Every finding on record at Complete Care at Plainfield LLC

Based on observations, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents.This deficient practice was identified on 1 of 2 nursing units (South Wing) and was evidenced by the following:On 7/20/26 at 7:47 AM, during the initial tour of the South Wing, the surveyor observed the following:-Entering the South Wing, the tile was noted to be a cream color tile, which was different than the brown colored flooring in the main lobby-Outside of the Utility room door, the floor had areas of buildup of a black substance and yellow substance-All along the outside of the nurse's station, there were areas of yellow and black buildup and multiple areas of cracked tiles-Outside room [ROOM NUMBER], the floor had a buildup of yellow discoloration-Near room [ROOM NUMBER], in the doorway, the floor was cracked from one side of the hallway to the other-Outside room [ROOM NUMBER], the floor had a buildup of black discoloration-Outside and inside of room [ROOM NUMBER], the floor had a buildup of black discoloration-Outside room [ROOM NUMBER], the floor had a buildup of yellow discoloration-Outside room [ROOM NUMBER], the floor had a buildup of black discoloration, and the wall had multiple scrape marks in it from the handrail down to the floor. On 7/20/26 at 9:18 AM, the surveyor toured the North Wing and observed the unit had the same brown colored flooring as the lobby.On 7/21/26 at 10:57 AM, the surveyor toured South Wing and noted the floors in same condition as the first observations.On 7/23/26 at 9:38 AM, the surveyor toured the South Wing and made the following additional observations:-Outside room [ROOM NUMBER], the floor had cracked tiles and a buildup of black discoloration-Between rooms [ROOM NUMBERS], there were cracked floor tiles, the floor had a buildup of black discoloration, and the handrail had multiple scrape marks-room [ROOM NUMBER] had cracked floor tiles at the entrance of the room; the bathroom door and the room door had multiple scrape marks-Between room [ROOM NUMBER] and the manager's nurse station there were multiple cracked tiles On 7/23/26 at 9:53 AM, the surveyor interviewed the porter, who stated he was responsible for the hallways on both units. He stated he swept and mopped the hallways on both units every day. The porter stated he scrubbed the walls up and down every day. He stated the last time he had done the stripping and the waxing of the floors on the South Wing was in June 2026. The porter stated he needed someone to cover the floors so he could do the stripping and waxing but he did not have anyone to cover him.On 7/23/26 at 9:55 AM, the surveyor interviewed the Director of Housekeeping (DH), who stated he makes environmental rounds 2 to 3 times a week. He stated the porter's responsibility was the hallways, mopping, sweeping, emptying trash, buffing twice a week but it was not always done due to other projects. The DH stated the South Wing hallway floors were stripped of the wax because they were working on the rooms. He stated the yellow and black buildup on the floors was from the wax that was still sitting there. The DH stated he had a meeting with the district manager and came up with a plan for the floors but stated he was unable to show the surveyor the plan because there was nothing in writing, it was only verbal. At 10:06 AM, the surveyor went to the South Wing with the DH. He acknowledged the black substance buildup in front of the soiled utility room and stated it was buildup. At that time, he obtained a spray bottle and a scraper. He sprayed the black substance and scraped it; the black substance immediately came up. On 7/23/26 at 10:23 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged there was a drastic difference in the South Wing's flooring. He stated the flooring was approved to be replaced on the North Wing in the past, but the South Wing flooring had not been approved yet.On 7/23/26 at 10:25 AM, the LNHA toured South Wing with the surveyor, he acknowledged the cracks in the floor, the cracked floor tiles, the hallway walls with the scrape marks, the buildup of the black and yellow discoloration on the floor for the entire unit as mentioned above. A review of the facility provided [NAME] Daily Schedule for the day shift and the Evening Porter for the evening shift did not reveal stripping and waxing were included in the schedules.On 7/23/2026 at 1:49 PM, during a meeting with the survey team, the LNHA, the regional LNHA, the Director of Nursing and the Regional Clinical Nurse were made aware of the above concerns. A review of the facility's policy Preventative Maintenance Program date implemented 9/30/2025, revealed Policy: A Preventative Maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.A review of the facility provided undated/untitled policy for floor care revealed Housekeeping In-Service Floor Care: Equipment needed.3 Scraper and rag.Mopping procedure: Hallway.use scraper to clean corners, along baseboards or to pick up any substance stuck to the floor. Occasional care: the area 1/4 along the baseboard collects dust and debris left by the buffer and mop. It is necessary to scrub and scrape these areas to ensure a clean appearance.Tile:.scraper-cleans surface spills. Use as needed. Buffing machine-used on a regular basis to clean and scrub surfaces of ceramic tile. Stripping pads-hard nylon pads used to scrub surfaces of ceramic tile. Nylon brush can also be used. NJAC 8:39-31.4(a)(b)(f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nursing staffing report daily. This deficient practice was evidenced by the following: On 7/20/26 at 7:19 AM, on entrance and initial tour, the posted staffing at the reception desk was noted to be dated 7/16/26 and included the staffing for the evening and night shifts for 7/16/26.On 7/23/26 at 9:29 AM, the surveyor interviewed the staffing coordinator (SC), who stated she was responsible for the staffing being posted. The SC further stated that on Fridays she would leave the papers for the weekends and then updated them when she got in. On 7/23/26 at 1:49 PM, the survey team met with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Regional Clinical Nurse, and the Regional LNHA and notified them of the above concerns. The LNHA stated that usually the SC handed the papers to the receptionist who would then post it. He acknowledged that the staffing should have been posted over the weekend. NJAC 8:39-41.2 (a)(b)(c)

Based on observation, interviews and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting the administration times of a medication, (Phos-NaK)(a phosphate and sodium supplement to treat low phosphorus levels and prevent kidney stones), to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times. This deficient practice was identified for three (3) of 28 doses on dialysis days for one (1) of (1) residents, (Resident #5), reviewed for dialysis services and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/20/2026 at 7:03 AM, the surveyor observed Resident #5 in bed with eyes closed. On 7/20/2026 at 8:30 AM, the surveyor observed Resident #5 in their room sitting up in bed with a breakfast tray on their overbed table. The surveyor attempted to interview the resident. The resident spoke another language and gave a thumbs up. The surveyor reviewed the electronic medical record for Resident #5. A review of the admission Record revealed diagnoses that included, but not limited to; end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis, anemia (low levels of healthy red blood cells), chronic kidney disease (CKD), metabolic encephalopathy (a brain function disorder caused by systemic illness, organ failure or chemical imbalances in the body), hypertension (high blood pressure), Type 2 Diabetes Mellitus (DM) (chronic condition the body does not use insulin properly leading to high blood sugar levels). A review of a comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 5/28/2026, reflected the resident had a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's individual comprehensive care plan (ICCP) revealed a focus area, with an initiated date of 8/25/25 and a revision date of 7/20/26, that Resident #5 needed hemodialysis related to renal failure at a dialysis center outside of the facility on Tuesdays, Thursdays, and Saturdays with a pickup time of 9:30 AM and a chair time of 10:30 AM. The interventions included but were not limited to; encouraging the resident to go for the scheduled dialysis appointments and indicated the dialysis center's name and address. Further review of the ICCP revealed a focus area for nutrition, dated as initiated 8/26/25 and revision dated 7/22/26 which indicated the resident had a history of abnormal phosphorus labs. The interventions included but were not limited to; provide supplements as ordered. A review of the resident's Order Summary Report (OSR) revealed a physician's order (PO) dated 5/21/26 for dialysis included the name of the dialysis center, days (Tuesday, Thursday and Saturday), and the time of pickup for 9:30 AM and chair time for 10:30 AM. Further review of the OSR revealed a PO with a start date of 7/5/26 for Phos-NaK Oral Packet 280-160-250 MG (milligrams) (Potassium & Sodium Phosphates), Give 1 packet by mouth four times a day for supplement for 7 days. A review of the July 2026 electronic medication administration record (EMAR), revealed on July 7th, 9th , and 11th at 13:00 (1:00 PM), the coded number 7 was entered. The corresponding Chart Code for 7 indicated other/see nurse notes. A review of the corresponding nursing electronic progress notes (EPN) for the above EMAR documentation revealed the following:-on 7/7/26 at 14:08 (2:08 PM) dialysis -on 7/9/26 at 12:34 (12:34 PM) OUT TO DIALYSIS-on 7/11/26 at 12:05 (12:05 PM) out to dialysis On 7/22/2026 at 9:53 AM, the surveyor interviewed the Registered Nurse (RN#1) who stated she was the medication nurse for Resident #5. RN #1 explained when a resident received dialysis, their medication was reviewed and the time of administration was usually switched so there were no medications that were supposed to be administered while the resident was out to dialysis. The surveyor, with RN #1, reviewed Resident #5's EMAR. RN #1 verified on 7/7/26 at 1:00 PM she had entered the coded number 7 which meant the resident was not administered the medication. RN #1 added there was a nursing note explaining the reason, that the resident was out to dialysis. RN #1 explained the PO for Phos-NaK was a new order for four times a day for seven days but at 1:00 PM on 7/7/26 the resident was at dialysis, and she wrote a progress note indicating that. RN #1 was unable to speak to why the PO was not changed to accommodate the time the resident was out to dialysis. RN #1 stated she did not enter the PO in the EMAR and would have to follow up with the Unit Manager (UM). RN #1 again stated she followed the PO and had not administered the Phos-NaK on 7/7/26 at 1 PM because the resident was not available. On 7/22/2026 at 10:02 AM, the surveyor interviewed the UM/Licensed Practical Nurse (UM/LPN #1), who stated when a resident received dialysis, the medications had to be reviewed with the physician and have the times changed to accommodate the dialysis times. The surveyor, with UM/LPN #1, reviewed the EMAR for Resident #5 and verified at 1 PM on 7/7, 7/9 and 7/11 the Phos-NaK was not administered because the resident was out to dialysis. UM/LPN #1 stated she thought the physician was notified. UM/LPN #1 added she thought that would be documented in the progress notes and would have to check. On 7/23/2026 at 10:14 AM, UM/LPN #1 stated the PO was for seven days and the physician was informed of the three doses that were not administered but was unable to provide documentation and was unable to speak to whether the PO should have been changed. On 7/23/2026 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Regional Clinal Nurse (RCN). The DON stated when a resident received dialysis, the medications needed to be scheduled for when the resident was in the facility and specific POs would be reviewed with the physician. On 7/23/2026 at 1:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, RCN and Regional Administrator and were made aware of the above concern for Resident #5. On 7/24/26 at 9:24 AM, the survey team met with the facility administrative team. The DON stated the nurses were educated to document physician notification when a medication was unable to be administered. The RCN added that the physician was notified by the UM/LPN #1 that Resident #5 had not been administered the Phos-NaK but there was no documentation. The DON and RCN acknowledged when a physician was notified that a resident was unable to be administered a medication because they were at dialysis, then the PO should have been changed to accommodate when the resident was out to dialysis. A review of the facility policy Hemodialysis dated as reviewed/revised 10/14/25, provided by the RCN, revealed the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents who received hemodialysis. In addition, the facility will ensure the physician's orders included any medication administration or withholding of specific medications prior to dialysis treatments. Also, the facility will communicate with the attending physician and/or nephrologist medication administration or withholding of certain medications prior to the dialysis treatment and document such orders. A review of the facility policy Medication Administration dated as reviewed and revised 10/20/25, provided by the DON, revealed medications are administered as ordered by the physician in accordance with professional standards of practice. In addition, the nurses ensure the six rights of medication administration are followed which included but not limited to the right time and right documentation. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss (specialized) mattress was functioning properly and accurately setup according to manufacturer instructions and a physician's order for a resident who was previously identified to have had an alteration in skin integrity.This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for pressure ulcers and was evidenced by the following:On 7/20/26 at 7:19 AM, during initial tour, the surveyor observed Resident #47 lying in bed, resting on an air mattress. The resident was unable to communicate with the surveyor. The resident's air mattress pump was observed to be set to a weight of 280 pounds.On 7/21/26 at 10:27 AM, the surveyor observed Resident #47 lying in bed receiving tube feeding (enteral nutrition that delivers liquid food, fluids, and medications directly into the stomach or small intestine when a person cannot safely chew or swallow), the resident's air mattress pump was noted to be set to a resident weight of 280 pounds. The resident was unable to communicate with the surveyor.On 7/22/26 at 10:34 AM, the surveyor observed Resident #47 lying in bed receiving tube feeding with the air mattress pump set to 280 pounds. The resident was unable to communicate with the surveyor.On 7/22/26 at 11:18 AM the surveyor conducted a record review for Resident #47.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included but were not limited to; stage 4 pressure ulcer (the most severe type of pressure injury, characterized by full-thickness skin and tissue loss ) of back, buttock and hip, gastrostomy status (feeding tube), dysphagia (trouble swallowing), abnormal weight loss, anemia (a blood condition where you have low red blood cells or hemoglobin, leading to fatigue, weakness, and shortness of breath), unspecified sequelae of cerebral infarction (the long-term or permanent health effects that remain after a brain stroke), and generalized muscle weakness.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/29/26, a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident's cognition was severely impaired, and the resident was unable to complete the assessment. The MDS revealed that Resident #47 was dependent on staff for all activities of daily living (ADLs) including movement, hygiene, toileting, and nutrition. The resident was noted to be frequently incontinent of bowel and bladder. Further review of the MDS indicated that the resident was at risk to develop pressure injuries and had one unhealed stage 4 pressure ulcer/injury. Additional review of the MDS revealed that the Skin and Ulcer/Injury Treatments section included a pressure reducing device for the bed and chair; pressure ulcer/injury care and turning/repositioning the resident. The resident's weight was recorded as 196 pounds. A review of the resident's individual comprehensive care plan (ICCP) included a focus area revised on 7/14/26, that the resident had a stage 4 ulcer. The first goal for the focus area was that the resident would have intact skin free of redness, blisters or discoloration by/through the review date of 10/14/26. Another goal listed was that the resident's pressure ulcer would show signs of healing and remain free from infection by/through the same review date. Interventions to achieve the goals included the following: administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor); educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Another focus area revised on 6/18/26 noted that the resident was at risk for skin injury related to a history of open blisters and immobility with a goal that the resident would not experience any additional skin breakdown or other complications and regain skin integrity. Interventions included assisting the resident with general hygiene and comfort, dietary consults, keeping linens dry and clean, using a low air loss mattress, and utilizing weekly skin assessments. A review of the Order Summary Report included the following physician orders (PO):A PO, dated 8/26/24, for: Low Loss Air Mattress: Check settings and functions every shift, for wound care.A PO, dated 3/23/26, for: Monitor Air pressure mattress functioning properly every shift for wound care.A review of the Wound Assessment Report included the following:An assessment report, dated 6/29/26, included: Wound Status: Stable, the measurements included Length: 8.00 cm, Width: 0.50 cm, Depth: 0.50 cm. An assessment report, dated 7/6/26, included: Wound Status: Improving with delayed wound closure, the measurements included Length: 7.00 cm, Width: 0.50 cm, Depth: 0.40 cm.An assessment report, dated 7/13/26, included: Wound Status: Improving despite measurements, the measurements included Length: 7.00 cm, Width: 0.50 cm, Depth: 0.40 cm.An assessment report, dated 7/20/26, included: Wound Status: Improving with delayed wound closure, the measurements included Length: 6.00 cm, Width: 0.50 cm, Depth: 0.40 cm.On 7/22/26 at 2:20 PM the surveyor interviewed the Licensed Practical Nurse (LPN) caring for Resident #47 regarding the air mattress pump settings. She told the surveyor that an air mattress was ordered by a doctor for residents with wounds or at risk to develop wounds and that wound care specialists or nursing would usually make the initial recommendation after a skin assessment. The LPN stated the mattresses were initially set up and assessed for function by facility maintenance staff prior to transferring a resident to them. The LPN stated that the numerical settings on the air mattress pump correlated to the resident weights and that the pump should be set to the resident's weight. The LPN stated it was important that the pump was set correctly to be therapeutic for the resident, that too soft or too hard could be uncomfortable for them. The LPN stated nurses check the mattress at the beginning of the shift, then she pushed a gloved hand into the mattress, telling the surveyor that was how she would check to make sure it held air. The LPN acknowledged the setting on the pump was 280 pounds. The LPN checked Resident #47's last recorded weight in their medical record and stated, it says 195.4 pounds. The LPN told the surveyor that they would report the weight discrepancy to maintenance and their manager because they were not comfortable adjusting the settings themselves at that time.On 7/22/26 at 2:55 PM the surveyor interviewed the Director of Nursing (DON) regarding the air mattress settings. The DON stated that residents with wounds and those at-risk for wounds would have a specialized mattress. The DON told the surveyor that maintenance staff would set up the beds and it was her expectation that nursing staff would check the settings after setup and every shift to prevent any additional skin breakdown. The DON explained that staff were in-serviced on air mattresses, and her expectation was that mattresses be set according to resident's weight and/or manufacturers' recommendations.A review of Operating Instructions - [Redacted] Operator's Manual for the air mattress and pump revealed the following: INDICATIONS: [Redacted] Alternating Pressure and Low Air Loss Mattress Replacement System, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. It can be used in a hospital, homecare, or other healthcare environment. MATTRESS: The [Redacted] System comes with an air cell mattress that provides low air loss, alternation and static pressure redistribution therapy.OPERATING INSTRUCTIONS: Step 1 Turn on the control unit power. The indicator of the power switch will come on. The control unit will start to blow air into the mattress.Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit.A review of a facility policy titled Use of Support Surfaces, implemented 9/1/25, included the following: Policy: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries.support surface refers to a specialized mattress.designed to manage pressure, shear, microclimate, or friction forces on tissue.Support surfaces will be utilized in accordance with physician orders.Support surfaces will be utilized in accordance with manufacturer recommendations.For powered devices, or those requiring air, the licensed nurse will check each shift and PRN for proper functioning and/or inflation.NJAC 8:39-27.1

Based on observations, interviews, review of medical records, and review of other pertinent facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate care, for 2 of 21 residents reviewed (Resident #4 and Resident # 6) for accurate coding of the MDS assessment. This deficient practice was evidenced by the following:1. On 7/20/26 at 8:30 AM, the surveyor observed Resident #4 in the common dining area eating breakfast.On 7/21/26 at 11:28 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #4 which revealed:A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; diabetes (high blood sugar levels), anxiety and dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). A review of the Quarterly MDS dated [DATE], indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated severely impaired cognition. A further review of section N, Medications, revealed that the resident was coded as receiving an antipsychotic (medications used to treat psychosis or other mental conditions) in the last 7 days, with a last gradual dose reduction (GDR) on 3/25/26. A review of the physician orders (PO's) did not reveal a current order for an antipsychotic. A review of a psychiatric progress note dated 6/3/26, revealed that Zyprexa (an antipsychotic medication) had been discontinued on 5/6/26. A review of the medication administration record (MAR) for May 2026, confirmed that Resident #4 last received Zyprexa on 5/5/26. On 7/21/26 at 12:53 PM, the surveyor interviewed the MDS Coordinator (MDSC) who acknowledged that the Zyprexa had been discontinued in May and the quarterly MDS dated [DATE] was coded incorrectly. 2. On 7/20/26 at 10:48 AM, the surveyor observed Resident #6 outside from North TV area in the designated smoking area. The Director of Nursing (DON) was there with a bin with cigarettes and lighters; the resident was able to light their own cigarette with a lighter provided by the DON. On 7/21/26 at 10:05 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #6 which revealed: A review of the admission Record revealed the resident was admitted to the facility with a diagnosis that included but were not limited to; hemiplegia (weakness affecting one side of the body) affecting left nondominant side. A review of the annual MDS dated [DATE], indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. A further review in Section J, Health Conditions, the question for tobacco use was coded as no, which meant Resident #6 was assessed as a non-smoker. A review of the Smoking assessment dated [DATE] indicated that Resident #6 smoked 3-4 times daily. A review of the individualized comprehensive care plan (ICCP) revealed a focus area initiated 1/30/25, which indicated that Resident #6 was a smoker. The ICCP interventions included: instruct the resident about smoking risks and hazards and about smoking cessation aids, instruct the resident about the facility policy on smoking, monitor oral hygiene, observe clothing and skin for signs of cigarette burns, and the resident is able to light own cigarette. A review of the facility provided list of residents who smoked included Resident #6. On 7/21/26 at 12:50 PM, the surveyor interviewed the MDSC, who stated smoking should have been coded on the annual MDS assessment and that she would modify the MDS. On 7/23/26 at 1:49 PM, the survey team met with the DON, the Licensed Nursing Home Administrator (LNHA), the Regional Clinical Nurse, and the Regional LNHA and notified them of the above concerns. On 7/24/26 at 9:24 AM, the survey team met with the DON, LNHA, MDSC, Regional MDSC, the Regional Clinical Nurse, and the Regional LNHA. The MDSC and the regional MDSC acknowledged the above coding errors. A review of the undated facility provided policy, MDS 3.0 Completion included: Policy:Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Definitions:OBRA Assessment refers to an assessment mandated by the Omnibus Budget Reconciliation Act of 1987, which specifies a Minimum Data Set (MDS) of core elements for use in assessing nursing home residents.ARD, or Assessment Reference Date, refers to the specific endpoint in the MDS assessment process (last day of MDS observation period). Policy Explanation and Compliance Guidelines:1 According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4 Care Plan Team Responsibility for Assessment Completion:a Interdisciplinary Responsibility for Completion of MDS sections:ii Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.iii The R.N. Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI, once all other disciplines have completed their sections. b Coding of Assessment:i All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment. NJAC 8:39-33.2 (d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on staff for Activities of Daily Living (ADL). This deficient practice was observed for 1 of 1 resident (Resident #23) reviewed for ADL care. The deficient practice was evidenced by the following: On 7/20/26 at 7:07 AM, during initial tour of the South Unit, the surveyor observed Resident #23 lying in bed, awake and alert. The resident informed the surveyor that their fingernails had not been cut in a while, and there was fungus on the right thumb nail. The surveyor observed the resident's fingernails. The right hand fingernails were long with jagged edges, there was a black looking substance under the fingernails, and the right thumb fingernail appeared thick, raised, cracked, and hollow with a blackened open area in the center. The resident's left hand was in a brace. The left hand fingernails were long and curved with jagged edges. The left fourth fingernail appeared thick, curved and long. The left fifth fingernail appeared dry, discolored with a yellow like tint, and the fingernail was separating from the nail bed. The left fingers had areas of black, dry patches of skin on each finger. On 7/20/26 at 11:09 AM, during a follow up interview with Resident #23, the resident was lying in bed. The resident's fingernails were still long, jagged, and not trimmed. The resident stated, I would prefer my nails be short. I spoke to the Unit Manager about a week or two ago that I need it cut. The surveyor reviewed Resident #23's electronic medical record which revealed the following: According to the admission Record ( admission summary), Resident #23 was admitted to the facility with diagnoses which included but were not limited to: Hemiplegia and Hemiparesis following Cerebrovascular disease affecting left non-dominant hand (residual paralysis or weakness on the left side of the body due to right-brain injury), hypertension (high blood pressure), muscle weakness, and candidiasis of skin and nail (a fungal infection caused by an overgrowth of yeast, mainly Candida albicans, thriving in warm and moist areas). A review of the Annual Minimum Data Set (MDS) Assessment, an assessment tool dated 6/10/26, revealed that Resident #23 had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #23 was dependent on staff for ADLs which included but were not limited to personal hygiene. A review of the individualized comprehensive care plan (ICCP) created on 6/21/23, included a focus area that the resident had an ADL self-care performance deficit related to Hemiplegia, Limited Mobility, and Stroke. Interventions included: Splint/Device: left upper extremity (LUE) resting hand splint to wear as tolerated by the patient. Remove for skin check and hygiene and skin integrity by nursing in all shifts as needed (PRN). Further review of Resident #23's ICCP revealed: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Personal Hygiene/Oral Care: The resident is totally dependent on (one) staff for personal hygiene. On 7/21/26 at 10:03 AM, the surveyor returned to the room and observed Resident #23 lying in bed, awake and alert. The resident's fingernails were in the same condition as previously described on 7/20/26. The resident stated, I need to get my nails cut, I can't keep them like that. On 7/21/26 at 10:22 AM, the surveyor interviewed Resident #23's assigned Certified Nursing Assistant (CNA #1), who stated the CNAs were responsible for cutting the residents' nails. The surveyor and CNA #1 went to Resident #23's room, and CNA #1 confirmed the resident's fingernails were long and that the resident's fingernails should not have been that long, because it carries dirt and bacteria under the nails. CNA #1 stated, I should have cut the resident's fingernails. The CNA further stated, the resident's fingernails have always been long. On 7/21/26 at 10:53 AM, the surveyor interviewed the assigned Licensed Practical Nurse (LPN #1), who stated the resident needed total care with activities of daily living (ADL). The surveyor and LPN #1 went to Resident # 23's room, and LPN #1 confirmed the resident's fingernails were long and unclean, with possible fungus on the resident's right thumb fingernail and left fifth fingernail. LPN #1 stated, No, it should not be that way, for hygiene purpose. LPN stated, The resident's fingernails do not appear to be cut for a while. The resident's fingernails should have been cut. On 7/21/26 at 11:08 AM, the surveyor interviewed the unit manager (UM#1), who stated the expectation for residents who depend on staff for care included: the CNAs performed tasks including but not limited to washing the residents from head to toe, fingernail care, and for the CNA to notify the nurse if the fingernails were long and they were unable to cut them. The surveyor and UM #1 went to Resident #23's room, and UM #1 confirmed Resident #23's nails were lengthy and needed to be cleaned. UM#1 stated the resident's right thumb fingernail was cracked, and the fifth left fingernail was discolored. UM #1 stated, No, it should not be this way because it can cause infection, especially if the resident scratches their skin. UM #1 further stated the CNA should have cut the resident's nails and if they were unable to, they should have notified us. UM #1 also confirmed that she knew that the resident's nails were long prior to the interview, and stated, I should have cut them. On 7/22/26 at 1:43 PM, the surveyor interviewed the Director of Nursing (DON), who stated the CNAs were responsible to cut the residents' fingernails, usually on the 3-11 shift, but not limited to that time. The DON confirmed the resident's nails should not have been that long because the resident could have scratched themself, and for infection control purposes. The DON stated while the resident was feeding themself, the germs from the resident's nails could get into the resident's mouth while eating. The DON further stated, the resident's nails should have been cut, and if the resident had refused, it should have been reported to the assigned nurse, the unit manager, or either me. On 7/23/26 at 1:53 PM, the survey team met with the Regional Licensed Nursing Home Administrator (RLNHA), LNHA, DON, and the Regional Clinical Nurse (RCN). The surveyor informed them of the above-mentioned concern regarding Resident #23's nail care. A review of the facility provided Certified Nursing Assistant Job Description under section Position Purpose included: Provides certified nursing assistant services to assigned residents in accordance with care plans, facility policies, and procedures at the direction of supervisor(s). Under section Major Duties and Responsibilities: Assists residents with or performs activities of daily living for residents in accordance with care plans and established policies and procedures. A review of the facility provided Nail Care Policy, implemented on 9/1/24, revealed Policy-the purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Under Policy Explanation and Compliance Guidelines:1.Identify conditions that increase risk for foot or nail problems, such as .stroke.2. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.3. Routine nail care, to include trimming and filing, will be provided on a regular basis and as needed.4. Procedure .h. Document completion of task, any complications, or if resident refuses. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with an order for anticoagulants. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #71), and was evidenced by the following:On 7/20/26 at 7:05 AM, during initial tour of the facility, the surveyor observed Resident #71 lying in bed with their gown above their head. The surveyor observed the resident's bed in low position with fall mats to the right side of the bed. 07/21/2026 at 1:22 PM, the surveyor observed the resident in their room seated in a reclining chair. The resident was dressed appropriately and no concerns noted. The surveyor reviewed the medical record for Resident #71. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (high blood pressure), anemia (low red blood cells), thrombophilia (blood is more likely to form blood clots), and long term use of aspirin (helps prevent recurrent heart attacks or strokes). A review of the most recent comprehensive Minimum Data Set, an assessment tool dated 4/23/26, indicated the resident's cognitive skills for daily decision making were severely impaired. A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 7/21/23, for anticoagulant therapy (Eliquis, aspirin) and at risk for bleeding related to disease process (DVT prophylaxis). The ICCP interventions included; administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness every shift, monitor, document, report as needed adverse reactions of anticoagulant therapy. A further review of the ICCP revealed that the anticoagulant therapy focus area had a resolved date of 7/22/26 after surveyor inquiry. A review of the Order Summary Report included the following physician orders (PO): A PO, dated 7/22/23, Aspirin Low Chew 81mg (milligrams), give 1 tablet orally one time a day to reduce the risk of heart attack, take with food. A further review of the PO revealed that the PO was discontinued on 4/2/26. A PO, dated 5/9/23, Eliquis tablet 2.5mg, give 1 tablet orally two times a day for DVT LE (deep vein thrombosis occurs when a blood clot forms in one or more veins, lower extremity). A further review of the PO revealed that the PO was discontinued on 2/18/26. On 7/21/26 at 12:35 PM, the Director of Nursing (DON), in the presence of the Regional Clinical Director, stated that the resident's anticoagulant medications Aspirin and Eliquis were discontinued. She further stated that the resident's care plan should have been updated when the medications were discontinued. The DON acknowledged that a care plan should be updated when there were any changes in the residents' care. She also stated that care plans were reviewed by the team as needed and quarterly. On 7/22/26 at 1:30 PM, the surveyor discussed the concerns with the Licensed Nursing Home Administrator (LNHA), DON, and Regional Clinical Director who confirmed that the residents care plans should have been updated when Aspirin or Eliquis was discontinued. NJAC 8:39-27.1(a)

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) have a system in place to ensure residents were receiving their identified activity preferences, and b.) have a system in place to ensure activities were conducted as scheduled. This deficient practice was identified for two of two residents (Resident #52 and unsampled Resident #83), reviewed for activities.This was evidenced as follows:1.On 7/20/26 at 7:24 AM, during initial tour of the South Unit, the surveyor interviewed Resident #52, who stated they attended activities often, but the activities were not creative and were boring since they (activities) were short staffed. On 7/21/26 at11:39 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #52.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, recurrent, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), and Type 2 Diabetes Mellitus without complications (a condition in which the body has trouble controlling blood sugar).A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 5/7/26, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident's preferences was noted as very important to do things with groups of people, very important for favorite activities, and very important to listen to music.A review of the individual comprehensive care plan (ICCP) revealed a focus area that the resident actively participated in recreation programs of choice with encouragement. Date Initiated: 05/20/26. A goal of resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. Date Initiated: 05/20/26. An intervention of establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Date Initiated: 05/20/26 and the resident's preferred activities are .bingo, karaoke, special programs, and special events. Date Initiated: 05/20/26.On 7/21/26 at 12:58 PM, the surveyor interviewed the Activities Director (AD), who stated activities were run by the activity staff. The AD stated if there was a call out, she would come in to run the activities. The AD stated activities staff record the attendance of residents for the activities. The AD then stated she recently had a staff member resign. At that time, she called the activities aid (AA) #1 to come to the main dining room to provide the attendance logs to the surveyor for review.On 7/22/26 at 9:25 AM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, the AD reviewed the attendance procedure for activities. The AD stated AA #1 was her full-time employee who took attendance on the resident census sheet (which was dated and listed each resident by wing and room number) by a slash mark next to the resident's name. The AD further explained the number of slash marks indicated how many activities the resident attended that day. There was no other information next to the resident's name to identify what activity was attended that day. The AD then explained that the information was transferred to the Activity Attendance Sheet for each unit which was broken down by the activity type, such as coffee, exercise, and music. The date range was handwritten on the top right corner. The AD was unable to explain how each resident's specific activity attendance was recorded daily. The AD stated the Activities attendance Sheets were started in April but the staff still used the old system (the census sheets with the slash marks). The AD was unable to explain why the staff still used the old system.On 7/22/26 at 1:17 PM, during an interview with the surveyor, the LNHA acknowledged the activities staff needed to tweak their charting on activities.On 7/23/2026 at 1:49 PM, during a meeting with the survey team, the LNHA, the regional LNHA, the Director of Nursing (DON), and the Regional Clinical Nurse were made aware of the above concerns. 2. On 7/20/26 at 7:24 AM, during initial tour of the South Unit, the surveyor interviewed Resident #52, who stated they used to have activities in the evenings. At 7:37 AM, the surveyor interviewed unsampled Resident #83, who stated the facility did not have activities at night.On 7/20/26 at 9:17 AM, during entrance conference, the surveyor requested the schedule for the activities staff for the time of the survey. A review of the activity's staff schedule did not reveal that activities staff were scheduled to work after 5 pm for the week of 7/19 to 7/25/2026.A review of the facility posted July 2026 activity's schedule revealed 6:30 PM card/tabletop games (MDR-main dining room) scheduled for Tuesday's and Thursday: 7/7, 7/9, 7/14, 7/16, 7/21, and 7/23/26.On 7/21/26 at 10:57 AM, the surveyor requested the activities schedule from 7/12/26 to 7/18/26 from the LNHA. On 7/22/26 at 9:25 AM, the surveyor interviewed the AD, who stated, only activity staff runs activities She stated if someone was not there then she would come in to replace them. On 7/22/26 12:24 PM, the surveyor requested an additional activities staff schedule from 6/28/26 to 7/11/26 from the regional LNHA.A review of the facility provided activity's staff schedule from 6/28/26 to 7/18/26 did not reveal activities staff were scheduled to work after 5 PM.On 7/23/26 at 10:15 AM, the surveyor interviewed the LNHA, who stated just activity's staff cover activities to my knowledge. The LNHA reviewed the activity staff's schedule and acknowledged none were scheduled past 5:00 PM. The LNHA then reviewed the July calendar and acknowledged Tuesday and Thursday activities for card/tabletop games scheduled for 6:30 PM. He was unable to speak to who covered those activities but stated he would follow up with the Activities Director.On 7/23/26 at 11:04 AM, during a follow up meeting, the LNHA stated he had confirmed with the AD that no evening activities had been conducted since AA#2 had left at the end June 2026.On 7/23/2026 at 1:49 PM, during a meeting with the survey team, the LNHA, the regional LNHA, the DON, and the Regional Clinical Nurse were made aware of the above concerns. A review of the facility's policy Activities revised 1/5/26 revealed Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preference. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community . Policy: 5 Scheduled activities are posted in the resident's room, where appropriate, and in a prominent place in the facility. 6. Residents are encouraged but not mandated to participate in scheduled activities.NJAC 8:39-7.1 (a); 7.2; 7.3 (a)(d)(f)

Based on observations, interviews, record review and other pertinent facility documentation it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection for a.) provision of wound care for 1 of 2 residents (Resident # 90) reviewed for pressure ulcers b.) proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) for 1 of 1 residents reviewed for EBP, (Resident #8) and c.) properly storing oxygen administration tubing in a protective bag when not in use by the resident for 1 of 2 residents (Resident #70) reviewed for respiratory care. This deficient practice was identified by the following: 1.) On 3/13/25 at 10:57 AM, the surveyor observed Resident #90 in the room, sitting up in a chair. The resident stated they had a left heel wound. The surveyor observed the resident wearing pressure reducing booties to the bilateral feet. The resident denied pain or discomfort. On 3/14/25 at 9:11 AM, the resident was observed lying in bed with head of the bed up. The surveyor interviewed the resident at that time and the Resident stated that that they had no concerns. The surveyor observed that the resident was wearing pressure reducing heel boots to the bilateral lower extremities. A review of the Admission Record (AR) (admission summary) indicated that Resident #90 was admitted to the facility with the diagnoses which included but was not limited to; pressure ulcer of the left heel and osteomyelitis (bone infection) of the vertebra. A review of the quarterly Minimum Data Set (MDS) an assessment tool that facilitates a resident's care, dated 12/25/24, indicated the resident had a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating the resident had moderate cognitive impairment and had an unstageable pressure ulcer. The surveyor reviewed the Treatment Administration Record (TAR) which contained a physician's orders (PO) dated 3/4/25 to apply to the left heel topically on the day shift (7:00 AM-3:00 PM) for wound care of the left heel wound. Treatment consisted of the following steps: 1. Cleanse with Dakin's (a dilute solution of sodium hypochlorite (0.4% to 0.5%) and other stabilizing ingredients, traditionally used as an antiseptic, e.g. to cleanse wounds in order to prevent infection) solution. 2. Apply Santyl (an enzyme (protein) that breaks down collagen in damaged or dead skin), Calcium alginate (dressing that promotes moisture balance, keep wounds clean, and facilitates natural healing) to the base of the wound. 3. Secure with Bordered gauze. 4. Change the dressing daily. On 3/14/25 at 9:27 AM, the surveyor observed Licensed Practical Nurse (LPN #1) perform wound care for Resident #90's ulcer on the left heel. - LPN #1 was observed applying an isolation gown and with an ungloved, unwashed hand remove clean 4 x 4 gauze dressings from a large packet of 4 x 4 gauze and then remove other items from the clean treatment cart. The LPN then put the 4 x 4 gauze dressings on top of the other items that she removed from the treatment cart such as a wrapped calcium alginate dressing, a box of Santyl ointment and a bottle of Dakin's solutions. The LPN did not disinfect the surface or set up a clean field on top of the resident's bedside nightstand and placed the 4 x 4s gauze, wrapped calcium alginate dressing, box of Santyl and Dakin's solution on the nightstand. -LPN #1 then washed her hands and applied gloves. LPN #1 with the gloves on, touched the resident's blanket and removed the resident's booties and socks. The LPN did not wash her hands or change her gloves and proceeded to touch the bottle of Dakin's solution and 4 x 4s gauze dressings. She proceeded to pour the Dakin's solution on the 4 x 4 gauze and cleansed the resident's left heel wound. -LPN #1 then removed her gloves, washed her hands and applied new gloves and went to the treatment cart to retrieve a tongue depressor. The LPN laid the tongue depressor directly on the surface of the undisinfected nightstand. She then opened the tube of Santyl and placed the lid of the Santyl on the resident's bed linen and placed the uncapped tube of Santyl on the resident's nightstand with the tip of the opened Santyl lying directly in contact with the surface of the undisinfected nightstand. She then applied the santyl to the tongue depressor to apply to the resident's left heel wound. - LPN #1 then removed her gloves and walked to the treatment cart to retrieve a new pair of gloves. She retrieved the gloves and put them in her back pocket. She then washed her hands, took the gloves out of her back pocket, applied the gloves and then applied the dressing to the left heel. She then proceeded to sign the dressing with the date and initials with a black marker, while the dressing was on the resident. On 3/14/25 at 9:49 AM, the surveyor reviewed the above mentioned wound care observations with LPN #1. LPN #1 admitted that there were multiple breaks in infection control while she was performing the wound care to the resident's left heel and explained that the breaks in infection control could potentially expose the resident to infection. On 3/14/25 at 10:03 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1). The surveyor explained the wound care observations for Resident #90s left heel. RN/UM #1 stated that LPN #1 needed more training related to infection control when performing treatments and should also not date dressings while on a resident because it was a dignity issue. She confirmed that LPN #1 should have disinfected and set up a clean field on the table that she was using to place the treatment supplies. RN/UM #1stated LPN #1 should not have put an ungloved hand in the package of 4 x 4 gauze dressing because it could contaminate all the dressings in the package. RN/UM #1 also confirmed LPN#1 should not have put gloves in her back pocket before applying them, put the cap to the Santyl in the resident's bed on the bed linen or put the uncapped tube of Santyl with the opening of the tube to lie directly on an undisinfected surface. RN/UM #1 added LPN #1 should not have laid the tongue depressor directly on the unclean resident nightstand. She stated that these were all breaks in infection control while performing wound care. On 3/14/24 at 10:30 AM, the surveyor interviewed the facility Infection Preventionist (IP) as well as the Regional Clinical Supervisor (RCS), who confirmed that LPN #1 should have performed hand hygiene and applied gloves before putting her hand in the packet of clean 4 x 4s dressings and should have prepped the nightstand by cleaning with disinfectant and putting down a clean field. The both also confirmed that the tube of Santyl could become contaminated because LPN #1 put the cap of the Santyl in the resident's bed linen and laid the tip of the tubing directly in contact with the undisinfected nightstand surface. They both confirmed LPN #1 had multiple breaks in infection control and that the resident's treatment would be re-done immediately. A review of the facility policy, dated 11/2018 and titled, Wound Care indicated that the procedure for wound care was to set up a clean field utilizing a disposable cloth and to place all items to be used during the procedure on the clean field. The policy specified that all clean items were to be on a clean field. The policy indicated that the staff were to wipe nozzles, foil packets, bottle tops etc. with alcohol before opening as necessary. The policy also indicated that after dressing were removed the staff member was to wash hands thoroughly and put on gloves and to wipe reusable supplies with alcohol (outside of containers that were touched with unclean hands) and return to the treatment cart. 2.) On 3/13/25 at 12:02 PM, the surveyor observed signage posted on Resident #8's door that the resident was on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). The posting indicated that staff were to wear gloves and isolation gown when performing direct resident care. There was also an isolation caddy hanging on the door which contained, gloves, gowns and mask. The resident was observed out of bed. The surveyor was unable to interview the resident due to the resident having severe cognitive deficits. The resident was observed to be clean and well dressed. On 3/14/25 at 8:56 AM, the surveyor observed Resident #8 in a net bed. The resident was sleeping, and no distress was observed. On 3/14/25 at 8:59 AM, the surveyor observed the Certified Nursing Assistant (CNA) assist the resident out of bed. The signage on the resident's door indicated that a gown and gloves were to be donned (applied) for EBP. The surveyor did not observe the CNA wearing the necessary personal protective equipment (PPE) such as a gown and gloves prior to direct resident care such as transferring the resident from the bed to the chair. On 3/14/25 at 9:01 AM, the surveyor interviewed the CNA, who stated that the resident required total care and had a gastrotomy tube. The CNA stated that the resident was non-verbal and incontinent of bladder and bowel. The CNA admitted that while performing direct resident care, she was supposed to don a gown and gloves. She stated that it would have been important to wear the proper PPE to protect the resident from infection. She stated she did not apply the PPE because she forgot. She explained that she was educated multiple times on the importance of applying PPE and should follow the directions according to the signage on the resident's door. A review of the AR indicated that Resident #8 was admitted to the facility with diagnoses which included but was not limited to Huntington's Disease (a condition in which nerve cells in the brain break down over time) and gastrostomy (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage). A review of the comprehensive MDS, dated [DATE], indicated that the resident had a BIMS of 00, which indicated the resident had severe cognitive impairment; required maximum assistance with activities of daily living and nutritional needs were met by way of gastrostomy tube. The surveyor reviewed a physician's order dated 5/8/23, that Resident #8 was on enhanced barrier precautions related to (r/t) g-tube (gastrostomy). The surveyor reviewed the resident's Individual Comprehensive Care Plan (ICCP) dated 11/3/23, which reflected the following: Focus: Resident #8 required enhanced barrier precautions related to indwelling medical device: Feeding tube. Interventions: -Clear signage must be posted on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. PPE, including gowns and gloves must be available immediately outside of the resident room. [CNA, Nurse] -EBP will be in place for the duration of Resident #8's stay in the facility or until resolution or discontinuation of the indwelling medical device that placed them at higher risk. On 3/14/25 at 11:40 AM, the surveyor interviewed the IP, who confirmed the CNA, who transferred the resident should have worn the appropriate PPE and was required to don a gown and gloves prior to performing direct resident care. Transferring a resident is a form of direct resident care. The IP confirmed that this was a break in infection control and facility policy. The facility policy dated 11/21/2023 and titled, Enhanced Barrier Precautions indicated that EBP wound be implemented for any residents with wounds and indwelling medical devices. According to the policy staff were to use PPE-gown and gloves during high contact resident care. 44833 3.) On 3/13/25 at 10:38 AM, during initial tour of the facility, the surveyor observed Resident #70 resting in their bed with their eyes closed. Behind the resident's bed, was a wall mounted oxygen delivery regulator with a humidifier bottle attached that had a long nasal cannula tube attached to it and was coiled around and hanging off the regulator. The nasal cannula tube was not stored in the plastic bag which was also hanging off the oxygen regulator. On 3/14/25 at 9:59 AM, the surveyor observed Resident #70's nasal cannula tubing was stored in the same position and condition as was observed the previous day. The resident was not in their room at this time. On 3/17/25 at 10:03 AM, the surveyor reviewed Resident #70's medical record and the following was indicated: A review of the resident's AR indicated that the resident was admitted to the facility with diagnosis which included but was not limited to: end stage renal disease (kidney disease), acute respiratory failure with hypoxia (sudden onset respiratory failure with low blood oxygen levels), and anemia. A review of the resident's quarterly MDS dated [DATE], indicated the resident had a BIMS score of 3 out of 15, which indicated severe cognitive impairment; and was receiving oxygen therapy. A review of the resident's physician's Order Summary Report indicated an order with start date of 10/2/24, to apply oxygen per nasal cannula at a rate of three liters per minute every shift, and a second order with a start date 10/5/24, to change oxygen tubing weekly and label and date with residents name of each component. A review of the resident's ICCP indicated a focus care area initiated on 10/3/24 for risk for ineffective breathing pattern. On 3/18/25 at 12:32 PM, the surveyor observed Resident #70 in their room hosting visitors and having lunch. The resident was not receiving oxygen, and the nasal cannula was attached to the oxygen regulator on the wall behind the resident's bed and draped over the regulator, not stored in a protective bag. On 3/18/25 at 12:32 PM, the surveyor interviewed LPN #2, who stated respiratory tubing should always be stored in a protective bag when not in use to prevent contamination and to follow infection control practices. On 3/18/25 at 1:26 PM, the surveyor interviewed LPN/UM #2, who stated that respiratory tubing should be stored in a protective bag when not in use to maintain infection control. On 3/18/25 at 1:36 PM, the surveyor and LPN/UM #2, observed the conditions in which Resident #70's oxygen tubing was being stored in the resident's room, to which LPN/UM #2 acknowledged that it should not have been stored draped over the oxygen regulator and outside of a protective bag. LPN/UM #2 further acknowledged that the tubing should have been in a protective plastic bag while not in use. On 3/28/25 at 1:53 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that when not in use, respiratory and oxygen tubing should have been stored in a protective plastic bag to maintain infection control. A review of the facility's Oxygen Administration policy with an updated date of 1/2024, did not include procedure to properly store respiratory tubing when not in use. On 3/29/25 at 9:52 AM, the RCS, in the presence of the survey team, provided the surveyor with a revised copy of the Oxygen Administration policy and stated that the facility revised the policy after surveyor inquiry to include: equipment maintenance and storage: . e. keep delivery devices covered in plastic bag when not in use. NJAC 8:39-19.1; 8:39-27.1(e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) identify and address multiple severe weight losses and consistently obtain reweights, b.) implement and monitor weekly weights, c.) evaluate and adjust nutritional interventions, e.) comprehensively assess the resident after a significant weight change and f.) revise the nutritional care plan. This was identified for 1 of 5 residents (Resident #47) reviewed for nutrition. The evidence was as follows: 1. On 2/8/23 at 11:45 AM, the surveyor observed Resident #47 lying in bed awake. The resident appeared thin, was not verbally responsive and was unable to maintain eye contact with the surveyor. The surveyor reviewed the medical records of Resident #47. Review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to unspecified protein-calorie malnutrition (protein calorie malnutrition happens when you are not consuming enough protein and calories), dysphagia (difficulty swallowing), Gastrostomy Status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/20/22 and 11/20/22, indicated that the resident's cognitive skills for daily decision making was severely impaired with total dependence of one-person physical assist for eating. A further review of the resident's MDS, Section K - Swallowing/Nutritional Status revealed that the resident had a feeding tube and significant weight loss that was not prescribed by the physician. Review of the Physician's Order (PO) dated 6/11/20, reflected that the resident had an PO for the tube feeding formula of Jevity 1.5 - one can (237 milliliter [mL]) via G-tube four times daily at 9AM, 1 PM, 5 PM, and 9 PM for a total volume of 948 mL. Review of the July 2022 through February 2023, Medication Administration Record (MAR) reflected the above corresponding PO's. Review of the resident's Monthly Record of V/S (vital signs) and Weights reflected the following weights: March 2022 127.4 lbs. April 2022 125 lbs. May 2022 122.8 lbs. June 2022 121.9 lbs. July 2022 122.1 lbs. August 2022 105 lbs. reweighed at 99.4 lb. - 22.7 pound (lb.) and 18.6% loss over one month September 2022 99.5 lbs. - 27.9 lb. and 21.9% loss over 6 months October 2022 100.8 lbs. - 24.2 lb. and 19.4% loss over 6 months November 2022 99.4 lbs. - 23.4 lb. and 19.1% loss over 6 months December 2022 95 lbs. - 26.9 lb. and 22.1% loss over 6 months January 2023 89.5 lbs. - 5.5 lb. and 5.8% loss over one month Review of the resident's progress notes from the hybrid (both paper chart and electronic medical records) medical record from July 6, 2022, through February 5, 2023, included the following documentation related to weight loss: The Quarterly Nutritional Assessment (NA) completed by the Registered Dietitian (RD), dated 8/23/22, indicated that the resident had significant weight loss in the past 6 months . Will suggest to reweigh resident and will check the reliability of the scale used. The RD also indicated that she would follow up. The Quarterly NA completed by the RD, dated 2/5/23, indicated that the resident had significant weight loss in the past 2 quarters . She also indicated that the resident was on Jevity 1.5 tube feeding. Gets 4 cans of Jevity 1.5 = gives 1420 calories and 60.4 grams protein. Resident gets 105% of the required calories .no recent laboratory reports are available except HBG and HCT which are both normal. Will continue to follow up. Review of the Quarterly IDCP (Interdisciplinary) care plan meetings dated 8/30/22 and 11/29/22 did not include documented evidence that the team was aware that the resident experienced significant weight losses. Review of the Nurses Progress notes did not include documented evidence that nursing was aware that the resident experienced significant weight losses. Review of the resident's Attending Physician (AP) Doctor's Progress Notes dated 10/8/22, 1/17/23, and 2/5/23 did not include documented evidence that the AP was aware of the resident experienced significant weight losses. Review of the resident's comprehensive care plan including the following focused areas: 1. The Nutrition- Dysphagia comprehensive care plan with an effective date of 3/1/22. 2. The G-tube feeding comprehensive care plan with an effective date of 3/1/22. 3. The Nutrition- Risk for Dehydration and weight loss with an effective date of 5/25/22. All three comprehensive focused care plan areas did not include documented evidence of the resident's significant weight losses. Further review of the G-tube feeding comprehensive care plan with an effective date of 3/1/22, indicated that the Goals will receive adequate nutrition and hydration via gtube with good tolerance over the next three months. It also indicated interventions to follow up significant labs, weight changes, skin integrity, BM. On 2/9/23 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The DON stated that the residents were weighed monthly by the Certified Nursing Aide (CNA)'s. She also stated that the CNAs would verbally communicate the weights to the nurses. She then stated that the nurses would document the weights in the Monthly Record of V/S and Weights form in the resident's paper chart in the Dietary section. During the interview, the DON informed the survey team that the resident would be reweighed if there was a weight discrepancy such as significant weight loss. She also stated that when a resident's weight loss was confirmed, the nurse would notify the resident's AP of the resident's weight loss. The DON stated that a dietary consult was usually a physician's order. She also stated that if the AP ordered a dietary consult, the nurses would verbally communicate this to the RD. On 2/14/23 at 12:32 PM, the surveyor interviewed the assigned CNA for Resident #47. She stated that the CNAs were responsible for weighing all the residents once a month, by the fifth of the month. She further stated that the nurses assigned the CNAs the residents who needed to be weighed and the CNA's would verbally communicate the residents' weights to the nurse, or would write it on the daily assignment sheets. The CNA stated that she was not aware that Resident #47 had weight losses. On 2/14/23 at 12:46 PM, the survey team interviewed the RD in the presence of the LNHA. The RD informed the survey team that the residents' weights were taken by the nursing staff every first week of the month. She stated that the Unit Manager (UM) nurse would report to her which residents had a weight loss of 5 lbs. or more and stated, I have continuous communication with nursing about residents that have lost weight. During the interview, the RD stated that when a resident had a significant weight loss, they would do a 3-day calorie count to determine if the resident's intake was meeting his/her needs and stated, we always do that. She further stated that she would discuss the calorie count results that were kept in the resident chart with the nurse, and she would explain how the results were related to the weight loss, which were documented in the medical record. On that same date and time, the RD informed the survey team that they did not have weight meetings. She stated that she would make recommendations and that there would be continuous follow up for any significant weight losses. She further stated that they would evaluate the residents on a quarterly basis whether there was an improvement or not. In addition, she stated that she reviewed the residents' weights monthly, reviewed the weight loss trends, and that she would follow up every month to ensure that the interventions were effective. She stated, weight is the most significant, sensitive yardstick of nutritional assessment of the patient. The RD stated that if a resident experienced a significant weight loss, monitoring weekly weights for four weeks would be warranted. She further stated that she would recommend to start a calorie count, nutritional supplements, and weekly weights by communicating to the nurses and the AP. On 2/15/23 at 10:28 AM, the surveyor interviewed the resident's AP in the presence of the survey team, who stated that she visited the resident every month. She also stated that after visiting the resident, she documented the encounter in the resident's paper medical records. During the interview, she acknowledged that she noticed a lot of weight loss for Resident #47. The AP acknowledged that she had not increased the resident's tube feed (TF) formula order prior to the surveyor's inquiry. She further acknowledged that she could have increased the TF and stated, I am not saying that I don't want to give her food. The AP could not verify when and who in the facility notified her that the resident had significant weight losses. The AP stated that if the resident had a significant weight loss, I would have documented that in the medical record. On 2/15/23 at 10:52 AM, the Unit Manager/Registered Nurse (UM/RN) stated that she would notify the resident's AP of a confirmed weight loss and that the AP would order a dietary consult. In addition, she also stated that the notification of weight loss and discussions had with the AP and RD should be documented in the resident's electronic medical records. She further stated that the RD would conduct her nutrition assessment and recommend a 3-day calorie count, and that she would notify the AP of the RD's recommendations. In addition, the UM/RN stated that if a resident was not getting enough calories to maintain their weight, she would expect recommendations from the RD. During the interview with the UM/RN, who further stated that when she returned to work last month she was informed that Resident #47 had a gradual significant weight loss over the last 6 months. She also stated that she did not notify the resident's AP regarding the resident's significant weight losses. On 2/15/23 at 12:42 PM, the LNHA, Regional RN#1 (RRN#1), DON, and MDS Coordinator met with the survey team. The RRN#1 confirmed that the RD did not have documented evidence in Resident #47's hybrid medical records to address the significant weight losses. She further confirmed that there was no documented evidence that the RD conducted follow-up assessments. During that same interview, the RRN#1 further stated that the AP acknowledged that she was aware of the resident's significant weight losses but there was no documented evidence in the resident's hybrid medical record that the AP addressed Resident #47's significant weight losses. The RRN#1 stated, that's a problem. On 2/16/23 at 11:05 AM, the LNHA, RRN#1, RRN#2, DON, and the Infection Control Preventionist Nurse (ICPN) met with the survey team. The RRN#1 acknowledged that the resident's bolus TF PO was never changed since 2019 to the present, until surveyor inquiry. She further stated that the resident suddenly, had a lot of weight loss in one month, and was wasting, and the AP never addressed the significant weight losses until after surveyor inquiry. She also acknowledged that resident's significant weight losses were not addressed in the resident's comprehensive care plans. On 2/16/23 at 11:47 AM, the survey team met with the LNHA, RRN#1, RRN#2, DON, and ICPN. There was no additional information provided. Review of the facility policy HMNR Role of the Registered Dietitian dated 12/2022, included that the Purpose was To ensure that the RD's are in adherence with rules and regulations set forth by the Centers for Medicare and Medicaid Services (CMS). In addition, it included Create a proper diet that fits all nutritional needs for residents/patients.; Participate in interdisciplinary care planning.; and Perform follow up assessment quarterly or more often if needed for long term care residents. Review of the facility policy HMNR Registered Dietitian Documentation dated 12/2022, included that the Purpose was .To ensure consistency in the documentation of nutrition care by Registered Dietitian's. To support and justify nutrition care. To document the results of nutrition care. In addition, it included the following: Nutrition Assessment and Consultation - Evaluation of nutrition/medical history lab values, anthropometric (measurements and proportions of the human body, such as weight) measurements . Action or recommendations with desired outcomes/measurable goal. To be entered in the [electronic medical record] under assessments .; Follow-up Evaluation . Effectiveness of nutritional intervention as it relates to goals. Monitor (review, measure status and timeliness), evaluate (compare with previous status, intervention goals and reference standards, and document progress (using defined indicators) . Re-assessment - Significant changes in lab values, anthropometric measurements, nutrient needs, . Care plan . Review of the facility policy HMNR Resident/Patient Weights dated 7/2022, included that the Purpose was To monitor the resident's/patient's nutritional status and appropriately respond to significant weight changes. In addition, it included the following: Weight can be a useful indicator of nutritional status .Weight goals should be based on a resident's/patient's usual body weight or desired body weight . Resident/patient weights will be monitored over time to identify weight loss/gain, verify weight measurements when changes in weight occur, and reassess weight interventions when appropriate . Facility scales will be calibrated annually or more often as needed by the Maintenance director/supervisor . Any resident/patient with a weight change of five (5) pounds or more will be re-weighed for accuracy . Any resident/patient with a significant weight change will be referred to the Dietitian for assessment . All resident/patient weights will be reviewed by nursing and dietary to determine significant change . Residents/patients with a recent history of weight loss or risk for weight loss may be weighed weekly as determined by the dietitian and or physician . Appropriate, individualized resident/patient interventions will be initiated to prevent and/or address significant unplanned weight changes . Residents/patients identified with significant weight loss/gain will be reviewed during nutrition rounds or facility weight meeting . The Dietitian will document in the medical record any resident/patient weight changes and interventions initiated, as well as in the care plan . Nursing or designee will notify the physician and or family/representative of any significant resident/patient weight changes. Review of the facility policy Tracking Weight Changes with a revised date of 12/21, included Weights will be documented for all individuals, for the purpose of assessing significant and gradual weight changes. In addition, it included the following: The facility will be responsible for obtaining accurate weights on a regular basis, and for keeping accurate records . A copy of the weight records will be forwarded to the appropriate professional each month: weight team leader, registered dietitian nutritionist (RDN) or designee, nursing supervisor, etc. The RDN or designee will review monthly weights and calculate significant change over one, three and six months . A copy of all significant weight losses and gains will be given to the interdisciplinary care team for appropriate review and documentation . All individuals with significant weight changes will be reweighed to assure accuracy of the weight prior to reporting to the staff, physician or family . The care plan team will review and document on all . significant weight changes, with appropriate referrals to the physician and RDN or designee. The RDN or designee will review all significant weight losses, . will make referrals and take action as necessary (including follow up documentation). The individual, family (or representative), physician and RDN or designee will be notified of any individual with an unintended significant weight change of 5% in one month, 7.5% in three months, or 10% in six months . Individuals with significant unintended weight changes will be added to weekly weights for a minimum of 4 weeks or until weight stabilizes. Review of the facility policy HMNR Care Plan dated 12/2022, included that the Purpose was To develop and implement a care plan for each resident/patient that includes the interventions needed to provide effective and person-centered . care of the resident/patient that meet professional standards of quality care. In addition, it included the following: The comprehensive care plan must describe . The services that are to be furnished to attain or maintain the resident/patient highest practicable physical, mental, and psychosocial well-being. Furthermore, it included that the care plan should be Prepared by an interdisciplinary Team, that includes but is not limited to - the attending physician or non-physician practitioner, a registered or licensed practical nurse . a Registered Dietitian . The care plan should also be Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive, significant change, quarterly, and annual review assessments. NJAC 8:39-11.2(e)(2) (i), 17.1(c), 17.4(a)(3), 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to follow a physician's order for Keppra (anti-epileptic medications used to control seizures) levels in the blood every three months for Resident #47. This deficient practice was identified for 1 of 21 residents reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/8/23 at 11:45 AM, the surveyor observed Resident #47 lying in bed awake, was not verbally responsive, and was not able to maintain eye contact with the surveyor. The surveyor reviewed the medical records of Resident #47. Review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to unspecified protein-calorie malnutrition (Protein calorie malnutrition happens when you are not consuming enough protein and calories), dysphagia (difficulty swallowing), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/20/22, indicated that the resident's cognitive skills for daily decision making was severely impaired. Review of the Attending Physician's (AP's) Doctor's Progress Notes dated 10/8/22, included a diagnosis of Seizure. Review of the Physician's Order (PO) dated 4/2/22, reflected a PO for Keppra 5 mL (milliliter) / 500 mg (milligram) via G-tube one time a day in the morning and Keppra 2.5 mL (250 mg) via G-tube in the evening. Review of the April 2022 through February 2023, Medication Administration Records (MARs) reflected the above corresponding PO's. Further review of the February 2023 POs included a PO for Keppra levels every three months, dated 8/26/20. Review of the hybrid (paper and electronic) medical records for Resident # 47 revealed that the last Keppra level was obtained on 4/15/22. There was no documented evidence in the resident's medical records that Keppra levels were obtained after 4/15/22 in accordance with the PO. Review of the resident's comprehensive care plans reflected a focus area for Neurological Diseases: Seizure Disorder effective on 9/6/22. Interventions dated 9/6/22, included to monitor drug treatment and dosage adjustments to minimize adverse reaction to other medications. On 2/8/23 at 12:12 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who acknowledged that the last Keppra level was obtained on 4/15/22, and should have been obtained again in July 2022, October 2022 and January 2023. The RN/UM could not speak to why the Keppra levels were not done. On 2/9/23 at 9:42 AM, the surveyor, in the presence of the survey team informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) of the above concerns. The DON stated that she would review the resident's medical records and would get back to the surveyor. On 2/13/23 at 9:19 AM, during a follow up interview with the DON and LNHA in the presence of the survey team, the DON acknowledged that there were no Keppra levels obtained after 4/15/22. She stated that the Keppra levels were missed and have fallen through the cracks. On 2/16/23 at 11:47 AM, the survey team met with the LNHA, Regional Registered Nurse (RRN#1), RRN#2, DON, and the Infection Control Preventionist Nurse (ICPN). There was no additional information provided. Review of the facility policy HMNR Laboratory, Radiology And Other Diagnostic Services last revised on April 2021 and effective on 4/2022, included that the Purpose was To ensure that laboratory, radiology, and other diagnostic services meet the needs of resident/patients. To ensure that results are reported promptly to the ordering practitioner to address disease prevention, potential concerns, and/or provide for resident/patient assessment, diagnosis and treatment. In addition, it included The nurse will ensure that arrangements are made for laboratory or diagnostic services when ordered by a physician, covering physician, consultant or nurse practitioner. NJAC 8:39-11.2(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the physician a.) addressed multiple severe weight losses, b.) implemented and monitored weekly weights, and c.) evaluated and adjusted nutritional interventions for 1 of 5 residents (Resident #47) reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 2/8/23 at 11:45 AM, the surveyor observed Resident #47 lying in bed awake. The resident appeared thin, was not verbally responsive and was not able to maintain eye contact with the surveyor. The surveyor reviewed the medical records of Resident #47. Review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to unspecified protein-calorie malnutrition (protein calorie malnutrition happens when you are not consuming enough protein and calories), dysphagia (difficulty swallowing), Gastrostomy Status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/20/22 and 11/20/22, indicated that the resident's cognitive skills for daily decision making was severely impaired with total dependence of one-person physical assist for eating. A further review of the resident's MDS, Section K - Swallowing/Nutritional Status revealed that the resident had a feeding tube and significant weight loss that was not prescribed by the physician. Review of the Physician's Order (PO) dated 6/11/20, reflected that the resident had an PO for the tube feeding formula of Jevity 1.5 - one can (237 milliliter [mL]) via G-tube four times daily at 9AM, 1 PM, 5 PM, and 9 PM for a total volume of 948 mL. Review of the July 2022 through February 2023, Medication Administration Record (MAR) reflected the above corresponding PO's. Review of the resident's Monthly Record of V/S (vital signs) and Weights reflected the following weights: March 2022 127.4 lbs. April 2022 125 lbs. May 2022 122.8 lbs. June 2022 121.9 lbs. July 2022 122.1 lbs. August 2022 105 lbs. reweighed at 99.4 lb. - 22.7 pound (lb.) and 18.6% loss over one month September 2022 99.5 lbs. - 27.9 lb. and 21.9% loss over 6 months October 2022 100.8 lbs. - 24.2 lb. and 19.4% loss over 6 months November 2022 99.4 lbs. - 23.4 lb. and 19.1% loss over 6 months December 2022 95 lbs. - 26.9 lb. and 22.1% loss over 6 months January 2023 89.5 lbs. - 5.5 lb. and 5.8% loss over one month Review of the resident's Attending Physician (AP) Doctor's Progress Notes dated 10/8/22, 1/17/23, and 2/5/23 did not include documented evidence that the AP was aware of the resident experienced significant weight losses. On 2/15/23 at 10:28 AM, the surveyor interviewed the resident's AP in the presence of the survey team, who stated that she visited the resident every month. She also stated that after visiting the resident, she documented the encounter in the resident's paper medical records. During the interview, she acknowledged that she noticed a lot of weight loss for Resident #47. The AP acknowledged that she had not increased the resident's tube feed (TF) formula order prior to the surveyor's inquiry. She further acknowledged that she could have increased the TF and stated, I am not saying that I don't want to give her food. The AP could not verify when and who in the facility notified her that the resident had significant weight losses. The AP stated that if the resident had a significant weight loss, I would have documented that in the medical record. On 2/15/23 at 12:42 PM, the LNHA, Regional RN#1 (RRN#1), DON, and MDS Coordinator met with the survey team. RRN#1 stated that the AP acknowledged that she was aware of the resident's significant weight losses, but there was no documented evidence in the resident's hybrid (electronic and paper) medical record that the AP addressed Resident #47's significant weight losses. The RRN#1 stated, that's a problem. On 2/16/23 at 11:05 AM, the LNHA, RRN#1, RRN#2, DON, and the Infection Control Preventionist Nurse (ICPN) met with the survey team. The RRN#1 acknowledged that the resident's bolus TF PO was never changed since 2019 to the present, until surveyor inquiry. She further stated that the resident suddenly, had a lot of weight loss in one month, and was wasting, and the AP never addressed the significant weight losses in the medical record until after the surveyor inquiry. On 2/16/23 at 11:47 AM, the survey team met with the LNHA, RRN#1, RRN#2, DON, and ICPN. There was no additional information provided. NJAC 8:39-23.2 (b)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 3 of 4 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the surveyor inspected the South Unit high end medication in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an unopened and undated bottle of Xalatan eye drops (medication for pressure in the eye, Glaucoma) that was stored inside the medication cart. The surveyor also observed an opened bottle of Timolol eye drops (Glaucoma) that was undated (pharmacy label date [DATE]) and an opened bottle of Dorzolamide eye drops (Glaucoma) that was opened with an opened date of [DATE], and was expired. The surveyor interviewed LPN #1 who stated that an unopened bottle of Xalatan eye drops should have been stored inside the medication refrigerator because once opened or once stored at room temperature, the medication will have a 42-day expiration date. LPN #1 also acknowledge that an opened bottle of Timolol eye drops should have been dated because once opened, it only had a 28-day expiration date. LPN #1 further stated that the Dorzolamide eye drops that was opened and dated [DATE], was expired and should have been removed from the medication cart. On [DATE] at 11:30 AM, the surveyor inspected the North Unit low-side medication Cart in the presence of LPN #2. The surveyor observed an opened bottle of blood Glucose test strips (a product to test the blood sugar levels) that was not dated. The surveyor also observed an opened bottle of Olopatadine eye drops (allergies) that was dated [DATE], and was expired. The surveyor interviewed LPN #2 who stated that an opened bottle of blood Glucose test strips should have been dated. LPN #2 also acknowledge that the Olopatadine eye drops were expired and should have been removed from the medication cart. On [DATE] at 11:00 AM, the surveyor inspected the South unit high-side medication cart in the presence of a Registered Nurse (RN#1). The surveyor observed a bottle of Xalatan eye drops that had an opened date of [DATE], but had no label containing a resident's name. They was no corresponding bag or box for the Xalatan eye drops. The surveyor interviewed RN#1 who stated that all the medication inside a medication cart or a medication refrigerator should have the name of a resident. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Unopened Xalatan eye drops should have been stored in a refrigerator. 2. Xalatan eye drops once stored at room temperature have an expiration date of 42-days 3. Timolol eye drops once opened have an expiration date of 28-days 4. Dorzolamide eye drops once opened have an expiration date of 28-days 5. Olopatadine eye drops once opened have an expiration date of 28-days. 6. Blood Glucose Test strips once opened have an expiration date of 90-days. On [DATE] at 1:35 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and discussed the above observations and findings. No further information was provided by the facility. A review of the facility's policy for Medication Storage dated ,d+[DATE], provided by the LNHA indicated the following: 6. Expired, discontinued and /or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy 8. Medications will be stored at the appropriate temperatures in accordance with the pharmacy/or manufacturer labeling. 9. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). A review of the facility's policy for Medication Labeling and Dating that was dated ,d+[DATE] and was provided by the LNHA indicated the following: 3. The label for each resident's individual medication container or package shall include at least the following: a. The resident's full name. Medication Dating: 1. The expiration date for all medications will be labeled expiration date unless the manufacturer gives specific requirements for beyond use dates. 2. Beyond use dates refer to a specific amount of a time a medication is still able to be used once it has been removed from the manufacturer's specified storage conditions (e.g., opened vial or package, removed from refrigeration). a. Once a medication has been removed from the manufacturer's specified storage conditions, the medication will be dated with the current date. b. When the medication reaches its beyond-use-date, based on the date it was opened or removed from the manufacturer's specified storage conditions, it will be discarded according to the facility policy. c. The beyond use date cannot exceed the manufacturer's expiration date. d. Medications requiring specific dating upon opening are typically labeled with cautionary and/or accessory labels alerting the nurse to this dating recommendation. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, interview, and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 of 21 (Resident # 77) residents reviewed. This deficient practice was evidenced by the following: According to the Resident Assessment Instrument Manual Version 3.0 of Centers for Medicaid and Medicare Services (CMS) guidelines, updated October 2019, a SCSA MDS is required within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, a SCSA/MDS must be completed. (For purpose of this section, a significant change is a decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related interventions, that has an impact on more than one area of the resident's health status and requires interdisciplinary review or revision of the care plan, or both.) On 2/6/23 at 11:42 AM, the surveyor observed Resident # 77 awake and seated in a wheelchair inside his/her room. The surveyor reviewed the electronic and paper medical record for Resident # 77. Review of the Admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated that the resident had severe cognitive impairment. The MDS also revealed that the resident's functional status for bed mobility required limited assistance with one person assistance, eating required supervision with setup, and toileting required extensive assistance with one person assistance. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated that the resident had intact cognition. The MDS also revealed that the resident's functional status for bed mobility improved. The MDS indicated the resident was independent with bed mobility requiring setup assistance. The resident improved with eating independently requiring setup assistance. The MDS further revealed that the resident's toileting status also improved requiring supervision with setup assistance. A review of the Occupational Therapy (OT) Plan of Care dated 11/22/22, revealed the resident began receiving OT services on 11/22/22. Review of the OT long-term goal plan was for the resident to complete bed mobility safely with supervision and that the resident will be able to perform toileting with supervision. On 2/14/23 at 10:53 AM, the surveyor discussed with the Registered Nurse Minimum Data Set (RN/MDS) Coordinator, Resident # 77's improvement in cognition and three areas in the functional status, Section G of the quarterly MDS dated [DATE]. The RN/MDS Coordinator acknowledged that the resident began rehab services on 11/22/22, to improve with his/her activities of daily living (ADLs). She stated that she didn't think the improvements in the functional status section of the 12/10/22 MDS required a significant change in status because the resident was expected to improve in his/her ADLs because of therapy services. She further stated that that she did not discuss the resident's cognitive and functional status changes with the Interdisciplinary Team. Review of the Quarterly IDCP [Interdisciplinary Care Plan] meeting dated 12/20/22, indicated that the IDCP team met and discussed that the residents needs are being met by staff including his/her medical and psychiatric needs are monitored daily .staff will continue to be supportive. There was no documented evidence that the team discussed the resident's improvement in cognition and in his/her functional status. Review of the resident's care plan with a focus area for at risk for ADL decline due to dementia dated 11/23/22, indicated a goal to show improvement in mobility status and in ADLs. On 2/14/23 at 2:00 PM, the surveyor discussed the above findings with the Licensed Nursing Home Administrator and the Director of Nursing. On 2/15/23 at 12:40 PM, the survey team met with the facility administration team who acknowledged that a significant change in status for Resident # 77 should have been completed. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, reflected on page 2-18 that a SCSA MDS must be completed no later than the 14th calendar day after determination that a significant change in resident's status occurred. The manual further reflected on page 2-22 that A significant change is a major decline or improvement in a resident's status. There was no additional information provided. NJAC 8:39-11.2(i)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to implement infection control policies and procedures in a manner that would decrease the possibility of spreading infection. This was found with 1 of 4 residents who were on transmission based precautions, Resident #13. The deficient practice was evidenced by the following: On 2/17/21 at 8:20 AM, during a medication pass observation, the surveyor entered the room of Resident #13 with the resident's assigned Licensed Practical Nurse (LPN). There was a sign on the resident's door. The sign read: Stop! Please see nurse before entering. Quarantine Precautions Contact and Droplet Precautions are in effect. Upon entering and exiting the room: Wash hands. Wear full PPE; Gown + Gloves + Eye Protection + N95 covered with a surgical mask. The LPN explained that the resident was recently readmitted from the hospital and was on quarantine precautions for 14 days due to the Covid-19 pandemic. The surveyor and the LPN donned full Personal Protective Equipment (PPE) which included an N95 mask covered with a surgical mask, a face shield, an isolation gown, and gloves. Upon entering the room the surveyor observed a Certified Nursing Assistant (CNA) in the room wearing an N95 mask covered with a surgical mask, and goggles. The CNA was not wearing a gown or gloves. The CNA was bent over by the bathroom cleaning what she explained was a spilled drink from the floor with paper towels. The resident was sitting up on the side of the bed (by the bathroom). The resident was not wearing a mask. When the CNA was done cleaning the spill she washed her hands. At that time the surveyor asked the CNA what the facility instructed the staff to wear when entering the room of a resident on Quarantine Precautions. The CNA stated I was told when we are going in to get something we don't need all of the PPE except goggles, N95 and mask, we don't need gown and gloves if we are bringing a tray or getting a tray or no direct contact. On 2/17/21 at 8:40 AM, the surveyor asked the LPN what the CNA was supposed to be wearing when she entered the room of a resident on Quarantine Precautions. The LPN said (The CNA) knows she is supposed to wear a gown and gloves, she had them when she went in the room. I was surprised when I went in there and she wasn't wearing them. I guess she got startled when she knocked down the drink and she didn't put it on. She knows. We all know to wear full PPE in those rooms. On 2/17/21 9:19 AM, the surveyor asked the Unit Manager/Registered Nurse (UM/RN) what PPE was required when entering the room of a resident on Quarantine Precautions. The UM/RN said A mask, N95, goggles or face shield, gown and gloves, when you go in the room for any reason, dropping off a tray, picking up a tray, the expectation is full PPE. On 2/17/21 at approximately 10:15 AM, the surveyor asked the Infection Preventionist (IP) what the CNAs were told to don when they entered the room of a resident on quarantine precautions. The IP stated Full PPE, N95 mask, covered by a surgical mask, goggles or face shield, gown and gloves. The surveyor asked what if the CNA was going in a room to get a tray, what PPE would be required. The IP stated Full PPE. The IP stated further I put together an explanation of PPE and what to wear when they go into a room of a resident on transmission based precautions. Every staff gets the in-service, nurses, aides, housekeepers. Every time we get a new employee I give them an in-service. If I was too see someone in a quarantine room without a gown on for instance I would write them up and report it to the Director of Nursing (DON). On 2/17/21 at 1:29 PM, the surveyor asked the DON what the expectation was for staff when they enter a room of a resident on quarantine precautions. The DON stated Full PPE if going in the room for any reason when someone is on quarantine precautions. On 2/19/21 at 9:00 AM, the surveyor reviewed the following: The facility's Pandemic Preparedness Infection Control Plan, Updated 1/15/21. Under the heading Quarantine Status/Admissions/Readmissions-July 7/2/20, Updated 10/24/20, 11/4/20. Number 1 read: Patients/Residents will be placed on quarantine status for 14 days requiring contact and droplet precautions using full PPE including N95 or higher respirator and eye protection (face shield, goggles, safety glasses) under the following circumstances: a. New admissions and readmissions (unless they have tested positive for Covid and recovered within the last 90 days) b. Patients/residents with a known exposure to an individual testing (+) for Covid-19. c. Patients/residents returning from a hospital ER visit. d. Patients/residents refusing Covid testing, if required by facility status. e. Residents who have gone out to a medical appointment or outing with family/representatives where the use of PPE, social distancing, or infection control practices is questionable (most physician offices, [MEDICAL TREATMENT] centers, other healthcare facilities follow requirements.) Assessment should be performed to identify risks. Number 7. read Team members should wear eye protection and an N95 or higher respirator at all times while in the quarantine area with gown and gloves added when entering patient/resident rooms. The facility's policy and procedure titled HMNR Contact Precautions. Last approved, 7/2020. Definition of Contact Precautions read: Measures that are intended to prevent transmission of infectious agents which are spread by direct of indirect contact with the resident or the resident's environment. Number 1. under Procedure read: Gowns and gloves must be worn by all personnel upon entering the room. This is a proactive measure, as unexpected resident contact or contact with environmental surfaces or items in the resident's room cannot always be anticipated. The facility's policy and procedure titled HMNR Droplet Precautions. Last approved, 6/2020. Definition of Droplet Precautions read: Actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the Physician visits and/or Nurse Practitioner (NP) visits were conducted in person and documented at required intervals. a.) physician's orders [REDACTED].#45 & #59) for several months and b.) There were a few months that the neither the NP nor Physician visited 4 of 4 residents (Resident #60, #74, #39 & #88) reviewed. This deficient practice was evidenced by the following: 1. On 2/10/21 at 12:10 PM, the surveyor observed Resident #60 in the resident's room laying in bed asleep. On 2/11/21 at 10:00 AM the surveyor reviewed the medical record of Resident #60 which revealed the following: According to the Physician Orders, Resident #60 had [DIAGNOSES REDACTED]. The resident's physician visited the resident up to and including 3/5/20. There were no visits by the physician after 3/5/20 through to the time of the survey on 1/31/21. Progress notes were written by the Nurse Practitioner on the following dates since the most recent visit by the resident's attending physician; 4/15/20, 5/19/20, 6/24/20, 7/24/20, 8/24/20, 9/23/20, 10/2/20, 11/16/20, and 12/18/20. 2. On 2/11/21 at 9:20 AM, the surveyor observed Resident #45 in the resident's room sitting in a wheel chair watching television. On 2/11/20 at 10:20 AM the surveyor reviewed the medical record of Resident #45 which revealed the following: According to the physician's orders [REDACTED]. The resident's physician visited the resident up to and including 3/5/20. There were no visits by the physician after 3/5/20 through to the time of the survey on 1/31/21. Additionally, none of the physician's orders [REDACTED]. On 2/11/20 at 10:30 AM the surveyor asked the Unit Manager/Registered Nurse (UM/RN) if the physician saw the resident during the period of time between 3/2020 and 1/2021. The UM/RN said no, he didn't come in because of Covid, we call him if we need to. The surveyor asked the UM/RN if the resident was seen by the NP during those 11 months. The UM/RN said the resident was not seen by the NP during that time. The UM/RN further added that Resident #45 was seen by specialists on a regular basis, and attended [MEDICAL TREATMENT] every Monday, Wednesday, and Friday and went to the wound doctor weekly. 3. On 2/10/21 at 10:00 AM, the surveyor observed Resident #59 laying in bed awake scrolling on the resident's cell phone. On 2/11/20 at 10:40 AM, the surveyor reviewed the medical record of Resident #59 which revealed the following: According to the physician's orders [REDACTED]. The resident's physician visited the resident up to and including 3/5/20. There were no visits by the physician after 3/5/20 through to the time of the survey on 1/31/21. On 2/11/21 at 1:10 PM, the surveyor asked the UM/RN if the resident was seen by a NP since the last time the resident was seen by the Attending Physician (3/5/20). The UM/RN said no. Additionally, none of the physician's orders [REDACTED]. 4. On 12/9/21 at 12:18 PM, the surveyor observed Resident #74 seated in a wheelchair inside the resident's room. The surveyor reviewed Resident #74's medical record that revealed the following: According to the physician's Progress Notes dated 2/28/19, Resident #74 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's physician visited the resident monthly up to and including 3/5/2020. There were no visits from the physician after 3/5/2020 through to the time of survey on 1/31/2021. The NP wrote monthly progress notes with the exception of April 2020, October 2020 and November 2020. Neither the physician or NP visited Resident #74 in April, October and November of 2020. On 2/11/21 at 11:30 AM, the surveyor interviewed the UMRN who stated they have been calling the MD to come in and he hasn't come in. 5. On 2/11/21 at 10:19 AM, the surveyor observed Resident #39 resting in bed watching television. The surveyor reviewed Resident #39's medical record that revealed the following: According to the facility Admission Record, Resident #39 was admitted with [DIAGNOSES REDACTED]. The resident's physician visited the resident monthly up to and including 3/5/2020. There were no visits from the physician after 3/5/2020 through 1/31/2021. The NP wrote monthly progress notes with the exception of November and December 2020. Neither the physician or NP visited Resident #39 in November and December 2020. On 2/11/21 at 1:22 PM, the surveyor interviewed the UMRN on the South Wing who confirmed the physician's last progress note located in the medical record was on 3/5/20. She continued to state that progress notes should be in the medical record so there will be proper communication between the doctor or NP and the nurse. 6. A review of Resident #88's closed record revealed the primary physician visited the resident monthly up to and including 3/5/2020. There were no visits from the physician after 3/5/2020 through to the time of survey on 2/19/2021. The NP wrote monthly progress notes for the duration of the resident's stay with the exception of April, 2020. Neither the physician or NP visited Resident #88 in April, 2020. On 2/17/21 at 10:40 AM, the surveyor interviewed the NP who stated that she was out sick in April, October and November 2020 and did not come into the facility. At 10:50 AM, the surveyor interviewed the primary physician via telephone who stated since the pandemic he has not been doing face to face visits with his residents, nor did he do telemedicine. He stated that he was in contact with the facility via telephone. During this time frame none of the residents reviewed experienced any untoward medical events. The survey team discussed the above concerns with the Administrator and Director of Nursing (DON) on 2/11/ and 2/17/21. The Administrator stated that the previous DON had discussed the issue with the previous Medical Director. However, the physician still did not come to see his residents nor did he delegate another practitioner to visit and sign orders for Resident #45 and #59. According to the facility's policy dated 10/20/20 regarding Physician Visits under Procedure #6: Patients must be seen at least once every 30 days for the 90 days after admission, and at least once every 60 days thereafter. NJAC 8:39-23.2(b)

Based on observation, interview and record review, it was determined that the facility failed to administer medication based on a physician's order in accordance with professional standards of nursing practice for 1 of 21 sample residents (Resident #82). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 6/13/18 at 10:00 a.m., the surveyor observed the Registered Nurse (RN) preparing to administer 5 medications, which included 1 tablet of [MEDICATION NAME] 325mg, to Resident #82. The RN stated the resident's medications should be administered crushed in applesauce. At that time, the surveyor observed the RN crush 5 medications which included the [MEDICATION NAME] tablet and place the crushed tablets into the applesauce. The RN then administered the medications in the applesauce to the resident. On 6/13/18 the surveyor reviewed the medical record for Resident #82 which revealed the resident was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR binder revealed a document, provided by the facility's pharmacy provider, containing a list of medications which should not be crushed. The surveyor reviewed the Physician's Order Sheet (POS) for (MONTH) (YEAR) which reflected the corresponding physician order for [REDACTED]. On 6/13/18 at 10:45 a.m., the surveyor interviewed the RN who stated he was aware [MEDICATION NAME] should not be crushed based on manufacturer's recommendation but forgot. The RN further stated he was aware of a Do not Crush medication list, located within the MAR binder. The surveyor with the RN reviewed the Do not Crush medication list. The RN acknowledged that [MEDICATION NAME] is on the Do not Crush medication list and he should not have crushed the medication. On 6/13/18 at 11:50 a.m., the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated there is a Do not Crush medication list located within the MAR binder. The RN/UM stated all nurses are made aware of the precautionary reference during orientation. The RN/UM acknowledged [MEDICATION NAME] should not be crushed and the RN should not have crushed the medication. On 6/15/18 at 11:00 a.m., the survey team met with the acting Director of Nursing (DON) who stated the RN acknowledged to her that he was nervous and crushed the [MEDICATION NAME] tablet in error. The acting DON further stated the RN should have obtained an order for [REDACTED]. A review of the Manufacturer's specifications for [MEDICATION NAME] tablets indicate that the medication should be swallowed whole. According to Hackensack Meridian Health at Cedar Brook's Medication Administration policy revised 6/2018, B: Medications must be administered in accordance with the written orders of the attending physician. NJAC 8:39-11.2(b)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate hand washing practices to prevent the spread of infection during a wound treatment observation. This deficient practice was identified for 1 of 1 resident, Resident #7. The deficient practice was evidenced by the following: During the initial tour on 6/11/18 at 08:11 a.m., the surveyor observed Resident #7 in bed, with a breakfast tray and able to feed self. On that same day and time, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that the resident had an in-house acquired (IHA) wound. The RN/UM stated that the IHA wound was a deep tissue injury (DTI) to the right heel. A review of the resident's face sheet revealed that Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 6/14/18 at 10:11 a.m., during wound observation, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to the resident's sacrum and the right heel. The surveyor observed the LPN perform hand washing prior to sanitizing the side table with no suds during hand scrubbing. The surveyor observed the LPN did not air dry the sanitized side table prior to placing a plastic bag on the edge of the side table. In addition, the surveyor observed the LPN did not air dry the sanitized side table and immediately placed the barrier on top of the side table. The LPN transferred the prepared treatment medications and supplies from the treatment cart to the side table. The surveyor observed the LPN removed gloves after sanitizing the side table and performed hand washing for 17 seconds under running water with no suds during hand scrubbing. The surveyor asked the LPN if there was soap in the dispenser and if it was appropriate to perform hand washing under running water. The LPN informed the surveyor that there was not enough soap in the dispenser and stated that Oh no, I shouldn't wash my hands under running water. The LPN continued the wound treatment and did not ask other staff to fill the soap dispenser. The LPN applied a new pair of gloves and removed the resident's blanket and exposed the sacrum with no dressing while the resident was positioned to the left side facing towards the window and removed gloves. The surveyor observed the LPN applied a new pair of gloves, cleanse the sacral area with normal saline (NS) and remove gloves. At that time, the LPN failed to perform hand washing prior to applying a new pair of gloves. At the same time, the surveyor observed the LPN apply Zinc Oxide, a treatment medication to the sacrum, covered with an adhesive dressing, re-apply the diaper and remove gloves. The surveyor observed the LPN performed hand washing for 17 seconds under running water with no suds. The LPN applied a new pair of gloves, touched the blanket on the lower leg of the resident and exposed the right heel. The LPN removed the sock on the right foot, placed a barrier below the right foot, cleansed the right heel with NS, dried the right heel with a gauze and removed gloves. At that time, the LPN applied a new pair of gloves, applied A and D ointment to the right heel, covered with an adhesive dressing and removed gloves. The LPN did not perform hand washing in between glove removal. The LPN applied a new pair of gloves, placed the sock to the right foot, removed the barrier and took the bilateral heel boots from the nightstand and removed gloves. At that time, the LPN applied a new pair of gloves and placed the bilateral heel boots to resident's feet. The LPN failed to perform hand washing in between glove removal. Afterward, the LPN covered the resident with a blanket and removed gloves. The surveyor observed the LPN performed hand washing for 15 seconds without soap and scrubbed hands under running water. The surveyor asked the LPN if there was soap in the dispenser and if it was appropriate to perform hand washing under the running water. The LPN stated, Oh, I'm sorry, I shouldn't scrub my hands under running water, I'll do the hand washing again. The surveyor observed the LPN touched the soap dispenser three times and there was no soap that was dispensed at that time and completed the hand washing for 15 seconds. The LPN applied a new pair of gloves, discarded the all treatment supplies on top of the side table including the barrier into the plastic bag and eventually to the treatment cart garbage plastic bag. At that time, the LPN donned a new pair of gloves without performing hand washing and walked in the hallway with gloves on. In addition, the surveyor observed the LPN remove the glove on her right hand in front of the nursing station and retained her left hand glove while holding the plastic of garbage. The surveyor observed the LPN disposed the garbage bag inside the Utility Room and removed the glove in her left hand. The LPN performed hand washing for 20 seconds inside the Nursing Station. The surveyor the LPN signed the Treatment Administration Record. On 6/14/18 at 10:39 a.m., the LPN stated that the sacral wound was a Stage 2 pressure ulcer and healing was in progress. The LPN also stated that the right heel wound was an intact DTI. The LPN stated that as a standard of practice and as per facility protocol, staff must perform hand washing before donning gloves with some exemptions. The LPN informed the surveyor that there was not enough soap in the dispenser. The LPN stated that the only time there was soap in the dispenser was the first two hand washing she did. The LPN also stated that soap was needed in the hand washing. The LPN informed the surveyor that the hand washing should be done for at least 20 seconds and not under running water as per facility protocol. On 6/14/18 at 10:45 a.m., the surveyor interviewed the RN/UM. The RN/UM informed the surveyor that staff must perform hand washing for at least 20 seconds, should not be done under running water and must be done every gloves removal per facility protocol. The RN/UM stated that staff must not wear gloves in the hallway as per infection control. At that same day and time, the surveyor and the RN/UM went to resident's room. The RN/UM informed the surveyor that there was no soap in the dispenser. The RN/UM stated that she will get housekeeping to get soap for the dispenser. According to the Centers for Disease Control and Prevention's (CDC), Hand Hygiene Guideline for Healthcare Providers with an updated date on 3/24/17 revealed that Hand Hygiene means cleaning your hands by using either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. In addition, CDC's Hand Hygiene Guideline revealed that Hand Hygiene must be performed after glove removal. On 6/14/18 at 11:55 a.m., the surveyor interviewed the RN/UM. The RN/UM informed the surveyor that the facility uses the purple top Super Sani-cloth germicidal disposable wipe for disinfecting the table and equipment and must air dry for at least two minutes. On 6/14/18 at 11:56 a.m., the surveyor interviewed the LPN. The LPN informed the surveyor that the staff must wait for at least three minutes to air dry the surface when sanitized with use of the purple top container. On 6/14/18 at 12:48 p.m., surveyor team met with the Administrator, Assistant Director of Nursing/Infection Control Nurse (ADON) and the Vice President of Nursing (VPN) and made aware of the concerns. On 6/15/18 at 9:17 a.m., the surveyor interviewed the LPN. The LPN informed the surveyor that I know I did bad yesterday with hand washing but will try to do it better next time. The LPN stated she knew the right thing to do but she did the hand washing the wrong way because she was nervous. On that same day at 11:12 a.m., the ADON and the VPN met with the survey team. The VPN informed the survey team that the LPN knew that the hand washing must be done for 20 seconds. The VPN stated that the LPN was nervous and was not aware that she performed hand washing in less than 20 seconds. The VPN also stated that according to the LPN there was not enough soap in the dispenser and it was only a little bit soap. A review of Infection Control Policy with the revised date on 10/25/16 provided by the ADON revealed that on page 1, Hand hygiene is a general term that includes: using alcohol-based hand sanitizers, handwashing with soap and water, changing gloves between tasks and residents. In addition, on page 2, Using friction, work lather on front and back of hands, between fingers, under fingernails, and nailbeds for 20 seconds, working up 2 inches above the wrist. NJAC 8:39-19.4 (a) (1, 2)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper kitchen sanitation practices, observe proper food preparation and sanitation during food preparation and distribution, and maintain food equipment services to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 2/27/17 at 6:20 p.m. during the initial tour of the kitchen in the presence of the Kitchen Porter (KP), the surveyor observed the following: 1. The walk-in freezer contained salami in plastic wrap and walnuts that were open and not dated. The freezer also contained a package of hot dogs that was open to air and not dated. 2. There was a one-eighth inch opening between the control box of the dishwasher and the dishwasher which was not properly caulked and created a space which was difficult to clean. The space contained rusty debris around the control box. 3. The broiler over the flat top contained a thick, greasy, dusty build-up. The exterior top of the broiler contained a greasy, dusty build-up. 4. The floor under 2 stoves contained a very thick greasy black build-up, papers and black debris. 5. The oil in the fryer contained concentrated food debris around the 4 sides of the fryer. The KP confirmed the above surveyor observations. At 6:40 a.m. the Registered Dietician (RD) joined the tour and the KP left. 6. A live insect was observed walking across the floor of the dry storage room. 7. The floor of the dry storage room contained pieces of uncooked pasta and pieces of paper debris. 8. The exterior top of the ice cream freezer contained a large amount of white debris. The RD did not know what the white debris was. The RD confirmed the above surveyor observations. At 7:58 a.m. the Food Service Director (FSD) joined the tour. 9. The flour and sugar bins were not labeled or dated as to when the bins were last cleaned and filled. The FSD agreed that the bins were not labeled or dated. On 2/28/17 the surveyor reviewed the following Policy and Procedures: Equipment Cleaning Frequency included that all equipment used in the Dietary Department will be cleaned after use, daily, weekly or monthly. The frequency for fryers - after each use weekly. The frequency for floors - 3 times daily. Labeling & Dating included that foods should be stored no longer than 72 hours after the date on the label and any foods not used within 72 hours should be discarded and not used. On 3/1/17 the survey team discussed the above with the Administrator and the Director of Nursing (DON). NJAC 8:39-17.2 (g)

Based on interview, and record review, it was determined that the facility failed to conduct thorough investigations into the possible causes of injuries of unknown origin for 3 of 3 investigations reviewed. The deficient practice was noted for 3 residents, #24, #25, and #26, as evidenced by the following: 1. On 3/3/17 the surveyor conducted Task 5G - Abuse Prohibition. The surveyor reviewed Resident #24's Safety Report for an incident that had occurred on 09/04/2016 at 10:00 a.m. The report revealed during morning care Resident #24 was noted with ecchymosis (bruising) on the lateral and medial aspects of the right foot. The resident denied pain and stated I don't know how it happened. The report included there were no definitive incidents identified that may have caused the injury. The section of the report that included the question was further investigation required was blank. On 3/3/17 at 10:00 a.m. the survey team met with the Administrator and the Director of Nursing (DON) and informed them of the findings. The DON stated that no further investigation was conducted after the incident and that there was no updated care plan regarding the incident. 2. On 3/3/17 the surveyor conducted Task 5G - Abuse Prohibition. The surveyor reviewed Resident #25's Safety Report regarding an incident that occurred on 07/13/2016 at 7:00 a.m. An abrasion was noted to the resident's right knee during rounds. The resident was unable to recall what happened. The resident's friend had spent most of the day with the resident. She did not recall any incident that may have caused the injury. The section of the report that included the question was further investigation required was blank. On 3/3/17 at 10:00 a.m. that survey team met with the Administrator and the Director of Nursing (DON) and informed them of the findings. The DON stated that no further investigation was conducted after the incident and that the care plan was not updated. 3. On 3/3/17 the surveyor conducted Task 5G - Abuse Prohibition. The surveyor reviewed Resident #26's Safety Report regarding an incident that occurred on 11/17/2016 at 5:30 a.m. The Certified Nursing Assistant (CNA) notified the nurse the resident had a purple discoloration on the right upper arm. The report included that there was no definitive origin of injury identified. On 3/3/17 at 10:00 a.m. that survey team met with the Administrator and the Director of Nursing (DON) and informed them of the findings. The DON stated that no further investigation was conducted after the incident and that the care plan was not updated. Refer to F279 NJAC 8:39-13.4(c)(2)(v)

Complaint #: NJ Based on interviews and record review, it was determined that the facility failed to provide the necessary care and services to 1 of 6 residents, Resident #6, which resulted in the resident's inability to maintain their physical well being in accordance with the comprehensive assessment and plan of care. On [DATE], the facility failed to follow their dietary procedures in the plating and serving of food to residents, which resulted in the serving of an improper diet, choking and subsequent death of a resident, Resident #6. The lunch tray meal, served to Resident #6 at approximately 12:40 p.m. and realized by facility nursing staff to be the wrong dietary consistency, was moved from in front of the resident by a nursing staff member and the correct diet ordered. The wrong lunch tray remained in the dining room on a counter within view of and near Resident #6. Resident #6 stood up from the table, ambulated to where the tray was placed, picked it up and carried it back to the table where the resident was sitting. Resident #6 started to rapidly eat the regular consistency veggie burger, exhibited intermittent coughing throughout the process, and consumed almost three quarters of it before the Charge Nurse, a Registered Nurse (RN #1) was able to get the resident to stop eating it and took the remaining piece away from the resident. Subsequently, the correct therapeutic diet, "Vegetarian, soft with meats finely chopped and honey thick liquids", was given to the resident at approximately 1:00 p.m.. The resident started to eat that diet, then suddenly stood up from the table and walked towards the counter by the television and collapsed to the floor at approximately 1:05 p.m. The [MEDICATION NAME] maneuver and abdominal thrusts were attempted on Resident #6 by the facility staff without success. CPR (Cardio-Pulmonary Resuscitation) was started by facility staff and 911 was called. The medics arrived at approximately 1:25 p.m., continued resuscitative efforts and transported Resident #6 to the hospital at approximately 2:10 p.m.. According to the hospital's emergency room record documentation, the resident was pronounced dead on arrival at 2:17 p.m. This deficient practice is evidenced by the following: 1. According to facility Registration Form/Face Sheet, Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Reference: Taber's Encyclopedic Medical Dictionary, 2011. Subsequent diagnoses, as documented on the Cumulative [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated [DATE], documented Resident #6 with a BIMS (Brief Interview Mental Status) score of 15, indicating that the resident was cognitively intact. Resident #6 did not require the assistance of staff for any activities of daily living, except for the supervision (oversight, encouragement or cueing) of eating. On record review, the surveyor observed in a nurse's note dated [DATE] at 12:45 p.m. the following: "During lunch time pt (patient) was choking with (sic) hamburger. [MEDICATION NAME] Maneuver given. Pt is able to cough out hamburger." A care plan dated [DATE], clarified by the Director of Nursing (DON) to be [DATE], was documented as follows: "Choking episode, risk for choking/aspiration secondary to decreased chewing ability and difficulty swallowing. Continue meals with supervision and increased monitoring." On [DATE], (again confirmed by DON to be 2012), Resident #6's diet was changed to 'Soft with meats finely chopped and nectar thick liquids'." On [DATE], a physician order [REDACTED]. This diet downgrade confirms a decline in the resident's ability to swallow thinner, nectar consistency liquids safely. A psychiatric consult, dated [DATE] documented the following: "Summary of Present Findings and Reason for Consultation: Treatment and ongoing assessment of HD ([MEDICAL CONDITION]'s Disease) patient who appears to be deteriorating." The opinion and recommendations of the psychiatrist were as follows: "(Resident #6) speech has deteriorated greatly. (Resident #6) tries very hard to communicate but is almost impossible to understand." On continued record review, the surveyor observed documented in a nurse's note of [DATE] at 1:05 p.m., the following: "While in solarium resident stood up from table and began walking, (resident) suddenly began to go down to the floor. (Resident #6) was noted unresponsive. Assisted to stationary chair. Abdominal breathing noted. [MEDICATION NAME] maneuver performed unsuccessfully. Transferred to floor, [MEDICATION NAME] maneuver performed, mouth swept of food, bread and meat. CPR initiated. 911 called, arrival at 1:25 p.m. CPR continued. 2:10 p.m., transported to hospital." The surveyor conducted interviews on [DATE] with the facility dietary and nursing staff as follows: At 11:30 a.m., the surveyor conducted an interview with the Charge Nurse of the [MEDICAL CONDITION]'s Unit, a Registered Nurse (RN #1). RN #1 reported that there is always a nurse on the unit. There was a nurse on the unit doing med-pass at the time this choking episode occurred. A STAT (an emergency situation in the building) was called and staff responded. The Code Cart and the AED (automatic external defibrillator) were brought as well and the resident was hooked up to the AED. 911 was called as well. At 11:55 a.m., the surveyor conducted an interview with the full time ,[DATE] nurse on the [MEDICAL CONDITION] Unit, (RN #2). She was observed standing with her medication cart in the hall at the entrance to the solarium on the [MEDICAL CONDITION] Unit. She stated, "I am always in the solarium dining room because of the choking risk. I was off on that day ([DATE])." At 1:25 p.m., the surveyor conducted an interview with the Dietary Supervisor (DS) and asked what the specific duties of the cook and dietary aides were during the plating process of meals. The DS reported that all staff who have worked since the incident have had inservicing about their duties. The DS also reported the following duties of each Dietary Aide during tray line: Dietary Aide #1: "Starts the tray line by placing diet card and condiments on tray." Dietary Aide: #2: "Calls to the cook for the food and puts on the tray the dessert and the bread. The cook puts the plate on the rack for her, she takes it down and puts it on the heating element (pellet), looks at it to ensure that the food is what the diet should be." Cook: "Plates food, according to diet called for by Dietary Aide #2." Dietary Aide #3: "Picks up the lid, checks to see that the food is correct with the diet card, recovers it and places the tray on the delivery cart." At 1:40 p.m., the surveyor conducted an interview with the Dietary Aide #2, who worked on [DATE]. She stated, "I'm supposed to ask the cook for the diet on the card and put it on the tray. I just called (Resident #6's) name, not the diet. We got inserviced on dietary aide duties after this happened. Now I know to call the diet and not the name." At 1:50 p.m., the surveyor conducted an interview with the Dietary Aide #1, who worked on [DATE]. She stated, "I put on hotplates, top, bottom,condiments and tickets with the patient's diet on it. We did get inserviced on the duties of the dietary aides. We all take turns doing the different duties." At 2:00 p.m. the surveyor conducted an interview with a CNA, (CNA #1) who was in the solarium/dining room at lunch on [DATE]. CNA #1 reported the following: "At about 12:40 p.m., (Resident #6) was given lunch tray by (CNA #2). When she opened it, she saw it was not the right diet and moved it away to the counter by the television. She went to get the charge nurse. (Resident #6) got up, took the tray and put it by (Resident #6). We all told (Resident #6) not to eat that, but (the resident) kept eating it anyway. (Resident #6) was a big eater. (Resident #6) was hungry. (Resident #6) would not give it up until he was told it was beef. (Resident #6) was a vegetarian. (Resident #6) always coughed when (Resident #6) ate. We always have a nurse in the dining room (solarium) to watch. RN #2 is always there, she just happened to be off that day." At 2:13 p.m., the surveyor conducted an interview with a CNA, (CNA #2). CNA #2 reported the following: "I gave (Resident #6) the lunch tray. I lifted the top off and saw that (Resident #6) could not have this. I took the tray and put it on the TV (television) counter and went to get the charge nurse, RN #1 in the main dining room. She told me to stay in the main dining room until she got back and RN #1 went to look at the tray. RN #1 came back and went into the kitchen to order another tray for (Resident #6). At 2:18 p.m., the surveyor conducted an interview with a CNA, (CNA #3). CNA #3 reported the following: "I was in the solarium feeding a resident. When CNA #2 opened the tray for (Resident #6) I noticed it was a full burger and we all knew (Resident #6) shouldn't eat that. CNA #2 took the tray away and put it by the TV. (Resident #6) got agitated, he was hungry, so us (sic) knowing (Resident #6), we weren't going to fight with him cause (Resident #6) can be combative. (Resident #6) got up, walked around and grabbed the tray. They told (Resident #6) no, don't, but by the time RN #1 came, (Resident #6) has eaten about 70% of it. RN #1 asked (Resident #6) if (resident) was okay, (Resident #6) gave 'thumbs up' and kept eating. (Resident #6) coughed, but (resident) always coughed." At 2:55 p.m., the surveyor conducted a telephone interview with the Cook from lunch on [DATE]. The Dietary Aide just asked me for the resident's food by name. She stated, 'I need a tray for (Resident #6).' I knew (Resident #6) was a vegetarian. I would not know if it is supposed to be chopped or regular unless they say so. Because they did not say chopped or pureed, I just gave a regular diet." At 3:00 p.m., the surveyor conducted a telephone interview with the Dietary Aide #3 from the [DATE] incident. She reported the following: "I'm supposed to put on juices, drinks, check tray and put it on truck. I did not uncover it, (the food) to check if it was the right consistency. Dietary Aides #2 and #3 are supposed to check the consistency, but I did not. We had inservice afterward about who does what on tray line." The facility called in this Reportable Event to the Department of Health Reportable Event Hotline, on Friday [DATE]. The Facility Reportable Event (FRE), documented that (Resident #6) grabbed the tray with regular veggie burger and consumed 60% before being coaxed to return uneaten portion to nurse. Resident then ate some of the finely chopped veggie burger, stood up and began walking when CNA #5 noted that (resident) did not look right. STAT (an emergency situation in building) called. Resident unable to speak/cough, [MEDICATION NAME] maneuver unsuccessful. Resident has [MEDICAL CONDITION]'s Disease and is at risk for choking. The surveyor conducted an interview on [DATE] at 5:10 p.m. with the Director of Nursing (DON) and the Administrator. The surveyor asked that in light of the history of choking on food and the need for a previous [MEDICATION NAME] maneuver to have been done, the fact that Resident #6 eats quickly, and frequently coughs while eating, should someone have been sitting with the resident while eating. The DON replied, "(Resident #6) just needed supervision." NJAC 8:,[DATE].1 (a)

Based on interview and record review it was determined that the facility failed to provide care to maintain normal bowel function for a resident who was at risk for the development of bowel constipation related to medication and immobility. This deficient practice resulted in a resident being hospitalized 2 times within a 2 month period for the development of a fecal impaction. This deficient practice was identified in 1 of 21 sampled residents, Resident #10 as evidenced by the following: Resident # 10 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the medical record revealed the following: The Minimum Data Set (MDS) of 3/7/11 indicated that the resident was staff dependent for activities of daily living (except eating), incontinent of bowel and did have a stomach tube in place for supplements to feeding when warranted. The surveyor reviewed the 1/11/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2010 and Senna, a bowel stimulating laxative, 8.6 milligrams (mg) 1 tablet 2 times daily. There was also an order [REDACTED]." The surveyor review of the November, December, and January Treatment Administration Record (TAR) indicated that the resident had not received any enemas in those months. Due to the side effect of constipation common to all narcotics, it is a standard of practice that increased water be consumed to help prevent constipation. The resident received 6 doses of [MEDICATION NAME] from 1/4 to 1/15/11. A nurse's note of 1/20/11 revealed,"noted abdomen distended, vomited once the food from breakfast-yellowish brown, rectal exam-soft bowel movement-medium, abdominal discomfort." The resident was sent to the hospital for an evaluation. A hospital progress note of 1/25/11, revealed that the resident was, "admitted for abdominal distention and colonic dilatation probably due to pseudo obstruction." A CAT scan performed at the hospital revealed, "markedly dilated colon with fecal impaction." The resident was treated with laxatives and the pseudo obstruction was resolved. The hospital progress note also indicated that the resident had a history of [REDACTED]. Review of the [DATE] readmission physician orders [REDACTED]. The resident remained on a pureed diet with honey thick liquids and a Glucerna [MEDICATION NAME] feeding if his food intake was less than 50%. A review of the 1/11/11 bowel accountability sheet indicated that Resident #10 had a large bowel movement on 1/15/11 and medium bowel movements on 1/18/11 and 1/19/11. A nurse's note of 3/10/11 at 8:30 a.m., revealed that the resident had abdominal distention and discomfort. The nurse performed a digital examination on Resident #10 which revealed soft brown stool. A Fleets enema was given to the resident with a moderate amount of soft brown stool return. The resident was sent to the emergency roiagnom on [DATE] for an evaluation and was again admitted to the hospital. A second CAT Scan of the abdomen was performed while in the hospital which revealed, "markedly dilated large bowel with probable fecal impaction." The resident was given tap water enemas at the hospital and discharged from the hospital on [DATE]. Review of the bowel accountability sheet indicated that the majority of the resident's bowel movements from 3/1/11 to 3/10/11 were identified as small. Review of Resident #10's care plan did not identify constipation or fecal impaction as a problem. There were no interventions identified to prevent recurrence. On 3/24/11 at 1 p.m, the unit manager stated that the resident had been taking [MEDICATION NAME] which may have contributed to the constipation. She stated that the resident had been taking the [MEDICATION NAME] 2 times daily since he was readmitted from the hospital in January until his 2nd hospitalization in March. She had no explanation as to the reason the physician increased the [MEDICATION NAME] to 2 times daily. She stated that Resident #10 mostly fed himself, he usually ate well and had not required the [MEDICATION NAME] feedings. She stated that the resident was not on a bowel regime, except the Senna tablets (1 tablet 2 times daily) which he had been taking since March 2010. There was no evidence presented that the facility staff was administering extra fluids through the stomach tube. She stated that the resident's medications were reviewed and changed after Resident #10's 2nd fecal impaction. The unit manager also stated that the care plan should have been updated but she failed to do so. NJAC 8:39 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to: 1. Establish and update the care plan for Resident #10 who developed 2 fecal impactions requiring hospitalization . 2. Develop individualized care plans for residents with facility acquired pressure ulcers (Residents #2, 9, and 10) which identified the actual site of the ulcers and interventions which were specific and appropriate to the site. This deficient practice was identified for 3 residents reviewed for pressure ulcers, Residents # 2, 9, and 10. 3. Failed to develop and implement care plan interventions for a resident identified for positioning, Resident #17. 4. Failed to develop and implement care plan interventions and enforce their smoking policy to address the safety of residents who smoked, Resident #12. The deficient practice concerning care planning was identifed in 5 of 21 residents, (Residents #10, 2, 9, 17. and 12) and was evidenced by the following: 1). Surveyor review of the medical record revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The sacral pressure ulcer was healed as of 3/14/11. However, on 3/14/11 the resident developed a 1 centimeter (cm) x 1 cm reddened area to the right buttock and a 2 cm x 2 cm stage II pressure ulcer to the left buttock. Review of the 3/1/11 care plan identified the resident's sacral ulcer which had healed. The care plan was not updated to identify the new areas of ulcer development or the indwelling catheter which was in place since admission to the facility. On 3/22/11 at 10a.m, the Unit Manager (UM) stated that she did not update Resident #2's care plan to reflect the resident's current status. Refer F281 and F314 Refer to F314 and F309 2). Resident #9 had [DIAGNOSES REDACTED]. Review of the medical record revealed the following: A nurse's note of 11/13/10 indicated that the resident had a skin opening on the right posterior lower buttock, a physician's orders [REDACTED]. A nurse's note of 1/10/11 revealed that the resident had a 1 cm x 1 cm stage II pressure ulcer in the same area. The wound nurse initially assessed the resident on 1/17/11 and noted an unstageable pressure ulcer that measured 3.8 cm x 2.5 cm. On 1/31/11, the wound nurse made the recommendation to limit the resident's out of bed time to 4 hours at a time, in order to relieve pressure. Again on 2/7/11, the wound nurse made the recommendation to limit Resident # 9's out of bed time to relieve pressure. On 3/21/11 the wound nurse identified the resident's pressure ulcer as a stage IV which measured 3 cm x 3 cm x 3 cm. The wound nurse made the recommendation to get the resident out of bed on Mondays, Wednesdays, and Friday for no more than 4 hours to relieve pressure to the affected area. Review of Resident #9's admission care plan dated 5/10/05 identified the, "potential for skin breakdown" secondary to right and left buttock pressure sores and bowel and bladder incontinence. The care plan did not identify the resident's current right pressure ulcer and the recommendations of the wound nurse to relieve pressure were not identified. On 3/22/11 at 12:30p.m, the UM stated Resident #9's care plan had not been updated. Refer to F314 3). Resident #10 had [DIAGNOSES REDACTED]. Review of the medical record revealed the following: The resident's gluteal area was healed as of 12/18/10. On 1/17/11 the wound nurse noted, stage II pressure ulcers to the resident's bilateral gluteal areas. Resident # 10 was hospitalized from [DATE] to 1/25/11 and again from 3/10/11 to 3/12/11 both times for a fecal impaction. The 1/25/11 Nurses Admission Record, indicated that the resident had a stage IV ulcer to the left heel and vascular right leg ulcers. The 3/12/11 Nurses Admission Record revealed a stage II sacral pressure ulcer and the chronic right leg vascular ulcers. On 3/23/11 at 10:45a.m, the surveyor and UM observed the resident's heels and bilateral gluteal area. The resident was noted to have bilateral gluteal redness and excoriations with stage II pressure ulcers on the right and left gluteal area and a black scab (Stage IV) on the left heel. Review of the 5/24/05 care plan identified, "open areas left and right foot ([MEDICAL CONDITION]), and sacral areas secondary to incontinence." The care plan did not identify the stage IV ulcer to the resident's left heel or the stage II bilateral gluteal ulcers. The care plan also did not identify the problem of 2 fecal impactions and there were no interventions identified to prevent recurrence. On 3/23/11 at 1p.m, the UM stated that Resident #10's care plan had not been updated. Refer to F314 and F309 4.) Resident # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the record revealed that Resident #17 was reviewed for positioning devices in 7/10 , however, no attempt was made to improve the resident's posture since that time. There were no evidence that a care plan had been initiated to address the issue of positioning. On 3/24/2011 at 10:30 a.m., the Director of Nursing stated to the surveyor that there were no care plan initiated for Resident #17 regarding positioning. Refer F246 5. The surveyor reviewed the medical record of Resident # 13 which revealed that this resident is alert and oriented resident with a [DIAGNOSES REDACTED]. The care plan revealed that Resident #13 is a non-independent smoker requiring an aide to accompany the resident when going outdoors to smoke and has scheduled times to smoke throughout the day. (10:00 a.m., 2:00 p.m., 4:00 p.m., 6:00 p.m. and 8:00 p.m. There was documentation in the progress notes of a smoking incident that occurred on 12/23/10 at 7:30 p.m. The resident dropped a cigarette and obtained [MEDICAL CONDITION] the left thigh. On 3/22/11 at 1:30 p.m. the surveyor interviewed 2 unit nurses and the Director of the [MEDICAL CONDITION]'s program who stated that Resident #17, left the building unsupervised with another resident for a smoke on 12/23/10 and was burned but refused treatment. However, the care plan dated 3/2010 was not updated to reflect the fact that this resident now required monitoring with smoking. NJAC 8:39-11.2(e)2 NJAC 8:39 - 11.2 (i) NJAC 8:39 27.1(a)