Every finding on record at Complete Care at Linwood, LLC

Based on observation, interview, and policy review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 02/12/2025 from 09:12 AM until 10:20 AM, the surveyor observed the following in the kitchen in the presence of the Regional Food Service Director (RFSD):1. In the dry storage closet an open bag of gelatin mix wrapped in plastic wrap and an opened bag of potato chips had no labeled open or used by date. The RFSD acknowledged it should be dated, and the items were removed. 2. The high-temperature dishwasher is set to operate between 150 F and 180 F, the final rinse temperature should be 180 F. The surveyor observed the wash temperature at 134 F, the RFSD confirmed the temperature and indicated it should be 150 F. The final rinse temperature was recorded as 150 F, the RFSD confirmed the machine was not at operational temperature and indicated the temperature should be180 F. The dishwasher was immediately stopped upon discovery of the temperature discrepancy. On 2/12/2026 at 09:45 AM during the kitchen tour the dishwasher temperature log was noted to have part of the lunch log entered. On the same day at 11:43 AM during interview with Dietary aide #1 (DA #1), when asked why the log for the afternoon temperatures was partially filled in before the lunch hour DA #1 indicated that it was a mistake and that they had got ahead of themselves. On 02/12/26 at 11:24am, upon return to the kitchen, boxes containing food products were observed stacked on the floor. Uncooked meat products were observed stacked with boxes of food products. The RFSD stated the boxes were from their recent delivery and should not be resting on the floor. The surveyor reviewed the facility provided policy titled, Dating and Labeling Policy with revision date January 2026 which reflected: for the kitchen to ensure food safety by maintaining proper dates and labels to all ready to eat food products. Use a black marker or date gun with legible writing to date and label products. Discard all foods that expire immediately. The surveyor reviewed the policy titled, Sanitization with revision date January 2023 which reflected the high-temperature dishwasher (Heat Sanitization) should reach a wash temperature of (150 F-165 F) and rinse temperature (165 F-180 F).The surveyor reviewed the policy titled, Food Preparation and Service with revision date January 2026 which reflected food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. NJAC 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a closed cover over the opening of 1 of 3 garbage containers. This deficient practice was evidenced by:On 02/12/2026 at 10:11 AM, the surveyor, accompanied by the Regional Food Service director (RFSD), observed the facility's outdoor trash disposal area. The surveyor observed three garbage containers (GC) situated at the rear of the property. One of the GCs had an open lid and contained trash which was exposed to the elements, and another GC observed overflowing with refuse. The area surrounding the three GCs was littered with debris, including but not limited to cardboard boxes and milk crates.On 02/17/2026 at 11:04 AM, during an interview with the surveyor, the Environmental Service Supervisor (EVSS) stated that the GCs should remain free from debris and the lids should be closed. The EVSS stated that the GCs are monitored by maintenance but should be a team effort. On 02/18/2026 at 09:47 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that both housekeeping and the maintenance departments are responsible for maintaining the GC area. The DOM stated the GCs are checked daily and will alert Environmental Services to clean up the area when necessary.The surveyor requested trash or refuse policies on 02/12/26 at initial tour and again on 02/18/26 at 10:22 AM, the facility failed to produce a policy. NJAC 8:39-19.3(c)

Based on observation, interview, record review and facility provide documentation, the facility failed to ensure staff and vendors utilized appropriate personal protective equipment (PPE) during resident care in accordance with facility policy and accepted standards of infection control practice.This deficient practice was evidenced by the following:During initial tour on 02/12/2026 at 10:12 AM surveyor #1 observed an ultrasound technician (UT) performing an ultrasound on Resident # 152 while in their room. The door to room indicated that the resident was on enhanced barrier precautions (a set of rules where nursing home staff wear gowns and gloves during high-contact care for certain residents to stop the spread of dangerous germs). The ultrasound technician was observed not wearing a protective gown while performing an ultrasound. A review of Resident # 152's electronic medical record (EMR) revealed that Resident #152 was admitted to the facility with a diagnosis of but not limited to prostate cancer, and obstructive and reflux uropathy (a blockage in the urinary tract that impedes urine flow). A review of Resident # 152's Care Plan revealed a focus for enhanced barrier precautions for a suprapubic catheter. During an interview on 02/12/2026 at 10:22 AM with surveyor #1, the ultrasound technician said the nurses did not inform her that the resident was on any precautions. When asked if the UT saw the sign on the door, she replied I didn't look. During an interview with surveyor #1 on 02/18/2026 at 9:43 AM, the Infection Preventionist (IP) said that all outside venders are required to wear Personal Protective Equipment (PPE), while performing any kind of care on the residents. The IP also said there are signs on the door to alert visitors and venders that they need to wear PPE, and if they have any questions to ask the nurses. During an interview on 02/18/2026 at 12:02 PM with Surveyor # 1, the Director of Nursing (DON) said, all vendors should follow the signs we have placed on residents' doors regarding Enhanced Barrier Precautions. To ensure germs are not spread. A review of a facility provided policy titled, Enhance Barrier Precautions (EBP) revealed under Initiation of EBP that b. an order for EBP will be obtained for a resident with any of the following, wounds, and or indwelling medical devices. the policy also revealed under, Implementation of EBP to, Provide education to residents and visitors. N.J.A.C. 8:39-19.4(a) On 02/13/2026 at 11:34 AM during a tour of the [NAME] Unit, Surveyor # 2 observed Certified Nurses Aide (CNA) # 1 inside Resident # 102's room. Outside of the doorway of the room was a sign indicating the room required Enhanced Barrier Precautions (a set of rules where nursing home staff wear gowns and gloves during high-contact care for certain residents to stop the spread of dangerous germs). At that time, the surveyor observed bed sheets on the floor, the privacy curtain half-way drawn, and CNA # 1 operating the bed remote control of Resident # 102 who was laying in the bed. CNA # 1 was not wearing a protective gown or disposable gloves. Upon exiting the room, during an interview with Surveyor # 2, CNA # 1 replied, Yeah, I should've when asked if she should have been wearing a disposable gown and gloves. CNA # 1 confirmed that she worked as a CNA in the facility but was employed by a staffing agency. A review of Resident # 102's Electronic Medical Record under Orders revealed a physician's order for Enhanced Barrier Precautions for every shift. The order was started on 09/20/2025. A review of the undated facility-provided policy titled, Enhance Barrier Precautions revealed that High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting . N.J.A.C. 8:39-19.4(a)

Based on observation, interview, record review and facility provided documentation, the facility failed to ensure residents were treated with dignity and respect during A.) incontinence care for 1 of 2 (Resident # 10) and B.) 3 of 3 dining rooms observed during the Dining Task.This deficient practice was evidenced by the following:A) During initial tour on 02/12/2026 at 9:23 AM, the surveyor observed Resident #10 in bed wearing two incontinence briefs. During an interview at the same time with the surveyor, the certified nurse's assistant (CNA) #1 said that they are not supposed to be wearing two incontinence brief. CNA # 1 said that the overnight staff are responsible. She concluded saying when we come and find it, we report it to the nurses.A review of Resident #10's admission record revealed that Resident # 10 was admitted to the facility with diagnoses of but not limited to, Dementia (a syndrome characterized by a decline in cognitive function), and type 2 diabetes.A review of Resident # 10 Minimum Data Set (MDS) dated [DATE] revealed under section H that Resident # 10 was always incontinent of bowel and bladder. A review of Resident # 10's Care Plan did not include any interventions for Resident # 10 to wear two incontinent briefs until after being brought to their attention by the surveyor. During an interview on 02/18/2026 at 12:02 PM with the surveyor, the Director of Nursing (DON) said that residents should not be wearing two incontinence briefs. B). On 2/13/2026 at 8:59 AM, the surveyor observed 5 residents eating breakfast in the south wing day room. All five residents were served on trays. During an observation of dining on 02/13/2026 at 12:21 PM in the south unit day room, the surveyor observed 8 residents being served lunch. All 8 residents were served their lunch on trays; there were no table clothes on the tables. The meals were left on the trays for the meal. During an observation of dining on 02/13/2026 at 12:28 PM in the south wing dining room the surveyor observed 8 residents all sitting at one table eating lunch off of trays.During an interview on 02/13/2025 at 12:33 PM with the surveyor, Licensed Practical Nurse # 1 (LPN) said that they usually serve the meals on trays in the dining room. When asked if that was conducive with a homelike environment, the LPN replied, no. A review of a facility provided policy updated January 2026 and titled, Dignity revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, and when assisting with care, residents are supported in exercising their rights. For example, residents are: Provided with a dignified dining experience. NJAC 8:39 - 4.1(a)12

Based on observation, interview, and review of other facility-provided documentation, it was determined that the facility failed to maintain a clean and sanitary environment for 1 of 4 units (South). This deficient practice was evidenced by the following: On 02/12/2026 during the initial tour, Surveyor # 2 observed the following: At 10:56 AM, Surveyor # 2 observed the Sub-Acute soiled utility room. There was a filled garbage bag on the floor garbage overflowing from the receptacle bin. At 11:02 AM, Surveyor # 2 observed the soiled biohazard room across from room [ROOM NUMBER]. There were filled garbage bags left on floor. A 11:08 AM, Surveyor # 2 observed the biohazard room located in the secured unit. There were filled garbage bags on floor. Also at that time, the surveyor observed a broken hand sanitizer dispenser next to room [ROOM NUMBER]. During initial tour on 02/12/2026 at 9:12 AM, the surveyor observed the following on the South Unit: An incontinence brief and used disposable glove on the floor near a trash bin with no trash bag, filled trash bags directory on the floor, and a broken tile on the floor in the biohazard room. In room [ROOM NUMBER] A, the molding was missing from the middle of the wall. On 02/18/2026 at 12:02 PM during an interview with the surveyor, the Director of Nursing (DON) said there should not be missing molding in the rooms, and trash on the floor, because it's not a homelike environment. She concluded by saying it can cause germs to spread in the facility. A review of a facility provided policy titled Safe and Homelike environment revealed, in accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to accurately implement a physician prescribed fluid restriction order for 1 of 1 resident's (Resident #11) reviewed for dialysis. This deficient practice was evidenced by the following:On 02/13/2026 at 08:59 AM the surveyor observed and interviewed Resident #11 in his/her room. Resident #11 stated that he/she has been receiving dialysis for about 2 months. The surveyor observed a bottle of diet soda, a bottle of water, a carton of milk, a small juice cup, and two clear glasses of a pink colored beverage on the resident's bedside table tray. The surveyor questioned Resident #11 whether he/she was on a fluid restriction. Resident #11 replied that they were unsure if they were. A review of Resident #11's admission Record revealed that, Resident #11 was admitted to the facility with diagnoses including but not limited to: Chronic Kidney Disease Stage 4 (kidneys no longer work as they should to meet your body's needs) and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to).A review of Resident #11's Order Summary Report revealed active orders as of: 2/13/2026, Resident #11 had the following physician's orders:1500 fluid restriction for nutrition. Dialysis on: Tuesday, Thursday and Saturday at Fresenius Kidney Care. Chair time 5:40AM.According to Resident #11's comprehensive care plan, Resident #11 had a Focus of: Dialysis related to renal failure, Date Initiated: 12/04/2025. The following was revealed under Goal: Monitor Intake and Output, date initiated 12/04/2025.Review of the nutrition evaluation dated 11/30/2025, reflected that the resident should continue with liberal diabetic, renal diet, monitor intake and resident will consume at least 75% of fluids offered. The most recent dietician note dated 12/30/2025 indicated to continue with current diabetic/renal diet with 1500cc fluid restriction prescribed by MD.The facility failed to provide an active diet slip when asked, one was written in the presence of the surveyor. On 2/17/2026 at 10:46 AM, during a telephone interview, the Registered Dietician (RD) indicated to the surveyor that fluid restrictions are monitored by the nursing and dietary. An interview with Licensed Practical Nurse #1 (LPN #1) on 02/17/2026 at 11:27 AM indicated that LPN #1 was unaware that Resident #11 had a fluid restriction. When questioned how fluid restricted residents' fluids were monitored LPN #1 stated that they take note of what is on the resident's tray and what fluids the aides provide. LPN #1 also indicated that resident #11 is able to let staff know how much he/she has drunk that day. Follow up interview with LPN #1 on 02/17/2026 at 12:19 PM when asked if resident #11's fluid consumption was being documented and where it could be found, LPN #1 stated they would be found in the progress notes or the 24-hour communication book. LPN #1 stated that there would be required documentation of resident's intake and output only if the physician ordered Intake and Output monitoring, further stating that Resident #11's fluid restriction was part of the diet order so there would be no documentation of Resident #11's fluid intake and output. Review of the 24-hour communication book revealed no documentation of resident #11's fluid intake and no progress notes provided any documentation of Resident #11 fluid intake. On 02/18/2026 at 12:02 PM during interview the Director of Nursing (DON) when asked where fluid observations should be documented the DON stated they should be documented in the residents Medication Administration Record (MAR) and/or Treatment Administration Record (TAR). The DON further stated that residents that are care planned to Monitor Intake and Output should have fluid observations documented on the residents MAR or TAR.Review of the policy titled Fluid Restriction revision date May 2021 reflects; The nursing department will document the amount of fluids the resident receives.Review of the policy titled Nursing Documentation revision date April 29, 2020, revealed under the heading Policy Statement: It is the policy of this facility for nursing documentation to be completed in the Electronic Medical Record (EMR) and/or nurse notes located in the resident's chart.N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary facial care to maintain proper grooming and personal hygiene. The deficient practice was observed for 1 out of 3 residents reviewed for Activities of Daily Living, (Resident #153).The deficient practice was evidenced by the following:On 2/12/2026 at 10:37 AM, during the initial tour of the facility, the surveyor observed Resident #153 resting in bed wearing a hospital gown. The resident's face had thick and untrimmed beard and moustache about 2 inches long. Their hair appeared oily and unkempt. There was a malodorous smell in the room. On 2/13/2026 at 11:38 AM, the surveyor observed the resident in bed wearing a hospital gown. The resident's face was shaven. Their hair appeared oily and unkempt. The resident stated to the surveyor that they did not want to go to the shower but wanted their face shaved. The resident stated that they had been in the facility for two weeks already but have not been offered to get shaved until that day. The resident denied that they were offered alternative to having a shower such as a bed bath or a hair wash in bed. The surveyor reviewed the electronic medical record (EMR) for Resident #153.A review of the admission Record face sheet (an admission summary) reflected that Resident #153 was admitted to the facility with diagnoses which included but were not limited to; legal blindness, cellulitis (a bacterial skin infection) of the right and left lower limbs, and abnormalities of gait and mobility.A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/10/2026, revealed an intact cognition. Further review of the MDS revealed that the resident required maximum assistance in bathing and moderate assistance in their personal hygiene which included shaving.A review of the resident's individualized comprehensive care plan initiated on 2/5/2026, revealed that the resident required assistance in completing their Activities of Daily Living (ADL) such as showering and shaving.A review of the Progress Notes (PN) and Medication/ Treatment Administration (MAR/ TAR) notes did not include any documented refusal of care from admission date to the time of surveyor inquiry on 2/12/2026. On 2/13/2026 at 11:42 AM, during an interview with the surveyor, Certified Nursing Assistant (CNA) #1 stated that they never had Resident #153 in their assignment before. They also stated that the resident asked them to be shaved because the resident did not want a beard and moustache. CNA #1 further stated that the resident refused to have a shower that day.On 2/17/2026 at 11:46 AM, during an interview with the surveyor, CNA #2 stated that when residents refuse to shower, they offer bed bath or hair wash in bed. CNA #2 further stated that they also report to their supervisor when residents refuse care. CNA #2 stated that shaving is part of their care. On 2/17/2026 at 11:47 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN) #1 stated that when residents refuse shower, they offer alternative time to give the residents shower. LPN #1 also stated that they document refusal of care in the MAR, PN, or on the 24-hour report. On 2/17/2026 at 11:57 AM, the surveyor reviewed the nursing 24-hour reports for February 2026. There was no documented refusal of care for Resident #153.On 2/17/2026 at 8:38 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that showers are scheduled upon admission. The DON stated that when a resident refuse shower or care, the nurses should report to the unit managers, offer a different shower time and document refusal in the EMR. The DON further stated that shaving is part of care on shower days and as needed.A review of facility-provided undated policy titled ADL Policy included under Procedure the following: 10.) A patient who requires Moderate Assistance depends on the assistance of the staff to complete about half of the activity. 11.) A patient who requires Maximum Assistance depends on the assistance of the staff in order to complete a large portion of the activity. Staff members will perform majority of the activity with the patient assisting as much as he/ she is able. N.J.A.C. 8:39 - 27.1 (a), 27.2 (d) (g) (h)

Based on observation, interview, review of medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 2 residents reviewed for position and mobility, (Resident #12) and was evidenced by the following: On 2/12/2026 at 9:43 AM, during the initial tour of the facility, the surveyor observed Resident #12 alert but non-verbal and resting in bed. The resident was mechanically ventilated via tracheostomy (a surgical opening in the neck created with a tube to keep the airway open for breathing). The surveyor noted the resident's right hand flexed from the wrist and the right fingers flexed in a fist. The fingernails of the right hand were observed to be trimmed. No positioning device was observed on the resident's right hand. There was no hand splint or roll noted on the resident's person, bed and room.On 2/13/2026 at 12:12 PM, the surveyor observed the resident sleeping in bed. The resident's right fingers were flexed into a fist. There was no hand splint or hand roll noted on the resident's person, bed and room.On 2/17/2026 at 10:18 AM, the surveyor observed the resident in bed together with Unit Manager/ Registered Nurse (UM/ RN) #1. The resident's right fingers were flexed into a fist. There was no hand splint or hand roll noted on the resident's person, bed and room. The surveyor asked UM/ RN #1 if they could look at the resident's right palm. UM/ RN #1 stated that the resident's right hand was contracted. The resident's right palm was observed to be intact and dry with no discoloration. The surveyor reviewed the medical record for Resident #12.A review of the admission Record face sheet (an admission summary) reflected that Resident #12 was admitted to the facility with diagnoses which included but were not limited to; chronic respiratory failure, dependence on respirator status, anoxic brain damage (damage to brain after being deprived of oxygen), and unspecified contracture.A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 1/28/2026, revealed severely impaired cognitive skills for daily decision making and unspecified contracture. Further review of the MDS reflected no participation on physical therapy (PT), occupational therapy (OT) or restorative nursing program (RNP). The MDS also indicated that no splint or brace assistance was applied for Resident #12.A review of the Order Summary Report (OSR) active as of 2/17/2026, did not reveal any active or discontinued order for devices used for positioning of the right hand. Further review of the OSR revealed that an order for evaluation and treatment for OT was discontinued on 10/10/2022.A review of the miscellaneous and therapy tabs in the electronic medical record (EMR) did not reveal any therapy reports, past or active for the resident.A review of the resident's individualized comprehensive care plan initiated on 4/24/2023, reflected a focus for limited mobility which did not include any intervention to prevent worsening of the resident's contracture on the right hand.On 2/17/2026 at 8:40 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that physical and occupational therapists put their recommended orders in queue on the EMR which the nurses would confirm if the physician agreed to the order. The DON confirmed to the surveyor that the facility did not have a program for restorative services. On 2/17/2026 at 9:57 AM, during an interview with the surveyor, UM/ RN #2 stated that therapy reports are located under the therapy or miscellaneous tab of the EMR. On 2/17/2026 at 10:04 AM, during an interview with the surveyor, the Director of Rehabilitation (DOR) was asked for the most recent PT or OT service reports for Resident #12. No OT/ PT service reports were provided to the surveyor. The DOR was also asked what positioning device the resident had. The DOR stated that the patient (Resident #12) did not have any positioning device because of the risk for wounds. The DOR stated that when the therapists evaluate a patient, the orders go to the EMR.On 2/19/2026 at 10:16 AM, during an interview with the survey team, the DON stated that Resident #12 would be started on OT service. The DON provided the surveyor with a copy of the OT Evaluation and Plan of Treatment (OTEPT) report for certification period 2/18/2026 to 5/11/2026, a period after the surveyor inquiry about the resident's contracture. A review of the OTEPT included a new goal for the patient to safely wear bilateral palm rolls 4 hours on/ 4 hours off without skin irritation to improve PROM (passive range of motion) for adequate hygiene and reduce pain caused by joint deformity.No PT/ OT policy was provided addressing rehabilitation services to the residents. N.J.A.C. 8:39-27.1(a), 27.2(m)

Based on observation, interview, and review of medical record and pertinent facility documents, it was determined that the facility failed to a.) label and store treatment medications securely inside the treatment cart for 1 unsampled resident (Resident #25), b.) monitor the temperature of refrigerated drugs and biologicals in 1 out of 5 medication rooms (north wing) inspected , and c.) store medications securely in their packaging inside the medication carts for 2 out of 5 medications carts (north wing front cart and east wing even cart) inspected during the medication storage and labeling task. The deficient practice was evidenced by the following: 1.) On 2/12/2026 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #25 in bed connected to a mechanical ventilator (a life-support machine that assists a person to breathe). The surveyor observed an uncapped, unlabeled, and unbagged 4-ounce tube of zinc oxide ointment on top of the overbed table located at the foot of the resident's bed. The surveyor also observed an uncapped, unlabeled, and unbagged 4-ounce tube of Vitamin A&D ointment on the windowsill to the right of the resident's bed. At the time of observation, the surveyor asked RN #1 if the treatment medications should be stored in the resident's room. RN #1 replied that the medications should have been labeled and stored inside the treatment carts. RN #1 stated that they were going to dispose of the 2 tubes. RN # further stated that the resident and their roommate were both unable to get up and transfer by themselves.The surveyor reviewed the electronic medical record of Resident #25.A review of the admission Record face sheet (an admission summary) reflected that Resident #12 was admitted to the facility with diagnoses which included but were not limited to; cerebral palsy (motor disorder caused by abnormal brain development), dependence on respirator status and persistent vegetative state.A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/2026, revealed that the resident was at high risk for skin injuries and was fully dependent on staff for all their activities of daily living including transfers. A review of Order Summary Report (OSR) active as of 2/13/2026, reflected a physician order for Zinc Oxide every shift that was discontinued on 1/8/2026. The OSR did not show any active or discontinued physician order for Vitamin A&D ointment.A review of the resident's individualized comprehensive care plan initiated on 11/25/2025, reflected a focus for high risk of skin alteration related to immobility which included an intervention for barrier cream as needed.On 2/17/2026 at 8:38 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that zinc oxide and A&D ointments should be stored in the treatment carts for privacy and infection control.On 2/17/2026 at 1:25 PM, during an interview with the surveyor, the Consultant Pharmacist (CP) stated that treatment tubes should be labeled with the resident's name, capped, bagged and kept in the treatment carts. CP further stated that treatment tubes should be labeled with residents' names because they cannot be shared with other residents. A review of facility-provided policy updated in June 2023, titled Medication Labeling and Storage reflected under Policy the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Under Medication Storage, the following was included: 5.) Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.2.) On 2/12/2026 at 11:12 AM, the surveyor toured the north wing medication room with RN/ UM #2. The surveyor observed warm air inside the refrigerator when it was opened. Located inside the refrigerator were the following medications and biologicals: 6 bags of 100 milliliter daptomycin 500 mg, 4 bags of 500 milliliter intravenous saline solution (0.9%) with 4 vials of powdered vancomycin 1.5 grams, 2 unopened and 1 opened vials of Aplisol solution, 10 boxes of Fluarix influenza vaccines containing 10 vials/ box. The surveyor asked RN/ UM #2 what the temperature inside the refrigerator was. RN/ UM #2 could not locate the thermometer inside the refrigerator. RN/ UM #2 stated that there should have been a thermometer inside the refrigerator and that they did not know what happened to it. RN/ UM #2 was observed to get a thermometer and placed it inside the first refrigerator.On 2/17/2026 at 8:40 AM, during an interview with the surveyor, the DON stated medication refrigerators need an internal thermometer to keep the temperature of medications according to manufacturer's recommendation. The DON also stated that the facility process was to keep the internal temperatures at 38 - 40'F.On 2/17/2026 at 1:23 PM, during an interview with the surveyor, the CP stated that medication refrigerators should have internal thermometers to make sure that the temperatures of medications were within the range recommended by manufacturers.A review of facility-provided policy updated in June 2023, titled Medication Labeling included the following under Policy: The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity and light controls.3.) On 2/13/2026 at 10:02 AM, during an inspection of the north wing front cart with RN/ UM #2, the surveyor observed 5 loose tablets inside the drawer of the medication cart. RN/ UM #2 stated that there shouldn't be loose tablets in the cart. RN/ UM #2 stated that the loose tablets should be disposed of in the drug disposal bottle located in the medication cart. On 2/13/2026 at 11:45 AM, during an inspection of the east wing even cart with RN/ UM #1, the surveyor observed 3 loose tablets inside the drawer of the medication cart. RN/ UM #1 stated that there should not be loose tablets in the cart. RN/ UM #1 stated that the loose tablets should be disposed of in the drug disposal bottle located in the medication cart. On 2/17/2026 at 8:42 AM, during an interview with the surveyor, the DON stated that there should not be loose tablets in the cart and that the nurses should be removing loose tablets from the cart.On 2/17/2026 at 1:27 PM, during an interview with the surveyor, the CP stated that there should not be loose tablets in the medication cart and that the nurses should be disposing them as they find them.A review of the facility-provided policy updated in June 2023, titled Medication Labeling and Storage indicated under Policy Interpretation the following: 1.) Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. N.J.A.C. 8:39 - 29.4 (a) (h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that infection control education was provided and documented for 1 of 1 agency staff members (CNA; Certified Nurse Aide) # 1 providing care to a resident in a room requiring Enhance Barrier Precautions (EBP). The deficient practice was evidenced by the following: On 02/13/2026 at 11:34 AM during a tour of the [NAME] Unit, Surveyor # 2 observed Certified Nurses Aide (CNA) # 1 inside Resident # 102's room.Outside of the doorway of the room was a sign indicating the room required Enhanced Barrier Precautions (EBP; a set of rules where nursing home staff wear gowns and gloves during high-contact care for certain residents to stop the spread of dangerous germs). At that time, the surveyor observed bed sheets on the floor, the privacy curtain half-way drawn, and CNA # 1 operating the bed remote control of Resident # 102 who was laying in the bed. CNA # 1 was not wearing a protective gown or disposable gloves. Upon exiting the room, during an interview with Surveyor # 2, CNA # 1 replied, Yeah, I should've when asked if she should have been wearing a disposable gown and gloves. CNA # 1 confirmed that she worked as a CNA in the facility but was employed by a staffing agency. A review of Resident # 102's Electronic Medical Record under Orders revealed a physician's order for Enhanced Barrier Precautions for every shift. The order was started on 09/20/2025. A review of CNA # 1's facility-provided orientation and competency information revealed only one document titled, Welcome to [Facility Name] Healthcare. The document including information about reporting allegations of abuse and reporting protocols. The document did not reveal information about infection control practices, procedures, protocols, or policies. The document concluded with CNA # 1's signature that acknowledged she received mandatory in-servicing prior to employment. On 02/18/2026 at 11:38 AM during an interview with the surveyor, the Director of Nursing (DON) explained that when agency-contracted CNAs come to the facility, they make rounds with the facility educator. The CNA is shown the facility and units. The DON said the facility discusses infection control with the CNAs. At that time, the surveyor requested the documentation confirming the CNA received infection control education. The DON confirmed they did not document the education and that it is delivered verbally. On 02/19/2026 at 10:07 AM during another interview with the surveyor, the DON said agency-contracted staff orientation includes receiving a facility tour, education on resident needs, infection prevention and control practices, the location and use of personal-protective equipment (PPE), hand-hygiene expectations, and a review of isolation and enhanced-barrier precautions. The DON continued that the facility clearly posted EBP signs outside resident rooms and that the sign includes step-by-step instructions. The DON concluded saying that the signs and personal protective equipment are clearly visible and understandable for all level of staff. At that time, the surveyor requested the documentation that the aforementioned education was provided to CNA # 1. The DON stated, No documentation, only verbally. A review of the facility-provided policy updated January 2026, titled, Policy for Orienting Agency Staff to the SNF for Agency CNA's. The policy statement revealed, It is the policy of this facility to ensure that all agency staff have a facility onboarding process to ensure the safety and wellbeing of the residents that reside in the facility. The policy also revealed that, The agency staff should be provided with a copy of the census for the side they are assigned to. This document will help them understand the patient population and their specific needs . N.J.A.C. 8:39-19.4(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date food products stored in a refrigerator, spice rack, and meat freezer; b) properly discard food products on or before the expiration date; and c) properly store food products in a manner without covers. The deficient practice was evidenced by the following: On [DATE] from 9:47 AM to 10:48 AM, the surveyor, accompanied by the Dietary Director (DD) and later at 10:47 AM joined by the Regional Dietary Director (RDD), observed the following: 1.) Next to the preparation table near the sink, the surveyor observed breadcrumbs inside a clear container labeled flour and not labeled with an open and use by date. The surveyor then observed a refrigerator referred to as the everything refrigerator. Within the refrigerator, the surveyor observed the following: 2.) A stick of butter opened to air and not labeled with an open and use by date. 3.) Two tomatoes in plastic wrap labeled with a use by date of [DATE]. 4.) One quarter pan of cooked puree pork labeled with a use by date of [DATE]. 5.) Two souffle cups filled with salad dressing that were not labeled with a use by date. 6.) A 1-gallon container of thousand island salad dressing labeled with an open date of [DATE] and use by date [DATE]. 7.) An opened, 48-ounce container of cottage cheese not labeled with an open and use by date. 8.) An opened, 32-ounce plastic bottle of lemon juice not labeled with an open and use by date. 9.) An opened, 8-pound container of feta cheese not labeled with an open date. 10.) An opened, 1-quart glass jar of minced garlic not labeled with an open and use by date. The surveyor then observed the spice rack located above the stove. The surveyor observed the following: 11.) A 16-ounce container of granulated garlic powder that was opened to the air. A 16-ounce container of ground ginger without a visible open and use by date label. A 16-ounce container of chili powder and 11-ounce container of parsley flakes, neither was labeled with an open date or use by date. An 11-ounce container of dry spice that was labeled with an open date of [DATE] and a use by date of [DATE]. An opened, 1-gallon container of soy sauce. A 1-gallon container of white vinegar, and a one quart container of gravy aid not labeled with an open and use by date. Also located on the rack above the stove, the surveyor observed: 12.) A 28-ounce bag of cream of wheat opened to air. An opened 28-ounce bag of cream of rice in plastic wrap, and two bags of 5-pound dry pancake waffle mixes opened to air and not labeled with an open and use by date. 14.) In a lower shelf under the preparation countertop, there was a 45-pound box of instant beef soup base in a plastic bag opened to air and not labeled with an open and use by date. The surveyor then observed the freezer referred to as the meat freezer. The surveyor observed the following within the freezer. 15.) Three pie crusts opened to air and not labeled with an open and use by date. 16.) One bag of opened, chicken nuggets in plastic wrap and not labeled with an open and use by date. 17.) One box of bacon opened to air and not labeled with an open and use by date. 18.) One quarter pan of vanilla pudding labeled with a use by date [DATE]. 19.) One bin filled with assorted juices with no individual expiration dates. During the observation with the DD and RDD, the DD stated that food items should be labeled with an opened and use-by date to ensure freshness. Further they said items exposed to air can become contaminated with bacteria and pose a risk for illness. Lastly, the DD said she will dispose of all the items. During an interview with the surveyor on [DATE] at 10:50 AM, the DD said every item is labeled once opened with an opened and use by date. A review of the undated facility policy titled, Dating and Labeling Policy, under Procedure revealed, 1.) Upon receiving and storing, all items must be labeled with the name of food and received date. Once opened, the label must be updated with the current date and a use by date of 3 days (including date opened) unless indicted on Labeling and Dating Protocol. The policy also revealed the following, 2.) Prepared Ready-to-eat foods are to be wrapped and labeled with the name of food and 3 days use by date (including date prepared) prior to being placed in refrigerator. 3.) All items with an expired use by date must be discarded immediately. A review of the undated facility policy titled, Dry Food Policy, revealed under, Procedure that, 1.) Upon delivery, all dry food items will be checked to ensure all packaging is intact and marked off against the packing slip. No torn or broken boxes, wet stains, missing labels. The policy also revealed that, 2.) Immediately after delivery, date products for proper rotation using first in and first out method, (FIFO). 3.) Keep products in original packaging or in tightly covered, clearly labeled containers. A review of the undated facility policy titled, Opened Foods and Storage Policy, revealed that 1.) All opened foods should be wrapped tightly with plastic wrap or stored in an airtight container to avoid exposure to air and contaminants. 2.) After proper wrapping, all opened items must have an opened on/made on and use by date. 3.) All opened foods must be discarded by end of day on use by date. N.J.A.C 8:,d+[DATE].2 (g)

Based on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 3 of 5 residents reviewed for medication management (Resident #70, Resident #92, and Resident #50). The deficient practice was evidenced by the following: On 10/03/2024 at 08:48 AM the surveyor requested from the Director of Nursing (DON) the CP's recommendations for Resident #70, Resident#92, and Resident # 50, from the last 6 months. 1. A review of the Admission Record for Resident#70 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Heart Failure, and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). On 10/03/2024 at 01:17 PM, the DON provided the surveyor with Resident #70's CP recommendation reports for April 2024 through September 2024. The CP recommendation dated 09/12/2024, indicated that the medication Carvedilol (medication used to treat blood pressure and heart failure) should be administered with food or meals. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/16/2024, indicated there was a duplicate order for Tylenol (medication used to treat pain and/or reduce fever). This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/16/2024, indicated to correct the MiraLAX (medication used to treat constipation) dosage. This recommendation was not completed or acted upon by the facility until 10/03/2024. 2. A review of the Admission Record for Resident#92 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Palliative Care, (specialized medical care for people living with a serious illness) Rhabdomyolysis (a condition caused by muscle injury or breakdown) and Hypertension (high blood pressure). On 10/03/2024 at 01:17 PM, the DON provided the surveyor with Resident #92's CP recommendation reports for April 2024 through September 2024. The CP recommendation dated 09/17/2024 indicated that a previous recommendation made on 08/15/2024 for Morphine sulfate to write separate orders for each indication was not addresses. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/15/2024 indicated to sequence the indication for Tylenol as needed. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/15/2024 indicated verify orders for Morphine Sulfate liquid dosage. This recommendation was not completed or acted upon until 10/03/2024. 38680 3.According to the Admission Record (AR), Resident #50 was admitted to the facility with the diagnoses which included but was not limited to hypertension and depression. The Admission Minimum Data Set (MDS), an assessment tool dated 09/02/2024, reflected that the resident had no cognitive deficits. On 10/04/2024 at 08:48 AM, the surveyor reviewed the Pharmacist Consultant (CP) comments report for Resident #50. The CP recommendation dated 09/16/2024, indicated the Ammonium Lactate (used to treat skin conditions) should be placed on the treatment administration record instead of the medication administrative record. This recommendation was not completed by the facility. The CP recommendation dated 08/27/2024, indicated that the medication Omeprazole (used to treat heartburn) should be administered on an empty stomach, at least 30 minutes before eating. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/27/2024, indicated not to crush Guaifenesin ER (used to treat congestion) and Potassium Chloride ER. This recommendation was not completed or acted upon by facility until 10/03/2024. The CP recommendation dated 08/27/2024, indicated to identify the duration of therapy for Guaifenesin ER. This recommendation was not completed or acted upon by facility until 10/04/2024. The CP recommendation dated 08/27/24, indicated the facility should clarify the diagnosis for Atenolol (used to treat blood pressure), Furosemide (used to treat water retention), and Umeclidinium (used to treat shortness of breath, wheezing). This recommendation was not completed or acted upon by facility until 10/03/2024. The CP recommendation dated 08/27/24, indicated that acetylcysteine (used to treat congestion) should be administered separately in the nebulizer. This recommendation was not completed or acted upon by the facility until 10/03/2024. On 10/07/2024 at 11:37 AM, the surveyor interviewed the North Unit Manager who stated that each nurse manager is responsible for completing the CP's recommendations. The Director of Nursing (DON) receives the report from the CP then the DON distributes the report to the Unit Managers. The North Unit Manager stated she normally completes the CP recommendations within two days, goes through them, and contacts the physician to review the recommendations. She stated that she was running behind for Resident #50's CP recommendations. She acknowledged that the CP recommendations for Residents #70, #92, and #50 should have been completed sooner. On 10/09/2024 at 10:19 AM, the surveyor interviewed the DON who stated the unit managers should complete the CP recommendations within five days. The surveyor reviewed the facility provided policy titled, Medication Regimen Review, implemented 09/1/2024. The policy reflected f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. NJAC 8:39-29.3 (a)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to A.) perform hand hygiene before applying gloves and between changing gloves and B.) failed to follow transmission-based precautions, specifically by not using a gown within a resident's room who was on transmission-based precautions. The deficient practice was observed for 1 of 2 nurses observed for Medication Administration task and 1 of 1 Resident (Resident # 425) reviewed for Transmission Based Precautions. This deficient practice was evidenced by the following: A.) On 10/03/2024 at 08:18 AM during the Medication Administration task, surveyor #1 observed Licensed Practical Nurse (LPN) # 1 putting on personal protective equipment (PPE) prior to administering medications to Resident #100. LPN# 1 did not perform hand hygiene prior to putting on gloves. On 10/03/2024 at 08:33 AM surveyor #1 observed LPN # 1 put on a pair of gloves without performing hand hygiene to place a medication patch on Resident # 32. LPN #1 then realized her pen was in her pocket to date the patch. LPN # 1 then took off the gloves and signed the patch before putting on a new pair of gloves. LPN # 1 did not perform hand hygiene between the glove change. On 10/03/2024 at 08:39 AM during an interview with Surveyor #1, LPN #1 replied Yes when asked if hand hygiene should be performed prior to putting on gloves. When asked if she had done that, LPN#1 replied, No. On 10/08/2024 at 12:31 PM during an interview with Surveyor # 1 the Infection Preventionist (IP) stated, Hand hygiene should be performed before and after using gloves, after using the bathroom, before and after eating, and any time visibly soiled. On 10/08/2024 at 02:22 PM during an interview with Surveyor # 1, the Director of Nursing (DON) replied Yes when asked if hand hygiene is required prior to putting on gloves and during glove changes. A review of a facility provided policy titled Administering Medications with a revised date of 1/2024 revealed under Policy Interpretation and Implementation that, 12. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administering medications, as applicable. A review of a facility provided policy titled Handwashing/Hand Hygiene with a revised date of 1/2024 revealed under Policy Interpretation and Implementation that, 2. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personal, residents, and visitors; 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice for preventing healthcare-associated infections. 51232 B.) On 10/04/2024 at 8:30 AM, Surveyor #2 from the hallway observed Registered Nurse (RN) #1 inside Resident # 425's room. At that time, Surveyor # 2 observed a sign on the room door that revealed Resident # 425 was on Contact Precautions. The sign had instructions that revealed a gown must be worn while inside the room. RN # 1 was not wearing a disposable gown while in the room. A review of Resident # 425's physician's orders located in the Electronic Medical Record revealed he/she had an order to maintain contact isolation precautions related to Group B Streptococcus (a highly contagious bacteria) and Methicillin Resistant Staphylococcus Aureus (a multi-drug resistant pathogen) in a wound located on the Resident's knee. The order revealed that, nurse to ensure proper isolation equipment is present: stop sign on door, supplies (gown, gloves, mask) are in the bin outside room . During an interview with Surveyor # 2 on 10/04/2024 at 8:35 AM, RN # 1 said she was not wearing a gown. RN # 1 then said she should be wearing a gown to protect herself and the resident from infection. During an interview with surveyor on 10/04/2024 9:03 AM, the Director of Nursing (DON) said if someone is on contact barrier precautions the nurses should be wearing personal protective equipment (PPE) while completing wound care. During an interview with surveyor on 10/04/2024 1:43 PM, Licensed Practical Nurse/Unit Manger (LPN/UM#1) said nurses should wear PPE when completing wound care for residents on contact or enhanced precautions to protect themselves. A review of a facility policy dated 09/01/2024 titled, Transmission-Based (Isolation) Precautions, revealed under contact precautions letter c, Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. N.J.A.C. S 8:39-19.4(a)

Complaint: NJ00167309 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to revise a comprehensive care plan to identify the nursing intervention required to care of a surgical wound infection. This deficient practice was identified for 1 of 26 residents (Resident #278) reviewed for care planning. The surveyor reviewed the medical record for Resident #278. A review of the Admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Under Section M (Skin Conditions) identified that Resident #278 had a surgical wound and surgical wound care. A review of Resident #278's Order Summary Report did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of Resident # 278's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of the individualized comprehensive care plan (ICCP) included a focus area area dated 7/12/2023 for enhanced barrier precautions [related to] surgical incision. The surveyor did not observe any interventions placed regarding surgical wound care. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) described a care plan as a blueprint for the resident and is used as a guideline of what works and doesn't work with the resident. LPN#1 confirmed that care plans are to be continuously updated during the resident's stay. LPN #1 identified that a care plan should identify if a resident has a surgical wound and any nursing interventions that were put into place to maintain it. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) acknowledged that there was no care plan update regarding the surgical wound infection. A review of a facility provided policy titled Care Plan, Comprehensive Person-Centered revealed under section Policy Explanation and Compliance Guidelines that, 8.) a. include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well being; 13.) Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. NJAC 8:39- 11.2(e)

Complaint # NJ167008; NJ167309; NJ100172185 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) obtain admission orders for a surgical wound b.) maintain nursing documentation of a surgical wound to prevent a delay in treatment for 1 of 26 residents (Resident #278) reviewed for wounds; c.) maintain and care for a central line catheter (tube travels through one or more veins until the tip reaches the large vein that empties into your heart) and d.) maintain treatment records that were complete with staff signatures according to professional standards of clinical practice for 2 of 26 (Resident #275 and #70) residents reviewed for medication administration and evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey 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. 1.) The surveyor reviewed the medical record for Resident #278. A review of the Admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Under Section M (Skin Conditions) identified that Resident #278 had a surgical wound and surgical wound care. A review of Resident #278's Order Summary Report did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of Resident # 278's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 7/12/2023 for enhanced barrier precautions [related to] surgical incision ns. The surveyor did not observe any interventions placed regarding surgical wound care. Review of Resident #278's electronic medical record (EMR) Progress Notes revealed the following entries: On 07/12/2023 at 4:31 AM, a Nursing Progress note recorded, abdomen soft non-tender to touch with good bowel sounds surgical incision on abdomen with steri-strips intact site clean and dry [ .]. On 7/12/2023 at 3:49 PM (time stamp was in bold found to be backdated and original creation date was identified as 7/17/2023 at 3:49 PM), a Nurse Practitioner progress note recorded, patient midline surgical incision [ .] clean dry and intact. The surveyor did not locate any surgical wound documentation for 7/13/2023. On 7/14/2023 at 6:27 AM, a Nursing Progress note recorded, patient had some sero-sanguinous drainage (thick clear or pink fluid from a wound) from the lower end of the incision [ .] area cleansed with [non sterile saline solution] and boarder gauze applied [ .] lower area around [abdomen] incision is pink [ .] boarder gauze noted to have sero-sanguinous [dressing] in AM so removed it & area cleansed with [non sterile saline solution] & a large boarder gauze applied [ .]. On 7/14/2023 at 3:58 PM (time stamp was in bold found to be backdated and original creation date was identified as 7/17/2023 at 3:58 PM), a Nurse Practitioner progress note recorded, surgical incision has distal erythema (redness and increased blood flow) and drainage- will place [them] on antibiotic and probiotic [ .] erythema to lower abdominal wound-purulent discharge (thick pus-like fluid that implies presence of infection). Upon review of the resident's MAR/TAR an antibiotic and probiotic was not submitted. On 7/15/2023 at 4:24 AM, a nursing progress note recorded, dressings to abdomen changed this shift due to dressings being soiled. The surveyor did not locate any surgical wound documentation for 7/16/2023; however, upon review of the resident's MAR/TAR, an order for cephalexin 500 milligrams (MG) was submitted for wound infection. On 7/17/2023 at 2:40 AM, a nursing progress note recorded, bandages removed from abdominal wounds, moderate amount of purulent drainage leaking from wounds, slightly thicker than water, water does have foul odor. Area cleansed and new bandages adhered to area [ .]. On the same date at 3:24 PM, a nursing progress note recorded, multiple steri-strips along medical incision line with an opening the lower end of incision with a quarter size dehiscence area which has clear drainage which was cleaned and abdominal pad placed and boarder gauze placed. MD made aware of all of the above findings and resident will be evaluated in the AM. Upon review of the resident's MAR/TAR, on 7/17/2023, the surveyor identified a physician's order to keep abdominal area clean and dry with [non sterile saline solution] and apply [conventional dry dressing] two times a day for [dehiscence] (reopening) of abdominal incision. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) confirmed that new facility residents should have their admission orders reviewed with the physician to ensure continuity of care. LPN #1 further advised that a resident with a surgical wound should have order upon admission on how to care for it. When asked regarding documentation, LPN #1 stated that if the wound was not being monitored something could get missed or lead to a decline in patient status. During an interview with the surveyor on 10/7/2024 at 10:43 AM, the Infection Preventionist (IP) revealed that admission orders for any type of a wound is important because the nurses need to know how to cleanse to prevent infection. When asked what signs are and/or symptoms of infection the IP stated, redness, swelling, tenderness, warmth, drainage, pus. The surveyor inquired about the expectations of documentation regarding wounds at which the IP responded that upon admission wounds should be thoroughly documented every shift upon it's resolution. During an interview with the surveyor on 10/7/2024 at 11:51 AM, the Licensed Practical Nurse Unit Manager (LPN/UM#1) confirmed that nursing is responsible for obtaining admission orders for a surgical wound. LPN/UM #1 further explained that nursing would assess for drainage, redness, increased pain, etc every shift and document their finding appropriately. When asked why these orders were important, LPN/UM #1 responded that nursing cannot decide on their own how to treat a surgical wound. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) acknowledged that there were not admission orders in place to monitor the resident's surgical site. The DON confirmed that the expectation is that every shift, or minimum every 24 hours, the surgical site should be documented on. The DON also identified that the two Nurse Practitioners Progress Notes were not entered in a timely basis. Upon review the DON confirmed that nursing's documentation should have demonstrated that they closed the gap in communication to see if any interventions needed to be in place to prevent any delay in care to the resident. A review of a facility provided policy titled Change in a Resident's Condition or Status revealed under section Policy Interpretation and Implementation that, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): [ .] e.) need to alter the resident's medical treatment significantly [ .]. A review of a facility provided policy titled Charting and Documentation revealed under section Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: a.) Objective observations; b.) Medications administered; c.) Treatments or services performed; d.) Changes in the resident's condition; e.) Events, incidents or accidents involving the resident; and f.) Progress toward or changes in the care plan goals and objectives [ .]. A review of a facility provided policy titled Admission Orders revealed under section Policy Explanation and Compliance Guidelines that, The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission [ .]. 33106 2. According to the Admission Record (AR) Resident #275 was admitted to the facility with the diagnose that included but was not limited to; surgical aftercare following surgery of the digestive system and diverticulitis (Inflammation of one or more pouches in the colon wall). The surveyor reviewed the Admission Assessment (AA) dated 08/24/23, which reflected that Resident #275 was alert and oriented to person, place time and situation and had a right upper arm peripherally inserted central catheter (PICC). The surveyor reviewed the physician's orders (PO) and there were no orders for the following: PICC line catheter, catheter care, dressing changes to the PICC line site or flushes to keep the PICC line patent. The surveyor reviewed the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of August 2023 and there was no documentation for the following: PICC line catheter, catheter care, dressing changes to the PICC line site or flushes to keep the PICC line patent. On 10/03/24 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated she had been employed in the facility for 7 years. The LPN/UM explained the process for residents admitted with PICC lines. She stated that the nurse would obtain the size and measurement of PICC line from the hospital and receive orders for: measurements, dressing changes, port connector changes, flushes, and to monitor the site for s/s of infiltration or infection. The LPN/UM reviewed the residents electronic medical record (EMR) in the presence of the surveyor and confirmed that there were no physician orders for the maintenance of Resident #275 right upper extremity PICC line. The LPN stated that even if the PICC line was not being used the staff were still required to assure that the PICC line was flushed, and the dressing was changed, and the site was monitored for signs and symptoms of infection. The LPN/UM stated that dressing changes were done on admission and then weekly. She added that PICC line flushes were usually done weekly for maintenance. The LPN/UM confirmed that physician orders should have been obtained for the residents PICC line to be flushed and there also should have been dressing change orders. The surveyor reviewed the EMR and observed a Health Status Note (HSN) dated 08/25/2023 at 08:33 AM. The LPN had documented that she had flushed Resident #275's right upper extremity PICC line however there were no PO to flush the line. She also documented that the PICC line was patent, intact with no signs and symptoms of infection. On 10/03/24 at 12:26 PM, the surveyor and the LPN/UM telephone interviewed the LPN regarding the documentation in the EMR on 8/25/2023 at 08:33 AM. The LPN stated that she could not remember the details about Resident #275 and that if there were no orders to flush Resident #275's PICC line, then maybe she documented on the wrong resident. The LPN had no further details regarding her documentation or Resident #275 On 10/03/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON) who explained that if a resident was admitted with PICC line, the nurse was responsible to find out when the PICC line was placed, confirm the PICC line's location, and length of PICC line. She stated that the nurse would be responsible to get an order from the physician for dressing changes and flushes. She stated that orders for flushes would be important to obtain to ensure that the PICC line remained patent. She also stated that it would be important to obtain orders for dressing changes to the PICC line site so that the resident was free from the potential of infection. The facility policy titled, Care and Maintenance of Central Venous Catheter implemented 09/01/2024, which indicated that the facility would adhere to accepted standards of practice regarding the care and maintenance of venous catheters. The policy indicated that compliance guidelines would include: -Document the indication for use. -Insertion date. -Type of catheter. The policy reflected that physician orders must be obtained for specific care and maintenance instructions and documentation activities should go into the nurse's notes and/or the Medication Administration Record. The facility policy titled Central Venous Access Catheter Flushing, Locking, and Removal implemented 09/01/2024, indicated that it was the policy of the facility to ensure that central venous catheters were flushed, locked, and removed consistent with current standards of practice. Compliance guidelines include obtaining physician's orders for the type of IV solution or medication, dose, rate, and length of treatment. The policy also indicated that the procedure would be documented. NJAC 8:39-27.1(a) 49712 3.) A review of Resident # 70's Admission Record indicated Resident #70 was admitted to the facility with diagnoses which include but were not limited to Heart Failure, Type 2 Diabetes Mellitus (a condition that occurs when the body doesn't respond properly to insulin, causing high blood sugar levels), and Morbid Obesity Due to Excess Calories ( a complex disease that occurs when the body stores to much fat due to an imbalance between calories consumed and calories used). A review of Resident #70's Treatment Administration Record (TAR) for March 2024 revealed a physician's order (PO) with an order date of 03/14/2024, for negative pressure therapy wound vac with Y connect to B/L [bilateral] hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed a blank on the TAR, there were no nurse's initials indicating the treatment was administered on 03/15/2024. Surveyor #3 observed a PO with and order date 03/07/2024 for Negative pressure therapy wound vac with Y connect to B/L hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024 and 03/13/2024. Surveyor #3 observed a PO with an order date of 03/07/2024 to change the wound vac canister weekly on Wednesdays. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/13/2024. Surveyor #3 observed a PO with an order date of 03/07/2024 to offload heals when in bed every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 04/09/2024 to check the function of an air mattress every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 04/09/2024 to apply skin prep to bilateral heels every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date 04/09/2024 to complete a pain assessment every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was not done on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 03/07/2024 to document lung sounds. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024 for day shift and 3/09/2024 on night shift. During an interview on 10/08/2024 at 09:42 AM with Surveyor #3 the Unit Manger (UM) # 1 stated, When there are blanks on the TAR it means the treatment was not signed off. When asked if there should be any blanks on the TARs, the UM replied, No. During an interview on 10/08/2024 at 02:22 PM with Surveyor #3 the Director of Nursing (DON) stated, It could mean that the nurse failed to sign out the treatment but it comes down to not documenting when asked what does it mean when there are blanks on the TAR. When asked if there should be any blanks, the DON replied, No. A Review of a facility provided policy titled Documentation of Wound Treatments dated 9/1/2024 revealed under Policy Explanation and Compliance Guidelines: that, 3. Wound treatments are documented at the time of each treatment. If no Treatment is due, an indication on the Status of the Dressing shall be documented each shift ( i.e., clean, dry, intact). A review of a facility provided policy titled Charting and Documentation with a reviewed date of 1/2024 revealed under, Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: b. Medications administered; c. Treatments or services performed; NJAC 8:39-27.1(a)

Complaint # NJ00177156, 00176805 Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received showers as scheduled for 1 of 2 sampled residents (Resident #21), reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: On 10/03/2024 at 10:39 AM, the surveyor observed Resident #21 in the room. He/She stated they would rather be home, but had no issues with this facility. According to the Admission Record Resident #21 was admitted to the facility with diagnosis that included but were not limited to intellectual disabilities and depression. The Minimum Data Set (MDS), an assessment tool, dated 08/28/2024 reflected that Resident # 21 was moderately cognitively impaired and that resident required substantial assistance with showering. A review of the September 2024 Treatment Administration Record (TAR) for Resident #21 reflected that the Resident was scheduled for showers every Sunday and Thursday on the day shift and if the resident refused a shower, staff should document in the electronic health record and the family must be notified. The same form reflected a blank for 09/5/2024. The form also reflected an n for 09/1/2024, 09/8/2024, 09/12/2024, 09/15/2024, 09/19/2024, 09/22/2024, and 09/26/2024. There was no documentation in the Progress Notes (PN), indicating the Resident refused to take showers and/or family was notified of the refusals for the month of September. On 10/04/2024 at 1:42 PM, the surveyor interviewed the Regional Clinical Director who stated that the nurses did not document in the progress notes however they did call and speak with the sister. She acknowledged that if something was not documented it was not done. On 10/07/2024 at 10:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who signed the September 2024 TAR. The LPN stated that most of the time Resident #21 refused the shower and she reached out to the family however it was not documented in the progress notes. She acknowledged that she should have documented it in the progress notes. A review of the facility's policy, titled, Bath, Shower/Tub reviewed on 01/2024, reflected : The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The same policy under Documentation revealed, The following information should be recorded on the resident's ADL record and/or in the resident's medical record. #5 If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. #6. The signature and the title of the person recording the data. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store, label, and remove expired drugs from the facility inventory. The deficient practice was observed in 1 of 3 medication rooms and 1 of 9 medication carts reviewed under the Medication Storage Task. On 10/04/2024 at 9:26 AM, the surveyor observed the [NAME] Wing Medication Storage room in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) #1. At that time, the surveyor observed the following concerns: Three cultures that expired on 09/23/2024. Three cultures that expired on 08/08/2024. Two urine vacutainers that expired on 06/30/2024. One 1000 milliliter (mL) bag of Dextrose solution that expired in July of 2024. Two bottles of Pantoprazole 2 milligram(mg)/mL with a use-by date of 08/30/2024. One bottle of Pantoprazole 2mg/mL with a use-by date of 09/27/2024. At that time, during an interview with the surveyor, the LPN/UM # 1 stated that all medication should have an opening date. Further, she stated that she did not know when the medication Pantoprazole expired but that it should be discarded after use. Lastly, she confirmed that the cultures and urine vacutainers were expired and needed to discard them. On the same date at 9:41 AM, the surveyor observed the [NAME] Wing odd-side medication cart in the presence of LPN # 1. At that time, the surveyor observed the bubble-package for the medication lorazepam 0.6 mg (medication used to treat symptoms of Anxiety). At that time, the surveyor observed that the paper on the back of the package was opened and torn for two tablets of lorazepam. At that time, LPN # 1 confirmed she did not look at the back of the package when she counted the medication in the morning. The LPN concluded by stating that she would notify the supervisor and discard the tablets. On the same date at 10:15 AM during an interview with the surveyor, LPN/UM # 1 said she did not know that when nurses were counting medications that they should be looking at the back of the package to ensure that the integrity of the paper that holds the medication was intact, worn, or torn. On the same date at 10:49 AM during an interview with the surveyor, the acting-Assistant Director of Nursing confirmed that when nurses count the medications, they should be looking at the front of the package and back of the package to ensure that nothing is worn, torn, or taped. Further, she said that if it is worn or torn, the medication could be lost, and the inventory could be wrong. She said that if the package is taped, then the nurse would not know if that were the correct medication. Lastly, if the issue is observed then the medication should be discarded, and the nurse should notify the supervisors and Director of Nursing before signing that the inventory was correct. On the same date at 1:03 PM during an interview with the surveyor, the Director of Nursing (DON) said that in-service education would be conducted for all nurses individually that tape is not to be used if the package is damaged, worn, or torn. A review of the facility provided policy titled, Storage of Medications updated on 1/2024 revealed under, Policy and Interpretation that, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. S 8:39-29.4 (a)

Complaint #NJ167309 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed fall. This deficient practice was identified for 1 of 4 residents (Resident #278) reviewed for accidents and was evidenced by the following: The surveyor reviewed the medical record for Resident #278. A review of the Admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Review of Resident #278's electronic medical record (EMR) Progress Notes revealed the following entries: On 07/22/2023 at 11:40 AM, a nursing progress note recorded, [Approximately] 11:35am, [ .lost their] balance and fell backward. [Vital signs] taken, body assessment performed, [pt] assisted back into bed. [Neurological] checks initiated and initial assessment [within normal limits] . The surveyor requested the full fall investigation for the above identified fall. Upon review of the facility provided Accident/Incident [sic] Report Checklist, the following was identified as being submitted but was not observed by the surveyor: Registered Nurse's Statement and Neurological Assessments. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) that a Licensed Practical Nurse was responsible for obtaining vital signs of a fallen resident and the Registered Nurse (RN) would complete the full resident assessment. LPN #1 confirmed that statements are obtained from any staff member that had contact with the fallen resident including, but not limited to, the LPN, RN, Certified Nursing Assistant (CNA). and the resident. LPN #1 explained that the statement would contain a thorough description of how the resident was found any interventions that were taken. During an interview with the surveyor on 10/8/2024 at 12:42 PM, the Licensed Practical Nurse Unit Manager (LPN/UM#2) advised that neurological checks were to be initiated with any unwitnessed fall and post fall documentation is expected to continue every shift for three days. LPN/UM#2 explained that the neurological checks were completed on a paper form then submitted with the post fall incident evaluation to the Director of Nursing (DON) who would be responsible for maintaining the documents and investigation. Upon review of Resident #278 EMR, LPN/UM#2 could not identify any post fall documentation. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) confirmed that a thorough fall investigation was not completed since statements were not obtained (specifically from the RN that completed the fall assessment), lack of post fall documentation of the neurological checks, follow-up documentation, and signature of the title person completing the report. The DON confirmed that the importance of investigating an unwitnessed fall was to rule out abuse. A review of a facility provided policy titled Accidents and Incidents-Investigating and Reporting revealed under section Policy Interpretation and Implementation that, 2. e.) The name(s) of witnesses and their accounts of the accident or incident [ .] l.) follow-up information [ .] n.) the signature and title of the person completing the report . A review of a facility provided policy titled Charting and Documentation revealed under section Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: a.) Objective observations; b.) Medications administered; c.) Treatments or services performed; d.) Changes in the resident's condition; e.) Events, incidents or accidents involving the resident; and f.) Progress toward or changes in the care plan goals and objectives [ .]. NJAC 8:39-9.4(f)

Complaint #: NJ00160150, NJ00169450, NJ00159215 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to, a.) provide sufficient staffing numbers to meet minimum staffing requirements and b.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: Refer F677(D) a.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One (1) direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. As per the Nurse Staffing Report completed by the facility for the weeks listed, the staffing-to-resident ratio did not meet the minimum requirements and is documented below: For the week of Complaint staffing from 10/23/2022 to 10/29/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 7 of 7 overnight shifts as follows: -10/23/22 had 12 CNAs for 133 residents on the day shift, required at least 17 CNAs. -10/23/22 had 3 total staff for 144 residents on the overnight shift, required at least 9 total staff. -10/24/22 had 13 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/24/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/25/22 had 14 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/25/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/26/22 had 13 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/26/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/27/22 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/27/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/28/22 had 13 CNAs for 139 residents on the day shift, required at least 17 CNAs. -10/28/22 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -10/29/22 had 9 CNAs for 138 residents on the day shift, required at least 17 CNAs. -10/29/22 had 7 total staff for 138 residents on the overnight shift, required at least 10 total staff. For the week of Complaint staffing from 12/11/2022 to 12/17/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in CNAs to total staff on 1 of 7 evening shifts, and deficient in total staff for residents on 7 of 7 overnight shifts as follows: -12/11/22 had 14 CNAs for 130 residents on the day shift, required at least 16 CNAs. -12/11/22 had 3 total staff for 130 residents on the overnight shift, required at least 9 total staff. -12/12/22 had 12 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/12/22 had 3 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/13/22 had 13 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/13/22 had 9 CNAs to 20 total staff on the evening shift, required at least 10 CNAs. -12/13/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/14/22 had 12 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/14/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/15/22 had 13 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/15/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/16/22 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -12/16/22 had 3 total staff for 137 residents on the overnight shift, required at least 10 total staff. -12/17/22 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -12/17/22 had 3 total staff for 137 residents on the overnight shift, required at least 10 total staff. For the 3 weeks of Complaint staffing from 12/03/2023 to 12/23/2023, the facility was deficient in CNA staffing for residents on 21 of 21 day shifts, deficient in total staff for residents on 1 of 21 evening shifts, and deficient in total staff for residents on 21 of 21 overnight shifts as follows: -12/03/23 had 12 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/03/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/04/23 had 13 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/04/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/05/23 had 13 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/05/23 had 4 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/06/23 had 14 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/06/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/07/23 had 13 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/07/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/08/23 had 14 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/08/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/09/23 had 12 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/09/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/10/23 had 12 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/10/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/11/23 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -12/11/23 had 4 total staff for 144 residents on the overnight shift, required at least 10 total staff. -12/12/23 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -12/12/23 had 3 total staff for 144 residents on the overnight shift, required at least 10 total staff. -12/13/23 had 13 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/13/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/14/23 had 14 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/14/23 had 4 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/15/23 had 13 CNAs for 141 residents on the day shift, required at least 18 CNAs. -12/15/23 had 3 total staff for 141 residents on the overnight shift, required at least 10 total staff. -12/16/23 had 13 CNAs for 139 residents on the day shift, required at least 17 CNAs. -12/16/23 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -12/17/23 had 13 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/17/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/18/23 had 9 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/18/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/19/23 had 14 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/19/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/20/23 had 12 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/20/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/21/23 had 14 CNAs for 141 residents on the day shift, required at least 18 CNAs. -12/21/23 had 3 total staff for 141 residents on the overnight shift, required at least 10 total staff. -12/22/23 had 11 CNAs for 139 residents on the day shift, required at least 17 CNAs. -12/22/23 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -12/23/23 had 14 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/23/23 had 10 CNAs to 23 total staff on the evening shift, required at least 11 CNAs. -12/23/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. On 12/29/23 at 7:39 AM, the surveyor interviewed CNA #3 who stated CNAs are usually assigned to 11 to 14 residents because of being short staffed often. The CNA further stated they will have only 9 resident assignment if lucky. On 12/29 at 8:25 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1), who stated short staffing could be a potential cause of resident incontinence care being affected. On 12/29/23 at 8:40 AM, the surveyor interviewed the Director of Nursing (DON) regarding staffing. The DON confirmed the required staffing ratio and stated she believed it was being met. On 12/29/23 at 9:52 AM, the surveyor interviewed the staffing coordinator. She stated the CNA staffing ratios for the 7 AM to 3 PM shift was 8 residents per CNA, for the 3 PM to 11 PM shift 10 residents per CNA, for the 11 PM to 7 AM shift 14 residents per CNA. She stated the facility meets these ratio requirements when there are no call outs but stated we have a lot of those (meaning call outs). She further stated since the facility runs on 12-hour nursing shifts, it's tricky. b.) On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2 and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. Resident #13's sheets were dry, and no odors were discovered. At that time, the resident granted permission for the surveyors to observe their incontinence brief. Surveyor #1 observed an incontinence brief applied to the resident. The CNA opened that brief exposing an additional brief underneath. The addition brief was damp. At this time the CNA informed the surveyors that residents should not be double briefed. He stated the reason the resident may have had two briefs put on was due to being a heavy wetter. On 12/29/23 at 8:05 AM, Survey# 1 and Surveyor #2 in the presence of CNA #4 observed Resident #14 in bed. Resident #14's sheets were dry, and no odor was discovered. At that time, the resident granted permission for surveyors to observe their incontinence brief. Surveyor #1 observed an incontinence brief applied to resident. The CNA opened the brief exposing an additional brief underneath. The additional brief was damp. At that time, CNA #4 stated that residents should never be double briefed with two incontinence briefs. The resident then asked the CNA to be helped to the toilet so that they could use the commode. Review of the facility's provided staffing policy titled Nursing Services dated 2/1/2022 included but was not limited to, .the facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment . providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident needs . Review of the facility's Activities of Daily Living (ADLs) policy (Updated 1/2023) indicated the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). NJAC 8:39-5.1(a), 27.1 (a), 27.2 (h)

Complaint #: NJ00160150 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to dependent residents. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2, and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. At that time, the resident granted permission for the surveyors to observe his/her incontinence brief. Surveyor #1 observed an incontinence brief applied to the resident. The CNA opened that brief exposing an additional brief underneath. The addition brief was damp. At this time CNA #3 informed the surveyors that residents should not be double briefed. He stated the reason this resident may have had two briefs put on is due to being a heavy wetter. On 12/29/23 at 8:05 AM, Surveyor # 1 and Surveyor #2 in the presence of CNA #4 observed Resident #14 in bed. Resident #14's sheets were dry, and no odor was discovered. At that time, the resident granted permission for surveyors to observe his/her incontinence brief. Surveyor #1 observed an incontinence brief applied to resident. CNA #4 opened the resident's brief exposing an additional brief underneath. The additional brief was damp. At that time, CNA #4 stated that residents should never be double briefed with two incontinence briefs. The resident then asked the CNA to be helped to the toilet so that they could use the commode. On 12/29/23 at 8:10 AM, the surveyor interviewed the Licensed Practical Nurse #3 (LPN #3), who stated that the majority of residents on this nursing unit have incontinence and require staff to check them every two hours. LPN #3 stated incontinence briefs should never be doubled up when applied to residents as it could cause skin disorders. On 12/29 at 8:25 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1), who stated residents should not be double diapered. She further stated, applying double briefs on residents could cause skin breakdown, and stated, I'm appalled, I don't know what happened. The RN/UM stated that short staffing could be a cause as to why this occurred, and that the CNA's receive education and know better. On 12/29/23 at 8:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated incontinent residents should be checked every two hours, and if they were a heavy wetter then they should be checked more frequently. The DON stated residents should never be double diapered, stating we don't practice that, it can cause skin breakdown. The DON stated that old school CNA's might double diaper, and it is not acceptable. According to the Admission Record, Resident #13 had diagnoses that included, but were not limited to: dementia and cerebral infarction (stroke). Review of Resident #13's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/4/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further revealed that Resident #13 was incontinent. According to the Admission Record, Resident #14 had diagnoses that included, but were not limited to: dementia and failure to thrive. Review of Resident #14's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further revealed that Resident #14 was incontinent. Review of the facility's Activities of Daily Living (ADLs) policy (Updated 1/2023) indicated the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). NJAC 8:39-27.1 (a), 27.2 (h)

C# NJ Based on observation, interviews and review of medical records, it was determined that the facility failed to consistently review and/or revise the care plan with appropriate interventions for 1 of 2 cognitively impaired residents (Resident #1) identified as at high risk for falls. Resident #1 had five falls from 2/21/12 to 4/1/12. The fall on 4/1/12 resulted in a fractured nose, head injury and a hand contusion. The evidence of this deficiency included: 1. The Resident Assessment Instrument dated 3/22/12 indicated that Resident #1 was cognitively impaired and required assistance with most activities of daily living, eating with supervision. His [DIAGNOSES REDACTED]. A psychological follow-up dated 2/17/12 included a reassessment concerning the Resident's "cognitive/functional/behavioral status." He was found to be "alert, disoriented x (times) 2 ... distractible..." His "learning/memory -(was) impaired, problem solving compromised..."judgment and insight impaired" with "decreased insight into his own behavior". Also "these above weaknesses have been present for years and there is no potential for this to change at this time." The most recent Fall Risk assessment dated [DATE] indicated the Resident was found to be "alert - (oriented x 3)", had 3 or more falls in the past 3 months and he was chair bound. His "gait/balance" indicated a balance problem while standing and walking, jerking or unstable when making turns and required use of an assistive device or wheel chair. There were no "predisposing diseases" indicated. A total score of "8" (total score of 10 or above represents a high risk for falls) was indicated. However an arithmetic error was made in calculating the score and the actual total score should have been "12", indicating the Resident was at high risk for falls. A Care Plan, dated 2/23/11 was faxed to the Department of Health and Senior Services with a Reportable Event Record/Report (FRE) dated 4/2/12. This Care Plan indicated that Resident #1 was "at risk of falls" related to "[MEDICAL CONDITION] drug use and cognitive impairment". Interventions included to monitor during high risk activity time and to encourage participation in diversional programs. On 5/3/11 interventions to place personal items within easy reach, ensure adaptive equipment be used, nonslip footwear and call bell within reach were added. Documentation in this Care Plan also showed a fall occurred on 2/6/12. An intervention dated 2/6/12 to "ensure safety" was to assist the Resident to the business office. Although there was no description of a fall in the Care Plan, a review of an incident report dated 2/6/12 at 11:00am indicated that the Resident was found on the floor of a ramp with his wheel chair behind him and that he was going to the business office without assistance. There were no injuries related to this fall and there were no further falls related to going to the business office. On 1/23/12 a "bed/chair alarm" was initiated to prevent falls. Another Care Plan, given to the Surveyor during the onsite survey, was preprinted (computer generated) and reiterated the above Care Plan interventions. Entries dated 5/3/11 included "place my personal items that I use daily within easy reach" and "call bell within reach". Entries dated 4/2/12 for "alarms", floor "mats" and "... bed in lowest position and lock brakes" were documented, however there were blank areas that failed to indicate the type of alarm(s) and when the alarms were to be used. Additional blank spaces failed to identify which side(s) of the bed the floor mats should be placed. a. Documentation in the incident report indicated that on 2/21/12 at 6:45pm a Certified Nurse Assistant (CNA) heard a "thump" and upon entering the room she found the Resident on the floor with socks on his feet. The Resident told staff that he was trying to get "candy" and "became dizzy and fell ." Staff documented, "it was noted that the bed alarm was turned off by (Resident)." It was also documented in the incident report that he was "alert, oriented, follows directions...improper footwear....ambulating without assistance..mentally challenged, very non compliant....history of recent fall". No injuries were observed. The Interdisciplinary Progress Note (IPN) on 2/21/12 at 7:45pm documented "reminded Resident to use call bell when he needs assistance and to please avoid standing alone, reminded CNA's to check Resident often and continue to check alarm often to ensure Resident has not turned alarm off." Another entry at 8:20pm indicated that staff had "checked" the Resident's alarm and found that it had been turned off. The Resident was asked who had turned it off and he stated "I did (it) makes noise". The Resident was asked to leave alarm on for his safety. b. The incident report dated 2/23/12 at 1:10pm and an IPN timed at 5:45pm indicated an "unwitnessed" fall when the Resident fell out of his wheel chair while attempting to pick up a napkin from the floor in the dining room. It was also documented that the Resident was "alert, oriented, follows directions...is non-compliant with getting up out of his wheelchair without assistance." Staff "reinforced" with the Resident to "call for help if something is out of his reach." There was no documentation that the chair alarm intervention had been implemented or if the Resident had the cognitive ability to comply with staff instructions. . c. Documentation in the IPN dated 3/1/12 at 4:30am indicated that on 2/29/12 at 11:40pm, an "unwitnessed" event occurred. The Resident was found on the floor when a nurse heard "a loud noise" coming from his room. The Resident told staff that he fell out of bed and hit his head while reaching for a cup of water. There was no documentation in the IPN or incident report if the bed alarm was applied and/or disabled prior to the fall or if the cup of water was within his reach. d. An IPN dated 3/5/12 at 12:30pm, documented that the Resident was found coming out of the bathroom with his pants around his ankles. Staff noted that the chair alarm was in place but had been "turned off". The Resident told staff "I know how to turn that off." e. Documentation in the IPN dated 3/29/12 at 11:15am, showed the Resident was "found sitting on bedroom floor" and he told staff that he hit his head. There was no incident report and/or investigation provided to the Surveyor at the time of survey. During interview with the Interim Director of Nurses on 4/9/12 at 11:05am, she confirmed that there was no incident report and/or investigation for the fall that occurred on 3/29/12, in the computer and she could not provide the Surveyor with any information related to this fall. She stated that "every fall has to have an incident report." In a post survey telephone interview on 4/20/12 at 8:20am, the Licensed Practical Nurse (LPN) stated that she worked on 3/29/12 when the Resident fell and that the incident report was handwritten (instead of computer generated) because "the computers were down." The incident report was faxed to the Surveyor on 4/20/12 at 8:50am. f. A Reportable Event Record/Report (FRE) dated 4/2/12, indicated the Resident on 4/1/12 at 5:50am was found on the floor of his room and that he hit his head. Although the FRE showed that a "bed and chair alarm in place" there was no indication that the alarm sounded or if it had been shut off by the Resident prior to the fall. According to an IPN, dated 4/1/12 at 8:00am and incident report also dated 4/1/12 at 5:50am, staff heard a "thump" from the Resident's room and "pt (patient) called 'help'" staff found the Resident "lying face down on floor next to (his) bed surrounded by puddle of ice water (from water pitcher)." "Mod. (moderate) amount of facial bleeding of indeterminate origin noted." "Pt stated his face hurt, denied pain anywhere else. Pt. requesting ice water during assessment. The Resident told staff "I wanted ice water." He was transported to the hospital for evaluation. Documentation also indicated that he was "forgetful". Further review of the incident report indicated that Resident #1 had a "Nasal deformity" with "crepitus noted on palpation" and an "Oval swelling noted on forehead." The Resident's "Mental Status" indicated "Alert, disoriented ..." and "forgetful." The Predisposing Environmental Factors indicated a "floor surface spill" and "wet area". The Predisposing Physiological Factors included a "Functional disability...", "Gait, balance, visual impairment", "History of recent fall" and "Alteration in level of consciousness". The Predisposing Situation Factors indicated that he was "Walking without proper assistive device". Documentation in the IPN dated 4/2/12 at 5:00pm, showed the bed/chair alarm was "intact and functioning noted x 3 incidents. Saw Resident turn chair alarm off" and it was turned back on and "explained to Resident the importance of alarm for safety." The Physician documented in an IPN dated 4/2/12 (untimed) that "Pt keeps falling, impulsive while in w/c (wheel chair)", "awake, alert". "Multiple fall/DM (Diabetes Mellitus)/Dementia/[MEDICAL CONDITIONS]" and "Fall precautions." There was no indication that the Physician was aware that the Resident at times would disable the bed/chair alarm. On 4/4/12 at 9:40am the Surveyor observed the Resident sitting in his wheel chair in the hallway. The Resident was observed with a fading bruise on his forehead. The chair alarm was on and in place and sounded when checked. When asked why he turns the alarm off he stated, because "(it) makes noise". During interview with a CNA on 4/4/12 at 11:50am, she stated that she checks the Resident "frequently to make sure it (bed/chair alarm) is on because he will turn it off." In an interview with another CNA on 4/9/12 at 11:20am, she stated that she was told in shift report to watch him closely and that staff "doesn't reach him in time before he falls." The Surveyor observed that on 4/4/12 and 4/9/12 that the Resident had a regular bed that could not be lowered and no floor mats. The CNA confirmed that his bed "did not go to the floor and that he did not have floor mats." The Unit Manager stated on 4/9/12 at 9:50am the Resident had been transferred to the hospital for a change in condition (unrelated to a fall). She stated that she ordered a low bed on 4/6/12 and that the Resident did not have floor mats as indicated in the Care Plan dated 4/2/12. During interview with the Director of Nurses (Interim) on 4/9/12 at 11:05am, she stated that "every fall has to have an incident report." She also acknowledged that two of the falls were related to the Resident "attempts to get water." In a post survey telephone interview on 4/20/12 at 8:20am, the Licensed Practical Nurse (LPN) verified that an intervention to prevent falls was to remind the Resident to use the call bell. She also stated that he "would not use it" and he would say that he "couldn't find it even if it was beside him." If he was out of his room, "he'd pick things up from floor or get up to close a door." He was "noncompliant and wouldn't listen." She further stated that "we just found out he removes the phone tab out of back of alarm" and that "one time" she observed him pull the cord out of the alarm box, inactivating the bed/chair alarm. On page 5 of the "Care Plans - Comprehensive policy "An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident...Care Plans are revised as changes in the resident's condition dictate....Care Plans are reviewed at least quarterly". NJAC 8:39-27.1(a)

C# NJ Based on observation, interviews and review of medical records and other information, it was determined that the facility failed to consistently implement identified safety interventions to prevent falls for 1 of 4 cognitively impaired residents (Resident #1) identified as a high risk for falls. Resident #1 had five falls from 2/21/12 to 4/1/12. The fall on 4/1/12 resulted in a fractured nose, head injury and a hand contusion. The evidence of this deficiency included: 1. The Resident Assessment Instrument dated 3/22/12 indicated that Resident #1 was cognitively impaired and required assistance with most activities of daily living. His [DIAGNOSES REDACTED]. A psychological follow-up dated 2/17/12 included a reassessment concerning the Resident's "cognitive/functional/behavioral status." He was found to be "alert, disoriented x (times) 2 ... distractible..." His "learning/memory -(was) impaired, problem solving compromised..."judgment and insight impaired" with "decreased insight into his own behavior". Also "these above weaknesses have been present for years and there is no potential for this to change at this time." The most recent Fall Risk assessment dated [DATE] indicated the Resident was found to be "alert - (oriented x 3)", had 3 or more falls in the past 3 months and he was chair bound. His "gait/balance" indicated a balance problem while standing and walking, jerking or unstable when making turns and required use of an assistive device or wheel chair. There were no "predisposing diseases" indicated. A total score of "8" (total score of 10 or above represents a high risk for falls) was indicated. However an arithmetic error was made in calculating the score and the actual total score should have been "12" indicating the Resident was at high risk for falls. A Care Plan, dated 2/23/11 was faxed to the Department of Health and Senior Services with a Reportable Event Record/Report (FRE) dated 4/2/12. This Care Plan indicated that Resident #1 was "at risk of falls" related to "psychotropic drug use and cognitive impairment". Interventions were to monitor during high risk activity time and to encourage participation in diversional programs. On 5/3/11 interventions included, place personal items within easy reach, ensure adaptive equipment (wheelchair) used, nonslip footwear and call bell within reach. Documentation in this Care Plan also showed on 1/23/12 that a "bed/chair alarm" was initiated to prevent falls. An intervention dated 2/6/12 to "ensure safety" was to assist the Resident to the business office. Although there was no description of a fall in the Care Plan, a review of an incident report dated 2/6/12 at 11:00am indicated that the Resident was found on the floor of a ramp with his wheel chair behind him and that he was going to the business office without assistance. There were no injuries related to this fall and there were no further falls related to going to the business office. Another Care Plan, given to the Surveyor during the onsite survey, was preprinted (computer generated) and reiterated the above Care Plan interventions. Entries dated 5/3/11 included "place my personal items that I use daily within easy reach" and "call bell within reach". Entries dated 4/2/12 for "alarms", floor "mats" and "... bed in lowest position and lock brakes" were documented, however there were blank areas that failed to indicate the type of alarm(s) and when the alarms were to be used. Additional blank spaces failed to identify which side(s) of the bed the floor mats should be placed. a. Documentation in the incident report indicated that on 2/21/12 at 6:45pm a Certified Nurse Assistant (CNA) heard a "thump" and upon entering the room she found the Resident on the floor with "... socks on" his feet. The Resident told staff that he was trying to get "candy" and "became dizzy and fell ." Staff documented, "it was noted that the bed alarm was turned off by (Resident)." It was also documented in the incident report that he was "alert, oriented, follows directions...improper footwear....ambulating without assistance..mentally challenged, very non compliant....history of recent fall". No injuries were observed. The Interdisciplinary Progress Note (IPN) on 2/21/12 at 7:45pm documented "reminded Resident to use call bell when he needs assistance and to please avoid standing alone, reminded CNA's to check Resident often and continue to check alarm often to ensure Resident has not turned alarm off." Another entry at 8:20pm indicated that staff had "checked" the Resident's alarm and found that it had been turned off. The Resident was asked who had turned it off and he stated "I did (it) makes noise". The Resident was asked to leave alarm on for his safety. b. The incident report dated 2/23/12 at 1:10pm and an IPN timed at 5:45pm indicated an "unwitnessed" fall when the Resident fell out of his wheel chair while attempting to pick up a napkin from the floor in the dining room. It was also documented that the Resident was "alert, oriented, follows directions...is non-compliant with getting up out of his wheelchair without assistance." Staff "reinforced" with the Resident to "call for help if something is out of his reach." There was no documentation that the chair alarm intervention had been implemented or if the Resident had the cognitive ability to comply with staff instructions. c. Documentation in the IPN dated 3/1/12 at 4:30am indicated that on 2/29/12 at 11:40pm, an "unwitnessed" event occurred. The Resident was found on the floor when a nurse heard "a loud noise" coming from his room. The Resident told staff that he fell out of bed and hit his head while reaching for a cup of water. There was no documentation in the IPN or incident report if the bed alarm was applied and/or disabled prior to the fall or if the cup of water was within his reach. d. An IPN dated 3/5/12 at 12:30pm, documented that the Resident was found coming out of the bathroom with his pants around his ankles. Staff noted that the chair alarm was in place but had been "turned off". The Resident told staff "I know how to turn that off." e. Documentation in the IPN dated 3/29/12 at 11:15am, showed the Resident was "found sitting on bedroom floor" and he told staff that he hit his head. There was no incident report and/or investigation provided to the Surveyor at the time of survey. During interview with the Interim Director of Nurses on 4/9/12 at 11:05am, she confirmed that there was no incident report and/or investigation for the fall that occurred on 3/29/12, in the computer and she could not provide the Surveyor with any information related to this fall. She stated that "every fall has to have an incident report." In a post survey telephone interview on 4/20/12 at 8:20am, the Licensed Practical Nurse (LPN) stated that she worked on 3/29/12 when the Resident fell and that the incident report was handwritten (instead of computer generated) because the computers were down." The incident report was faxed to the Surveyor on 4/20/12 at 8:50am. f. A Reportable Event Record/Report (FRE) dated 4/2/12, indicated the Resident on 4/1/12 at 5:50am was found on the floor of his room and that he hit his head. Although the FRE showed that a "bed and chair alarm in place" there was no indication that the alarm sounded or if it had been shut off by the Resident prior to the fall. According to an IPN, dated 4/1/12 at 8:00am and incident report, also dated 4/1/12 at 5:50am, staff heard a "thump" from the Resident's room and "pt (patient) called 'help'" staff found the Resident "lying face down on floor next to (his) bed surrounded by puddle of ice water (from water pitcher)." "Mod. (moderate) amount of facial bleeding of indeterminate origin noted." "Pt stated his face hurt, denied pain anywhere else. Pt. requesting ice water during assessment." The Resident told staff "I wanted ice water." He was transported to the hospital for evaluation. Documentation also indicated that he was "forgetful". Review of the emergency department information dated 4/1/12, indicated the Resident was observed with increasing facial swelling and pain over his nose, an elevated temperature of 100 degrees Fahrenheit, headache, excessive drowsiness, inability to breath from both sides of his nose and sinus pain. The discharge [DIAGNOSES REDACTED]. He returned to the facility the same day with ice being applied to his nose and left hand. Further review of the incident report indicated that Resident #1 had a "Nasal deformity" with "crepitus noted on palpation" and an "Oval swelling noted on forehead." The Resident's "Mental Status" indicated "Alert, disoriented ..." and "forgetful." The Predisposing Environmental Factors indicated a "floor surface spill" and "wet area". The Predisposing Physiological Factors included a "Functional disability...", "Gait, balance, visual impairment", "History of recent fall" and "Alteration in level of consciousness". The Predisposing Situation Factors indicated that he was "Walking without proper assistive device". Documentation in the IPN dated 4/2/12 at 5:00pm, showed the bed/chair alarm was "intact and functioning noted x 3 incidents. Saw Resident turn chair alarm off" and it was turned back on and "explained to Resident the importance of alarm for safety." The Physician documented in an IPN dated 4/2/12 (untimed) that "Pt keeps falling, impulsive while in w/c (wheel chair)", "awake, alert". "Multiple fall/DM (Diabetes Mellitus)/Dementia/COPD (Chronic Obstructive Pulmonary Disease)" and "Fall precautions." There was no indication that the Physician was aware that the Resident at times would disable the bed/chair alarm. On 4/4/12 at 9:40am the Surveyor observed the Resident sitting in his wheel chair in the hallway. The Resident was observed with a fading bruise on his forehead. The chair alarm was on and in place and sounded when checked. When asked why he turns the alarm off he stated, because "(it) makes noise". During interview with a CNA on 4/4/12 at 11:50am, she stated that she checks the Resident "frequently to make sure it (bed/chair alarm) is on because he will turn it off." In an interview with another CNA on 4/9/12 at 11:20am, she stated that she was told in shift report to watch him closely and that staff "doesn't reach him in time before he falls." The Surveyor observed that on 4/4/12 and 4/9/12 that the Resident had a regular bed that could not be lowered and no floor mats. The CNA confirmed that his bed "did not go to the floor and that he did not have floor mats." The Unit Manager stated on 4/9/12 at 9:50am that the Resident had been transferred to the hospital for a change in condition (unrelated to a fall). She stated that she ordered a low bed on 4/6/12 and that the Resident did not have floor mats as indicated in the Care Plan dated 4/2/12. During interview with the Director of Nurses (Interim) on 4/9/12 at 11:05am, she acknowledged that two of the falls were related to the Resident "attempts to get water." In a post survey telephone interview on 4/20/12 at 8:20am, the Licensed Practical Nurse (LPN) verified that an intervention to prevent falls was to remind the Resident to use the call bell. She also stated that he "would not use it" and he would say that he "couldn't find it even if it was beside him." If he was out of his room, "he'd pick things up from floor or get up to close a door." He was "noncompliant and wouldn't listen." She further stated that "we just found out he removes the phone tab out of back of alarm" and that "one time" she observed him pull the cord out of the alarm box, inactivating the bed/chair alarm. In the "Monitoring Subsequent Falls and Fall Risk" section of the "Falls and Fall Risk, Managing" policy included "The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling." "If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions." NJAC 8:39-27.1(a)