Every finding on record at Clover Meadows Healthcare and Rehabilitation Cente

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a safe consistent manner in order to prevent food borne illness. The deficient practice was evidenced by the following: On 6/23/26 at 8:28 AM, the surveyor entered the kitchen and observed the FSD preparing and handling food at the kitchen counter without a hairnet on.At that time, the surveyor interviewed the FSD and he acknowledged that he was not wearing a hairnet. The FSD then left from preparing and handling the food at the kitchen counter, walked to and opened the kitchen door to exit the kitchen to retrieve a hairnet, then opened the kitchen door to re-enter the kitchen, walked back to the kitchen counter and continued to prepare and handle the food in the kitchen without washing his hands. The surveyor interviewed the FSD who stated, Oh, I should have washed my hands, I am sorry, then went and washed his hands. The FSD stated the importance of the hair net was to prevent contamination and prevent hair from falling into the food. The FSD stated the importance of handwashing was to avoid cross contamination and germs after touching the door and prevent germs from going into the food. The FSD further stated, I should have worn my hair net before handling the food and washed my hands after getting the hair net outside of the kitchen. On 6/25/26 at 11:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the expectation was for kitchen staff to wear hairnets, beardnets, wash hands after leaving the kitchen and upon entry, and to wash hands again prior to handling food. The LNHA further stated the FSD should have worn a hairnet upon entering the kitchen, and after he went to get his hairnet, he should have washed his hands prior to continuing to handle the food. On 6/25/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, Regional Nurse, the Administrator in training and the Regional Director of Operations. The surveyor made the facility administration aware of the above-mentioned concerns. A review of the Hand Hygiene Competency Validation provided by the LNHA, revealed the FSD had completed the annual return demonstration on 2/6/26. A review of the facility's Hairnet and [NAME] Guard Policy, updated on 1/2026, and provided by the LNHA. The Policy indicated, contain hair and facial hair from contaminating food and food services. The Procedure revealed: 1. All employees are to cover their hair at all times. 3. Any employee entering the kitchen must adhere to these rules. A review of the facility's Hand and Hygiene, policy updated on 11/2025, and provided by the LNHA. The policy indicated It is the policy of the facility to prevent the spread of infection by hand washing. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for Activities of Daily Living (ADL). This deficient practice was observed for 1 of 1 resident (Resident #47) reviewed for ADL care. The deficient practice was evidenced by the following:On 6/22/26 at 10:55 AM, during an initial tour, the surveyor observed Resident #47 watching TV in their bed. The surveyor observed the resident's chin with grey colored, curled facial hair and both hands with long, jagged fingernails with sharp edges. The resident stated, that needs to be done while pointing towards their facial hair. The resident stated they (the nails) need to be cut short, and I cannot do it by myself. The resident stated, my aide used to cut my nails and now she moved and since then no one has done them.The surveyor reviewed the Electronic Medical Record (EMR) for Resident #47:A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; seizures (an abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior), muscle weakness and polyneuropathy (a condition in which many peripheral nerves throughout the body become damaged, leading to symptoms such as numbness, tingling, weakness, or pain). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 6/4/26, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating the resident's cognition was moderately impaired. Further review of the MDS indicated that the resident was dependent on staff for their ADLs including personal hygiene. A review of the individualized comprehensive care plan (ICCP) created on 2/27/23 included a focus area that the resident had an ADL self care performance deficit related to decrease mobility and required assistance with care with a significant decline in function 3/4/26. Interventions included but were not limited to; the resident required assistance of 1 person during ADLs . Evaluate the ability to perform the items of ADLs (. personal hygiene). On 6/24/26 at 11:43 AM, the surveyor observed the resident's lunch tray in front of them. The resident stated that the aide (the Certified Nurse Aide /CNA) had given them a bed bath. The surveyor observed the resident with grey colored curled facial hair and long jagged fingernails on both hands. On 6/24/26 at 12:19 PM, the surveyor interviewed CNA #1 who was assigned to Resident #47. During an interview with the surveyor, CNA #1 stated that she was familiar with the resident. CNA #1 stated during morning care and showers, she helped her residents brush their teeth, cut their nails, shave them and then she further stated, I also do their hair if they need help, which all my residents do. CNA #1 stated if she observed a resident with long fingernails and facial hair, she would ask the residents first and then she would cut their nails short and shave their facial hair. CNA #1 stated normally the residents ask for it and if they did not ask for it, she would still shave their facial hair. She then stated, I look at my face and I do not have facial hair, and I do not want to see my loved one with facial hair. CNA #1 stated if she was not allowed to trim the resident's nails, then she would clean, file and paint the nails and make sure there was no food stuck underneath the nails. She stated if the residents had long nails and they were not clean; they could have bacteria and cause infection which could make the residents sick. CNA #1 stated the resident had never refused care. CNA #1 stated Resident #47 was total care which meant the resident could not do anything for themselves and they needed total care from head to toe. The surveyor accompanied CNA #1 to Resident #47's room and she confirmed the resident had a lot of facial hair and long fingernails and further stated the hair did not get that long in 2 days.On 6/24/26 at 12:54 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN#1) stated she did not know if the CNAs clipped the resident's nails or if the podiatrist did. She stated the CNAs did shave the facial hair and if the resident was able to shave themselves then they would give them the supplies. LPN #1 stated long fingernails should be clipped because if the resident was confused and they were incontinent of bowel movement, while they were waiting for the CNA to clean them, their hands could go into their briefs, and the stool could get stuck under their nails and that could make them sick. LPN #1 stated the residents with longs nails could scratch themselves and that way the bacteria could get in and make them sick. LPN #1 stated if she observed a resident with long facial hair, she would ask the resident first and assist them accordingly. She stated shaving hair was important because hair carried a lot of bacteria. She stated the residents might not like their appearance with facial hair and if they did not mind then we would take care of them. After the surveyor inquiry, LPN #1 observed Resident #47's nails and the facial hair and stated the CNA was filling the nails and confirmed the fingernails and facial hair were long. On 6/24/26 at 1:12 PM, during an interview with the surveyor, the LPN/Unit Manager (LPN/UM) stated the expectation from the staff was that they were supposed to trim and file the resident's nails and ask the residents if they wanted to be shaved and then shave them. The surveyor made the LPN/UM aware of the above-mentioned findings for Resident #47. The LPN/UM stated the staff was supposed to check and observe residents' nails and facial hair on the shower days and as needed to keep them clean as it was a part of hygiene care. The LPN/UM stated shaving was also a part of hygiene care as for dignity. The LPN/UM stated the nurses, and the CNAs were responsible for nail care unless the resident had any medical condition such as hardening of the nails, then they would not do it. She stated it was for dignity and infection control for long nails, and the residents did not need to ask for nail care and shaving their facial hair.On 6/25/26 at 9:49 AM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned findings for Resident #47. She stated nail care was provided on daily basis during care. The DON stated for facial hair, the resident should be asked during care and shaving could be done at any time. The DON stated it was important for dignity.On 6/25/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, Regional Nurse, the Administrator in Training and the Regional Director of Operations. The surveyor made the facility administration aware of the above-mentioned concerns for Resident #47.A review of the facility provided policy Resident Hygiene date updated 1/2026 revealed under Policy: To ensure that all residents in the facility receive the necessary assistance,. and services to maintain optimal personal hygiene, grooming,. promoting physical and psychosocial well-being. Procedure: C. Hair and Nail Care - Residents' fingernails and toenails will be trimmed, cleaned, and filed regularly. Facial shaving .assistance will be provided. A review of the facility provided ADL Care Policy date updated 11/2025 revealed under Policy: It is the policy and procedure of this facility for the CNA's to adequately provide ADL care to the residents. Procedure: 1. ADL care, including assisting residents with . grooming.NJAC 8:39-27.1(a), 27.2(g)

Complaint # 2581082Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to update and revise a resident's Comprehensive Interdisciplinary Care Plan (CICP) after facility identification of a skin condition. This deficient practice was identified for 1 of 3 residents (Resident #1) and was evidenced by the following:A review of the resident admission Record (admission summary) indicated that Resident #1 was admitted to the facility with the diagnoses which included but was not limited to dementia, depression, and malignant neoplasm of the breast.A review of the annual Minimum Date Set (MDS-an assessment the facilitates a resident's care) dated 9/27/25, indicated that Resident #1 had severe cognitive deficits and was dependent on staff for activities of daily living. The MDS also reflected that the resident was at risk for the development of pressure ulcers. The MDS indicated that the resident had interventions in place such as a pressure reducing device for the wheelchair and bed, with application of ointments and medication to the skin.On 10/23/25 at 9:30 AM, during initial tour, the surveyor conducted incontinent checks with the Licensed Practical Nurse Unit Manager (LPN/UM). The surveyor observed Resident #1 lying in bed. The resident was not interviewed due to poor cognition. The resident gave the LPN/UM permission to check the incontinent brief to ensure cleanliness and dryness. The surveyor observed that the resident was clean and dry, and bed linen was clean. The surveyor observed a dressing applied to Resident #1's right buttocks, dated 10/22/25. The LPN/UM removed the dressing, and the surveyor observed a small fluid filled blister. On 10/23/25 at 9:45 AM, the surveyor reviewed Resident #1's electronic medical record which revealed the following:A review of the Progress Note (PN) dated 10/20/25 at 23:15 hours (11:15 PM), indicated that a weekly skin and foot evaluation had been completed and documented that the resident's skin was intact and free from abnormal findings.A review of the PN dated 10/21/25 at 12: 20 PM, indicated that a blister was identified on the right buttocks during morning care. The physician was notified, and a treatment order was received and implemented. The note also indicated that the family was informed.The facility Injury Report (IR) dated 10/21/25 at 12:05 PM, indicated that during morning care, a Certified Nursing Assistant reported to the nurse that Resident #1 had a blister on the right buttocks. The blister measured 1 cm x 0.5cm x 0 cm. Due to confusion, Resident #1 was unable to explain how the blister could have occurred. The IR reflected that a treatment was performed to the area and that the physician and Responsible Party (RP) were notified. The IR revealed that the interventions that were instituted after identified of wound were, weekly wound rounds with the wound care consultant, offlaid bilateral heels and initiate wound treatment.The physician Order Audit Report reflected a physician order dated 10/22/25 to apply bacitracin to the right buttocks and cover with a bordered foam dressing everyday shift for 5 days.A review of Resident #1's CICP dated 9/19/24, indicated that Resident #1 had a potential for skin breakdown, not an actual skin breakdown. The goal stated: [Resident #1] skin will remain intact, and interventions included the following: Apply Skin barrier cream per facility protocol and as needed, assist/remind to reposition frequently and monitoring the skin weekly and PRN (as needed) per protocol. On 10/23/25 at 10:10 AM, the surveyor interviewed the Registered Nurse (RN) who stated that Resident #1 required complete care with all aspects of activities of daily living and received preventive protective skin care. The RN confirmed that the resident had a blister on the right buttocks which required a treatment. The RN further stated that once that blister was identified as a new skin impairment, that its was the LPN/UM responsibility to update that CICP with new preventive protective skin treatment interventions.On 10/23/25 at 10:20 AM, the surveyor interviewed the LPN/UM who stated that when a blister was identified, staff usually monitor it to determine if it developed into a wound. The LPN/UM stated that a blister was not considered a wound, and therefore, there was no need to update the CICP at that time.On 10/23/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) who reviewed Resident #1's CICP and stated that once the blister was identified on 10/21/25, the CICP should have been updated to reflect an actual impairment. The DON further stated that new preventive and treatment interventions should have been included in the CICP.Despite identification of the new skin issue and initiation of treatment interventions on 10/21/25, the facility did not update or revise the resident's CICP to reflect the new skin integrity concern and corresponding interventions.The facility policy dated 6/2025 and titled, Care Plans-Comprehensive indicated that an individual comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Each resident's care plan was designed to aid in preventing or reducing declines in the resident's functional status and or functional levels. Care Plans were revised as changes in the resident's condition dictates.N.J.A.C. 8:39-11.2(g)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined the facility failed to ensure a.) a physician's order (PO) was in place for a resident who used a machine that helps you breathe for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), which the resident brought from home, b.) a PO was in place for the proper settings, c.) a PO was in place to maintain the cleanliness of the machine and it's parts in accordance to the manufacturer's instructions. This deficient practice was identified for 1 of 3 residents (Resident #9) reviewed for respiratory care; and d.) respiratory masks were stored properly after use to prevent contamination. This was identified for 2 of 3 residents (Resident #9 and #238) that were reviewed for respiratory care. This deficient practice was evidenced by the follows: 1. On 1/12/25 at 11:07 AM, the surveyor observed Resident #9 in bed covered with a sheet. The surveyor observed a nasal pillow mask (a type of mask that delivers air pressure directly into the nostrils through small, flexible pillows) lying directly on the bed. The mask was connected to a breathing machine which the resident identified as a CPAP (Continuous Positive Airway Pressure machine, which is one of the most common treatments for sleep apnea.) The resident stated the machine was brought from home and they have used it since admission. The resident stated they self applied and removed the nasal pillow mask. The resident acknowledged the mask was not bagged. The resident stated the staff do not bag the nasal pillow mask. In addition, the resident stated their granddaughter cleaned the mask the night before. The resident further stated that nursing staff stated that a PO was required for them to clean the machine and its parts. The surveyor reviewed the electronic medical record (EMR) for Resident #9. A review of Resident #9's Admission Record (an admission summary) reflected the resident had diagnoses which included but were not limited to; Chronic Obstructive Pulmonary Disease (COPD) [lung disease that blocks airflow and make it difficult to breathe], morbid (severe) obesity, chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues), and obstructive sleep apnea. A review of a quarterly Minimum Data Set, a tool to facilitate the management of care dated 10/8/24, reflected the resident had a Brief Interview for Mental Status score of 15 out of 15, which reflected the resident had an intact cognition. It also reflected the resident had the diagnoses indicated above. A review of the individualized comprehensive care plan (ICCP) reflected a focus area for altered respiratory status and difficulty breathing related to sleep apnea with an initiation date of 1/9/23. Further review, reflected the resident used a BIPAP (Bilevel Positive Airway Pressure machine, which helps you breathe.) It did not reflect the proper settings, nor care instructions until 1/14/25, which was after surveyor inquiry. A review of the Order Summary Report (OSR) did not reflect a PO for the use of a BIPAP or CPAP machine, the proper settings, or the instructions to maintain the cleanliness for a CPAP or a BIPAP machine and its parts. A review of the electronic Medication Administration Record's (eMAR) and the electronic Treatment Administration Record's (eTAR) for Resident #9 from October 2024 through January 2025, did not reflect any treatments or care for a BIPAP or CPAP machine. A review of the Vitals Summary Oxygen Saturation report from 10/1/24 through 1/14/25, reflected the resident's oxygen saturation was checked on the following dates while the resident's machine for sleep apnea was in use: 10/14/24 used BIPAP machine, oxygen saturation at 96% 11/3/24 used BIPAP machine, oxygen saturation at 97% 11/21/24 used CPAP machine, oxygen saturation at 98% 12/5/24 used CPAP machine, oxygen saturation at 97% 12/7/24 used BIPAP machine, oxygen saturation at 98% 12/9/24 used CPAP machine, oxygen saturation at 100 % 12/10/24 used CPAP machine, oxygen saturation at 97% 12/12/24 used CPAP machine, oxygen saturation at 97% 12/13/24 used CPAP machine, oxygen saturation at 98% 12/16/24 used CPAP machine, oxygen saturation at 98% 1/12/25 used BIPAP machine, oxygen saturation at 99% A review of progress notes from 10/1/24 through 1/15/25, did not include any documented evidence that the resident used a BIPAP or CPAP, breathing machine. On 1/13/25 at 12:25 PM, the surveyor interviewed the resident in their room. The resident stated the company that provided the breathing machine for sleep apnea sent replacement tubing, nasal pillow masks and filters to their family's home. On 1/14/25 at 11:05 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) / Unit Manager (UM) [LPN/UM #1]. She acknowledged the resident's breathing machine was used for sleep apnea and was the resident's personal machine from home. She stated it was the responsibility of the facility to maintain the machine (cleanliness, apparatus changes, etc.) LPN/UM #1 could not speak to how often the machine or mask needed to be cleaned or the frequency of which parts needed to be changed. She reviewed the POs in the EMR in the presence of the surveyor and acknowledged there were no POs for the machine or for its maintenance. On 1/15/25 at 10:02 AM, LPN/UM #1, in the presence of the survey team, stated she was aware of the resident using their personal BIPAP machine but she remained unaware of what and how often the family brought in replacement equipment. On 1/15/25 at 11:07 AM, the surveyor interviewed the resident about the sleep apnea machine in the presence of a second surveyor. The resident stated it was a CPAP machine. The resident stated the machine was provided and monitored by [name redacted] sleep center. The resident stated a telehealth appointment was conducted every six months. The resident stated the company provided replacement equipment and that the nasal pillow mask needed to be cleaned daily and changed weekly and the filter needed to be changed weekly as well, which the resident's family took care of. The resident stated the staff stated they were unable to complete these tasks since there were no PO's to do so. On 1/15/25 at 11:47 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the survey team. She was unsure if a PO was required to clean a CPAP or BIPAP machine, or if the staff needed to clean it periodically. She stated the machine settings required a PO. The IP stated the machine would not work properly if it was not cleaned properly. In addition, she stated the nasal pillow mask should be stored in a bag when it was not in use to avoid contamination which could cause infection. She stated the UM was responsible to ensure POs were in place for the breathing machine, and how to clean and store equipment. On 1/15/25 at 2:26 PM, the survey team met with administrative team: Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the IP, the Operations staff, and the Regional Nurse. The Regional Nurse informed the survey team that LPN/UM #1 verified the breathing machine was a BIPAP machine and the setting should be 15/5. She and the DON acknowledged that there should have been POs for the BIPAP machine use, settings, and it's care according to manufacturer's instructions. She also stated a PO was placed for a pulmonary (lung) consultation. The LNHA acknowledged that it was the facility's responsibility to clean the machine. The Regional Nurse stated it was nursing's responsibility to ensure these POs were in place. The administrative team acknowledged this information should have been included in the resident's ICCP. On 1/15/25 at 2:50 PM in the presence of the survey team, the Regional Nurse stated the nurse called [name redacted] the sleep study group to confirm which type of machine (BIPAP or CPAP) the resident had, the settings, and how to care for it (the machine) and to coordinate care going forward with the sleep study group. On 1/16/25 at 11:24 AM, the survey team met with the LNHA and DON. The DON stated that respiratory masks should be bagged and kept in the nightstand table drawer when not in use. In addition, she stated nursing obtained the manufacturer's instructions for Resident #9's BIPAP machine. The LNHA stated if there was an outside piece of equipment in a resident's room, staff should report this to the DON to ensure it was addressed properly. 41858 2. On 1/12/25 at 10:00 AM, during initial tour, the surveyor observed Resident # 238 in their bed. The surveyor observed a nebulizer machine with a nebulizer mask on the resident's nightstand. The mask was lying directly on the facility provided newsletter with a facility provided gown resting on top of the mask. The resident stated, the nurse gives me the mask with the medicine in it and then comes back and takes the mask and puts it on the nightstand. The surveyor observed the resident was unable to reach the nightstand. The surveyor reviewed the EMR for Resident #238. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus with Diabetic neuropathy, unspecified (nerve damage usually in hands and feet) and COPD, unspecified. A review of the ICCP revealed: a Focus of oxygen therapy Date Initiated: 01/09/2025. Interventions: monitor for s/sx (signs/symptoms) of respiratory distress. A review of Resident #238's OSR revealed a PO for Ipratropium-Albuterol Solution 0.5-2.5 (3) Mg/3 ML (milligram/milliliter) 3 ml inhale orally via nebulizer four times a day for asthma .order date: 1/9/2025. A review of the eMAR for January 2025 revealed the above medication was administered at 0600 AM on 1/12/25. On 1/15/25 at 10:36 AM the surveyor interviewed the LPN #1, who stated a nebulizer mask should be rinsed and dried after use and stored in a bag. On 1/15/25 at 10:50 AM, the surveyor interviewed the LPN/Unit Manager (UM) #1, who stated a nebulizer mask should be rinsed and dried after a treatment was given and stored in bag to be keep it free from germs. On 1/15/25 at 11:19 AM, the surveyor interviewed the DON, who stated a nebulizer mask should be stored in a bag when it was not being used. On 1/15/25 at 11:50 AM, the surveyor interviewed the IP, who stated a nebulizer mask should be stored in bag, you don't want to leave it all over the place because it is going on the face. On 1/15/25 at 2:25 PM, the surveyor made with the LHNA, the DON, the IP, the Operations staff, and the Regional Nurse aware of the above concerns. A review of the facility's policy Oxygen Tubing and Respiratory Products revised 6/2024, revealed Policy: It is the policy and procedure of this facility that all oxygen tubing is of single use for a single resident, clean and properly stored and dated to prevent the transmission of infection 7. All nebulizer tubing shall be dated and stored in a bag when not in use and replaced every 7 days. NJAC 8:39-29.2(d).

COMPLAINT# NJ00179885 Based on observation, interview and record review, it was determined that the facility failed to submit a report to the New Jersey Department of Health (NJDOH) within the two-hour timeframe for an allegation of abuse made by a resident, (Resident #82). The deficient practice was identified for one (1) of four (4) residents reviewed for abuse investigations and was evidenced by the following: On 1/12/25 at 11:00 AM, the surveyor observed Resident #82 in bed. The surveyor interviewed the resident, and the resident had no concerns. On 1/14/24 at 11:15 AM, the surveyor observed the resident in their room in bed. The surveyor interviewed the resident regarding an incident in November but the resident had not wanted to speak about any incident regarding staff. The surveyor reviewed the medical record for Resident #82. A review of the Admission Record revealed diagnoses which included but not limited to; heart failure, generalized muscle weakness and difficulty in walking. A review of the most recent comprehensive significant change Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care) dated 12/26/24, reflected that the resident had a brief interview of mental status (BIMS) score of 13 out of 15, indicating the resident had an intact cognition. A review of a Reportable Event Record/Report provided by the Licensed Nursing Home Administrator (LNHA) that was completed by the Director of Nursing (DON) indicated an allegation Resident stated to the 7-3 pm Nurse that [they] was slapped across the right side of [their] face by the night nurse and that she came in [their] room and shut [their] O2 (oxygen). In addition, the report indicated that the date of the significant event occurred on 11/18/24 and the time of that event was 8:30 AM. The report also indicated that the significant event was called in to the NJDOH on 11/18/24 at 2:59 PM, more than six (6) hours after the time of the event. On 1/14/24 at 10:54 AM, the surveyor interviewed the DON who verified the time of the known allegation from Resident #82 was 8:30 AM and the NJDOH was notified at 2:59 PM. The DON stated that she was unsure why it took until 2:59 PM to call in the event. The DON added that she was trying to figure out what had happened because when she reached the facility that morning the resident was already taken to the hospital for a different reason. She stated it was confusing and took a while to get the information. The DON added that the night nurse (11 PM-7AM) in question had already left the facility. The DON then stated that an investigation was completed, and the allegation was not substantiated, and that the resident had stated they made a false accusation after returning from the hospital. The DON also stated that the Licensed Nursing Home Administrator (LNHA#1) that was previously here was aware of the statement made by Resident #82 prior to the resident going to the hospital. On 1/14/25 at 12:06 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that she had been the UM for five years and had written the nursing progress note dated 11/18/23 at 9:03 AM regarding Resident #82 that indicated Resident is awake alert oriented with periods of forgetfulness, called in resident's room by Nurse, Resident stating [they] was slapped across right side of [their] face by the night nurse and she later came in to [their] room again and shut off [their] oxygen and slammed the door but the door was too heavy that it couldn't be slamme shut. The UM/LPN explained that she was called to the resident's room by the 7 AM to 3 PM nurse and that the night nurse (11 PM to 7 AM) had already left the building. The UM/LPN added that she had immediately notified her DON. On 1/14/24 at 1:13 PM, the surveyor interviewed LNHA#2, who stated that he had been employed as the LNHA for the facility for six (6) weeks and that there was no employee designated with the title of Abuse Coordinator but that he was responsible. LNHA#2 reviewed the Resident Rights: Abuse/Neglect Policy dated as reviewed 11/2023 and acknowledged that the policy had not indicated any requirements for a timeframe as to when to report an allegation of abuse to the NJDOH. The LNHA then stated that any allegation of abuse was considered a reportable to the NJDOH and should be done within two (2) hours of the incident. LNHA#2 acknowledged that a statement from a resident that a nurse slapped them would be an allegation of abuse and should be reported within two (2) hours to the NJDOH. LNHA#2 added that he was aware of an incident with Resident #82 that occurred before he started to work at the facility but thought the statement that the resident was slapped had occurred in the hospital. LNHA#2 stated that he would have to further review as to why the allegation was not reported within the two (2) hours. On 1/16/25 at 11:24 AM, the survey team met with LNHA#2 and DON. LNHA#2 stated that he could not speak for the previous administrator (LNHA #1) that was here when Resident #82 had made the allegation but thought that it was possible that because the resident had a care plan that indicated prior accusatory statements had been made that that was the reason for not calling the NJDOH right away. The DON stated that she had taken the statement seriously and after the first hour she knew she needed to call the NJDOH but got caught up and wanted to hear what had happened from the resident and agency nurse who were both not in the facility. LNHA#2 stated that they have to err on the side of caution and report. LNHA#2 and the DON acknowledged that reporting was required within two hours and that an investigation would occur after. A review of the facility policy for Incident/Accident Investigating and Reporting updated 6/2024, provided by LNHA#2 included In the event that the incident is found to be reportable based on the DOH reportable guidelines, the necessary information will be reported to the DOH in a timely manner. A review of the facility policy for Resident Rights: Abuse/Neglect Policy dated as reviewed 11/2023, provided by LNHA#2 included the section Reporting Results of the Investigation: A. Results of all investigations of suspected abuse or neglect will be reported to the Administrator or designee at the immediate conclusion of the investigation. B. Decisions to report alleged incidents of resident to resident abuse will be made on a case by case basis by the administrator. The policy had not indicated when to report to the NJDOH. NJAC 8:39-4.1(a)(5), 9.4(f)

Based on observation, interviews, record review, and facility documents it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate a resident's dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 1 resident, Resident #62, reviewed for dialysis. 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 1/12/2025 at 10:36 AM, during the initial tour, the surveyor observed Resident #62 in their room with the lights off. The resident was in bed and their eyes were closed. On 1/12/2025 during entrance conference with the surveyor, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) from 11:17 AM to 11:42 AM, the LNHA verified that the facility did not have an onsite dialysis unit. The surveyor reviewed the electronic medical record (EMR) for Resident #62. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 diabetes Mellitus without complications, Hypertensive heart (complications of high blood pressure that affect the heart), essential primary hypertension (htn-high blood pressure) and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood). A review of the admission Minimum Data Set (MDS), an assessment tool, dated 11/2/24 revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, indicating the resident's cognition was not able to be assessed. Further review of the MDS, revealed the resident was receiving dialysis. A review of the individual comprehensive care plan (ICCP) revealed: Resident needs dialysis hemo (treatment that filters waste from the blood) r/t (related to) renal (kidney) failure goes to dialysis tues (Tuesday)-thurs (Thursday) and Saturday (Sat) Date Initiated: 10/28/2024. Intervention: May schedule time of medication to accommodate dialysis schedule. A review of physician orders (PO) revealed a PO: ESRD on dialysis Tues Thurs and Saturday pick up 5:15 am chair time 6:15 am return 9:15 am every shift every Tue, Thu, Sat; Start date 10/28/24. A review of the October 2024 Medication Administration Records (MAR) revealed on 10/29/24 (Tues) code 9 was entered for the administration times of 0900 and 1000; and on 10/31/24 (Thurs) a code 1 was entered for the administration times of 0900 and 1000 ;and the November 2024 MAR revealed 11/2/24 Sat and11/12/24 Tues, a code 9 was entered for the administration times of 0900 and 1000; 11/5/24 Tues, 11/9/24 Sat, 11/14/24 Thurs, 11/23/24 Sat, 11/26/24 Tues, code 1 was entered for the administration times for 0900 and 1000 for following medications: -AmLODIPine Besylate Oral Tablet 10 MG (miligrams) (Amlodipine Besylate) Give 10 mg by mouth one time a day for HTN. HOLD if SBP is BELOW 100, start date 10/27/24. -Aspirin 81 Oral Tablet Chewable (Aspirin) Give 81 milligrams by mouth one time a day for CAD (coronary artery disease-disease in the heart's major blood vessels) start date 10/27/24 -Calcitriol Oral Capsule 0.25 MCG (micrograms) (Calcitriol) Give 1 capsule by mouth one time a day every Tue, Thu, Sat (Saturday) for CKD (chronic kidney disease) Start date 10/29/2024 -FLUoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day every Tue, Thu, Sat for depression, start date 10/29/2024. - SITagliptin Oral Tablet 25 MG (Sitagliptin) Give 1 tablet by mouth one time a day for DM (diabetes mellitus), start date 10/27/2024. -Triphrocaps Oral Capsule 1 MG (B-Complex w/ (with) C & Folic Acid) Give 1 capsule by mouth one time a day for Supplement, start date 10/27/2024. -Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder) Give 2 tablet by mouth three times a day for CKD 2 caps (capsules)=1334 mg, start date 10/29/2024. A review of the MARs chart code revealed a 1= out on med pass with meds and a 9=other/See nurses notes. A review of the nursing progress notes revealed the following progress notes: -10/29/2024 at 10:05 Note Text: out on pass-dialysis; author LPN#1. -10/31/2024 at 10:10 Note Text: out on pass-dialysis; author LPN#1. -11/2/2024 at 15:57 Narrative: Resident was out at dialysis the whole shift, did not return on 7/3 shift. Author RN/LPN (registered nurse/licensed practical nurse) -11/5/2024 at 12:44 Narrative: Resident is back to facility this morning following their dialysis treatment earlier. Author LPN #1. -11/9/2024 at 10:58 Narrative: Resident returned to facility at 1050 following their dialysis treatment. Author LPN #1. -11/12/2024 at 13:09 Narrative: Came back to facility at 1050 after dialysis treatment. Author LPN #1. -11/14/2024 at 14:58 Narrative: Came back to facility at 1050 after dialysis treatment. Author: LPN #1. -11/23/2024 at 05:15 AM Narrative: Resident OOF to dialysis. Author: LPN#2 -11/26/2024 at 06:52 Narrative: Left Facility to HD (hemodialysis) at 6:40am with ambulance. Author RN #1. Further review of the progress notes for the above mentioned dates and medications did not reveal documentation that the physician was notified or that the medications were given. On 1/15/25 at 10:36 AM, the surveyor interviewed License Practical Nurse (LPN) #1, who stated Resident #62 receives dialysis Tuesday, Thursday and Saturday; they get picked up at 5 AM and come back around 10 AM or 11 AM on those days. LPN #1 stated we (the nurses) change medication times according to the dialysis schedule. He then stated, if for some reason the resident came back after 10 AM, he would use the code for out on pass and let the doctor know. LPN #1 accessed the eMAR in the presence of the surveyor. He verified a 1= out on pass, and stated the medication was not given because the patient was not there. He stated if a 9 was entered it meant there would be a progress note explaining why the medication was not given. LPN #1 could not show the surveyor a note the physician was notified or that the medications were given for the above mentioned dates. On 1/15/25 at 10:53 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated the resident received dialysis Tuesday, Thursday, and Saturday, leaves at 5 am and comes back around 10 AM or 11 AM. She further stated if a resident was not in the building, medications should not be schedule at that time. They (the medications) should be scheduled for the time the resident was in the building. The LPN/UM stated the doctor should be called after one occurrence to make them aware and to change the time of the medications. At that time, the LPN/UM accessed the electronic MAR in the presence of the surveyor. She reviewed Resident #62's November MARs. She acknowledged the codes on the above mentioned dates and was unable to verify if the physician was notified or that the medications were given for the above mentioned dates. The LPN/UM could not speak to why the medications were scheduled for the times when the resident was not in the building on Tuesday, Thursday, or Saturday. She stated the doctor should have been called and the times changed. She stated it was important for residents to get their medications to keep them therapeutic. On 1/15/25 at 11:08 AM, the surveyor interviewed the DON, who stated residents, who were receiving dialysis, medications should not be timed for when the resident was not in the building. She stated the doctor should definitely be called if the medications were unable to given. Medicines. The DON further stated after one time, the doctor should be called and medication times changed. At that time, the DON reviewed Resident #62's November MARs in the presence of the surveyor. She acknowledged the above mention codes for a above mentioned dates and medications. She reviewed the EMR and verified the medications were not given or that the doctor was not called. She was unable to speak to why the medications were not given. The DON stated it was important for residents to receive their medications because of imbalance, they need to be given on a regular basis. On 1/15/25 at 2:25 PM, the surveyor made with the LNHA, the DON, the Infection Preventionist, Operations staff member, and the Regional Nurse of the above concerns. No additional information was provided. A review of the facility policy, Dialysis Medication revised 10/2024, revealed: Policy: It is the policy and procedure of this facility to ensure that residents underdoing dialysis receive the appropriated medications to manage their condition. Procedure: 1. The facility may adjust all medications according to the dialysis schedule. 2. Any changes to dialysis schedule, the facility will notify the MD and adjust medication schedule accordingly. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was identified on 1/12/25, and was evidenced by the following: On Sunday, 1/12/25, at 09:00 AM, the surveyor observed the nursing staffing report posted at the front reception desk. The receptionist was present. The nursing staffing report was dated Friday 1/10/2025, which reflected all shifts for that day. On 1/13/25 at 8:04 AM, the surveyor observed the nursing staffing report posted at the front reception desk had not been updated from 1/10/2025. The receptionist was present. On 1/13/25 at 10:46 AM, the surveyor observed the nursing staffing report posted at the front reception desk had not been updated from 1/10/2025. The receptionist was present. On 1/14/25 at 8:00 AM, the surveyor observed the nursing staffing report posted at the front reception desk dated 1/13/25 for all shifts. On 1/14/25 at 11:53 AM, the surveyor interviewed the Staffing Coordinator/Central Supply (SC/CS) staff member, who stated she was the person who posts the staffing at the front desk. The surveyor asked who posts the staffing on the weekends, the SC/CS stated We don't do it. I post it on Monday. The surveyor made the SC/CS aware of the above observations and that staffing should be posted every day, she stated gotcha. On 1/14/25 at 12:01 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated staffing was posted every day and the receptionist changed it. The surveyor made the LNHA aware of the above findings and the interview with the SC/CS. A review of the facility's policy Staffing Ration Reports reviewed 10/2024, revealed: Policy: It is the policy and procedure of this facility to post the daily staffing ratios. Procedure: 1. The staffing coordinator or designee will post the Staffing Ration Report at the Front desk. NJAC 8:39-41.2 (a)

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 10/26/23 at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the narcotic logbook for the North Wing Back Hall medication cart. The Controlled Drugs Accountability/Count Sheet for August, September, and October 2023 shift logs revealed the following incomplete or blank sections: 8/5/23 - 11 PM -7 AM total incoming count section containing counts for Bingo, Boxes, Bottle, and Sheet. 8/6/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/19/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/22/23 - 7 AM - 3 PM outgoing nurse signature 8/27/23 - 3 - 11 PM outgoing nurse signature 8/31/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet, and incoming and outgoing 11-7 nurse signature. 10/1/23 - 7 AM - 3 PM total incoming and outgoing bottle count, 3 - 11 PM total incoming and outgoing sheet count, 11 PM - 7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 10/7/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 10/9 - 10/17, 10/21 - 10/22/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 10/9, 10/13, 10/14, 10/17/23 - 11 PM -7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. At this time, the surveyor interviewed LPN #3 who stated that both the incoming and outgoing nurses on the shift were to complete the narcotic count and the narcotic count log together at the time of the count. On 10/26/23 at 11:19 AM, the surveyor in the presence of the Registered Nurse #1 (RN #1) reviewed narcotic logbook for the East Wing Front Hall medication cart. The Controlled Drugs Accountability/Count Sheet for August, September, and October 2023 shift log revealed the following incomplete or blank sections: 8/20/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. Incoming and outgoing nurse signatures for 7 AM - 3PM and 11 PM - 7 AM. 8/21/23 - 11 PM -7 AM total incoming and 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/23/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/26/23 - 11 PM - 7 AM outgoing nurse signature 8/27/23 - 3 - 11 PM, 11 PM - 7 AM total incoming and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/28 - 8/29/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/29/23 - 11 PM - 7 AM incoming and outgoing nurse signatures 8/30/23 - 7 AM - 3 PM and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/30/23 - 7 AM - 3 PM outgoing nurse signature 8/31/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 9/8/23 - 3 - 11 PM total incoming and 7 AM - 3PM and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM, and 3 - 11 PM outgoing nurse signatures 9/9/23 - 3 - 11 PM and 11 PM - 7 AM outgoing nurse signatures 9/10/23 - 3 - 11 PM, 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 3 - 11 PM incoming and outgoing nurse signatures 9/11/23 - 11 PM -7 AM total incoming, 7 AM - 3PM, 3 - 11 PM, and 11 PM - 7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM, and 11 PM - 7 AM incoming and outgoing nurse signatures 9/12/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/19/23 - 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/20/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/23/23 - 3 - 11 PM, 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM outgoing nurse signature 9/24/23 - 11 PM -7 AM total incoming, 3 - 11 PM, and 11 PM - 7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/25/23 - 7 AM - 3 PM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/27/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/29/23 - 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 3 - 11 PM, and 11 PM - 7 AM incoming and outgoing nurse signatures 9/30/23 - 7 AM - 3 PM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM incoming and outgoing nurse signatures 10/12/23 - 11 PM - 7 AM incoming and outgoing nurse signatures 10/13/23 - 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. At this time, the surveyor interviewed RN #1 who stated that both the incoming and outgoing nurses on the shift were to complete the narcotic count and the narcotic count log together at the time of the count, and there should not be any blanks on the logs. On 10/26/23 at 11:48 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager #2 (LPN/UM #2), who confirmed the incomplete sections of the logs, and stated they should not be blank and if not documented, then not done. On 9/6/23 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the narcotic shift log should be completed and signed by two nurses together, the incoming and the outgoing nurses, when the shift-to-shift narcotic count is completed. She confirmed that this process is in place to keep track of accountability, which is very important because you're dealing with narcotics. A review of the facility's Narcotic and Controlled Substance policy with a reviewed date of 1/2023, included, It is the policy and procedure of this facility to comply with the Controlled Substance Act. As well as to monitor narcotic administration and to ensure accountability for all narcotics. The section titled procedure included, a narcotic count will be completed by two licensed nurses prior to the end of each shift, opening of a unit and closing of a unit. NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store medications and properly label opened multidose medications. This deficient practice was observed in 1 of 1 medication storage rooms and 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the North Wing Back Hall medication cart. The following was observed: One (1) opened aluminum envelope of dorzolamide hydrochloride and timolol maleate ophthalmic solution, usp 2%/0.5% preservative free (a prescription eye drop medication used to treat glaucoma) labeled from the manufacturer to contain 15 single use containers, opened and contained 18 single use containers. The opened envelope had the date ,d+[DATE] written on it but was not labeled with a resident's name. One (1) opened bottle of artificial tears eye drops in its box with the opened date of ,d+[DATE] and no resident identifier or name. Two (2) vials of nitroglycerin (a prescription medication used to treat heart disease and chest pain) without a pharmacy label on the medication vials. At this time, the surveyor interviewed LPN #3, who acknowledged that these medications should have all been labeled with resident names. On [DATE] at 11:19 AM, the surveyor in the presence of the Registered Nurse #1 (RN #1), reviewed the East Wing Front Hall medication cart. The following was observed: Two (2) opened fluticasone propionate and salmeterol 250 micrograms (mcg) /50 mcg inhalation powder inhalers (a medication used to treat lung disease), each one inhaler was dated as being opened on [DATE] with no resident name on the inhaler device, and the second was in its opened box which was labeled as being opened on [DATE] with no opened date and no resident name on the inhaler device. At this point, RN #1 informed the surveyor that the inhalers themselves should be labeled with the date opened as well as resident name. On [DATE] at 12:25 PM, the surveyor, in the presence of Licensed Practical Nurse/Unit Manager #1 (LPN/UM #1) reviewed the North Wing medication storage room and the following was observed: One (1) box of budesonide inhalation susp 1 milligram (mg) /2 milliliter (ml) (a medication used to treat lung disease) containing one opened foil pouch which contained 3 single use vials. The pouch was labeled as being opened ,d+[DATE] with instructions on box from manufacturer to use within two weeks of opening. One (1) box albuterol sulfate inhalation solution 2.5 mg / 3 ml (a medication used to treat lung disease) with one opened foil pouch dated ,d+[DATE] containing two single use vials. LPN/UM #1 informed the surveyor this medication pouch should be only good for seven days after opening. On [DATE] at 12:47 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that all nursing staff are responsible to ensure medication storage are kept in good order, medications are labeled appropriately, and not expired. The DON confirmed that inhalers and other multiuse medication devices should be labeled with resident name and date opened so that they don't get mixed up if separated from the box. A review of the facility's Medication Storage policy with reviewed date ,d+[DATE], included, medications are stored in the containers which they are received. Transfer between containers is performed only by the issuing pharmacy. Drug containers that are soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels, are returned to the pharmacy. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed. A review of the facility's Medication Labeling policy with reviewed date of ,d+[DATE], included contents of one container may not be transferred to another container. N.J.A.C. 8:,d+[DATE].4

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment and medication administration. This deficient practice was identified for 2 of 2 residents (#20 and #52) reviewed for dignity and was evidenced by the following: 1. During the initial tour of the facility on 10/24/23 at 10:45 AM, the surveyor observed Resident #20 seated in the wheelchair in the hallway outside of their room. When interviewed, the resident reported a positive cough last evening. Review of Resident #20's Admission Record revealed that the resident was readmitted to the facility in October of 2023 with diagnosis which included but were not limited to: muscle weakness, difficulty in walking, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort breathing), heart failure, end-stage renal (kidney) disease and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). Review of Resident #20's Quarterly Minimum Data Set (MDS), an assessment tool dated 09/14/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. On 10/26/23 at 11:48 AM, the surveyor observed Resident #20 seated in a wheelchair at the bedside with their lunch tray on the bedside table in front of them. The resident reported a positive cough and stated that they did not feel well and did not feel hungry, but the food was good. The resident lifted the lid that covered their plate which revealed that the resident had only eaten rice and beans and pudding for lunch. At 12:15 PM, the surveyor observed Resident #20 seated in the wheelchair in the hallway outside of their room. The resident was accompanied by Licensed Practical Nurse (LPN) #3 and their attending physician. The physician used a stethoscope and listened to the resident's lung sounds in the hallway with both residents and staff nearby. The surveyor observed that the Director of Nursing (DON) was present in the nurse's station. The surveyor motioned to the DON to view the physician as he assessed the resident's lung sounds in the hallway. The DON approached the physician and told him that he should not have listened to the resident's lung sounds in the hallway. The physician stated that the residents moved around a lot and sometimes it was hard to find them when they were in the dining room. When the surveyor asked the physician if he examined residents in the dining room previously, he stated, I will document that the resident refused to go into their room because he/she wanted to eat in the dining room. The surveyor informed the physician that the resident had already eaten lunch in their room. At that time, the resident was observed seated in the dining area with friends, but was not eating. On 10/27/23 at 9:57 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that Resident #20 was set in their ways. LPN/UM #1 further stated that she assumed that the resident should have been brought back to their room to do whatever needed to be done for privacy. On 10/30/23 at 11:11 AM, the surveyor interviewed the DON who stated that Resident #20 was sometimes difficult, but she would not make excuses and maintained that she had spoken with the physician after the surveyor's observation. The DON stated that if the resident had given the physician a hard time, he should have asked a staff member for assistance. 2. On 10/26/23 at 9:02 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 as she administered four oral medications to Resident #52 in the hallway in plain view of multiple staff members who were nearby. LPN #1 then wheeled the resident back to their room and knocked on the door before she entered. The resident's room mate answered the door and denied the resident access to the room as they were not dressed. LPN #1 then proceeded to administer the resident's eye drops in the hallway in the presence of staff. At 9:23 AM, in a later interview with LPN #1, she stated that she should have administered Resident #52's medications and eye drops in their room to ensure privacy. LPN #1 further stated that she did not think about it at the time. On 10/30/23 at 11:06 AM, the surveyor interviewed the DON who stated that when LPN #1 administered medications and eye drops to Resident #52 in the hallway it was a privacy issue. Review of the facility policy Privacy and Dignity (Reviewed 06/23) revealed the following: Residents have the right to be treated with courtesy, consideration, and respect for the resident's dignity and individuality. Residents have the right to have physical privacy. The resident shall be allowed, for example, to maintain the privacy of his or her body during medical treatment and personal hygiene activities, such as bathing and using the toilet, unless the resident needs assistance for his or her own safety. NJAC 8:39-4.1(a) 12

Based on record review and interview, it was determined that the facility failed to transfer discharged or expired resident's personal needs account (PNA) funds back to the appropriate jurisdiction within 30 days of death or discharge and ensure that the total amount in the PNA account did not exceed the Supplemental Security Income (SSI) resource limit. This deficient practice was identified for 7 of 7 residents reviewed for PNA accounting (Resident #7, #9, #298, #299, #300, #301, and #302). This deficient practice was evidenced by the following: The surveyor reviewed the Clover Meadows Healthcare and Rehabilitation Center Funds Balance Report - Resident Trust Liability (RTL) dated [DATE]. The RTL indicated the following balances: Resident #7 had $3,243.35, Resident #9 had $2,129.42, Resident #298 had $2.912.53, Resident #299 had $2,670.82, Resident #300 had $3,589.39, Resident #301 had $2,302.49, and Resident #302 had $2,729.20. Further review of these resident's medical records indicated that Resident #298 expired on [DATE], Resident #299 was discharged on [DATE], Resident #300 was discharged on [DATE], Resident #301 expired on [DATE], and Resident #302 was discharged on [DATE]. Resident #7 and Resident #9 still resided at the facility. On [DATE] at 11:05 AM, the surveyor interviewed the Director of Social Services (DSS) who informed that she is currently responsible for monitoring the resident's PNA accounts and ensures that the resident's PNA balance does not exceed the SSI limit of $2,000, confirmed that Resident #7 and Resident #9 should not have balances above that amount, and was unaware that they had exceeded that amount. The DSS could not speak to why the other residents still had a balance as they were no longer residing in the facility, and informed the surveyor that the business office is responsible for ensuring the accounts for those residents are handled appropriately. On [DATE] at 11:58 AM, the surveyor interviewed the Accounts Receivable Manager (ARM) in the business office by phone. The ARM stated that when residents are discharged or expire, their remaining balances are released to the appropriate jurisdiction or responsible party and are not kept by the facility. The ARM stated he would have to review these files. On [DATE] at 1:29 PM, the surveyor had a follow up call with the ARM, who acknowledged that these funds were behind and did not get to them as quickly as we should have, and that they should not have been in the fund balance at the facility this long. On [DATE] at 10:29 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged that these funds were overlooked and late in being sent out. Review of the facility's Personal Fund policy with review date ,d+[DATE] included any resident who is receiving benefits under any assistance program that has an asset level limit will be informed by the social worker or designee whenever the personal account balance is within $2,000 of the allowable limit. NJAC 8:,d+[DATE].1 (a) ,d+[DATE]

Complaint # NJ00167863 Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of resident to resident abuse for 2 of 2 residents (Residents #52 and #64) reviewed for resident to resident abuse. This deficient practice was evidenced by the following: The surveyor reviewed Resident #64's electronic health record (EHR) and noted a Behavior Note within the Progress Notes (PN) that was documented on 09/23/23 at 6:38 PM, that was written by the Registered Nurse (RN) and revealed that the resident was observed taking food off of the food cart. Certified Nursing Assistant (CNA) covered the food cart and the resident became argumentative, cursed at another resident and a confrontation occurred with the same resident. No injuries were noted. CNA intervened, removed resident from the area and resident was taken back to his/her room. The RN indicated that both the resident's physician and responsible party were notified and psychiatry was reconsulted. On 10/25/23 at 10:44 AM, the surveyor interviewed CNA #3 who stated that while not assigned to Resident #64 today, she was familiar with the resident. CNA #3 stated that the resident cursed her out and hollered at her when she offered the resident a shower. CNA #3 further stated that awhile ago, she heard a noise and came out of a room and saw Resident #64 who kicked another resident who was seated in a wheelchair. CNA #3 was unable to recall who the resident had kicked. On 10/25/23 at 10:55 AM, the surveyor interviewed CNA #4 who stated that Resident #64 tried to get into the food cart every other day and cussed and swung at staff who tried to redirect the resident away from the food cart. CNA #4 stated that the staff tried to pass out food as fast as they could to ensure that the resident did not access the food cart. CNA #4 further stated that Resident #64 once kicked Resident #52 and the incident was reported. Review of Resident #52's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: dementia, anxiety, difficulty in walking and unspecified sequela (consequence of previous disease or injury) of cerebral infarction (stroke). Review of Resident #52's Quarterly Minimum Data Set (MDS), an assessment tool dated 08/26/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed that the resident required extensive assistance of one person for transfers to the wheelchair. The surveyor reviewed a Nursing Note written by a RN within the Progress Notes (PN) in the EHR dated 09/23/23 at 6:43 PM, which revealed that another resident was observed taking food off of the food cart. CNA covered the food cart and the same resident became argumentative, cursed at this resident and a confrontation occurred with the same resident. CNA intervened and separated both residents. Supervisor assessed resident. No injuries or redness were noted. The RN indicated that the resident's physician and responsible party were notified. Further review of the PN revealed that there was no further documentation written within the PNs until 10/05/23 at 3:37 PM, when a Monthly Nursing Comprehensive Summary was documented. At that time, the resident's skin was described as intact. On 10/25/23 at 12:44 PM, the surveyor observed Resident #52 seated in a wheelchair at the nurse's station. The resident was pleasant, but was confused to situation when interviewed. On 10/27/23 at 9:55 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that when a resident to resident altercation occurred she spoke with the residents involved and made a mitigation plan to prevent recurrence. DSS stated that she had not spoken with Resident #52 because the resident did not recall after three minutes due to their cognitive status and had no recollection and it may have been traumatic for the resident. DSS stated that she had spoken with Resident #64 who denied the incident. DSS stated that the incident may have been over a sandwich. DSS stated that interventions to prevent recurrence would be in the care plan. Review of Resident #52's Care Plan (CP) revealed that there was no entry that corresponded to the resident to resident altercation that was documented within the resident's PN on 09/23/23, until after surveyor inquiry on 10/30/23. Review of the CP entry revealed that the resident was involved in a resident to resident on 09/23/23, in which another resident kicked him/her per statement. The goal indicated that the resident would not be involved in future altercations involving injury. Interventions included: (09/23/23) Resident was immediately separated and assessed for injury with no injuries apparent. (09/24/23) Reassessed for any injuries-none apparent, resident does not recall event. (09/25/23) Resident reassessed by Unit Manager/Director of Nursing (UM/DON) with no injuries or ill effects . On 10/30/23 at 10:50 AM, the surveyor requested and reviewed the investigation that pertained to the resident to resident altercation that occurred on 09/23/23. Review of the Incident/Accident Report that was completed by the RN indicated that Resident became belligerent after CNA covered food tray and started cursing and kicked another resident in the right let. No injury obtained by resident. A statement was obtained from CNA #4 on 09/23/23, who also confirmed that Resident #64 got upset when the cover was pulled down on the food cart and started to yell. Resident #64 backed up and Resident #52 was behind him/her. Resident #64 told Resident #52 to move and called the resident a B word and a whore and kicked him/her on the right side of their leg. Review of the Reportable Event Record/Report dated 09/25/23 at 5:30 PM, revealed that the DON indicated that the following interventions were implemented after the incident/event: Resident #52's leg was reassessed the next day with no injuries, bruising and/or redness noted. The same upon assessment for Monday 09/25/23. The surveyor reviewed both the PN and the Skin Assessments within Resident #52's EHR and did not find documented evidence that Resident #52's right leg was assessed as described. Review of the weekly Skin Assessments indicated that a Weekly Skin Assessment was completed by a Licensed Practical Nurse (LPN ) on 09/27/23, and no skin abnormalities were noted at that time. On 10/30/23 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) who maintained that Resident #52 was assessed for several days with skin assessments and no injury was noted. The DON further stated that she was unsure if it actually happened because there was no bruise. On 10/30/23 at 1:14 PM, in a later interview with the DON, she stated that she did not have skin assessment documentation to validate that Resident #52's lower extremity was assessed daily after the resident was kicked by Resident #64 as previously described and reported to the New Jersey Department of Health. The DON stated that the skin assessments should have been documented within the resident's EHR. Review of the facility policy, Nursing Documentation (Reviewed 06/23) revealed: It is the policy of the facility to document by exception. All documentation confirms that care was provided. It assists in communication to other team members; it also identifies resident's status and clinical findings and interventions. Your responsibility in documentation acts as proof care was provided. All documentation is done in EHR. .Documenting your assessment post event includes interactions and any resulting actions taken to care for the resident. NJAC 8:39-13.4(c)2 i-vi

Complaint #NJ00151166 Based on interviews, medical records review, and review of other pertinent facility documentation on 10/30/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #243) left the facility against medical advice (AMA) and ended up at the hospital. The hospital reached out to the facility when the resident was ready for discharge from the hospital and the facility would not permit Resident #243 to return back to the facility. The deficient practice was identified for Resident #243, 1 of 1 residents reviewed for transfer/discharge and was evidenced by the following: According to the Admission Record, Resident #243 was admitted to the facility with diagnoses which included but were not limited to bell's palsy (weakness of the facial muscles on one side of the face), hypotension (low blood pressure), and essential hypertension (high blood pressure). Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/13/21, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #243 was cognitively intact. On 12/13/2021, Resident #243 was examined by a psychiatrist who determined that the resident was competent to make their own decisions. The Progress Note (PN) revealed the initial incident occurred on 12/14/2021 when Resident #243 left against medical advice (AMA) and presented back to the facility on the same day and was permitted to return to the facility. The urinalysis for Resident #243 came back positive for amphetamines. Another PN written by the Social Worker (SW) dated for 12/15/2021 revealed there was an Interdisciplinary Team (IDT) care conference note which stated the purpose of the meeting with sister, the Power of Attorney (POA) to discuss future sign-outs and inability to potentially readmit moving forward. Zoloft was increased from 50 mg to 100 mg, the POA indicated that Resident #243's judgement was lacking and the SW noted that Resident #243 demonstrated recent inappropriate behaviors due to frustrations and ultimately resulted in Resident #243 signing out of the facility AMA. Care plan interventions included an additional meeting with psychiatrist in order to change medication, increase effective ways in coping with frustrations, and the next review would include following meeting with psychiatrist, medication change, allowing time for it to take effect, and review ability to process frustrations. The timeline received from the facility revealed that the POA was not in agreeance and asked the facility for specific areas of care to be implemented, asked the facility to retrieve the medical records, and asked for Resident #243 to be seen by his/her neurologist and asked that Resident #243 not get discharged without placement since the facility helped Resident #243 get out of their apartment lease so the resident had nowhere else to go and further noted that Resident #243 was not compliant with medications. The PN revealed the second incident occurred on 12/30/2021 when Resident #243 left the facility AMA again and refused to sign the release form. The surveyor reviewed the files and could not find any incident reports for Resident #243. The surveyor requested a copy of the incident reports from the facility for the first incident which occurred on 12/14/2021 which was documented in the progress note by the SW and the second incident which occurred on 12/30/2021 which was documented in the PN by the Case Manager. The facility was unable to provide any incident reports regarding the resident leaving AMA and in addition, was unable to provide notification to the Department of Health. The Case Manager confirmed with the surveyor that she followed up with the hospital and the hospital asked if the facility would take the resident back. The Case Manager stated that after speaking with the Director of Nursing (DON), who is currently the Regional DON (RDON), the Case Manager was advised by the former DON that the facility would not take Resident #243 back to the facility because they could no longer accommodate Resident #243's needs. Review of the Physician's orders did not reveal an order for a discharge and there was no written 30-day notification available to the surveyor that was sent to the POA and/or Resident #243 whom the psychiatrist deemed competent to make their own decisions. The policy updated for 01/2023, titled Discharge/Transfer Out of the Building revealed the objective was to facilitate safe, effective transfer of residents for provision of services not available in this facility. 1. Nursing will notify MD, DON/ADON and Social Services with the request for a transfer. 2. The nurse will document physician orders in PCC. NJAC 8:39 5.1(d)

Based on interview and record review, it was determined that the facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for 2 of 19 residents reviewed for comprehensive assessments (Residents #29 and #143). This deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. The MDS completion date for an annual assessment must be no later than 14 days after the ARD (ARD + 14 calendar days). 1) According to the Face Sheet, Resident #29 was admitted to the facility with diagnoses including but not limited to type 2 diabetes (high blood sugar) and end stage renal (kidney) disease. A review of the most recent Annual Minimum Data Set (MDS), an assessment tool, for Resident #29 revealed an ARD of 9/15/23 with a completion date of 10/16/23. A review of the medical record on 10/24/23 reflected that the annual MDS assessment for Resident #29 had not been completed according to the RAI manual (ARD + 14 days would be 9/29/23). On 10/30/23 during surveyor interview with the Regional MDS Coordinator and facility MDS Coordinator, they stated a comprehensive MDS should be completed within 14 days of the Assessment Reference Date and acknowledged that the annual assessment for Resident #29 was completed late. 38680 2. According to the Face Sheet, Resident #143 was admitted to the facility with diagnoses including but not limited to: acute kidney failure and kidney transplant status. A review of the Minimum Data Set (MDS) Admission Assessment for Resident #143 revealed an ARD of 10/15/23 with a completion date of 10/26/23. A review of the medical record on 10/31/23 reflected that the MDS for Resident #143 had not been completed in accordance with RAI manual. During an interview on 10/31/23 at 10:17 AM, the Registered Nurse/MDS Coordinator (RN/MDS) confirmed the admission assessment had not been completed by 10/24/23 as required. She confirmed that the admission assessment was completed on 10/26/23 two days past due. A review of the facility provided MDS policy reviewed 10/2023 reflected that it is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements. NJAC-11.2(e)

Based on observations, interviews, and review of medical records and other facility documention, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 1 resident reviewed for hospice (Resident #9). This deficient practice was evidenced by the following: During the initial tour of the facility on 10/24/23 at 10:31 AM, the surveyor observed Resdient #9 lying in bed with the bed positioned up against the wall and a fall mat was placed on the left side of the resident's bed. The resident smiled but did not respond when spoken to. Review of Resident #9's Admission Record revealed that the resident was readmitted to the facility in June of 2023, with diagnosis which included age-related osteoporosis with current pathological fracture (bone fracture which occurs without adequate trauma), right femur (bone of the thigh), subsequent encounter for fracture with routine healing, mild intellectual disabilities, and schizophrenia (mental condition). Review of Resident #9's Order Summary Report revealed an order dated 09/21/23, admit to hospice. Further review of the resident's Minimum Data Set (MDS) 3.0 Assessment History, an assessment tool contained within the resident's Electronic Health Record (EHR), revealed that a SCSA was not completed for the resident within 14 calendar days from the residents hospice election as required. Review of an Addendum To Initial Certification contained within the Resident #9's hospice binder revealed that the resident's Date of Initial Certification for hospice services was 09/21/23, with a primary hospice diagnosis of right hip fracture. On 10/23/23 at 10:23 AM, the surveyor observed the Hospice Licensed Practical Nurse (HLPN) at Resident #9's bedside. When interviewed, HLPN confirmed that the resident received hospice services from an outside hospice provider and all of the documentation related to the resident's hospice care was kept current within the resident's hospice binder. On 10/30/23 at 9:52 AM, the surveyor interviewed the MDS Coordinator (MDSC) in the presence of the survey team. The MDSC stated that if a resident elected to go on hospice a Significant Change Assessment was completed. MDSC explained that she was new to the position and did not have a lot of experience with it and relied on nursing to keep her informed. On 10/30/23 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she would have imagined that the MDSC should have completed the SCSA for Resident #9 within the required time frame. The DON further stated that the MDSC was new to the position. On 10/30/23 at 11:25 AM, the Regional MDSC clarified that the SCSA was required to be completed within 14 days of a significant change in resident condition, such as hospice election. On 10/30/23 at 12:51 PM, in a later interview with the MDSC, she stated that a SCSA MDS was not completed for Resident #9 until today after surveyor inquiry. MDSC further stated that there was some confusion as to when the resident went on hospice. Review of the facility policy, Significant Change in MDS Policy (Updated 09/23) revealed the following: Policy: It is the policy and procedure of the facility to ensure that each resident who experiences a significant change in status is comprehensively assessed during he CMS(Centers Medicare/Medicaid Services)-specified Resident Assessment Instrument (RAI) process. .A significant Change in Status MDS is required when: A resident enrolls in a hospice program . Review of the facility policy, MDS Policy (Reviewed 10/23) revealed the following: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements. Purpose: .To provide information on the resident's condition. To facilitate development of a comprehensive care plan. To ensure care delivery that enhances the resident's quality of life. To help achieve the highest and practical level of self sufficiency. Procedure: .Assures the completeness and accuracy of the information in the MDS . NJAC 8:39-11.2(i)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 19 residents reviewed (Resident #40 and #56). This deficient practice was evidenced by the following: 1.On 10/24/23 at 12:21 PM, the surveyor observed Resident #40 in the room sitting on the bedside. Resident #40 stated he/she had been at the facility for five years and had no concerns. Resident #40 told the surveyor they were pleased that they could smoke at the facility. Resident # 40 was admitted to the facility in 2019. Medical diagnoses included but were not limited to acute kidney failure, alcohol dependence, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of the annual Minimum Data Set (MDS), an assessment tool, dated 08/03/23 indicated that the resident had a Brief Interview of Mental Status score of 14, meaning the resident was cognitively intact. On 10/24/23 the surveyor reviewed Resident #40 care plan which showed the focus of the resident being a smoker. The care plan was initiated on 12/17/19. On 10/27/23 at 11:50 AM, the surveyor reviewed Resident #40 MDS list. The resident's entry MDS dated [DATE] section J, titled health conditions was marked no for tobacco use. Review of the annual MDS dated [DATE], 08/13/22, and 08/13/23 section J was marked no for tobacco use. On 11/01//23 at 11:15 AM, the surveyor reviewed the resident smoking Safety Evaluation. The evaluation had an effective date of 08/28/2019 and indicated at that time the resident was an independent smoker and did not require assistance. 2.On 10/24/23 at 10:33 AM, during the initial tour of the facility the surveyor observed Resident #56 was out of bed in a wheelchair. The resident told the surveyor they were going outside to Take care of things. The surveyor asked if the resident was a smoker and they replied, yes. Review of the Admission Record revealed that Resident #56 was admitted to the facility in 2020. Medical diagnoses included but were not limited to diabetes (high blood sugar), anemia, alcohol abuse, and tobacco abuse. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 06/21/23 indicated the resident had a Brief Interview of Mental Status score of 15, meaning the resident was cognitively intact. On 10/25/23 at 01:21 PM, the surveyor reviewed Resident #56 care plan which showed a focus that the resident had a potential alteration in safety related to smoking. The care plan was initiated on 8/19/2021. On 10/25/23 at 01:51 PM, the surveyor reviewed Resident #56 entry MDS dated [DATE], section J titled Health Conditions was marked no for tobacco use. The surveyor then reviewed the annual MDS dated [DATE], 06/20/22, and 06/21/23. All three annual MDS were marked as no for tobacco use under section J. On 10/26/23 at 12:10 PM, the surveyor reviewed Resident #56 smoking assessment dated [DATE] which revealed the resident was an independent smoker and did not need assistance. On 10/30/23 at 09:52 AM, the surveyor interviewed the MDS Coordinator (MDSC) regarding Resident #40 and Resident #56 MDS. The surveyor asked the MDSC how new admission smokers were communicated to her department. The MDSC stated that nursing, activities, and the MDS department all do resident assessments. The surveyor then asked who was responsible for section J of the MDS which included tobacco use and she said, Section J is done by MDS department, that could have been an oversight. On 11/01/23 at 12:20 PM, the surveyor reviewed the MDS policy with a revision date of 10/2023. Under the procedure section, number three stated that the facility assures the completeness and accuracy of the information in the MDS. NJAC 8:39-11.1

Based on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASARRs (Resident #56) and was evidenced by the following: On 10/24/23 at 10:33 AM, during the initial tour of the facility the resident was out of bed in a wheelchair. The resident told the surveyor they were going outside to Take care of things. The surveyor asked if the resident was a smoker and Resident #56 replied, Yes. On 10/24/23 at 12:18 PM, during resident record review the surveyor reviewed Resident #56 Pre-admission Screening and Resident Review (PASARR) one which was completed prior to admission to the facility on [DATE]. Under the section of Mental Illness screening, it was marked no, meaning the resident did not have a diagnosis or evidence of a major mental illness. Review of the Admission Record revealed that Resident #56 was admitted to the facility in 2020. Medical diagnoses included but were not limited to diabetes (high blood sugar), anemia, alcohol abuse, and tobacco abuse. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 06/21/23 indicated the resident had a Brief Interview of Mental Status score of 15, meaning the resident was cognitively intact. The surveyor then reviewed Resident #56 entry MDS dated [DATE] section I, titled active diagnoses. The section for the diagnosis of schizophrenia was marked no, review of the annual MDS dated [DATE] was marked no for schizophrenia. The surveyor then reviewed the annual MDS dated [DATE] which was marked as yes for a diagnosis of schizophrenia. On 10/25/23 at12:03 PM, the surveyor requested to view the residents PASARR two. The facility provided surveyor with the PASARR one. Review of the PASARR one indicated that Resident #56, on admission to the facility on [DATE], did not have a diagnosis of or evidence of a major mental illness limited to the following disorders: schizophrenia, schizoaffective, mood, panic, anxiety, or another mental disorder that may lead to chronic disability. On 10/27/23 at 10:50 AM, the surveyor interviewed the Director of Social Services (DSS) who had been with the facility since 05/2021 regarding PASARRs. The DDS said, new admissions come in with a PASARR one and if not, I will complete one. The surveyor then asked the process if a resident had a new diagnosis after admission to the facility. The DDS told the surveyor, I would complete a new PASARR one in that event and if positive I would alert mental health, I access all diagnoses on the residents face sheets. The surveyor asked the DDS how she would be alerted to a new psychiatric diagnosis on an admitted resident, and she stated that she would be told in the morning meeting. The DDS could not speak to why a new PASARR one was not completed again at the time of Resident #56 new diagnosis. On 11/01/2023 at 10:10 AM, the surveyor reviewed the policy titled PASRR with a revised date of 06/2023. Number five, under the procedure section of the policy read that if a resident is admitted and the team identifies a PASRR needs revision a new PASRR will be initiated. NJAC 8:39-27.1 (a)

NJ Complaint #NJ00165907 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure that the job description of a Certified Nursing Assistant (CNA) was followed by allowing the cutting of a residents hair. This was indentified in 1 of 1 resident reviewed (Resident #40) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/24/23 at 12:21 PM, the surveyor observed Resident #40 in the room. The resident voiced no concerns to the surveyor during the interview. On 10/25/23 at 10:05 AM, the surveyor reviewed a complaint filed by Resident #40 regarding a Certified Nursing Assistant (CNA) cutting of the resident's hair. Resident # 40 was admitted to the facility in 2019. Medical diagnoses included but were not limited to acute kidney failure, alcohol dependence, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of the annual Minimum Data Set (MDS) an assessment tool dated 08/03/23 indicated that the resident had a Brief Interview of Mental Status score of 14, meaning the resident was cognitively intact. On 10/25/23 at 10:46 AM, the surveyor, with the resident's permission entered Resident #40's room. The surveyor asked the resident if he/she ever had an issue with the CNA's cutting his/her hair. The resident told the surveyor, I was in a different room and two girls came in and they pushed me on the bed and held my head and they cut the back of my hair off. The one who cut my hair was moved to the other side of facility and the other girl was agency and she was fired. The surveyor asked the resident how much hair was cut off and the resident said, About a foot and a half, pointing to the back of the head. The surveyor observed that the resident had hair in a folded ponytail held by a rubber band. On 10/25/23 at 11:10 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2) regarding the resident's hair. The LPN/UM #2 said the resident never showered, and one day she/he agreed with two CNAs to be given a shower and they talked about his/her hair. LPN/UM #2 said the ponytail went to the resident's buttocks and was dirty and matted. Resident #40 agreed, according to the CNAs to get hair washed and the ponytail cut off while in the shower. When they all (two CNAs and the resident) came out of the shower and after the ponytail was cut off by the CNAs the resident stated that he/she did not want the haircut. On 10/25/23 at 11:30 AM, the surveyor reviewed the Certified Nurse Aide Job Description. Under accountabilities the job description indicated that the CNA bathes the resident in the bed, tub or shower, combs hair, cleans fingernails and gives shampoos. Cutting a resident's hair was not a part of a Certified Nurses Aides Job description. On 10/25/23 at 01:27 PM, the surveyor interviewed CNA #2, who was caring for the resident on that day. The surveyor asked CNA #2 what was including in the job description, and she told the surveyor, Teeth, hair, (wash hair, comb hair, cut hair, dye hair), and basic hygiene). CNA #2 told the surveyor the resident agreed to hair being trimmed because it was all stuck together. The surveyor then asked CNA#2 if she normally cuts hair and she stated, Yes, I paint nails, cut hair, and dye hair. The surveyor asked CNA#2 if she was trained on hair cutting and she responded, No I thought it was part of my job description. I always ask the family first, but now we are no longer able to cut hair. I don't know why he didn't go to the hair salon. On 10/25/23 at 1:40 PM, the surveyor interviewed the Director of Nursing (DON) regarding staff education and who was responsible. The DON told the surveyor that it was a shared responsibility of herself, the Assistant Director of Nursing (ADON), the Unit Managers, and Administration. On 10/27/23 at 10:07 AM, the surveyor interviewed LPN/UM #1 regarding CNA job responsibilities. The LPN/UM #1 said the CNAs do activities of daily living, morning care, render oral hygiene, dressing, linens, beds, hydration and are the eyes and ears to the nursing staff. The surveyor asked LPN/UM #1 to define morning care and she said, hair brushing, dressing, showers, and shampoo their hair. The surveyor asked the LPN/UM #1 if CNAs can cut a resident's hair and she replied, I am not aware of the policy here, if the resident were to ask. I have never witnessed hair cutting. I would ask the ADON or the DON. I would suggest the beautician at the facility to the resident. On 10/27/23 at 10:20 AM, the surveyor interviewed the ADON regarding a CNA job description. The ADON said, The CNAs do washing and grooming of the whole body, shampoo hair on shower days, brush hair, and get the residents dressed and out of bed. The surveyor asked the ADON if a CNA can cut a resident's hair and the ADON responded, No, no that's why we have a hairdresser come in. NJAC 8:39-27.1 (a)

Based on observations, interviews, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to properly assess and monitor a resident that was previously identified as a high risk for falls after a fall occurred in accordance with professional standards and the facility policy for 1 of 1 resident (Resident #9) reviewed for falls. 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 state: 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. During the initial tour of the facility on 10/24/23 at 10:31 AM, the surveyor observed Resident #9 lying in bed with the bed positioned up against the wall and a fall mat was placed on the left side of the resident's bed. The resident smiled when spoken to but did not speak when spoken to. On 10/25/23 at 10:23 AM, the surveyor observed the Hospice Licensed Practical Nurse (HLPN) #1 at Resident #9's bedside. When interviewed, HLPN #1 stated that the resident had fallen at the facility which resulted in a right shoulder fracture. HLPN #1 explained that the resident was deemed not to be a surgical candidate and was admitted to hospice services with uncontrolled pain. HLPN #1 was unable to state when the fall occurred. The surveyor reviewed an Initial Certification to Hospice form that was noted within the resident's hospice binder which indicated that the resident was admitted to hospice services in September of 2023 with a primary diagnosis of right hip fracture. On 10/25/23 at 12:34 PM, the surveyor interviewed CNA #2 who stated that she worked at the facility for seven years. CNA #2 stated that Resident #9 was dependent for all aspects of care and required assistance to turn and reposition for a couple of years now. CNA #2 stated that the resident and was unable to roll or attempt to get out of bed and required a mechanical lift for transfers. CNA #2 further stated that she was not at the facility when the resident had fallen and did not know how the fall occurred. Review of Resident #9's Admission Record (an admission summary) revealed that the resident was readmitted to the facility in June of 2023 with diagnosis which included age-related osteoporosis (deterioration in bone mass with increasing risk to fragility fractures) with current pathological fracture (bone fracture that occurs without adequate trauma and is caused by a preexistent pathological bone lesion), right femur (the thigh bone), subsequent encounter for fracture with routine healing, mild intellectual disabilities, and schizophrenia (mental disorder). Review of Resident #9's Annual Minimum Data Set (MDS), an assessment tool dated 09/07/23, revealed that the resident's Brief Interview for Mental Status (BIMS) score was unable to be completed as the resident was rarely/never understood. Further review of the assessment revealed that the resident required extensive assistance of two persons for bed mobility and transfers and required supervision of one person for locomotion (how resident moves between locations) on the unit. Review of Section I of the MDS revealed active diagnosis which included but was not limited to: dislocation of the unspecified parts of the right shoulder girdle. Review of Section J of the MDS revealed that the resident had not had any falls since admission /entry or reentry or the prior assessment. The surveyor then reviewed Resident #9's Quarterly MDS Assessment, dated 06/08/23, under Section J which revealed that the resident had a fall within the last month which did not result in fracture. Review of Resident #9's Fall Risk Assessment effective 03/19/23, revealed that Resident #9 had a score of 20 on the assessment which indicated that the resident was a high risk for falls and a second Fall Risk assessment dated [DATE], had a score of 18 which indicted that the resident as a high risk for falls. Review of Resident #9's Progress Notes (PN) revealed an entry dated 05/10/23 at 10:29 PM written by Licensed Practical Nurse (LPN) #4, indicated that LPN #4 was notified by the Certified Nursing Assistant (CNA) that Resident #9 had an unwitnessed fall and fell out of their wheelchair at the base of the door. LPN #4 documented that he assessed the resident for any visible injuries and there were none as the resident did not verbalize or gesture to indicate the presence of pain. LPN #4 documented that both he and the CNA assisted the resident back into their chair and two CNAs then used a mechanical lift to assist the resident into bed for further full head to toe assessment. LPN #4 documented that both the MD (Medical Doctor) and family were contacted with no response. There was no documented evidence within the resident's medical record to indicate that the resident was assessed by a Registered Nurse (RN) immediately post-fall prior to transfer back into the chair or bed for the presence of injuries. Further review of the PNs revealed that the next PN was a Behavior Note, was written on 05/11/23 at 3:58 PM, by a RN which failed to contain documentation to indicate that post-fall monitoring was in place. The RN documented that the resident was awake, alert and oriented x 2-3 (self, place, time) with screaming behavior noted. A second Behavior Note dated 05/11/23 at 9:53 PM, was written by an LPN and indicated that it was shift 4/9 post fall, and no visible injuries were noted, and the resident was medicated for pain as ordered. There was no documented evidence within the PNs that were reviwed in the twenty-four hour period that followed the resident's fall to indicate that the resident's neurological status was assessed post-fall with neurological checks (looks at how appropriately the resident responds in three key areas, eye opening, verbal and motor skills) to rule out head trauma for an unwitnessed fall and post-fall notes for shifts 2/9 and 3/9 were not found. Review of the Resident #9's Care Plan (CP) revealed an entry that was initiated on 02/03/21 and revised on 10/30/23, which revealed that the resident had potential for falls related to poor safety awareness, impulsivity, vision problems, bilateral conductive hearing loss, and gait/balance problems. Further review of the CP revealed an entry dated 01/26/23 and revised 03/20/23, which revealed that the resident slid off the bed intentionally, witnessed by nurse. Staff will assist him/her out of bed during the morning rounds into his/her wheelchair. The goal was revised on 06/18/23 by the former Unit Manager, for the resident to be free from injuries related to fall accidents through the next review date. Review of Interventions included an entry dated 08/19/21, Staff to check on Resident #9 frequently and offer him/her to go back to bed around mealtimes. On 05/10/23, an intervention was added to the CP which indicated that prior to the end of 7-3 pm shift assess for any immediate needs such as: hunger, toileting, pain etc. and assist with the same. Review of Resident #9's Order Summary Report (OSR) revealed an order dated 07/15/23, for floor mat to left side of bed every hour of sleep at bedtime for preventative measures. Further review of the OSR revealed that the resident was admitted to hospice on 09/21/23. On 10/26/23 at 1:20 PM, the surveyor phoned LPN #4 who identified as an agency nurse via speaker phone in the presence of the survey team with his permission. LPN #4 denied any recollection of Resident #9's fall. LPN #4 stated that as an LPN, he was permitted under his scope of nursing practice to assess residents' post-fall. When the surveyor asked what a post-fall assessment entailed, LPN #4 stated that he was busy, and it was not a good time to talk. LPN #4 failed to provide the surveyor with a more convenient time to be interviewed when offered. On 10/27/23 at 9:50 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that she began working at the facility on 10/12/23. LPN/UM #1 stated that when a resident fell the nurse was required to perform an assessment and complete an incident report. LPN/UM #1 stated that while she was unsure of what the facility policy indicated, under the scope of practice of an LPN an RN was required to perform a resident assessment post-fall. On 10/30/23 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #9 was admitted to hospice due to natural progression, there was no fall. The DON stated that the resident's fall that occurred on 05/10/23 was addressed with an x-ray company who stated that the fracture was more acute. The DON stated that she probably documented the conversation that she had with the radiologist (a doctor who specialized in radiology and used x-rays) somewhere. The DON stated that technically, an LPN could not perform a resident assessment under their scope of practice. The DON stated that the Registered Nurse Unit Manager who was here the next day would have assessed the resident. The DON further stated that there also would have been a supervisor here as well. The surveyor informed the DON that there was no documented evidence contained within the resident's medical record to indicate that the resident was immediately assessed by an RN after the fall that was sustained on 05/10/23, nor was there documented evidence that neurological checks were performed to rule out head trauma. The DON agreed to provide the surveyor with all investigations related to Resident #9. The surveyor reviewed an Incident/Accident Report (I/AR) dated 05/10/23 at 3:45 PM, that was initiated by LPN #4 which indicated that Resident #9 slid out of their wheelchair during an unwitnessed fall. No injury occurred. Resident able to move all extremities without difficulty. No internal or external injury and rotation noted. Denies pain or discomfort, neuro checks in progress. Further review of the I/AR revealed that the physician was notified at 4:30 PM and the resident's responsible party was notified at 7:30 PM. The surveyor reviewed an Investigation of Incident/Accident Statement dated 05/10/23 that was written by a CNA, which indicated that Resident #9 was up in the wheelchair after she changed the resident around 2:30 PM. The CNA documented that when she left at the end of her shift the resident was in the chair in the day room. There were no further statements attached to the investigation other than the CNA's and LPN #4's. There was no neurological check sheet attached to the investigation or contained within the resident's medical record to demonstrate that neurological checks were performed for a 24-hour period post-fall. On 10/30/23 at 1:14 PM, the DON presented the surveyor with an X-ray report dated 05/30/23, which had a note written at the bottom of it which she stated proved that Resident #9's fall on 5/10/23, had nothing to do with the resident's diagnosis of femoral fracture as it was an acute injury. The hand written entry dated 05/10/23, revealed No injury, stated this was an acute occurrence. The DON stated that the interview should have been documented within the resident's medical record but was not. The DON further stated that she received a statement today from the RN Charge Nurse (RN/CN) who worked on 05/10/23, who stated that LPN #4 did not let the supervisor know about the resident's fall until a few hours later and she assessed the resident at that time. The DON stated that the RN/CN also should have documented the resident assessment in the resident's medical record and the RN Unit Manager should have also documented that she assessed the resident the following day. There was no documented evidence within the resident's medical record to confirm that the resident was assessed by a RN as described by the DON. On 10/30/23 at 3:57 PM, the surveyor attempted to phone the RN/CN for clarification, but was unable to reach her. On 10/30/23 at 8:15 PM, the surveyor interviewed the Radiologist who stated that on 05/30/23, the facility requested that he read Resident #9's x-ray and his impression was an unhealed recent longitudinal fracture (fracture extends along length of bone) extending from the medial femoral metaphyseal cortex (neck portion of long bone) to the intercondylar notch (a groove at the distal end of the femur) and recommended that the facility correlate the impression with a trauma history. The Radiologist explained that in the elderly with severe osteoporosis you do not know the exact time frame of the injury. The Radiologist further stated that the injury was recent and unhealed up to one month and the fracture could have been up to a month old. On 10/31/23 at 8:49 AM, the surveyor interviewed the DON who stated that perhaps she did not speak with the same Radiologist as the surveyor, though the DON provided the surveyor with the Radiologists contact information. The DON further stated that LPN #4 should have immediately called for the RN Supervisor to assess Resident #9 for injury and prevent further injury, as she was not called to assess the resident until after the resident had already been placed back in bed. When the surveyor asked how the RN Supervisor assessment and post-fall neurological checks could be verified? The DON stated that if it was not documented, then it was not done. On 10/31/23 at 10:24 AM, the surveyor interviewed the Speech Language Pathologist/Director of Rehabilitation (SLP/DOR) who stated that Resident #9 was seen by Occupational Therapy on 05/11/23 and an assessment was done to look at positioning after the resident fell from the wheelchair. The SLP/DOR reviewed the therapy notes in the presence of the surveyor and stated that the resident did not exhibit any pain during the assessment. The SLP/DOR explained that pain was assessed through nonverbal methods such as gestures and grimacing and there was nothing. The SLP/DOR stated that the resident was very loud, so she would have imagined there would have been yelling if the resident had pain. The SLP/DOR explained that the resident self-propelled backward in their wheelchair and used their feet to do so at the time of the assessment. The SLP/DOR further stated that whenever the resident was up in the wheelchair it was in the dayroom in a supervised area with a back cushion in place for fall prevention. On 10/31/23 at 10:53 AM in a later interview with the DON, she stated that a three-day post fall documentation was required to be documented within Resident #9's electronic health record every shift for three days. The surveyor conveyed that the documentation contained within the resident's medical record did not reflect that the documentation was completed as described. The DON stated, It is not there? The DON stated that the neurological checks were documented on the 24-hour report. The DON provided the surveyor with the 24-hour report dated 05/10/23, which revealed the following: Resident #9 fell at 3:45 PM. MD notified; Family contacted with no answer. Follow up. Neuro checks. There was no documented evidence contained within the resident's medical record to suggest that the recommendation for neurological assessment checks and follow-up with the resident's responsible party or physician was completed. On 10/31/23 at 12:03 PM, the DON stated that she did not find a neurological check sheet within the investigation or within Resident #9's medical record. The DON further stated that the purpose of the neurological checks was to rule out a brain bleed or injury after a fall. Review of the facility policy, Incident/Accident Reporting Policy And Procedure (Reviewed 03/2023) revealed the following: It is the policy of this facility to provide a system whereby residents' incidents/accidents are reported, their causes identified when possible, and timely interventions are established to reduce the probability of repeated incidents. Procedure: It is the responsibility of the Lisenses [Sic.] Nurse who first witnessed the incident/accident to initiate and complete the Incident/Accident Report in its entirety utilizing input form the staff present at the time of the incident/accident. The Nurse assesses the residents' condition, renders appropriate treatment, i.e., first aid or calls the Physician who orders specific treatment or decides if the resident is to be transferred to the emergency room . The nurse also informs the responsible party immediately of any injury that may require residents to be transferred from the facility. In case of a fall, a Fall Risk Assessment and a Post Fall Inspection Tool is completed. In case of an actual or suspected neurological involvement, a 24-hour Neurological Assessment is completed. .A 3-day post fall monitoring and documentation will be done by all shift nurses assigned to residents who sustained a fall. A 3-day post incident monitoring and documentation will be done by all shift nurses for residents with a reported incident or injury of unknown etiology. Review of the facility policy, Nursing Documentation (Reviewed 06/23) revealed the following: It is the policy of this facility to document by exception. All documentation confirms that care was provided. It assists in communication to other team members; It also identifies resident's status and clinical findings and interventions. Your responsibility acts as proof care was provided . Gather information and prepare to chart, it is your responsibility as the professional or long term care staff member to document what you found, what you did or did not do for the resident. .Proper nursing documentation provides evidence that the nurse has acted as required or ordered. .Document all Events including falls, skin tears, any skin abnormalities etc.tell the whole story, be concise, stay limited to the facts. Review of the facility policy, Injury of Unknown Origin Policy and Procedure (Revised 04/23) revealed the following: .A 3-day post fall monitoring and documentation will be done by all shift nurses assigned to residents who sustained a fall . Review of the facility Position Summary (Job Description) for Position Title, Licensed Practical Nurse revealed the following: In conjunction with the RN/Unit Director, the Licensed Practical Nurse utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of individualized nursing care plans to ensure that the needs of residents are met. He/she assists in the orientation of and supervision of nursing personnel, attends to the daily operations of the unit per shift, unit level, and assumes responsibilities of a leadership role. Responsibilities/Accountabilities: .Communicates pertinent data to charge nurse, superior and/or physician; Review of the facility Position Summary (Job Description) for Position Title, Registered Nurse revealed the following: Takes an active role in direct resident assessment and care; .Assesses each resident daily and implements a change in the course of action as needed; .Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process; NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to properly document the correct amount of Oxygen administered in the progress notes. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for respiratory care, and was evidenced by the following: On 10/26/23 at 11:50 AM, the surveyor observed Resident #2 receiving Oxygen via nasal cannula with a setting of 2 liters/minute. A review of the face sheet revealed that Resident #2 was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease ( a respiratory disease), and congestive heart failure (a disease where the heart does not pump blood as well as it should), and pneumonia (an infection of the lungs) with a history of home Oxygen use. The Admission Minimum Data Set, an assessment tool, dated 9/19/23 indicates a Brief Interview of Mental Status score of 5 (indicating severe cognitive impairment) and utilized oxygen both while a resident and while not a resident (prior to admission to facility). The physician orders included an order for Oxygen via nasal cannula with at 2 liters/minute dated 9/13/23 and review of Medication Administration Records (MARs) for September 2023 and October 2023, indicated Oxygen via nasal cannula at 2 liters/minute was administered on each day. A review of the progress notes with dates of 9/13/23, 9/16/23, 9/18/23, 9/26/23, 10/14/23, 10/15/23, 10/17/23, and 10/18/23 indicated that Resident #2 received Oxygen via nasal cannula at 3 liters/minute. On 10/27/23 at 06:55 PM, the surveyor interviewed Licensed Practical Nurse # 2 (LPN #2) via telphone, who wrote the progress notes indicating Resident #2 received Oxygen via nasal cannula at 3 liters/minute. She stated that she believed Resident #2 utilized 3 liters/minute of Oxygen at one point. She also stated that the notes with Oxygen via nasal cannula at 3 liters were written in error. On 10/30/23 at 10:31 AM, the surveyor interviewed the Director of Nursing, who stated that if the order is for Oxygen at 2 liters/minute and the MAR is signed for 2 liters/minute, then the progress notes should state 2 liters / minute. A review of the facility provided policy titled Nursing Documentation revised 6/23, indicated proper nursing documentation provides evidence that the nurse has acted as required or ordered. and use accurate information. NJAC-29.2 (d)

A.) Based on observation, interview and medical record review, it was determined that the facility failed to consistently and properly store and secure hazardous materials and/or sharps containers which contained used syringes in a safe manner, resulting in an Immediate Jeopardy situation for the safety of cognitively impaired residents residening on the North Unit (referred to but not reviewed) and for residents with known wandering behaviors (Resident #10, #11 and #12). The Immediate Jeopardy was identified on 5/7/13 at 10:30 a.m., and the immediacy was abated on 5/7/13 at 3:04 p.m., upon receipt of an acceptable plan of correction which included removal of the hazardous materials from the identified areas. The deficient practice was evidenced by the following: 1. On 5/7/13 at 10:30 a.m. surveyors were conducting a tour on the North Unit and entered an unlocked soiled utility room. The surveyors observed three filled syringe (sharps) containers on top of a bio-hazardous bin located on the floor, an aerosol can of wax remover and one rusty, approximately three inch spackle knife on top of a shelf. The surveyors observed staff going in and out of the unlocked room. At 10:50 a.m. the surveyors interviewed the Maintenance Director (MD) regarding the open Janitors Closet. The MD stated that staff was supposed to keep the closet locked. The surveyors at that time showed the MD the sharps containers and the other items contained in the soiled utility room. The MD revealed the soiled utility room had always been unlocked and there was no key for the door. The MD stated he will make sure they get a lock as as soon as possible. At 11:50 a.m. the surveyors again observed the soiled utility room which was open and the aforementioned items remained unsecured.(Refer to #1) At 12:20 p.m. the surveyors again observed the soiled utility room open. The 3 sharps containers had been removed, however, the biohazardous waste bin, the aerosol can of wax remover and the rusty spackle knife remained and were removed by the MD at that time. At 10:40 a.m. the tour continued to the unlocked Janitors Closet on the same unit, where the surveyors observed multiple hazardous cleaning materials which included; one and a half gallons of "Mauve" a liquid antibacterial hand soap, one "highly flammable" aerosol can of "Dust Up", one gallon of odor eliminator, a can of furniture polish, and one gallon of "Green"" restroom cleaner. The Material Safety Data Sheets (MSDS) indicated the following precautions; a.) For the "Green" restroom cleaner: ( if ingested, Harmful; can be irritating to the mouth, throat and gastrointestinal system, causing a burning taste and difficulty breathing. Do not induce vomiting. Drink large quantities of water. Seek medical attention immediately. If inhaled; get to fresh air and seek medical attention immediately.) b.) For the furniture polish; (contents are highly flammable, if ingested contact a physician or poison control center. For inhalation, if symptoms develop move victim to fresh air and seek medical attention, if symptoms persist.) c.) For "Mauve" antibacterial soap; (may cause redness and swelling of eyes, if ingested may be irritating to the mouth, throat and gastrointestinal system and seek medical attention if irritation persists.) d.) For "Dust-Up" an aerosol product; (the product is flammable, routes of exposure indicated eye contact, inhalation, skin contact and ingestion. Contact with eyes may cause irritation. Inhaling the product may be harmful or fatal. If ingested may cause delayed lung damage.) During an interview on 5/8/13 at 9:30 a.m. and 9:39 a.m. respectively, two Certified Nursing Assistant (CNA) revealed that two ambulatory residents (Residents #10 and #12) wandered and resided on the North Unit. The CNA's further revealed Resident #11 ambulated independently, resided on East Unit and wandered daily to the North Unit. The three identified residents who wandered had the potential to enter the Janitors Closet and soiled utility room where the hazardous items were improperly stored. This was evidenced by the following: 1. On 5/7/13 at 10:00 a.m. during the initial tour, the surveyor observed Resident #10 ambulating independently in the hallway. The resident was very confused and did not respond to the surveyor. On 5/8/13 at 8:30 a.m. the surveyor observed Resident #10 in bed and a Wanderguard was noted on the left wrist. At 12:40 p.m. the surveyor noted the resident with a coat on, wearing purse and ambulating independently out of the resident's room. On 5/8/13 at 12:45 p.m. the surveyor reviewed the medical record for Resident #10. According to the Accumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 4/8/13 indicated the resident had a severe cognitive impairment and independently ambulated. A review of Resident #10's Care Plan dated 1/2012, revealed the resident was an elopement risk due to dementia. 2. On 5/7/13 at 9:10 a.m. Resident #12 was observed seated at table in a chair in the Main Dining room. During a tour on 5/7/13 at 9:30 a.m., the Registered Nurse (RN) stated that Resident #12 ambulated independently and was confused. On 5/8/13 at 9:15 a.m. the surveyor reviewed the medical record for Resident #12. According to the Care Plan Resident #12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 4/7/13 did not reflect the resident's cognition. The surveyor interviewed the MDS Coordinator regarding the cognition of Resident #12. The MDS Coordinator stated the resident refused to answer the questions related to cognition on the MDS and that the resident was confused. A review of Resident #12's Care Plan dated 3/2013, identified the resident as an elopement risk and the resident had a Wanderguard. 3. During a tour of the East Unit accompanied by the Licensed Practical Nurse (LPN) at 9:30 a.m., the LPN stated Resident #11 had a [DIAGNOSES REDACTED]. On 5/8/13 at 10:30 a.m. the surveyor reviewed the medical record for Resident #11. According to the Accumulative [DIAGNOSES REDACTED]. A review of Resident #11's Interdiciplinary Progress Notes (IPN) dated 3/22/13 at 3:00 p.m., reflected the resident was ambulatory and confused, looking to go home. Sits for minutes only. A subsequent IPN dated 3/26/13 at 3:20 p.m. reflected the resident was pacing back and forth in the building and was difficult to redirect. A review of Resident #11's Care Plan dated 3/2013 indicated the resident was a "Flight Risk" and used a Wanderguard. When the Administrator was interviewed by the surveyor on 5/7/13 at 1:25 p.m., he stated the facility had stored the sharps containers in that area for years, since he has had the building. The Administrator further stated "the sharps should not be stored there." He revealed on the East Unit the full sharps containers are stored in the locked medication room and "doesn't have room in the North medication room to store the full sharps containers." A review of the facility's policy "Sharps Container Storage and Disposal dated 3/10, indicated; (when moving sharps container from area of use; terminal disposition of the full sharps container will be responsibility of the Environmental Services Department Manager/Director or designee and disposal will be made on a routine basis.) There was no documented evidence this policy was consistently followed. The immediacy of the hazardous materials was corrected on 5/7/13 at 3:04 p.m. based on an acceptable plan of correction which included the following: 1. Hazardous materials, the full sharps containers and rusty spackle knife were removed from the identified areas and the areas secured. All other similar areas including the Janitor's closet were inspected for the same issues and ensured they were closed and secure. 2. In-services were conducted for housekeeping and all facility staff on the hazards of these materials and proper storage of medical waste/sharps dispensers. The sharps containers will now be stored in the Janitors closet and will be secured. 3. The Administrator will do daily inspections of the areas of the soiled utility rooms and Janitor's closet to ensure they are free of hazardous materials and secured. Appropriate actions will be taken for staff non-compliance including counseling and disciplinary action. NJAC 8:39-27.1 (a) While the Immediate Jeopardy was abated for Resident #10, #11 and #12 and for other confused residents, this deficient practice continued at F323 at a lower scope and severity of (E) level and was evidenced as follows: B.) Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to implement identified safety interventions to a.) address falls for 1 of 6 residents reviewed (Resident #2), b.) implement identified safety interventions to prevent bruises for 2 of 2 residents reviewed (Resident #8 and # 18), and c.) maintain a safe resident environment. These deficient practices were evidenced by: 1. The surveyor, in the presence of the registered nurse (RN), observed Resident #2 on 5/7/13 at 9:15 a.m. seated in a recliner chair in the unit day room. The RN told the surveyor the resident was cognitively impaired and had a history of [REDACTED]. The surveyor reviewed the medical record, care plan, and three fall investigations on 5/13/13. The resident's 7/14/12 annual MDS and 4/16/13 quarterly MDS assessed the resident with severe cognitive impairment, total dependence upon staff for bed mobility and transfer, and was non-ambulatory. The resident's current (4/2012) fall/safety risk care plan indicated concerns of ambulatory dysfunction, debilitation, and decreased mental reasoning related to safety. Undated care plan interventions while the resident was in bed included; a low bed with half side rails placed against the wall with a tab alarm and a crash mat on the floor. Undated care plan interventions while the resident was out of bed included the use of a wheelchair with a self releasing seat belt, a tab alarm, and an abductor pillow. Fall investigations provided by the facility on 5/13/13 detailed three falls: 6/12/12, 7/2/12, and 2/28/13 and revelaed the following: On 6/12/12 at 7 a.m. the resident was observed by the CNA on the floor near the bed siderail. The CNA stated she was on the way to another resident when she walked past Resident #2's room and saw her on the floor. The report indicated a bed alarm was not used. On 7/2/12 at 12:30 p.m. the resident was seated in the day room in preparation for lunch in a gerichair with an alarm in place. The nurse documented in the investigational report Resident #2 fell on her face from the gerichair. Sustained left eye lacerations and complained of a headache and slight pain. The resident was transported to the hospital. On 2/28/13 at 5 a.m. the resident was found by staff on the floor next to the bed. The nurse documented in the investigational report an alarm was used and it was working. However, the nurse said the staff was alerted to the resident's room when the resident called out for help. The resident sustained [REDACTED]. The resident was transported to the hospital. The surveyor spoke with the DON on 5/14/13 at 1 p.m. requesting additional information about the fall occurrences. The DON responded to the surveyor on 5/15/13 at 9:30 a.m. She related that on 7/2/12 the resident fell out of the gerichair very quickly. One CNA was in the day room, but was unable to get to the resident before she fell out of the chair. The DON explained on 2/28/13 the resident's bed alarm was placed on the open, low side of the bed and had too much slack on the cord to trigger the alarm. Additionally, she said the resident most likely received the facial injury on the extended side rail of the bed. 2. On 5/9/13 at 10:35 a.m., in the presence of the LPN/UM the surveyor observed a CNA transporting Resident #18 via wheel chair. The resident was wearing a hospital type gown. The resident was leaning to left/forward and the resident's exposed left arm was observed rubbing on the wheel as the wheel chair moved during transport. The LPN/UM approached the resident and told the CNA to stop pushing the resident in the wheel chair. The LPN/UM revealed at that time, the resident was weak and "should not have been transported by the CNA." She further stated the resident has fragile skin and didn't know why the CNA got the resident "out of bed in that condition." The CNA returned Resident #8 to bed with the assistance of a nurse. The LPN/UM reported the incident to the nurse who was assigned to care for Resident #8. The LPN/UM informed the nurse the CNA had the resident "all the way over in the wheel chair" and the resident's "left arm was rubbing on the wheel as it was turning." In addition, she stated an incident report would be completed and assess the resident for injury. The surveyor reviewed Resident #18's medical record on 5/9/13. According to the medical record Face Sheet, Resident #18 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated the resident had a moderate cognitive deficit, required extensive two person assistance with transfers, and was non-ambulatory. The Fall Risk assessment dated [DATE], indicated the resident was at high risk for falls. The Care Plan confirmed the resident was at fall risk. Interventions included; staff will assist with all transfers. The Care Plan did not reflect the residents mode of locomotion. A Physiatry (PM&R) Rehab Therapies Prescription dated 5/1/13, indicated Resident #18 was to utilize a wheel chair for mobility and positioning. A review of an IPN dated 5/9/13 at 11:03 a.m., reflected at 10:40 a.m. the resident was observed being transported in a wheelchair in the hall in front of the nurses station. Resident #18's left arm was hanging over the chair and resident was observed leaning forward. The resident was re-positioned in the wheel chair and returned to bed. The resident's physician was informed and evaluated the resident for injuries, there where no injuries observed. An Incident/Accident Report dated 5/9/13 at 10:40 a.m., reflected, Resident #18 was observed with the left arm hanging over the wheelchair during transport. A statement dated 5/9/13, from the CNA obtained during the course of the investigation, reflected the CNA transported the resident to the day room by wheel chair and didn't realize the resident's arm was hanging on the side when I move. A review of an "Employee Corrective Action Form" dated 5/10/13, revealed "Employee observed pushing resident in wheelchair with arm hanging over side of w/c (wheelchair) rubbing on wheel." The Employee was inserviced on proper positioning of residents in wheelchair and to pay closer attention to the resident while giving care, transferring, and propelling in the wheelchair. 3. The surveyor reviewed the medical record for Resident #8 on 5/8/13. The medical record Face Sheet indicated that Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an assessment tool dated 3/16/13, indicated that the resident was cognitively impaired and required assistance for transfer out of bed to chair. The MDS also indicated that Resident #8 did not ambulate and needed set up assistance for feeding. A review of Interdisciplinary Progress Notes (IPN) dated 4/20/13, revealed that staff observed an 18 cm x 15 cm bruise on the resident's left thumb. The bruise was further described as purplish in color with slight yellowish discoloration around the area. The surveyor reviewed the Incident/Accident Report dated 4/20/13. According to a statement from a staff member dated 4/19/13, on 3 p.m. to 11 a.m. shift; the staff observed that Resident #8 "had a jerk to the left hand" to the point where the resident drops the drink when they pick it up. Another statement dated 4/20/13, indicated that Resident #8's right hand had a spasm during feeding and drinking. The surveyor reviewed the supervisor's report on the details of investigation and resolution dated 4/20/13. The report indicated an Occupational Therapy (OT) screen would be placed for "possible need for adaptive equipment for shaking." The surveyor reviewed OT documentation and did not find any evidence that the a screen was performed for Resident #8. A review of Resident #8's current care plan did not reflect any revisions or updates in relation to the bruise or the resident's shaking hands. On 5/5/13 at 9:30 a.m., the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). She stated the bruise would not "necessarily trigger for the resident's care plan to be updated unless the resident had fragile skin." She then added that this was an isolated incident. The LPN/UM also told the surveyor that they have "a couple theories" on how the bruise occurred. She stated that the theories included: Resident #8 might have jammed the thumb under the overbed table during meal from the shaking hands or that the resident may have hit the hand on bed rail. On 5/5/13 at 12:15 p.m. the surveyor interviewed the OT Director and inquired about the OT screening. She told the surveyor that they were new to the facility and have only been at the facility one month. She stated that she would look to see if Resident #8 had an OT screen in the past month. In the presence of the surveyor, the OT Director looked through the OT records and could not find any evidence of an OT screen being completed. She told the surveyor that the screening information would be in the resident's medical record if it was done and that it was not contained in the medical record. During interview with the Administrator on 5/14/13 at 12:55 p.m., he stated that their turnaround time for OT screen was two days and that it was unusual for the screen to not have been done. He also stated it was not their practice to not screen for three weeks after it was recommended. On 5/15/13 at 9:30 a.m. the Administrator told the surveyor that the screening was completed on 5/14/13, after surveyor inquiry. 4. On 5/9/13 the surveyor observed in the presence of facility management the following: a.) At 11:22 a.m., the surveyor observed an Oxygen concentrator in resident room 204. The Oxygen concentrator was plugged into a multi-outlet power strip, not directly into a wall outlet as required. b.) At 11:45 a.m., the surveyor observed an Oxygen concentrator in resident room 119 by the door that was plugged into a multi-outlet power strip, not directly into the wall as required. In that same room, the surveyor observed the Oxygen concentrator was "on" and running at 2 liters per minute (LPM). The tubing for the machine was in the bed covers, creating an Oxygen rich environment that supports combustion. During an interview, at the time, the CNA in the room stated that the resident was attending an activity. 5. On 5/7/13 12:50 p.m. in the North Unit Day Room during a lunch meal, the surveyors observed a CNA carry a dining room chair from the pantry side of the day room to the other side of the day room. The CNA picked up the dining chair placed it over her head and while walking with the dining chair over her head carried it over two resident who were seated in wheelchairs at the dining tables. NJAC 8:39-31.2(e)

UNCORRECTED DEFICIENCY Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to a.) implement identified safety interventions for 1 of 15 residents reviewed (Resident #8); b.) assure that hygiene equipment was maintained in a safe manner for 1 of 15 residents reviewed (Resident #15); and c.) consistently monitor facility water temperatures. This deficient practice was evidenced by: The deficient practice was evidenced by the following: 1. The medical record was reviewed by the surveyor on 7/17/13. According to medical record Face Sheet, the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 6/6/13, reflected Resident #8 was incontinent of bladder and bowel. The Care Plan dated 6/10/13 indicated the resident was at risk for pressure sores due to incontinence. The front page of the Care Plan reflected side rail pads were to be utilized. There was no further documentation as to why the side rail pads were to be utilized. During a tour of the facility on 7/17/13 at 11:40 a.m., Resident #8 was observed in bed with bilateral full side rails in place. The right side rail had a full side rail pad in place. The left side rail did not have a side rail pad in place. During an interview on 7/18/13 at 1:55 p.m., with the Certified Nursing Assistant (CNA), who was assigned to provide care to Resident #8, revealed the side rail pads are in place because the resident "flails a little bit" and so the resident doesn't get bruised. When the Licensed Practical Nurse was interviewed by the surveyor on 7/18/13 at 2:00 p.m., she stated the side rail pads are in place to Resident #8's bed to protect the resident from falling off the bed and protect the resident from bruising when turning. There was no evidence that the siderail pads were consistently utilized for resident safety as indicated by staff and the care plan. 2. On 7/18/13 at 12:00 p.m. the surveyor conducted a tour on the North Unit. The surveyor observed room #208 resident bathroom. The white ceramic toilet had the toilet seat pushed upright with the back to the toilet tank. A raised toilet seat was clamped to the ceramic bowl of the toilet with four rusted brackets. Where the toilet was attached to the floor, at the middle/front of the ceramic toilet bowl there was a missing/cracked off piece of the ceramic base measuring approximately 3 inches by 2 inches. At the point of the missing/cracked piece of the ceramic toilet bowl there was a crack that bifurcated up the pedestal portion of the toilet onto the underside of the bowl portion of the toilet. The surveyor also observed two handrails in the bathroom. The one on an adjacent wall, the right hand rail, had approximately 75% of the hand rail covered with orange/brown colored rust. On 7/18/13 at 2:40 p.m. the survey team toured the facility with the Administrator. The Administrator was brought to room #208 by the survey team and was directly shown the cracked toilet and rusted hand railing in the resident's bathroom. The Administrator had no comment. The medical record was reviewed by the surveyor on 7/18/13. According to the Face Sheet, Resident #15 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE], reflected the resident had a severe cognitive impairment. On 7/18/13 at 1:00 p.m. the surveyor conducted an interview with Resident #15. The resident stated that they use the toilet in their bathroom and the resident revealed he/she wasn't sure if the raised toilet seat was for him/her or the roommate and that both residents used that toilet seat. Resident #15 stated that he/she used both handrails and noticed that the one hand rail had rust on it. She/he added, "I told them but nothing happened." When the surveyor inquired, Resident #15 did not recall to whom she/he reported the rusted hand rail. The resident further stated "I never got hurt on the hand rail, I hold on at the top of the handrail where there isn't much rust. I have never seen anyone clean my toilet, my room they clean, but not that toilet." 3. During an interview with the Maintenance Director on 7/18/13 at 12:25 p.m., he stated that he was hired in May 2013 by the facility and since his date of hire he has not taken water temperatures in resident rooms or shower rooms to assure that water temperatures were at an acceptable and safe level. He revealed that he does not have a thermometer to evaluate water or room temperatures and thinks it might be at home. In addition, the Maintenance Director revealed he "goes by feel" to evaluate water and room temperatures. A review of the Plan of Correction submitted by the facility with a completion date of 6/1/13, reflected that all resident plans of care were reviewed to ensure those residents who are at risk for injury have an intervention in place to prevent injury. In addition, the CNA who provided care to Resident #8 was to have been inserviced regarding education on the use of care plans. This was not implemented for Resident #8. NJAC 8:39-27.1 (a)