I would not know if there was a response. I let the 11:00 PM to 7:00 AM shift know. The company texting phone stays at facility. The RN stated she knew prior to [DATE], that the resident had pulled at his/her perma -catheter. I was aware of him/her having a history of pulling the perma-catheter out. They [the facility staff] have morning meetings. I would email a report to the DON, and other parties involved to make them aware of things that happened. The RN stated that information on the email included things such as the census, admissions, run down of what's going, and on any staff call outs. She further stated that there would be a verbal report to the on-coming shift. The RN stated that every shift was supposed to monitor the hemodialysis perma-catheter during rounds, make sure Resident #76 was calm, and monitor the site. I would think that would be part of the report, to monitor specifically for pulling at the cath [hemodialysis perma-catheter]. A review of the facility provided email, Clinical Rounds [DATE], sent on [DATE], included but was not limited to; Resident #76- pulled perma-cath last night and went to ER; contact list updated per family request. A second facility provided email, ,d+[DATE] Shift rep [report] ,d+[DATE], sent [DATE], included but was not limited to; Admission/s [Resident #76] reinserted perma-cath- resident still attempts to pull out perma-cath. A third facility provided email, ,d+[DATE] report, sent on [DATE], included but was not limited to; Resident #76 pulled his/her perma-catheter and then he/she was coded then he/she pronounced [deceased ] at 11:27 PM. [name redacted] funeral parlor. A review of the facility provided, Accidents and Incidents - Investigating and Reporting, policy edited [DATE], included but was not limited to; Policy Statement: all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The nurse supervisor and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The nurse supervisor and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the DON within 24 hours. 7. Incident/Accident reports will be reviewed by the Safety Committee To analyze any individual resident vulnerabilities. Continuous Quality Improvement: 1. The quality improvement program shall include a systematic review and evaluation of incidents and accidents, prevention, management, and documentation practices. 2. The center will collect and analyze data to evaluate outcomes or performance. Data analysis shall focus on recommendations for implementing corrective actions and improving performance. A review of the facility provided, Hemodialysis Pre and Post Care, policy revised ,d+[DATE], included but was not limited to; Purpose: to assist the resident in maintaining homeostasis pre-and post- hemodialysis. To assess and maintain patency of hemodialysis access. Detect complications of access site related to cannula separation. General Information: Routes of hemodialysis treatments will be monitored for potential complications or infections. Treatment sites are to be assessed regularly and more frequently if complications arise. Assess resident for: change in physical and/or mental function. Post Dialysis Care: 6. Report any significant change in resident's behavior. A review of the facility provided, Rapid Response Protocol, revised [DATE], included but was not limited to; Rapid response events are high risk situation . that may have resulted in, or like to results in, serious physical or mental harm . Timely response to the event is essential to know the facts and to take action to mitigate risks. Steps to Follow Immediately when an Event Occurs: obtain statements and document on appropriate forms, create a timeline of events determine if event is reportable to state regulatory agencies, Ombudsman. Concluding the Investigation: 1. what steps were taken to protect the person involved (immediate and ongoing)? Rapid Response Trigger Events: unexpected death. A review of the facility provided, Care Plans, Comprehensive Person-Centered, edited [DATE], included but was not limited to; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8.h. incorporate identified problem areas. n. Aid in preventing or reducing decline in the resident's functional levels. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 11. Care Plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration between the resident's problem areas and their causes, and relevant clinical decision making. 14. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident's condition. A review of the facility provided, Director of Nursing, dated ,d+[DATE], included but was not limited to; Position Summary: responsible for the day to day coordination and oversight of all of the Nursing Department in accordance with current Federal, State and local regulations. NJAC 8:,d+[DATE].1(a)

Based on observation, interview and document review, it was determined that the facility failed to ensure: a) the dish machine was functioning properly and washing and sanitizing at appropriate temperatures, b) foods were consistently labeled with a use-by date, c) the kitchen walls and environment were maintained in a clean and sanitary manner, and d) hair restraints were appropriately worn to contain exposed facial hair to prevent the spread of potential infection and food borne illness. The deficient practice was evidenced by the following: On [DATE] at 8:59 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. The FSD was observed wiping down spice containers and was wearing a beard restraint that did not cover his mustache. The surveyor inquired as to the uncovered facial hair and the FSD stated I think mustaches are allowed. 2. The walk-in refrigeration unit contained: - Vanilla, Strawberry and Chocolate 4-ounce nutritional drinks that were not labeled with a use-by date. The FSD stated they were good for one week and they should be labeled. - An unopened 5-pound package of feta cheese. The FSD could not locate a use-by date and stated he did not know when it expired, and it should be dated. -An opened box of individual cream cheese packages without a use-by date and the FSD was unable to locate a use-by date. - One gallon of chocolate syrup without a use-by date. - One container of blue cheese dressing without a use-by date. - One gallon jar of jalapenos with a received date of [DATE] and no use-by date. - A box that contained 3 logs of partially frozen ground beef without a use-by date or date the item was pulled from the freezer. The FSD stated I cannot tell when it was pulled. -A 5-pound box of fresh mushrooms that had a received date of ,d+[DATE] and no use-by date. The FSD stated should have had a sticker. 3. The walk-in freezer contained: -One package of pre-molded puree beef, one shrimp and one vegetable that were all undated, and were not labeled with a use-by date. - One package of frozen sliced deli ham that was undated with a use-by date. 4. Four loaves of undated white bread and four packages of dinner rolls were located on a rack. The FSD stated I thought they had a date, and stated we should be putting dates on it. 5. Two of three of the ceiling vents in the cooking/food preparation area had visible dark dust like debris extending outward of the vent area. 6. At 9:42 AM, the dish machine was observed in use and staff was in the process of cleaning multiple acrylic type drink pitchers. The surveyor was informed that the wash temperature should reach 150 degrees Fahrenheit (F) and the rinse temperature should reach 180 F. At that time the rinse gauge for the dish machine was visibly distorted and filled with condensation and was not be moving. Upon surveyor inquiry and with the FSD present, the food service staff (FSS) repeated the wash cycle with the pitchers in the dish machine, and the wash temperature gauge did not rise above 125 F, and the rinse gauge was unable to be read due to condensation. The FSD requested to drain the dish machine and refill to see if that would rectify the problem. The FSS (#1) drained and re-filled the dish machine with water. When asked the FSS when the gauge became filled with condensation, the FSS stated it had been like that for several days. At 9:44 AM, the dish machine was again observed in use and the wash temperature was at 110 F, and not reaching the 150 F as indicated and the rinse gauge was unable to be read. The FSD then stated, we may need paper [referring to shutting down the malfunctioning dish machine] and the FSD stated he would contact the service provider. At that time, the surveyor observed a clip board posted in the kitchen with the dish machine temperatures for [DATE] which revealed Breakfast, Wash Standard greater than or equal to 150 F, with Rinse Standard greater than or equal to 180 F, which repeated for Lunch and Dinner. Breakfast was documented with Wash 165 F, and Rinse 180 F with initials next to it, Lunch was documented with Wash 165, Rinse 185 and initialed and Dinner was also documented with the Wash 160 and Rinse 185, and also initialed. On [DATE] at 2:10 PM the surveyor conducted a second observations of the dish machine which was in use and two FSS (#1 & #2) were operating the dish machine and confirmed that they were cleaning the lunch dishes. At that time, the surveyor observed that the rinse gauge was now clear and the temperature was reaching above 180 degrees F and there was now steam observed coming from the dish machine. The FSS #1 stated that the wire and the thermostat had been changed. The surveyor, in the presence of the FSD, observed that the Wash temperature was still not meeting 150 F while the dish machine was in use and was at 120 F. FSS #2 was also observed with a beard restraint that did not fully cover his facial hair and was removing clean dishes from the dish machine. When inquired about the Wash temperature, the FSD confirmed that the dish machine was still not meeting the wash temperature and regarding the beard restraint, the FSD stated there was only one size of beard restraint. On [DATE] at 11:42 AM, the Liscensed Nursing Home Administrator (LNHA) provided the surveyor with two Extra Service Request documents from the company that services the dish machine. One was dated [DATE] and timed at 2:13 PM which revealed. The Rinse temperature gauge was not displaying correctly and Guage corroded and had humidity inside. Replaced and now measuring correctly. A second Ectra Service Request dated [DATE] at and timed at 10:11 AM revealed Wash tank temperature not reaching 150 F and High limit switch sensor was not working correctly not letting the heating contactor to engage. The Photos included Thermostat replaced and adjusted. [DATE] at 12:32 PM, the surveyor conducted a telephone interview with the dish machine service technician (ST) regarding the dish machine. The ST stated he was contacted on [DATE] a second time after he was already at the facility and changed the dish machine gauge because there was corrosion in the rinse gauge and that would be the only way that the facility would know if the temperature was reaching the appropriate level. The ST stated that he did not look at the Wash temperature on the first service call. The ST stated that he needed to adjust the Wash temperature gauge and there was adjustments that needed to be made since the set points needed to be changed. The surveyor asked the ST if the facility should have been using the dish machine when the temperatures were not meeting the requirements. The ST stated that the facility should only be using the dish machine when it meets the proper temperatures and confirmed that he was not contacted regarding any concerns with the dish machine meeting the required temperatures until [DATE]. On [DATE] at 10:28 AM, the surveyor conducted a follow-up kitchen observation during meal preparation, accompanied by the Registered Dieititian (RD) and observed: 1. The walls in the kitchen were visibly soiled with splatter type debris throughout the kitchen and there was debris under the preparation tables and toward the back of the kitchen by the bread rack. The RD confirmed the surveyor's observations and stated that the areas needed to be addressed. 2. A black cart, containing a case of soda that was identified for resident use, was visible soiled. 3. The plastic wrap container on the preparation table was visible soiled with stains. 4. The area by the dish machine area between the cooking battery, adjacent to a steamer, contained a rack that was identified as containing clean pans. The steamer which was indented as needing repair was dripping liquid onto the clean items. 5. The walk in refrigeration unit gasket was lifted. The surveyor reviewed the following policies which revealed: The Food Receiving and Storage Polidy, Revised [DATE], Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). The Preventing Food Borne Illness- Employee Hygiene and Sanitary Practices Policy Revised [DATE], Hair Nets, 15. Hair nets or caps and/ or beard restraints are worn when cooking, preparing or assembling food as to keep hair from contacting exposed food, clean equipment, utensils and linens. The Sanitization Plicy Revised [DATE]. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: a. High-Temperature Dishwasher (Heat Sanitization): 1. Wash temperature (,d+[DATE] F) and 2. Rinse temperature (180 F) . ; or 165 F for stationary rack, single temperature machine. NJAC 8:,d+[DATE].2(g)

Based on interview and document review, it was determine that the facility failed to ensure that sufficent staffing was identified by the Quality Assurance and Performance Improvement (QAPI) program, and the QAPI policy was followed to identify adequate staffing as a concern that was expressed by 5 of 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 10/06/23 at 10:50 AM, two surveyors conducted a resident council meeting with five unsampled residents. Five of five residents stated that call bell response was excessive and up to 1-2 hours at times, and one unsampled resident stated that he/she would take him/herself to the bathroom because staff was just not around. The residents (5/5) stated that the quality of care provided from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM was not good and that staff seemed like they did not want to be there and could care less. 10/12/23 at 1:12 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI process. The LNHA stated QAPI was for self-identifying concerns in the building, and asked if staffing was identified as an area for monitoring. The LNHA stated that the staffing coordinator provided a daily staffing report and staffing sheets. The LNHA confirmed, and stated no there was no QAPI specific to staffing and the LNHA stated she would provide the surveyor with a list of the current QAPIs. On 10/12/23 at 1:43 PM, the LNHA provided a list of eighteen current QAPIs and staffing was not listed as a current QAPI. On 10/13/23 at 9:15 AM, the surveyor again asked the LNHA if there were any current QAPIs related to staffing. The LNHA stated the staffing coordinator was completing a monthly staffing report related to the current state requirements, but not a QAPI. A review of the facility provided QAPI plan goals revealed II. Scope: . The QAPI plan includes policies and procedures use to: identify and use date [data] to monitor outcomes, establish goals and thresholds as a performance measurement, identify and prioritize opportunities for improvement and systematically analize the root cause of issues and opportunities for improvement . The Quality Assurance and Performance Improvement (QAPI) Program- Covernance and Leadership policy, Revised March 2020 Revealed: 4. The responsibilities of the QAPI Committee are to: a. Collect and anylyze performance indicator data and other information; b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services. NJAC 33.2(c)13; 33.3

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents highest practical wellbeing by failing to a) provide necessary services to maintain activity of daily living (ADLs) and b) failing to provide restorative nursing services to residents. This deficient practice was identified for 3 of 5 (Residents #55, #63 and #47) and expressed by 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced as follows: Refer to F677 & F688 a) On 10/04/23 at 9:35 AM, the surveyor interviewed an unsampled resident saying there is never enough staff. The unsampled resident stated all the shifts are short staffed and especially on night shift. The unsampled resident stated aides say I don't have time to do that. I got too many people. On 10/04/23 at 9:54 AM, the surveyor interviewed the CNA stated she has 10 residents to care for today and that 10 residents are the max over 10 is too much. The CNA stated she goes without a break or lunch because she cannot take short cuts during care for the residents. The CNA stated 7 out of 10 residents needed total assistance. The CNA also stated she cannot get all her work completed with 10 residents. On 10/04/23 at 10:05 AM, the surveyor observed Resident #55 in bed. Upon inquiry the resident stated he had not been changed since last night. At 10:20 AM, while communicating with the resident the CNA entered the room. The CNA informed the surveyor that he/she is from hospice and provides care for the resident. The Resident agreed to be checked for incontinence and the brief, resident's T-shirt, and blue pad protecting the bed were all saturated in urine. On 10/04/23 at 10:45 AM, the surveyor observed Resident #63 in bed and noted the resident was nonverbal. The surveyor left the room and informed the (RN) Registered Nurse that she would like to check Resident #63 for incontinence care. The CNA positioned the resident to her left side and noted the resident was saturated with urine, including the blue pad protecting he bed. On 10/04/23 at 12:30 PM, the surveyor returned to Resident #63's room and observed the resident in the same position. The surveyor observed the resident had not been provided mouth care yet. It was also observed that the resident's nails were long with a brown coasted substance underneath the fingernails. On 10/06/23 from 10:50 AM to 11:18 AM, a surveyor conducted a resident counsel meeting with five unsampled residents. When asked about staffing, five of five residents stated the attention in care has gotten worse and things used to be more detailed. The residents stated they felt like the care was being rushed, staff was always in a hurry and interactions with residents were less. Five of five resident agreed that the quality of care wasn't good. One resident stated staff seemed like they just didn't want to be there and could care less. Another resident stated that he/she was under the impression that the night shift was hiding from the residents. b) On 10/05/23 at 9:15 AM, the surveyor observed Resident #47 which revealed some possible limited range of motion to bilateral lower extremities and increase in tremors observed during resident interview. Resident #47 stated that he/she would like to get out of the bed and attend physical therapy, and get out of the room. Resident #47 indicated that he/she informed the Unit Manager that he/she would like to get out of the bed two weeks ago and nothing was done. The surveyor reviewed Resident# 47's electronic medical record (EMR). Resident (R #47) was admitted to the facility with diagnoses which included but were not limited to: Morbid obesity, muscle weakness, type 2 diabetes mellitus with unspecified complications, difficulty in walking, Addisonian crisis (an emergent adrenal crisis) and tremors. A review of the Quarterly Minimum Data Set with assessment reference date (ARD) of 09/18/23, found R #47 was coded with functional limitation in range of motion to the lower extremity (impairment on both side). In Section O. Special Treatment and Program, the coding for Restorative Nursing Program found R #47 was coded 0 (zero) for the number of days each of the following restorative programs were performed for at least 15 minutes a day in the last 7 (seven) calendar day, passive range of motion, active range of motion, and splint application. A review of the Restorative Nursing Communication Form dated 07/21/23 had the following recommendations: Active/ Active Assistive Range of Motion to bilateral lower extremities. Ankle pumps, hip flexion, hip abduction and short arc Quads. The goal was to maintain and prevent decline in the resident's range of motion to enable good hygiene and prevent skin breakdown. On 10/10/23 at 10:12 PM, following the conversation with Resident #47 regarding their concerns, the surveyor interviewed the CNA who cared for Resident #47. The surveyor asked when was Resident #47 was last transferred out of bed to the recliner chair. The CNA stated, It had not been done since I have been here. The CNA added, usually he/she would get out of the bed with physical therapy. Upon further inquiry, the CNA added that restorative care had not been completed due to not having enough staff since the CNA assigned to complete restorative care had to take on a resident assignment and could not perform restorative care duties. On 10/12/23 at 1:09 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding staffing. The LNHA stated that the DON and Staffing coordinator usually was responsible for the staffing. The LNHA stated that she was aware of the state regulations for staffing requirements. The DON and Staffing Coordinator reviewed the staffing and based on the census and acuity changes would be made. The LNHA said, I believe they are meeting the minimum staffing requirement. NJAC 8:39 - 5.1 (a); 27.1 (a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that preventive measures to prevent and promote healing of pressure ulcers were in place and consistently followed. This deficient practice was identified for (Resident #63), 1 of 4 residents reviewed for pressure ulcers and was evidenced by the following: During the initial tour on 10/04/23 at 10:45 AM, the surveyor observed Resident #63 lying in bed. Resident #63 was nonverbal, the head of the bed was elevated with the side rails in the upper position. The surveyor performed an incontinence tour with the Certified Nursing Assistant (CNA) and observed that Resident #63 was saturated with a yellow color substance. The incontinent brief was saturated, the blue pads to protect the bed along with the pull sheet was saturated. Resident #63 had two dressings, the sacral dressing and the dressing on the ischium which were both saturated with a yellow color substance. The CNA informed the surveyor that Resident #63 was a heavy wetter when inquired regarding the last time Resident #63 was changed, the CNA stated that she changed the resident at 8:00 AM. The surveyor reviewed Resident #63's electronic medical record (EMR) on 10/06/23 at 12:55 PM. The Admission Face Sheet reflected that Resident #63 was admitted to the facility with diagnoses which included but were not limited to: Difficulty walking, muscle weakness, anoxic brain damage and dysphagia. The Admission Minimum Data Set (MDS) an assessment summary dated 05/24/23, revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Section M of the MDS which addressed skin condition, revealed that Resident #63 was assessed as being at high risk for pressure sores. Resident #63 scored 12 on the Braden Scale indicative of being at high risk. According to the skin assessment performed on admission ( 05/18/23), Resident #63 was admitted with redness to the sacrum. There was no open area. The surveyor reviewed Resident #63's Care Plan (CP). The CP formulated on 05/18/23 had a Focus for: At risk for alteration in skin integrity related to immobility. The Goal was for Resident #63 to remain free of breakdown within limits of disease process. Interventions included: Barrier cream to perineal/buttocks as needed. Initiated 05/18/23. Encourage and assist to reposition; use assistive devices as needed. Initiated 05/18/23. Therapy evaluation and treatment per physician orders. Initiated 05/19/23. Laboratory values dated 05/19/23 revealed Albumin 3.5 normal 3.5-5.2 Protein Total 6.1. normal 6.4-8.3. Prealbumin dated 05/25/23 was 24 normal value 20-40 mg/dl. Further review of the Progress Notes revealed the following entries in the EMR: -05/24/23 timed 15:34 Resident is dependent with all care. Hoyer lift for transfers from bed to [recliner chair]. 17:26, Sacral DTI (deep tissue injury), no open wound, fungal rash. fungal rash - sacrum. -05/26/23 timed 15:36 PM, Resident #63 was seen on wound rounds on 05/25/23 noted with DTI to sacrum with dark discoloration. Measures 3 centimeters (cm) x 3 cm. Recommendations: Low Air Loss mattress., Roho cushion to wheelchair and repositioning. -06/01/23 skin Note: Resident was seen on skin round for evaluation and treatment of wounds. measures 3 cm x 3 cm. Noted with discoloration. Discussed with staff to continue to offload. Recommendations: Low Air Loss mattress, Roho cushion and repositioned. -Skin Note dated 05/05/23 Right hip small blood blister 0.5 cm x 0.4. Area dark red purple in color. -Skin Note of 06/08/23: Visited by wound care Unstageable pressure injury measures: 2.5 cm x 3 cm x 0.2 cm. debridement performed (removal of dead tissue). On 05/26/23 the wound care recommendations were to have a Low Air Loss Mattress and offloading. The facility provided the Low Air Loss Mattress on 06/09/23 after the resident developed an unstageable pressure ulcer to the sacrum. A wound care order was to change the dressing daily and when soiled. Review of the nurses' notes from 06/25/23 to 10/12/23 did not reflect when wound care was provided and the wound condition except when the Wound Care Team visited. On 07/27/23 Resident #63 developed another wound on the left ischium area with the following measures: 3 cm x 3 cm x .1 cm. The wound was classified as an irritant contact dermatitis, with macerated periwound. Recommendations: Increase dietary protein, and dietary supplement. Offloading: Recommend turning and positioning as per standard of care. Avoid positioning which places direct pressure to the wound site. Low Air Loss Mattress with turning and positioning measures in place. Recommend limiting continuous time spent sitting to less than 2 hours per session on an appropriate pressure reducing surface. The recommendations were not added to the care plan. On 06/04/23 the surveyor observed Resident #63 in bed positioned in supine position from 10:49 AM to 12:30 PM. The facility did not have a system in place to evaluate when the resident was last turned or cared for per the recommendations. On 10/11/23 10:52 AM, the surveyor observed wound care with the Licensed Practical Nurse. The sacral wound had the following measures: 2.5 cm x 2.5 cm x 0.2 cm. The wound on the left ischium measures: 5.5 cm x 4.75 cm x 3 cm. Both wounds were noted with necrotic and slough tissue. The sacrum had a foul odor when the dressing was removed. None of the observed wound conditions were documented after the observed wound care. The nurses only initialed that wound care was completed. Following the wound care, the surveyor interviewed the UM regarding the wound. Upon inquiry she stated she had not observed the wound for 2 weeks. An interview with the Infection Preventionist on 10/11/23 at 12:15 PM, she stated that she constantly reminded staff the importance of following the recommendations from wound care. She could not comment on the rationale for not having measures in place to prevent the wound from worsening. On 10/10/23 at 10:44 AM, the surveyor interviewed the Registered Nurse IP regarding how Resident #63's Plan of Care was communicated to the CNA. The IP stated that that in the morning the Unit Manager gave reports to the nurses and the CNAs. She further added that all information regarding a resident care was entered and accessible to staff under Task on the Electronic Plan of Care (E-POC). On 10/12/23 at 11:28 AM, the surveyor again interviewed the Unit Manager regarding the order on the wound care recommendations to off-load and reposition Resident #63. The Unit Manger stated that staff should check and reposition the resident every 2 hours and as needed. The surveyor asked the Unit Manager how she would know if the resident was checked and repositioned every 2 hours, she did not have any comment. On 10/12/23 at 12:30 PM the Unit Manager provided a log where the CNAs documented that Resident #63 was turned and repositioned x 1 every shift. There was no documentation in the clinical record regarding Resident #63's being checked and repositioned every 2 hours. The facility was informed of the above concerns for Resident #63 on 10/12/23 at 2:20 PM. A review of the facility's policy for Pressure Ulcers/ Skin Breakdown- Clinical Protocol revised April 2018, indicated the following: Assessment and Recognition The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss and a history of pressure ulcer (s). In addition, the nurse shall describe and document/ report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. Monitoring During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. (The policy was not being followed. Staff failed to review the care plan and implement interventions identified to reduce/prevent pressure ulcer. Resident #63 sacral wound had not improved. Resident #63 developed another wound on 07/2723. There was no revision made to the care plan.) NJAC 8:39-27.1 (e)

Complaint NJ #162687 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to: a) provide appropriate incontinence care, and personal hygiene care for 2 of 20 residents (Resident #55 and #63) on 1 of 2 resident units, and b) failed to offer nail care to a resident who was dependent assistance from staff for care (Resident #61). The deficient practice was evidenced by the following: 1. On 10/04/23 at 10:05 AM, the surveyor observed Resident #55 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry the resident stated he/she had not been provided with incontinence care since last night. At 10:20 AM, while conversing with the resident, a Certified Nursing Assistant (CNA) entered the room, informed the surveyor that she was from Hospice and would provide care to the resident. The surveyor informed both the resident and the CNA the purpose of the visit. The Resident agreed to be checked for incontinence care. The CNA positioned the resident to the left side and removed the sheet to expose the resident's incontinence brief. The incontinence brief was soaked with urine. The resident had a green T-shirt on which was also soaked with urine. The bedding including the blue pad to protect the bed was also soaked with urine. That same day, at 10:45 AM, the surveyor entered Resident #63's room. The surveyor observed the resident in bed. Resident #63 was nonverbal and the head of bed was elevated. The room was untidy. The surveyor left the room and informed the Registered Nurse (RN) that she would like to check Resident #63 for incontinence care. The CNA reported to the room and informed the surveyor that Resident #63 was a heavy wetter. The CNA positioned the resident to the left side and the surveyor observed that Resident #63 was saturated with urine. The blue pads including the bedding were saturated with urine. The surveyor also observed that the resident had some redness on the back and buttocks. The resident had two wounds, one on the sacrum and the ischium area (part of the hip bone) and the dressings were saturated with urine. On 10/04/23 at 12:30 PM, the surveyor returned to the room and observed the resident was in the same position. The surveyor observed the resident had not been provided with mouth care yet. At 11: 45 AM, the surveyor continued the unit tour. The surveyor observed Resident #61 in bed, the resident was alert and able to maintain a conversation. The surveyor observed that Resident #63's nails were long with a brown coated substance underneath the fingernails. On 10/05/23 at 10:42 AM, the surveyor performed an incontinence round with the CNA and noted that Resident #63 was soiled with dry feces on the perineal area. The resident indicated that he/she had not received care yet. On 10/04/23 at 9:13 AM, the surveyor observed Resident #61 in bed, the nails were long an jagged with a brown coated substance underneath the finger nails. On 10/05/23 at 10:42 AM, the surveyor observed Resident #61 in bed, the CNA was at the bedside providing care and observed the resident's nails were not trimmed or cleaned. On 10/06/23 at 8:45 AM, the surveyor observed Resident #61, after morning care had been provided, with nails long and jagged, and a brown substance was under [NAME] the finger nails. On 10/06/23 at 9:09 AM the surveyor interviewed a random CNA who stated, for dependent residents, she provided care from head to toe. It is important for the residents to get care to prevent decline and help with the quality of life. ADLs (Activities of Daily Living) covered hygiene, dressing, and nail care as needed. Nail care entailed filing and cleaning underneath the nails. Nail care was explained during orientation. Nail care was not included in the documentation in the electronic medical record. Nail care was not also covered under ADLs. On 10/06/23 at 9:23 AM, the surveyor interviewed the Unit Manager (UM) who stated that she was not aware of a policy for nails care and where it would be documented. She stated that is basic care. The surveyor escorted the UM to the room where we both observed that Resident #61's nails were long and a brown substance noted underneath the finger nails. The UM stated, to the resident your nails needed to be trimmed and the resident responded, yes. On 10/11/23 at 10:15 AM, during a second interview with the UM she confirmed the CNAs were to provide nails care during morning care. An interview with the CNA who cared for Resident #61 revealed that nail care was not included in the Kardex [resident care guide] but nails should be checked and cleaned as part of the morning care. On 10/11/23 the surveyor visited Resident #61 and observed that the nails were trimmed and cleaned. The resident stated, it feels good and showed their hands to the surveyor. On 10/12/23 at 10:10 AM the surveyor returned to the [NAME] Unit. A strong urine odor was permeated from the hallway while approaching Resident #55's room. The surveyor entered the room and observed a CNA at the bedside. The CNA informed the surveyor that he just reported to the room to care for Resident #55 and observed that the bedding including the mattress was saturated with urine. The surveyor left the room and asked the Licensed Practical Nurse (LPN) to verify the condition of the room. The LPN stated, it smelled like urine to me. The CNA had the resident positioned to the left side. The resident's brief was saturated with urine and covered with feces. The mattress was wet with urine. The CNA informed the surveyor that the Hospice aide had not reported to work this morning and he would care for Resident #55. On 10/12/23 at 11:30 AM, an interview with the UM revealed that the Hospice Aide reported to work at 12:00 PM on 10/11/23 and today did not report to work yet. She could not comment on whether or not the facility's staff had provided care to the resident this morning. On 10/12/23 at 10:19 AM, the surveyor entered Resident #61's room. The surveyor performed an incontinence care with the CNA. The surveyor observed that Resident #61 incontinent brief was saturated with urine although Resident #61 had an indwelling urinary catheter in place. Also noted dry feces in the perineal area. On 10/12/23 at 10:25 AM, during an interview with the CNA, the CNA revealed that she provided care to Resident #61 this morning and the brief was saturated with urine. Upon inquiry, the CNA stated that she forgot to report to the nurse that the catheter was leaking. Resident #61 had an unstageable sacral wound and the dressing was observed saturate with urine. The surveyor left the room and informed the Unit Manager that the indwelling urinary catheter was leaking. On 10/12/23 the surveyor reviewed the resident's electronic medical record (EMR) for Resident #55. Resident #55's Admission Record (AR) revealed, Resident #55 was admitted to the facility with diagnoses which included but were not limited to: Difficulty in walking, generalized muscle weakness, Parkinson's Disease and Bipolar Disorder and irritable bowel syndrome. The Quarterly Minimum Data Set (MDS) assessment tool dated 08/14/23, revealed that Resident #55 was severely cognitively impaired. Resident #55 received a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #55 was totally dependent on staff for care. Review of the Care Plan for Resident #55 initiated on 08/01/22, included a Focus for ADL Self Care Deficit related to: physical limitations and weakness post hospitalization . The goal was for Resident #55 to be clean, dressed and well-roomed daily to promote dignity and psychosocial well-being. The interventions were to assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan did not indicate when staff were to provide care to the resident, or the frequency for staff to turn and reposition the resident. On 10/12/23 the surveyor reviewed Resident #61's EMR which revealed the following: Resident #61 was admitted to the facility with diagnoses which included but were to limited to: Pressure Ulcer of sacral region, unstageable, sepsis, difficulty in walking and muscle weakness. According to the (MDS) Minimum Data Set, dated dated dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. The MDS also indicated that Resident #61 required extensive assistance for Activities of Daily Living (ADL) and was always incontinent of stool. However, a conversation with Resident #61 revealed that he/she was awake and alert and able to make his/her needs known. The CNA confirmed that Resident #61 was very alert and able to participate with care. Review of the Care Plan for Resident #61 initiated on 07/03/23 with no revision date, revealed a focus for ADL self-care deficit related to physical limitation and neurological deficiencies related to Parkinson's disease. The goal was for Resident #61 to be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. To have ADL (Activity of Daily Living) met with staff assistance. The interventions included: Assist to bathe and shower as needed. Assist with daily hygiene, grooming, dressing, oral care and eating as needed. On 10/12/23 at 10:30 AM, the surveyor interviewed the CNA who cared mostly for the resident on 10/04/23, 10/05/23, 10/06/23, 10/11/23 regarding Resident #61's care. The CNA revealed that Resident #61 was able to feed her/his self after set-up, able to assist with turning and able to make his/her needs known. When asked regarding the resident nail care, the CNA did not have any comments. On 10/12/23 the surveyor reviewed Resident #63's EMR which revealed the following: Resident #63 was admitted to the facility with diagnoses which included but were not limited to: Difficulty walking, muscle weakness, anoxic brain damage and dysphagia. The Admission Minimum Data Set (MDS)dated 05/24/23, revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Resident #63 had a care plan initiated on 05/18/23 and revised 05/26/23 for urinary incontinence. The goal was for resident #63 will have no complications due to incontinence. Resident #63 also had a care plan for ADL self-care deficit related to recent hospitalization post cardiac arrest with anoxic brain with the following goal: Resident #63 will be maximum assist with bed mobility upon discharge. Resident #63 will be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. The interventions included bilateral upper 1/4 rails, occupational and physical therapy evaluation and treatment per physician's orders. Resident #63 had a care plan for palliative care initiated 06/09/23 with the following goals: Will be comfortable, will have advance directives honored by staff. One of the interventions included to encourage and assist to reposition as needed for comfort. Staff confirmed that Resident #63 was totally dependent on staff for care, was nonverbal and all needs must be anticipated. (The care plan did not include any directive to direct care staff regarding Resident #63's specific person-centered care requirements for ADL care). On 10/06/23 at 3:47 PM the surveyor conducted a telephone interview with Resident #63's Representative (RR). The RR stated she had concerns with the care and discussed the concerns with the Registered Nurse (RN) on the first floor. The RR stated that he/she had noticed a decline in the care and that Resident #63 would be soiled and observed large amount of secretions on the clothing when he/she had visited in the evening. The RR further stated that Resident #63 did not have any wounds upon admission and was informed that the resident had the first wound after Resident #63 was left in the chair for extended periods of time. The second wound was also developed at the facility per the RR. The RR stated during visits in the evening, the resident would be soiled and needed to be changed. When the RR informed the staff, the staff would state that this is not their time yet and Resident #63 would have to wait. When inquired if the issue was reported to the nurse, the RR stated when the resident was on the first floor, that he/she had reported the incident to the nurse. On 10/10/23 at 09:38 AM, the surveyor interviewed the RN that the RR reported the concerns regarding the care. The RN indicated that she could not recall the incident and did not inform the Director of Nursing of the RR concerns with the care. The above concerns with incontinence and nails care were discussed with the DON and the Licensed Nursing Home Administrator during the survey, and again on 10/12/23 at 2:20 PM. The surveyor then asked the DON who was responsible to coordinate the hospice care with the facility as Resident #55 was observed soiled for 2 days, and staff indicated that the hospice aid did not report to the facility on time for 2 days. The DON stated that the UM was responsible to monitor and ensure that residents were provided with incontinence care. NJAC 8:39- 27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to ensure opened multi-use medication vials stored inside of the medication cart was labeled and dated with an open and expiration date upon opening. This deficient practice was observed during a medication storage review and was evidenced by the following: On 10/06/23 at 7:20 AM, in the presence of the Registered Nurse and the Licensed Practical Nurse (LPN), the surveyor reviewed the inventory of medications and treatment products in the Medication Administration Cart. Upon review of the medication cart contents the surveyor observed one opened and undated multi-use dose of Insulin Lantus pen for Resident #47. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial and pen-injector 28 days after opening. The surveyor then observed two glucometer strips were opened and not dated on two medications carts. On 10/06/23 at 7:40 AM, the surveyor asked the Registered Nurse the facility's process for dating medications upon opening. The nurse stated that all multi-dose vials were to be dated when they were opened. The RN indicated that she had not checked the date of opening on insulin vials in the medication administration cart at the beginning of her shift. She mentioned that per training and competency, every nurse should put the date of opening on multi-dose medications. When interviewed, at that time, the LPN stated the medication should have been dated when opened. NJAC 8:39-29.4

Based on observations, interviews, record reviews, and review of facility provided documentation, it was determined that the facility failed to provide treatment and services to limit the potential of infection for 2 of 2 residents (Resident #69 and #61) reviewed for the use of indwelling urinary catheter [a tube used to drain urine from the kidneys]. The deficient practice was evidenced by the following: A.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. Surveyor #1 observed a urinary catheter tube draining into a urinary catheter bag with a privacy bag over it on the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the therapy gym. The surveyor observed the urinary catheter with the catheter bag on the side of the resident's wheelchair. A review of the electronic medical record (EMR) revealed that Resident #69 had been admitted and readmitted to the facility. Resident #69 had diagnoses which included but were not limited to; chronic kidney disease, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of the Order Listing Report, active orders as of 10/05/23, included an order dated 09/13/23 to monitor urinary catheter output every shift. There were no other orders regarding the indwelling urinary catheter. A review of the Treatment Administration Record (TAR) for September 2023, revealed the staff were monitoring the catheter output every shift. The TAR and Medication Administration Record (MAR) did not document any other care or information regarding the urinary catheter. A review of the TAR and MAR for October until discharge revealed the staff were monitoring the catheter output every shift, but no other documented care or information regarding the urinary catheter. A review of the patient centered on-going Care Plan included but was not limited to; a focus are of Activities of Daily Living (ADL) care deficit related to weakness with interventions including assist of 1 to 2 persons with ADLs. The care plan failed to include any other information regarding the risks, care, or interventions of the indwelling urinary catheter. On 10/06/23 on 9:09 AM, the Registered Nurse Infection Preventionist (RN IP) stated that any resident with an indwelling urinary catheter should have orders which document the catheter size, to change the collection bag when soiled changed frequently because they get dirty, and to flush the tubing as needed. On 10/10/23 at 8:22 AM, the Licensed Practical Nurse (LPN) caring for Resident #69 stated the indwelling urinary catheter had been removed on 10/6/23. She reviewed the orders on the TAR and stated there were no orders to flush or do care, just to empty the catheter. On 10/10/23 at 8:27 AM, the RN unit manager (RN UM) stated the resident had the indwelling urinary catheter upon readmission to the facility. She stated the procedure would be for an order for daily catheter care, to monitor output, be sure the collection bag was not touching the floor, and for perineal care. The RN UM accessed the current MAR and TAR and acknowledged there were only orders to monitor the output every shift. She further stated, I guess we don't know if it's [indwelling urinary catheter care] done it's not on there [documented on the MAR or TAR]. On 10/10/23 at 9:14 AM, the Director of Nursing (DON) stated the procedure for indwelling urinary catheter care would be documentation of the balloon number [the inflated device to hold the catheter in the bladder] and the diagnoses. She stated the care would consist of checking the output, securing the tubing, observing the urinary drainage, providing flushes as needed, and perineal care. Surveyor #1 made the DON aware of the lack of orders besides monitoring the output. The DON stated, the care is part of the routine, the nurses should just know to do it. The DON further stated that the care plan would also inform the staff of how to care for the resident with an indwelling urinary catheter and the indication of use. The DON stated the order for indwelling urinary catheter care would be in the TAR and that's where it would be documented. 27193 B.) During the initial tour of the facility on 10/04/23 at 10:29 AM, the surveyor observed Resident #61 awake and lying supine in bed. The surveyor observed the catheter drainage bag along with the dignity bag (used to keep an indwelling urinary catheter's drainage bag concealed for resident privacy). The surveyor observed both the urinary drainage bag and attached tubing lying directly on the floor next to the resident's bed. On 10/05/23 at 10:40 AM, the surveyor reviewed the medical record of Resident #61 which revealed that the resident had an indwelling urinary catheter, the rationale or the diagnosis for the indwelling urinary catheter was not provided. The admission evaluation dated 07/03/23, reflected that the resident had an indwelling catheter in place. The physician order sheet dated 07/04/23, reflected a telephone order dated 07/04/03, for catheter care and catheter output every shift. An entry dated 09/20/23, revealed a physician order for the resident to receive an oral antibiotic (Bactrim DS 800-160 milligrams ) twice daily for five days to treat a Urinary Tract Infection (UTI). The surveyor also observed that the resident had a history of a UTIs having been diagnosed with a UTI on 09/04/23. On 10/05/23 at 9:06 AM, the surveyor observed Resident #61 lying in bed. The urinary drainage bag was in the privacy bag which was secured to the frame of the bed. The privacy bag was resting directly on the floor. The surveyor reviewed the resident EMR. The admission Face Sheet (an admission summary), reflected that Resident #61 had diagnoses which included but were not limited to: pressure Ulcer of sacral region, unstageable, sepsis, difficulty in walking and muscle weakness. Resident #61's admission face sheet did not include urinary retention as a diagnosis. According to the Minimum Data Set (MDS), dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. Normal score 15. The Admission and the Quarterly Minimum Data Set assessment dated respectively 05/26/23 and 07/03/23 did not reflect that Resident #61 had an indwelling urinary catheter in place. Review of the Care Plan for Resident #61 initiated on 07/03/23 with no revision date, did not have a Focus for catheter care. The Physician Order Sheet, dated 10/12/23, revealed a telephone order for the indwelling urinary catheter dated 07/04/23. The order did not include the catheter size and when the catheter should be changed. The surveyor reviewed the care plan with the Unit Manager. A focus for indwelling urinary catheter was not addressed into the care plan until 10/06/23. On 10/12/23 at 2:20 PM the above concern was discussed with the Director of Nursing (DON). The DON provided the surveyor with a copy of the facility's policy entitled, Catheter Care: Indwelling Catheter which revealed the following: Perineal Care edited 4/25/22, included but was not limited to; Purpose: to provide cleanliness and comfort to prevent infections and skin irritation. Documentation: 1. Date and time care was given. 2. Name and title of individual providing care. 7. Signature and title of person recording the data. Catheter Care, Urinary, revised 08/22, included but was not limited to; Purpose: to prevent urinary catheter-associated complications. Preparation: 1. Review the resident's care plan to assess for special needs. Perineal Care. Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Documentation: 1. Date and time catheter care was given. 2. Name and title of individual giving the care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color, clarity, and any odor. 9. Signature and title of the person recording the data. NJAC 8:39-19.4(a), 27.1(a)

Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to: a.) the administration of medications and b.) adhering to facility policy for Medication Administration. The deficient practice was identified on 2 of 2 Units observed for medication pass administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a . On 10/07/23 at 7:18 AM, during an observation of the medication administration cart on the [NAME] Unit with the Licensed Practical Nurse (LPN) who worked the 11:00 PM -7:00 AM shift and the Registered Nurse (RN ) assigned to the 7:00 AM-3:00 PM shift, revealed an orange pill was stored in a medication cup inside the top drawer. Both nurses were at the medication cart ready to start the narcotic count. The Licensed Practical Nurse (LPN) who worked the night shift stated that the medication could have been Benadryl, but the RN then identified the medication as Protonix (acid suppressing medication). The RN pulled a box from the middle drawer and opened one of the pills and verified that the pill as Protonix. Both nurses declined that they placed the open medication inside the medication cart. b. On 10/06/23 at 7:45 AM, the surveyor informed the Registered Nurse (RN) 07:00-3:00 PM shift she would be followed for medication pass administration. The Registered Nurse ( RN ) poured 1 tablet of Metoprolol (medication used to control hypertension) for Resident #60. Resident #60 was in the hallway. The nurse escorted the resident to the room and left the medication on top of the medication. cart. The surveyor observed one resident in the hallway and one ancillary staff. The surveyor remained next to the medication cart and informed the Unit Manager who just exited from another room in the hallway. The Unit Manager verified that one pill was in the medication cup and the nurse was not around. The Unit Manager removed the cup from the medication cart and went to the room to get the nurse. The nurse indicated that she forgot. On 10/07/23 at 9:15 AM during an interview with the Unit Manager, she stated that was not the facility protocol. She went on to state that medications should not be left unattended on top of the medication cart. 38079 c.) On 10/06/23 at 6:30 AM, Surveyor #2 observed a staff member standing in front of a medication cart in the middle hall of the first unit. The staff member was identified as the Registered Nurse Supervisor (RNS) who had been working the 11:00 PM to 7:00 AM shift. The RNS had his computer open and informed Surveyor #2 that he was in the middle of preparing and pouring a pain medication for a resident. Surveyor #2 asked if he would be administering any other residents any medication and the RNS stated he would be administering a Tylenol (a pain and fever reducing medication) to a different resident. On 10/06/23 at 6:33 AM, the RNS exited the first resident room and documented in the computer. The RNS next walked into another resident's room. Surveyor #2 stood by the medication cart and could hear the RNS talking to the resident. On 10/06/23 at 6:37 AM, the RNS exited the second resident room. Surveyor #2 was still standing at the medication cart. Surveyor #2 asked about observing the administration of the Tylenol. The RNS stated he had already administered the medication. When inquired how that was done since he had not returned to the medication cart to obtain the medication, the RNS stated he had it ready and with him. Surveyor #2 asked for clarification. The RNS stated, it was pre-poured. At that time, the RNS stated that it was not the facility procedure to pre-pour medications and carry them around because the medications could easily get mixed up. On 10/06/23 at 9:42 AM, the DON was made aware and stated that the nurses know better and should never pre-pour medication. The DON stated that by pre-pouring medication, the medications could become mixed up and possibly be given to the wrong resident. On 10/10/23 at 11:13 AM, the DON stated that the pharmacy consultants would assess the nurses yearly with medication administration competencies. The DON stated that she was unable to find a previous competency for the RNS, but that the consultant pharmacy conducted an observation with him on 10/06/23. A review of the facility provided, Administering Medications policy edited 5/21/19, included but was not limited to; 10. Check the label three times to verify the right resident, right medication, right dosage, right time, and right method before giving the medication. 12. The expiration/beyond use date is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 19. The medication cart is kept closed and locked when out of sight. No medications are kept on top of the cart. NJAC 8:39-11.2(b), 29.4 (a)(b)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to revise comprehensive person-centered Care Plans for 2 of 20 residents (Resident #76 and #63) reviewed for care planning. The deficient practice was evidenced by the following: a.) A review of the electronic medical record (EMR) revealed that Resident #76 had diagnoses which included but were not limited to; dependence on renal dialysis [the process of purifying blood when the kidneys are not functioning properly], major depressive disorder, anxiety, and vascular dementia without behavioral disturbance. The most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate care, dated [DATE], included but was not limited to; a Brief Interview of Mental Status (BIMS) of 08 out of 15 which indicated the resident was moderately cognitively impaired. Section E0200 indicated the resident had no behaviors. The Order Listing Report dated [DATE] through [DATE], included but was not limited to; socially inappropriate yelling to exhaustion. A review of the on-going patient centered Care Plan included but was not limited to; a focus area of at risk for adverse effects related to the use of anti-anxiety medication initiated [DATE]. The CP revealed a focus area of cognitive loss related to vascular dementia and end stage renal disease initiated [DATE]. The CP revealed a focus area of at risk for behavior symptoms related to dementia-restlessness, initiated [DATE]. The CP revealed a focus area of renal insufficiency. A goal was to have no complications related to dialysis devices or treatments, initiated [DATE] and revised [DATE]. The CP failed to be revised to identify the resident's behaviors of dislodging his/her dialysis access or the expressed feelings towards not wanting to go to dialysis. A review of the EMR Progress Notes (PN) revealed the following: On [DATE] the Social Worker (SW) documented she had spoken to the resident's family regarding the resident's feelings towards dialysis. At this time, resident will continue dialysis and IDT [Interdisciplinary Team] and the family will continue communication. On [DATE], the Licensed Practical Nurse (LPN) #1 documented the resident had dislodged his/her dialysis access port located to the right chest. The resident was noted to be bleeding profusely. On [DATE], LPN #1 documented resident was found trying to remove his/her perma-catheter [dialysis access]. On [DATE], LPN #2 documented that Resident #76 had been found with his/her perma-catheter dislodged, bleeding, cardiopulmonary resuscitation (CPR) started, 911 emergency services called, and the resident was pronounced deceased by the emergency services physician. The resident was also noted with occasional yelling/screaming. On [DATE] at 11:38 AM, the LPN Unit Manager (LPN UM) stated the resident was very confused and would try to ambulate unassisted. She further stated that the Dialysis center reported a behavior that the resident attempted to remove his/her colostomy [a surgically created opening to empty the contents of the colon into a bag]. On [DATE] at 11:39 AM, the Certified Nursing Assistant (CNA) stated that Resident #76 would try to pull out his/her dialysis perma-catheter. The CNA stated, I would tell him/her not to touch it. The CNA stated that before the resident's privately hired companion aide would arrive, the CNA would bring Resident #76 to the nurse's station to be monitored for trying to pull out the dialysis perma-catheter. On [DATE] at 11:38 AM, during an interview with a surveyor, the SW stated the resident wasn't oriented and at times did not want to go to dialysis. The SW stated the resident only verbalized this once or twice. She further stated she was not aware that the resident had ever pulled out his/her dialysis perma-catheter and that if that had happened, she would expect there to have been an Interdisciplinary Team meeting. On [DATE] at 12:02 PM, the Licensed Nursing Home Administrator (LNHA) stated that Resident #76 had been sent to the hospital on [DATE], for dislodging the dialysis perma-catheter. She stated that she did not recall if she was present in the morning meeting for clinical issues regarding [DATE], but that she would expect that issue to have been discussed. The LNHA stated that when a resident was sent to the hospital, the team would discuss if anything could have been done in house prior to the transfer. The LNHA stated that she had been aware of other instances when the resident dislodged the perma-catheter and that if an investigation had been completed, there would be a rationale and interventions would have been put into place to prevent recurrence. On [DATE] at 1:35 PM, the LPN UM stated that there was documentation in the EMR that Resident #76 would pull at the perma-catheter and that it was like a behavior. A review of the facility provided email Subject Clinical Rounds [DATE], sent [DATE], included but was not limited to; [Resident #76] pulled perma-catheter last night and went to emergency room . A review of the facility provided email Subject ,d+[DATE] Shift rep [report] ,d+[DATE], sent [DATE], included but was not limited to; [Resident #76] Admission perma-catheter reinserted - still attempts to pull out perma-catheter. A review of the facility provided email Subject ,d+[DATE] report, sent [DATE], included but was not limited to; [Resident #76] pulled his/her perma-catheter and then he/she was coded, pronounced [deceased ] at 11:27 PM. 27193 2. The surveyor reviewed Resident #63's clinical record on [DATE] at 12:55 PM. The Admission Face Sheet reflected that Resident #63 was admitted to the facility with diagnoses which included but were not limited to; difficulty walking, muscle weakness, anoxic brain damage (brain damage caused by lack of oxygen to the brain) and dysphagia. The Admission Minimum Data Set (MDS) an assessment summary dated [DATE], revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Section M of the MDS which addressed skin condition, revealed that Resident #63 was assessed as being at high risk for pressure sores. Resident #63 scored 12 on the Braden Scale indicative of being at high risk. According to the skin assessment performed on admission ([DATE]), Resident #63 was admitted with redness to the sacrum. There was no documented open area. The surveyor reviewed Resident #63's Care Plan (CP). The CP initiated on [DATE] contained a Focus area for :At risk for alteration in skin integrity related to immobility. The Goal was for Resident #63 to remain free of breakdown within limits of disease process. The CP Interventions included: Barrier cream to perineal/buttocks as needed. Initiated [DATE]; Encourage and assist to reposition; use assistive devices as needed. Initiated [DATE]; and Therapy evaluation and treatment per physician orders. Initiated [DATE]. Further review of the Progress Notes revealed the following entries dated: [DATE], timed 15:34 [3:34 PM], Resident is dependent with all care. Hoyer lift for transfers from bed to [recliner chair]; [DATE], timed 17:26 PM [5:26 PM], Sacral DTI (deep tissue injury), no open wound, fungal rash. fungal rash - sacrum; [DATE], timed 15:36 PM [3:36 PM], Resident #63 was seen on wound rounds on [DATE] noted with DTI to sacrum with dark discoloration . Measures 3 centimeters (cm) x 3 cm. Recommendations: Low Air Loss mattress. Roho cushion to wheelchair and repositioning. [DATE], skin Note: Resident was seen on skin round for evaluation and treatment of wounds. measures 3 cm x 3 cm. Noted with discoloration. Discussed with staff to continue to offload. Recommendations: Low Air Loss mattress, Roho cushion and repositioned. Skin Note of [DATE]: Visited by wound care unstageable [full thickness skin and tissue loss] pressure injury measures: 2.5 cm x 3 cm x 0.2 cm. debridement performed (removal of dead tissue).Mattress and offloading. The facility provided the Low Air Loss Mattress on [DATE] after the resident developed an unstageable pressure sore to the sacrum. The wound care order was to change the dressing daily and when soiled. Review of the nurses' notes from [DATE] through [DATE] did not reflect when wound care was provided and the wound condition and was only documented when the Wound Care Team visited. On [DATE] Resident #63 developed an additional wound on the left ischium area with the following measurements: 3 cm x 3 cm x .1 cm. The wound was classified as an irritant contact dermatitis, with macerated periwound. Recommendations: Increase dietary protein, and dietary supplement. Offloading: Recommend turning and positioning as per standard of care. Avoid positioning which places direct pressure to the wound site. Low Air Loss Mattress with turning and positioning measures in place. Recommend limiting continuous time spent sitting to less than 2 hours per session on an appropriate pressure reducing surface. The recommendations were not added to the CP for Resident #63. On [DATE] the surveyor observed Resident #63 in bed positioned in supine position from 10:49 AM to 12:30 PM. The facility did not have measures in place to evaluate when the resident was last turned or cared for. On [DATE] at 10:52 AM, the surveyor observed wound care with the Licensed Practical Nurse. The sacral wound had the following measures: 2.5 cm x 2.5 cm x 0.2 cm. The wound on the left ischium measures: 5.5 cm x 4.75 cm x 3 cm. Both wounds were noted with necrotic and slough tissue and emitted a foul odor. The observed wound conditions were not documented after wound care. The nurses only initialed that wound care was completed. Following the wound care, the surveyor interviewed the UM regarding the wound. Upon inquiry she stated she had not observed the wound for two weeks. An interview with the Infection Preventionist on [DATE] at 12:15 PM, revealed that stated she constantly reminded staff the importance of following the recommendations from wound care practitioners. Upon inquiry, she could not comment on the rationale for not having measures in place to prevent the wound from worsening. [DATE] at 10:44 AM, the surveyor interviewed the Registered Nurse IP regarding how Resident #63's Plan of Care was communicated to the CNA. The IP stated that that in the morning the Unit Manager gave reports to the nurses and the CNAs. She further added that all information regarding a residents care was entered and accessible to staff under Task on the Electronic Plan of Care (E-POC). On [DATE] at 2:02 PM, the above concerns were addressed again with the LNHA and the DON. The facility had no additional information to provide. A review of the facility provided, Care Plans, Comprehensive Person-Centered, edited [DATE], included but was not limited to; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8. h. incorporate identified problem areas. n. Aid in preventing or reducing decline in the resident's functional levels. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 11. Care Plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration between the resident's problem areas and their causes, and relevant clinical decision making. 14. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident's condition. NJAC 8:,d+[DATE].1; 11.2(e)(i); 27.1(a)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to develop a person-centered baseline Care Plan (CP) for residents within 48 hours of admission/readmission. The deficient practice was identified for 2 of 20 residents (Resident #69 and #61) reviewed for CP and was evidenced by the following: a.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. The surveyor observed an indwelling urinary catheter tube and collection bag present [a tube used to drain urine from the kidneys into a collection bag] and attached to the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the facility therapy gym. The surveyor observed a urinary catheter tube and collection bag attached to the side of the resident's wheelchair. A review of the electronic medical record (EMR) revealed that Resident #69 had been recently readmitted to the facility. Resident #69 had diagnoses which included but was not limited to; chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of the Order Listing Report, as of 10/5/23, included an order dated 09/13/23 for staff to monitor urinary catheter output on every shift. There were no further orders regarding Resident #69's indwelling urinary catheter. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for both September 2023 and October 2023 through discharge revealed that staff documented the catheter output, however, the MARs and TARs failed to document and indicate any additional information, including care, regarding the urinary catheter. A review of the Resident #69's person-centered on-going CP failed to include any information initiated upon readmission regarding the use of an indwelling urinary catheter, goals, or interventions. On 10/06/23 at 8:39 AM, during an interview with Surveyor #1, the Director of Nursing (DON) stated the process of a CP was that upon a resident's admission the facility would identify things which included risks, pain, falls, diabetes, and urinary catheters. She stated those things should be documented on the CP and that the purpose of the CP was for staff to know how to take care of resident. The DON further stated the CP would include interventions and goals so the staff would be able to evaluate and make changes as needed. The DON stated that care plans were reviewed on Thursdays by the Interdisciplinary Team which included nursing, therapy, and the social worker. On 10/10/23 at 8:27 AM, Registered Nurse Unit Manager (RN UM) stated that Resident #69 had an indwelling urinary catheter upon readmission. She stated that the staff would perform daily catheter care, monitor urinary output, ensure the catheter and bag would not touch the floor, and perform perineal [area surrounding genitals] care. The RN UM stated the information would be documented on the TAR and also in the CP. The RN UM accessed the CP and then acknowledged the information regarding the catheter was not documented. On 10/10/23 at 9:14 AM, the DON stated the indwelling urinary catheter would be documented on the resident's CP. The CP would inform the staff how to take care of the indwelling urinary catheter. On 10/12/23 at 2:02 PM, concerns were discussed with the Licensed Nursing Home Administrator (LNHA) and the DON. On 10/13/23 at 9:44 AM, the DON provided a resolved CP for Resident #69. The CP documented date initiated: 10/06/23. The DON acknowledged the CP was not developed upon Resident #69's readmission to the facility but it should have been. 27193 b.) On 10/04/23 at 9:13 AM, during the initial tour of the facility, the surveyor observed and interviewed Resident #61 in his/her room. The resident was awake and alert and able to be interviewed. At that time, the resident stated to the surveyor that he/she fell at home and was readmitted to the facility for follow up care. The surveyor observed a urinary catheter drainage bag along with the dignity bag lying on the floor. On 10/05/23 at 9:40 AM, the surveyor returned to the unit and observed the urinary catheter drainage bag hung on the bedrail and the privacy was bag touching the floor. On 10/05/23 at 10:40 AM the surveyor reviewed the medical record of Resident #61 which revealed that the resident required the use of an indwelling urinary catheter, the rationale or the diagnosis for the indwelling urinary catheter was not provided. The admission evaluation dated 07/03/23 reflected that Resident #61 had an indwelling urinary catheter in place. The physician order sheet dated 07/04/23 reflected a telephone order dated 07/04/03 for urinary catheter care and catheter output every shift. A review of Resident #61's CP indicated that the resident did not have a CP related to the inddwelling urinary catheter care, or the care related for maintenance of the urinary catheter drainage bag. According to the (MDS) Minimum Data Set assessment dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. According to the MDS dated [DATE] and 07/03/23 Resident #61 was not coded as having a Foley Catheter. On 10/05/23 at 10:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that the resident had a wound and had a urinary catheter since admission. The LPN stated that if a resident had a urinary catheter for wound healing or urinary retention, that it should be reflected in the CP. The surveyor reviewed the CP along with the LPN and the LPN was unable to locate a care plan for the urinary catheter or any interventions and directives for the staff to follow to care for/and maintain the urinary catheter and the drainage bag to prevent complications and maintain function. On 10/06/23 at 9:30 AM, the surveyor interviewed the Unit Manager (UM) regarding the urinary catheteere care. The UM provided a urology consult which revealed that the resident had a [brand name] urinary catheter in place and the UM could not provide the rationale for the catheter. The UM reviewed the resident's CP in the presence of the surveyor. There was no focus, goals or interventions for the urinary catheter. A CP for the urinary catheter was developed, after surveyor inquiry, on 10/06/23. On 10/10/23 at 10:39 AM, the surveyor interviewed the DON in the presence of the survey team and the Administrator. The DON stated if a resident had a urinary catheter in place, a CP for catheter care should have been initiated. A review of the facility provided, Care Plans, Comprehensive Person-Centered, edited 04/25/22, included but was not limited to; 7. The care planning process will: b. includes an assessment of the resident's strength and needs. 8. a. include measurable objectives and timeframes. b. describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. f. includes goals upon admission and desired outcomes. h. incorporates identified problem areas. i. incorporates risk factors. L. reflects treatment goals, timetables, and objectives in measurable outcomes. m. identifies the professional services responsible for each element of care. n. aids in preventing or reducing decline in the resident's functional status. p. reflects recognized standards of practice for problem areas and conditions. q. includes medical or nonmedical care appropriate. 10. Identifying problem areas developing interventions that are targeted and meaningful to the resident are the endpoint of the interdisciplinary process. 14. The Interdisciplinary Team must review and update the care plan: c. when the resident has been readmitted to the facility from a hospital stay. NJAC 8:39-27.1(a)

Based on interviews, review of electronic medical records (EMR), and review of facility provided documentation, it was determined that the facility failed to report an unexpected death to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #76), reviewed for unexpected death. The deficient practice was evidenced by the following: A review of the EMR revealed that Resident #76 had diagnoses which included but was not limited to; dependence on renal dialysis [the clinical purification of blood by dialysis to substitute for the normal function of the kidney], vascular dementia with behavioral disturbances, and anxiety disorder. Resident #76 had a perma-catheter [a dialysis access site] located on the right upper chest area. The most recent Quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated [DATE], documented a Brief Interview of Mental Status (BIMS) of 08 out of 15 which indicated moderate cognitive impairment. The MDS further documented that Resident #76 required extensive assistance for Activities of Daily Living (ADL) except for eating which required supervision only. The MDS documented the resident received hemodialysis while a resident at the facility. The Order Listing Report included an order to assess the dialysis site for signs and symptoms of infection/bleeding every shift, and that the resident was socially inappropriate by yelling to exhaustion. The on-going patient centered Care plan included a focus area of renal insufficiency initiated [DATE], with interventions that included to check the access site for evidence of infection, swelling or excessive bleeding. A review of the Progress Notes (PN) included but were not limited to the following: Dated [DATE], a Licensed Practical Nurse (LPN) #1 documented a Situation Background Appearance and Review (SBAR - a summary), which included but was not limited to; Situation: 1. patient perma-cath to right chest wall was dislodged. 3. Situation has gotten worse. Appearance: 2. Pulse - unable to determine, O2 [oxygen] sats [saturation] 73 % (normal saturation level would be between 95% - 100%). Interventions: 3.e. call for 911 and 3.f. emergency medical transport. A PN dated [DATE], documented by the LPN included but was not limited to; at around 11 PM .a Certified Nursing Assistant (CNA) noticed blood on the resident's blanket Observed bleeding with right upper chest perma-cath pulled out Cardio Pulmonary Resuscitation (CPR) initiated .ambulance personnel arrived and continued CPR, resident pronounced [deceased ] by [name redacted] physician at 11:27 PM. On [DATE] at 12:17 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that she had spoken to the nurse regarding the situation on [DATE] but did not document the conversation. The DON further stated it was not a usual occurrence and that she should have asked for an investigation. The DON stated that the incident had not been reported to the NJDOH. On [DATE] at 12:02 PM, the Licensed Nursing Home Administrator (LNHA) stated that Resident #76 had died at the facility because his/her perma-catheter came out on [DATE]. The LNHA further stated there was no investigation completed to determine a causal factor and that the situation should have warranted an investigation. She stated that after thinking about it, she had realized it was an unusual occurrence and it should also have been reported to the NJDOH. On [DATE] at 1:35 PM, the DON stated, I should have investigated, and I should have reported [to NJDOH]. A review of the facility provided, Rapid Response Protocol, revised [DATE], included but was not limited to; Steps to Follow Immediately when an Event Occurs: determine if event is reportable to state regulatory agencies. Rapid Response Trigger Events: unexpected death. NJAC 8:,d+[DATE].4(f)

Based on observation, record review and interview it was determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This deficient practice was identified for 1 of 1 resident (Resident # 47) reviewed for ROM and was evidenced by the following: On 10/04/23 at 09:30 AM, during the initial tour, the surveyor observed Resident (R #47) in bed watching television and the resident expressed some concerns with receiving restorative care to maintain physical function. During the lunch meal R #47 was observed in bed with his/her meal tray and was observed eating independently. On 10/05/23 at 9:15 AM, observation revealed some possible limited range of motion to bilateral lower extremities and increase in tremors observed during resident interview. Resident #47 stated that he/she would like to get out of the bed and attend physical therapy, and get out of the room. Resident #47 indicated that he/she informed the Unit Manager that he/she would like to get out of the bed two weeks ago and nothing was done. The surveyor reviewed Resident# 47's electronic medical record (EMR). Resident (R #47) was admitted to the facility with diagnoses which included but were not limited to: Morbid obesity, muscle weakness, type 2 diabetes mellitus with unspecified complications, difficulty in walking, Addisonian crisis (an emergent adrenal crisis) and tremors. A review of the Quarterly Minimum Data Set with assessment reference date (ARD) of 09/18/23, found R #47 was coded with functional limitation in range of motion to the lower extremity (impairment on both side). In Section O. Special Treatment and Program, the coding for Restorative Nursing Program found R #47 was coded 0 (zero) for the number of days each of the following restorative programs were performed for at least 15 minutes a day in the last 7 (seven) calendar day, passive range of motion, active range of motion, and splint application. A review of the Restorative Nursing Communication Form dated 07/21/23 had the following recommendations: Active/ Active Assistive Range of Motion to bilateral lower extremities. Ankle pumps, hip flexion, hip abduction and short arc Quads. The goal was to maintain and prevent decline in the resident's range of motion to enable good hygiene and prevent skin breakdown. On 10/10/23 at 10:12 PM, following the conversation with Resident #47 regarding their concerns, the surveyor interviewed the CNA who cared for Resident #47. The surveyor asked when was Resident #47 was last transferred out of bed to the recliner chair. The CNA stated, It had not been done since I have been here. The CNA added, usually he/she would get out of the bed with physical therapy. Upon further inquiry, the CNA added that restorative care had not been completed due to not having enough staff since the CNA assigned to complete restorative care had to take on a resident assignment and could not perform restorative care duties. On 10/10/23 at 10:15 AM, the surveyor interviewed the Unit Manager regarding restorative care and out of the bed and Range of Motion (ROM). The UM revealed that the facility had a restorative program that could not be fulfilled due to staffing issues. The UM stated that following admission, Resident #47 refused to get out of the bed with a mechanical lift due to an incident that occurred that day. However, the UM confirmed that Resident #47 requested to get out of the bed 2 weeks ago but there was no chair to accommodate the request. The UM further stated that Resident #47 needed a special chair to get out of the bed. Regarding Passive Range of Motion exercise, The UM stated that the Certified Nurse Aides (CNAs) were responsible for performing range of motion and would document Restorative Care in the computer software. On 10/10/23 at 10:15 AM, the UM provided a copy of the restorative care and it had not been completed for Resident #47. According to the order, Resident #47 was transitioned to restorative care on 07/21/23. On 10/10/23 at 11:07 AM, the surveyor interviewed the Physical Therapy (PT) Director and inquired regarding the restorative process. The PT Director confirmed that Resident #47 was transitioned from Occupational therapy to restorative process on 07/21/23. Prior to discharge, the restorative CNA would be trained and the contract will be presented to the UM who will sign also the contract. The PT Director stated that he was not made aware of a request for a special chair and would assist if he was made aware. The PT Director informed the surveyor that he would address the concern today referring to 10/10/23. On 10/10/23 at 11:30 AM, with the assistance of the CNA, the Kardex (CNA software where care was documented) was reviewed. CNA reported entries were made when restorative care was completed. The surveyor reviewed the documentation and could not find any entries for restorative care. The surveyor then inquired if the software included refusal. The CNA demonstrated that they could document refusal. The surveyor then inquired if Restorative was documented for the month of September, the CNA confirmed that there was no documentation for restorative care. On 10/10/23 at 11:45 AM, the surveyor requested the restorative documentation book for review, there was no documentation regarding Resident #47 receiving restorative care as ordered. The UM confirmed there was no documentation. She elaborated that restorative nursing could not be assigned due to staffing shortages. The UM stated, if they do not have enough CNAs on the floor, the restorative CNA had to provide resident care. According to the document provided, Resident #47 received one session of restorative care on 10/03/23. On 10/11/23 at 10:38 AM, the surveyor observed Resident #47 in bed. Resident #47 stated that he/she was very happy. Resident #47 informed the surveyor that he/she was out of the bed for 2 hours yesterday. The surveyor observed there was now a special chair in the room. The resident stated, it feels very good to get out of the bed. The CNA and the PT director facilitated the transfer out of the bed. I have been waiting for 3 months for that. On 10/12/23 at 2:20 PM, the facility was made aware of the concerns with restorative care. On 10/13/23 at 9:54 AM, during an exit interview with the DON and Licensed Nursing Home Administrator (LNHA). They confirmed they were unaware that restorative care was not being completed. The LNHA stated every CNA was responsible for completing restorative care. NJAc 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to update a care plan for Resident #8 for the care and treatment of [REDACTED].#4, #5, and #17. This deficient practice was identified for 4 of 24 residents reviewed for comprehensive care plans as evidenced by the following: 1. Resident #8 was admitted to the facility on [DATE] after sustaining a cervical (C2) neck fracture from a fall. The resident was admitted wearing a hard, "Miami" neck brace for immobilization. Review of the Admission Minimum Data Set (MDS), an assessment tool, dated 9/7/12, indicated that Resident #8 was assessed as not at risk for developing pressure ulcers. The corresponding Care Area Assessment (CAA) indicated that the area of pressure ulcer risk "triggered" on the MDS "due to assistance need for bed mobility." The CAA identified that Resident #8 "wears Miami collar at all times." The CAA however did not assess this as a potential source of pressure. Review of the Care Plan (CP) dated 9/14/12 indicated that Resident #8 was "at risk for skin breakdown" due to factors which included "increased ADL assistance" and "inability to reposition self secondary to cervical fracture." The "Goal" identified on the CP indicated that Resident #8 "will attempt to remain free from skin breakdown x 90 days." The facility failed to identify the "Miami" neck brace as a potential pressure source for Resident #8. In addition, after the resident developed a Stage 3 pressure ulcer from the brace, the CP was not updated to reflect the actual open wound; and no new interventions were implemented to prevent further injury. Refer to F314 2. During the initial tour with the Unit Manager (UM) on 9/20/12 at 10:20 a.m., the surveyor observed Resident #8 in bed. The resident complained of (c/o) constipation. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Interdisciplinary Progress Note dated 9/8/12 indicated that Resident #8 c/o constipation for more than 3 days. Review of the Physician order [REDACTED]." In addition, "[MEDICATION NAME] 10 mg" suppository daily as needed "for constipation if MOM is ineffective." Review of the medical record indicated that the facility failed to follow the resident's prescribed bowel regimen and on 9/20/12 the administration of an enema was ordered. The facility failed to develop a comprehensive care plan for bowel management for Resident #8. Refer to F309 3. On 9/20/12 at 9:40 a.m. the surveyor observed Resident #5 in bed with a urinary catheter and drainage system in place. On 9/21/12 the surveyor reviewed Resident #5's medical record. The resident had an admitting [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Upon further review of the medical record, the surveyor noted that Resident #5 did not have a care plan in place for Foley care and for complications of catheter usage, including infection. 4. On 9/20/12 at 9:48 a.m. the surveyor observed Resident #4 with a urinary catheter and drainage system in place. On 9/21/12 the surveyor reviewed Resident #4's medical record. The resident had an admitting [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] triggered for urinary incontinence/indwelling catheter due to long term catheter use based on the resident's diagnosis. Upon further review of the resident's medical record, the surveyor noted that Resident #4 did not have a care plan in place for Foley care and for complications of catheter usage, including infection. 5. The surveyor reviewed Resident #17's medical record on 9/24/12. According to the Admission Face Sheet, the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The Physical Therapy Evaluation/Plan of Care dated 8/28/12, indicated Resident #17 had sustained a fall at home prior to admission and had a left wrist and left [MEDICAL CONDITION]. In addition, the evaluation reflected the resident had a left leg immobilizer and left wrist splint in place. During a tour of the facility on 9/20/12 at 1:05 p.m. and 9/25/12 at 9:10 a.m., the surveyor observed Resident #17 in a wheelchair with a left leg immobilizer and left wrist splint in place. During an interview with Resident #17 on 9/25/12 at 9:10 AM, the resident stated in the morning "I request 2 people to get me out of bed; they use a slide board in the morning because my legs are stiff. All other times they use 1 person." When the surveyor interviewed the Unit Manager (UM) on 9/24/12 at 1:25 PM, she stated the resident's care plan should reflect the type of transfer the resident required. The UM also stated that Resident #17 required "1 person medium assist" for transfers from bed to wheelchair and wheelchair to bed. A review of a Physical Therapy note dated 9/2/12 reflected the resident was "transferred to chair with sliding board" and max (maximum) assistance of 1. There was no documentation on the care plan that reflected the type of transfer the resident required. NJAC 8:39-11.2(d)(e)(i)