Every finding on record at Country Arch Care Center

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/31/26 at 10:36 AM, the surveyor conducted an interview with the Regional Food Service Director (RFSD) and Registered Dietician (RD) prior to the initial tour of the kitchen. The RFSD and RD stated the following:-Dietary staff were required to wash their hands at the designated handwashing sink.-Dented cans were stored separately from the cans to be used for meals.-The dish machine was a low temperature dish machine that required a chemical sanitizer.-Dishware was required to be air dried.-The nursing unit pantries were maintained by nursing, dietary, and housekeeping.-Leftover food and food brought in by visitors should be labeled, dated, and stored for three days. On 3/31/26 at 10:58 AM, the surveyor, accompanied by the RFSD and RD, observed the following in the kitchen: 1. At the designated handwashing sink, the RFSD washed his hands and left the water running for the surveyor. When the surveyor placed their hands under the stream of water, the water was cold. At that time, the RFSD checked the temperature of the water which was 72 degrees Fahrenheit (F). The RFSD stated the water temperature should be between 90 to 100 F in order to kill germs. 2. In the dry storage area, there was a 15 ounce (oz) can of pumpkin that was dented and stored in the area for cans in rotation. The RD removed the dented can and the RFSD stated it should not have been stored there because dented cans were not safe and could be contaminated. 3. At the low temperature dish machine, the surveyor observed the dish machine in use. When asked how the dietary staff test for the dish machine's chlorine sanitization for the final rinse, the RFSD stated the facility did not test the dish machine's chemical sanitization. At that time, the surveyor requested for the chemical sanitization to be tested, and the RD brought QAC QR test strips (strips used to measure the concentration of quat-based sanitizers for three compartment sinks) which had expired in 2020. The RFSD continued to try to use the incorrect test strips which did not work. When the surveyor informed the RD that the strips were incorrect, she left and brought back chlorine test strips and the RFSD tested the chlorine sanitization. The surveyor reviewed the Low temp dishwasher log for March 2026 which revealed the staff did not document the chemical sanitization level for the entire month. 4. In the area designated for clean pans, there were two six-inch full deep pans wet nested together. The RFSD removed the two pans to be re-washed and stated they should not be wet nested to prevent bacteria growth. 5. In the area designated for clean dishes, there were five plates that were chipped. The RFSD stated they would remove the chipped plates from circulation because they were not safe for residents or employees to handle. On 4/2/26 at 9:43 AM, the surveyor, accompanied by Licensed Practical Nurse (LPN) #1, observed the following in the refrigerator/freezer designated for resident food on the 100 Unit: 1. Three 3.25 oz containers of strawberry gelatin with an expiration date of 3/28/26. 2. A 4 oz container of cranberry juice that was not labeled with an expiration or use-by date. 3. The freezer did not have a thermometer, and the temperature of the freezer had not been recorded on the refrigerator/freezer temperature log. 4. A single plastic wrapped popsicle that was not labeled with an expiration or use-by date. 5. Three plastic ice trays with the top of the ice uncovered and exposed. There were reusable ice packs on top of the ice trays touching the ice. 6. Five plastic cups that were previously filled with water and frozen with the top of the ice uncovered and exposed. At that time, LPN #1 removed and discarded the expired food items and cups of ice. The LPN stated that nursing was responsible for maintaining the refrigerator to check for expired items and ensure the refrigerator/freezer was at the correct temperature. She further stated that nothing should be touching the top of the ice trays. On 4/2/26 at 10:53 AM, the surveyor, accompanied by LPN #2, observed the following in the refrigerator/freezer designated for resident food on the 200 Unit: 1. The freezer did not have a thermometer, and the temperature of the freezer had not been recorded on the refrigerator/freezer temperature log. At that time, LPN #2 stated that nursing was responsible for checking the refrigerator/freezer temperatures. On 4/7/26 at 11:12 AM, the surveyor, in the presence of the survey team, interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to inform them of the concerns in the kitchen and nursing unit refrigerators/freezers. The LNHA stated that dented cans should be moved to the dented can area, items in the dry pan area should be dry, chipped plates should not be used to serve meals, and the water at the handwashing sink should be between 90 - 110 F. The DON stated the overnight nursing staff were responsible for checking the unit refrigerators/freezer to ensure the temperatures were correct and that there were no expired food items. A review of the facility's Handwashing policy, revised 2018, did not include specific instructions regarding the kitchen's designated handwashing sink, such as the required water temperature. A review of the facility's Dented Can Inspection and Handling policy, created 2/12/24, included, Damaged cans will be immediately removed from usable stock and placed in a separate designated area labeled 'Dented Cans, and Do not store damaged cans with usable inventory. Further review of the policy included, Dietary staff must inspect all cans, remove damaged products, and report issues promptly. A review of the facility's Dishware Drying and Prevention of Wet Nesting policy, dated 4/1/25, included, All pots, pans, utensils, and dishware must be properly cleaned, sanitized, and fully air-dried prior to storage to prevent contamination and wet nesting. A review of the facility's Low Temperature Dishmachine (Chemical Sanitization) policy, undated, included, Final rinse must include an approved sanitizer: Chlorine (hypochlorite): ~50 ppm [parts per million] on dish surface tested daily. A review of the facility's Dishware Inspection and Safety Protocol policy, created 2/15/23, included, Dishware will be inspected during dishwashing, while plating meals, and prior to serving residents, and Staff will check for chips along rims or surfaces, cracks, hairline fractures, and rough or sharp edges. Further review of the policy included, Any chipped or cracked item must be immediately removed from service and discarded in a safe manner. A review of the facility's Foods Brought by Family/Visitors policy, revised 5/18/24, included, The nursing staff is responsible for discarding perishable foods on or before the 'use by' date. A review of the facility's Food Storage Procedure policy, undated, included, All foods stored in the refrigerator or freezer will be labeled and dated, and Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements. A review of the facility's Product Fact Sheet for the cranberry juice, dated 1/1/26, included, Shelf-Life/Handling: 12 months frozen from manufactured date or 14 days once thawed. NJAC 8:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 2 dining areas observed, (100 Unit) and was evidenced by the following: On 4/1/26 at 11:58 AM, the surveyor observed lunch in the 100 Unit dining area. The surveyor observed one (1) unsampled resident and Resident #30 sitting at the same table. A staff member was seated and feeding the unsampled resident their lunch. Resident #30 had not received their lunch tray. Resident #30 asked the surveyor, Miss, am I going to eat my noon meal? Resident #30's was not served their lunch until 12:09 PM. On 4/2/26 at 11:09 AM, the surveyor interviewed the Certified Nursing Assistant (CNA ) who stated that residents who are seated at the same table should receive their meal trays at the same time. The CNA further stated that staff should not start feeding other residents seated at the same table until all residents' trays are served their meal because it affects the resident's dignity. On 4/2/26 at 11:16 AM, the surveyor interviewed the Director of Nursing (DON) who stated that residents that were seated at the same table should receive their meal trays at the same time. The DON further stated that she would expect residents' meals be served at the same time 100% of the time for dignity purposes. On 4/7/26 at 11:13 AM, the surveyor interviewed the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), the Regional DON, the Regional LNHA, and the survey team, who stated that it was important to serve all residents at the same table their meals at the same time for dignity. A review of the facility's Communal Dining policy, undated, included the purpose was to ensure a safe, dignified and enjoyable communal dining for residents. A review of the facility's Resident Dignity policy, undated, included that all residents will be treated with dignity and respect. NJAC 8:39-4.1(a)12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 2 of 3 garbage dumpsters. This deficient practice was evidenced by the following: On 3/31/26 at 11:30 AM, the surveyor, accompanied by the Regional Food Service Director (RFSD) and Registered Dietician (RD), observed the facility's designated garbage disposal area. There were three garbage dumpsters that each had two lids. Two of the garbage dumpsters each had one lid open, exposing the trash bags inside. At that time the RFSD stated the garbage dumpster lids should be closed to prevent pests. On 4/7/26 at 11:12 AM, the surveyor, in the presence of the survey team, interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA stated that staff rounded the dumpster area throughout the day to ensure the dumpster lids were kept closed. A review of the facility's Dumpster Area Maintenance Protocol, dated 2/10/25, included, Dumpster lids must be closed after use. NJAC 18:39-19.3(b)

Complaint# NJ00172367 Based on interviews, record review, and review of other pertinent facility documentation on 06/12/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #3), and was evidenced by the following: According to the Admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Dementia, Transient Cerebral Ischemic Attack, Muscle Weakness A review of the Resident #3's Progress Notes (PN) revealed that on 03/21/2024 at 12:53 A.M, Registered Nurse (RN) documented that Resident #3 needed to be sent out to the hospital for an injury near the right eye area. A further review of the Resident #3's PN, dated 03/21/2024 at 5:53A.M. and documented by LPN, revealed as follows: Return from E.R. 4:10am via stretcher accompanied by 2 EMT from Atlantic ambulance BP 136/76, pulse 78, respiration 19 and Pulse oximeter 97% on room air. sutures to right eyebrow intact no complaint pain needs attended.'' A review of Resident #3's MR revealed no NJUTF for the 03/21/2024 transfer to the hospital. During an interview with the surveyor on 06/12/24 at 4:30 P.M. the Director of Nursing (DON) stated she was unable to locate the 03/21/2024 NJUTF for Resident #3. A review of the facility's undated policy titled, Transfers (Hospital or another facility). Revealed under Policy Statement A patient transfer form is to be completed at the time of transfer to hospital or another facility. NJAC 8:39-35.2 (d) 12

Based on observation, interview, and record review, it was determined that the facility failed to a.) store foods in a manner intended to prevent the spread of food borne illness and b.) maintain a clean storage for food and cooking utensils as evidenced by the following: On [DATE] at 9:44 AM, the surveyor toured the kitchen with the Food Service Director (FSD), observed the following: 1. In the freezer the surveyor found; one opened box of carrots without an open and a use by date. The interior bag holding the carrots was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 2. In the freezer the surveyor found; one opened box of chopped celery. The exterior of the box was unlabeled. The interior bag was unlabeled, wide open to the elements with large ice crystals. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 3. In the freezer the surveyor found; one opened box of chicken tenders that was unlabeled. Inside the box was an interior bag of chicken tenders that was opened and unlabeled. Also, inside the chicken tender box was a bag labeled garlic bread. There was not a label or date on the garlic bread. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. Surveyor and FSD continued the kitchen tour, and the surveyor observed the following: 1. The tilt skillet was observed to have white slimy substance covering most of the surface area. The FSD stated, it had not been used since he was hired a week prior. The surveyor asked the FSD to wipe it with a paper towel. The sediment was removable with a dry paper towel indicating it had not been cleaned after previous use. 2. Convection oven: was covered with thick baked on brown streaks and sediment. FSD acknowledged it was not cleaned. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. 3. The oven/stovetop range catch tray was covered with sediment, burnt on food and white congealed substance. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. 4. Microwave: the interior was not clean with sediment on all the walls, door and top. The FSD did not have a cleaning schedule in place and was unable to provide an accountability chart for staff. 5. Toaster crumb tray was not clean and had thick built-up sediment that was burnt on. The FSD did not have a cleaning schedule in place and was unable to provide an accountability chart for staff. 6. Utility refrigerator gasket seals were covered with black discoloration that was filled with sediment within the ridges of the seal. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. On [DATE] at 9:40 AM, the surveyor toured the kitchen for second time with the FSD. Surveyor observed in the walk-in freezer an opened box of minute steaks, the box was dated ,d+[DATE]. The inside bag was wide open, not dated, and the meat was exposed. The FSD had no response to why the meat was not sealed and open to the elements. The FSD was unsure of what the date of ,d+[DATE] meant, (i.e., received, opened, or expired). He did state, I was in the freezer all weekend. A review of the facility's Food Storage Procedure, undated, given to surveyor by LNHA on ,d+[DATE] at 10:12 AM included the following: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 5. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 8. Uncooked and raw animal products and fish will be stored separately and below fruits, vegetables and other ready to eat foods. A review of the policy Labeling and Dating Procedure in the Dietary Department review date [DATE], included the following: Procedure: 1. Food items, as appropriate, will be labeled and dated by dietary staff using the facility labeling system, and the Food Service Director / designee will oversee labeling and dining. Label System Process: 1. Received Date 2. Pulled Date 3. Opened date; a) Food items will be labeled with an open date once the individual item is opened for use. A review of the Food Service Manager Position Summary dated revised ,d+[DATE], revealed: 2. Adheres to all the sanitary regulations governing handling and serving of food. 5. Develops, revises, and adapts work techniques and methods for more efficient operation of unit and for training employees. On [DATE] at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator, Director Of Nursing, Administrator in Training/Registered Nurse/Infection Prevetionist Nurse, and [NAME] President of Clinical Services, and the facility management were made aware of the above findings and concerns. NJAC 8:,d+[DATE].2(g)

Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a) accurate documentation of the needed information in the Nurse Staffing Report, b) minimum State staffing requirements were met for 14 of 14 day shifts and on 3 of 14 overnight shifts reviewed, c) physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner, d) that nurse aides received the minimum required number of in-service hours, and e) LNHA and Medical Director attended the QAPI (Quality Assurance and Performance Improvement) meeting routinely necessary to provide for the needs of residents. This failure had the potential to affect all 105 residents who currently live in the facility. The evidence was as follows: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. On 10/06/23 at 9:54 AM, the survey team met with the Administrator in Training/Registered Nurse (AiT/RN) and the Director of Nursing (DON) during the Entrance Conference. The facility management confirmed that the Licensed Nursing Home Administrator (LNHA) will be coming in later and will proceed with the Entrance Conference meeting without the LNHA. On that same date and time, the surveyor provided a copy of a blank Nurse Staffing Report to the facility management to be used to fill out information for the weeks of 10/17/23-10/23/23, 10/24/23-10/30/23, 01/01/23-01/07/23, and 12/25/2022-01/07/2023. The surveyor also notified the facility management to submit the Nurse Staffing Report as soon as possible to the surveyor and to send it via email in order for the NJ Department of Health to run the provided reports to determine compliance with NJ mandated staffing law. On 10/11/23 at 9:51 AM, the survey team met with DON and the LNHA. The surveyor notified the facility management of concerns regarding the requested documents that were asked by the surveyor during the Entrance Conference on 10/06/23. The surveyor mentioned that the requested documents were asked also yesterday (10/10/23) and followed up by the surveyor to the DON, AiT/RN which included the Nurse Staffing Report. On 10/12/23 at 8:33 AM, the surveyor reviewed the provided Nurse Staffing Report via email (scanned documents) and showed that on the week of 01/01/23-01/07/23, the LNHA who signed the Nurse Staffing Report did not include the census on each day. The surveyor immediately notified the LNHA to review the submitted document and advised them to follow the directions on how to accurately fill out the form. On 10/19/23 at 9:08 AM, the surveyor in the presence of the survey team notified the DON of the concern regarding the submitted revised Nurse Staffing Report because there were discrepancies in the previously submitted reports (included NAs and TNAs) and new reports (did not include the previously counted NAs and TNAs), the missing census on 01/01/23-01/07/23, and multiple non-legible numbers. The surveyor notified the DON that the facility had to follow the correct and accurate way of submitting the Nurse Staffing Report and that the TNAs (temporary nursing assistants) and the NAs (non-certified nursing assistants) must not be counted as CNAs. On 10/19/23 at 9:26 AM, the surveyor in the presence of the survey team notified the LNHA of the above concerns regarding the submitted Nurse Staffing Report. The LNHA stated that he thought that during the time of the pandemic, the TNAs and CNAs could be counted as CNAs which was why the facility added them to the CNAs ratio. The surveyor referred the LNHA again to the website NJ Portal where the instructions and how to properly submit an accurate report. The LNHA stated that it was fine and that he would just check and revise the submitted forms. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN (also the Infection Preventionist Nurse of the facility according to the LNHA and DON), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified of the above findings and concerns. On 10/19/23 at 01:32 PM, the Human Resource Director (HRD) submitted via email the revised Nurse Staffing Report that was signed by the LNHA. 2. As per the Nurse Staffing Report completed by the facility for the two (2) weeks of staffing prior to survey from 9/17/2023 to 9/30/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 3 of 14 overnight shifts as follows: -09-17-23 had 7 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/18/23 had 8 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/19/23 had 7 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/20/23 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/20/23 had 6 total staff for 101 residents on the overnight shift, required at least 7 total staff. -09/21/23 had 9 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/22/23 had 10 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/23/23 had 9 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/24/23 had 8 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/25/23 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/26/23 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/26/23 had 7 total staff for 107 residents on the overnight shift, required at least 8 total staff. -09/27/23 had 11 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/28/23 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/29/23 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -09/30/23 had 9 CNAs for 106 residents on the day shift, required at least 13 CNAs. -09/30/23 had 7 total staff for 106 residents on the overnight shift, required at least 8 total staff. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), DON, and VPoCS. The LNHA acknowledged that there was a concern with short staffing. On 10/18/23 at 9:54 AM, the surveyor interviewed the Staffing Coordinator (SC) regarding staffing. The SC acknowledged that the facility was aware of the number of CNAs required but did not always have the required number of CNAs. 3. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN of Resident #1 revealed that there was no Physician Note after 6/30/23. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the LNHA, AiT/RN/IPN, DON, VPoCS and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x 3 months. The VPoCS stated that it was an expectation that the MD visits and notes then every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyors that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months note of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and entered the notes late. On that same date and time, the surveyor asked the LNHA if he was aware that the MD did not have PN documented in the timely manner, and the LNHA stated that now he knew. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy and that the facility followed the regulations. 4. The surveyor reviewed five (5) randomly chosen nurse aides' for their mandatory in services and showed the following information: CNA #1 was hired 01/02/1999 CNA #2 was hired 09/24/2021 CNA #3 was hired 04/01/2007 CNA #4 was hired 03/24/2016 CAN #5 was hired 12/29/2022 The facility could not provide the in services completed from the CNAs' hiring date to their anniversary date for CNAs#1, #2, #3, #4, and #5. On 10/18/23 at 11:30 AM, the DON and the unlicensed Practical Nurse Staff Educator informed the team that they (facility management) could not find documentation that the 12 hours of competencies were completed. In addition, the DON stated that she reviewed the in-service training book and that information documented on the Continuing Education Record did not meet the 12-hour requirements. 5. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON during the Entrance Conference. The facility management confirmed that the LNHA will be coming in later time and will proceed with the Entrance Conference meeting without the LNHA. At this time, the surveyor asked for a copy of the last three quarters' QAPI sign-in sheets, policy, and procedure. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated 4/20/23=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated 8/08/23=MD and LNHA did not attend the meeting QAPI dated 9/26/23=LNHA did not attend the meeting A review of the QAPI Program Plan that was provided by the AiT/RN/IPN revealed that the QAPI Plan was adopted on 11/01/19 and signed by the previous LNHA, MD, previous DON, previous ADON/IPN, and QAPI Coordinator that included the following: Governance & Leadership: The Administration assures the QAPI plan is reviewed on an annual basis by the QAPI team and approved by the governing body .The facility QAA Committee meets a minimum of quarterly and functions under the direction of the QAPI team. The QAPI team monitors data monthly from QAA findings and identifies areas for improvement to assure the achievement of the highest level of quality throughout the organization. QAPI Framework: The Administrator, DON, Infection Control and Prevention Officer, medical director, and three additional staff from the QAPI team. The QAPI coordinator is responsible for identifying projects, planning meetings, and document activities. Responsibility and Accountability: The administrator and/or QAPI coordinator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our organization. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and VPoCS. The surveyor asked the LNHA if he was aware of the missing physician's visit notes, and the LNHA stated that he was not aware not until the surveyor's inquiry. The surveyor also asked the LNHA if he was aware that the MD was not also present during the last three quarters' QAPI meeting, the LNHA stated I am very aware now. On that same date and time, the LNHA confirmed that they (the facility) knew now that the governing body should be in the QAPI meeting as well. The LNHA acknowledged that the governing body was not present in the QAPI meeting. A review of the Administrator's signed job description included the following: Position Summary: The Administrator is responsible for planning and is accountable for all activities and departments of the facility subject to rules and regulations promulgated by government agencies to ensure proper healthcare services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. Responsibilities/Accountabilities: Meet with licensing authorities as required and accompany them throughout any survey of the facility; superintend physical operation of the facility; oversee and guide department managers in the development and use of departmental policies and procedures; conduct committee meetings such as Quality Assurance, Infection Control, Pharmaceutical Services, and Safety Committee. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. NJAC 8:39-23.2(d); NJAC 8:39-25.2(a)(b); NJAC 8:39-27.1(a); NJAC 8:39-33.1(a)(b)

Based on the interview, record review, and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to a) required physician visits and notes, b) attends mandatory quarterly QAPI (Quality Assurance and Performance Improvement) meetings, and c) minimum State staffing requirements were met. This failure had the potential to affect all 105 residents who currently live in the facility. This deficient practice was evidenced by the following: 1. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN of Resident #1 revealed that there was no Physician Note after 6/30/23. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the Licensed Nursing Home (LNHA), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS) and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x 3 months. The VPoCS then stated that it was an expectation that there would be a face-to-face visit and notes every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, then the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/17/23 at 01:48 PM, the surveyor interviewed the MD in the presence of the survey team. The MD informed the surveyor that she started working at the facility in 2005 and she probably has 99% of residents in her care, that I come in every day, and this was her main facility. The MD stated Sometimes it's my fault I'm behind, with notes. She further stated that she does see all residents and addresses the problem. The MD acknowledged that she missed some notes. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyor that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months notes of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and the PN were entered late. The facility management acknowledged that the facility did not comply with the required visit notes. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy with regard to physician visits. The VPoCS further stated that instead they (facility management) follows the regulations as guidance about physician visits. A review of the provided typewritten responses for the concerns that were discussed on 10/17/23 that were provided by the LNHA included that the MD Visits missing in documentation were acknowledged by the MD and that the facility had no MD Visit policy. 2. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON during the Entrance Conference. The surveyor asked for a copy of the last three quarters' QAPI sign-in sheets, policy, and procedure. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated 4/20/23=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated 8/08/23=MD and LNHA did not attend the meeting QAPI dated 9/26/23=LNHA did not attend the meeting On 10/17/23 at 01:48 PM, the surveyor interviewed the MD in the presence of the survey team. The surveyor asked the MD if she attended quarterly meetings in the facility, and the MD stated If I'm available I attend the meeting. The surveyor then asked the MD if she was not able to attend if she sent someone to represent her in the meeting, and the MD responded that she did not send someone to represent her in the quarterly QAPI meeting. On that same date and time, the surveyor asked the MD who was in charge of Infection Control in the facility and who attended the QAPI that reports for Infection Control. The MD stated that I think usually ADON is in charge, of the Infection Control and who attended the QAPI meeting. The MD further stated that at this moment she was not sure who was Infection Preventionist of the facility was. At this time, the surveyor asked the MD who discussed vaccinations in the QAPI meeting, and the MD responded Frankly I don't remember who reported it. The MD stated that she would go to the facility tomorrow to verify the QAPI sign-in sheets. On 10/18/23 at 10:37 AM, the survey team met with the MD. The MD verified the sign-in sheets for QAPI in the presence of the survey team and the MD confirmed that her signature was on the 9/26/23 QAPI meeting and not on 4/20/23 and the 8/08/23 QAPI sign-in sheets. The surveyor asked the doctor if she knew why she was not present on the dates of 4/20/23 and 8/03/23 and the doctor had no response. On that same date and time, the surveyor asked the MD how often the QAPI meetings were and what was the expectation with regard to her attendance. The MD stated that when the AiT/RN/IPN came in as the new administrator in April 2023, the big classic quarterly meetings were changed to more frequent meetings because there was so much stuff to go over and things had changed with the meeting. The MD further stated that she was not sure how and when the frequent meeting. She further stated that the quarterly QAPI meeting used to be a set date one Thursday in certain month not sure how it was set up the date. The MD informed the surveyors that the facility was working toward arranging the set schedule for QAPI meetings. At this time, the surveyor asked the MD if the AiT/RN/IPN was the administrator who was the LNHA. The MD stated that the LNHA whom the surveyor was referring to was the Regional LNHA. The MD further stated that the LNHA whom the survey team was referring to was not at the facility every day and the AiT/RN/IPN was the one who was at the facility every day. 3. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON. The facility management confirmed that the census (counts all residents in a facility) was 105 plus one bed hold. On 10/11/23 at 9:10 AM, the surveyor interviewed Certified Nursing Assistant #1 (CNA#1) who informed the surveyor that he's been working at the facility as a regular floater for the 7-3 shift and at times at 3-11 shift with no regular wing assignment, been at the facility for [AGE] years. Then CNA#2 joined the interview and both stated they were aware of the NJ (New Jersey) mandated staffing law of a 1:8 ratio (one CNA to eight residents). Both CNAs informed the surveyor that the mandated staff-to-resident ratio was not always being followed. At this time, CNA#1 informed the surveyor that he had 10 residents on his assignment today at 100 wing. CNA#1 stated that the usual ratio in the 7-3 shift was around nine to ten residents per CNA. He further stated that on a worse day with calls out can reach up to 11 per piece per CNA. Furthermore, the surveyor asked both CNAs if they were able to finish their assignments, and CNA#2 stated that they still take care of the resident but it takes time for them to finish their assignments. The surveyor asked the CNAs if they notified their management about their concerns with staffing and CNA#1 stated that they (facility management) were aware. The surveyor then asked CNAs what was the facility management responded to their concern, CNA#2 stated that the facility management told them that they were doing something about it but they did not know what was the plan. A review of the 100 Wing 7-3 shift Assignments that were provided by the AiT/RN/IPN for date 10/06/23 showed the following: Census: 46 residents Nurses: Licensed Practical Nurse #1 (LPN#1), LPN#2 CNAs: CNA#3 with nine (9) residents, CNA#4 with nine residents, CNA#5 with nine residents, CNA#6 with 10 residents, CNA#7 with nine residents A review of the 100 Wing 7-3 shift Assignments that were provided by the LNHA for date 10/11/23 showed the following: Census: 47 residents CNAs: CNA#3 with nine residents, CNA#4 with nine residents, CNA#6 with 10 residents, CNA#2 with nine residents, CNA#1 with 10 residents Further review of the above 10/06/23 and 10/11/23 assignments revealed that the NJ mandated law ratio for 1:8 was not followed. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, AiT/RN/IPN, DON, and VPoCS. The LNHA acknowledged that there was a concern with short staffing. On 10/18/23 at 9:54 AM the surveyor interviewed the Staffing Coordinator (SC) regarding staffing. The SC acknowledged that the facility was aware of the number of CNAs required but did not always have the required number of CNAs. On 10/18/23 at 10:37 AM, the survey team met with the MD. The surveyor asked the MD if staffing issues were discussed during the QAPI meeting. The MD stated I am not sure about staffing being discussed in the QAPI. Then the MD asked the surveyor if there was an issue with staffing at the facility. The MD also asked the survey team if the facility management notified the surveyor that there was a problem with staffing. At this time, the surveyor notified the MD of the above findings, and that the facility management acknowledged the concern. On 10/18/23 at 11:03 AM, the surveyor asked the DON in the presence of the survey team for a copy of the MD policy and signed job description of the MD and she stated that she would get back to the surveyor. On the same date and time, the DON informed the surveyor that the MD was not an employee of the facility and was only a contracted service MD which was why the facility had no signed job description and policy. A review of the facility's Medical Director Agreement that was provided by the LNHA showed in Section II Obligations of Medical Director 2.3 (a) To attend and participate in quarterly Quality Improvement Committee, Infection Control, Pharmacy, and Therapeutics meetings as scheduled. This was signed by the previous Administrator. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. N.J.A.C 8:39-23.1, 2, 3

Based on interview and review of pertinent facility documentation, the facility failed to have: a) the Medical Director (MD) present for two out of three Quality Assurance and Performance Improvement (QAPI) meetings, b) the Licensed Nursing Home Administrator (LNHA) present for three out of three QAPI meetings, and c) set QAPI meeting schedule. This failure had the potential to affect all 105 residents who currently live in the facility. The deficient practice was evidenced by the following: On [DATE] at 8:57 AM, the survey team entered the facility and met with the Receptionist who instructed the surveyors to use the touchless thermometer attached to a wall to check the surveyors' temperature, log in the binder temperature, and answer the COVID-19 screening questions. Later on, an employee introduced herself to the survey team as the facility's Administrator in Training and a Registered Nurse (AiT/RN). The AiT/RN provided a business card that included her name with the title of Administrator. On [DATE] at 9:54 AM, the survey team met with the AiT/RN and the Director of Nursing (DON). The facility management confirmed that the census (counts all residents in a facility) was 105 plus one bed hold. The surveyor asked for a copy of the last three quarters' sign-in sheet for QAPI, policy, and procedure. The facility management informed the surveyor that it was the Licensed Practical Nurse (LPN) who was the facility's designated Infection Preventionist Nurse who attended the QAPI meeting and was responsible for the facility's infection control. The surveyor asked for a copy of the LPN/IPN's resume, signed job description, and certificate of completion for infection control. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated [DATE]=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated [DATE]=MD and LNHA did not attend the meeting QAPI dated [DATE]=LNHA and LPN/IPN did not attend the meeting A review of the license verification site in New Jersey (NJ) revealed that LPN/IPN had an expired license in another state and a pending reinstatement of LPN license in NJ. A review of the NJ license verification for Administrators in NJ showed that the AiT/RN had no current LNHA license in NJ. On [DATE] at 11:58 AM, the surveyor followed up with the DON the documents that were asked during the Entrance Conference which included the LPN/IPN's resume, signed job description, and certificate of completion for IP. The DON stated that she wanted to correct the LPN/IPN had a clerical assistant job and not functioning as a nurse. The DON further stated that the facility's IPN was the AiT/RN (AiT/RN/IPN). The DON informed the surveyor that the LPN will eventually be the LPN/IPN once the NJ license is available. On [DATE] at 12:32 PM, the survey team met with the Director of Rehab/Occupational Therapist (DoR/OT). The surveyor asked the DoR/OT about the QAPI meetings. The DoR/OT informed the surveyors that he attended QAPI meetings. The DoR/OT was unable to state how often the QAPI meeting was, who attended the meetings, and how he knew the next QAPI meeting schedule. The DoR/OT stated to the surveyor that the surveyor should check the records. Later on, the DoR/OT stated that all department heads attend QAPI meetings. Then the surveyor asked who else besides the department heads attended the meeting and DoR/OT asked the surveyor to check the QAPI sheet. On [DATE] at 10:37 AM, the survey team met with the MD. The MD verified the sign-in sheets for QAPI in the presence of the survey team and the MD confirmed that her signature was on the [DATE] QAPI meeting and not on [DATE] and the [DATE] QAPI sign-in sheets. The surveyor asked the MD if she knew why she was not present on the dates of [DATE] and [DATE] and the doctor had no response. On that same date and time, the surveyor asked the MD how often the QAPI meetings were and what was the expectation with regard to her attendance. The MD stated that when the AiT/RN/IPN came in as the new administrator in [DATE], the big classic quarterly meetings were changed to more frequent meetings because there was so much stuff to go over and things had changed with the meeting. The MD further stated that she was not sure how and when the frequent meetings, used to be set date on Thursdays in the month not sure how it was set up the date. The MD informed the surveyors that the facility was working toward arranging the set schedule for QAPI meetings. On [DATE] at 9:39 AM, the surveyor met with the LNHA for a QAPI interview in the presence of the survey team. The surveyor asked the LNHA how often the QAPI meetings, and the LNHA responded that it was used to be quarterly then recently four months ago it was done monthly. He further stated that it was consistently quarterly every Thursday before, but the LNHA was unable to state when every Thursday. The LNHA was unable also to state when every month the scheduled QAPI meetings. The LNHA indicated that the QAPI meeting was being announced in the morning meeting when the next QAPI meeting, not written, communication of the schedule was verbal. The surveyor asked the LNHA if the MD attended morning meetings, and the LNHA stated No. The surveyor then asked the LNHA how will the MD know the schedule meetings for QAPI if the MD does not attend morning meetings, and the LNHA had no response. On that same date and time, the LNHA confirmed after checking the provided last three-quarters sign-in sheets for QAPI meetings, and LNHA stated that he was not in the meeting on [DATE], [DATE], and [DATE]. Furthermore, the surveyor asked the LNHA who the key person must be present during QAPI meetings, the LNHA stated that it was the DON, LNHA, and I am not 100% sure if the MD and maybe the Infection Preventionist. The surveyor notified the LNHA of the above concerns. On [DATE] at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and VPoCS. The surveyor asked the LNHA if he was aware of the missing and late physician's visit notes, and the LNHA responded that not until the surveyor's inquiry. The surveyor also asked the LNHA if he was aware that the MD was not also present during the last three quarters' QAPI meeting, the LNHA stated I am very aware now. On that same date and time, the LNHA confirmed that they (the facility) knew now that the governing body should be in the QAPI meeting as well. The LNHA acknowledged that the governing body was not present in the QAPI meeting. A review of the QAPI Program Plan that was provided by the AiT/RN/IPN revealed that the QAPI Plan was adopted on [DATE] and signed by the previous LNHA, MD, previous DON, previous ADON/IPN, and QAPI Coordinator that included the following: Governance & Leadership: The Administration assures the QAPI plan is reviewed on an annual basis by the QAPI team and approved by the governing body .The facility QAA Committee meets a minimum of quarterly and functions under the direction of the QAPI team. The QAPI team monitors data monthly from QAA findings and identifies areas for improvement to assure the achievement of the highest level of quality throughout the organization. QAPI Framework: The Administrator, DON, Infection Control and Prevention Officer, medical director, and three additional staff from the QAPI team. The QAPI coordinator is responsible for identifying projects, planning meetings, and document activities. Responsibility and Accountability: The administrator and/or QAPI coordinator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our organization. On [DATE] at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information. NJAC 8:,d+[DATE].1 (a)(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident: a) on 6/23/23 that resulted in a nose fracture for Resident #27 and b) Resident 208. This deficient practice was identified for two (2) of six (6) residents reviewed for accident and was evidenced by the following: 1. On 10/10/23 at 11:44 AM, the surveyor observed Resident #27 sitting in their room and could not be interviewed as the resident spoke in [dialect redacted]. At that time, the activities/translator was at the activities area, attending to other [dialect redacted] speaking residents. On 10/10/23 at 12:47 PM, the surveyor observed the resident was not in the room and found the Certified Nursing Assistant (CNA) in the room instead. In the presence of the surveyor and Licensed Practical Nurse (LPN), the CNA stated that she was waiting for the resident to call her from the bathroom. At that time, the LPN stated that the resident was obsessed with their bowels. The door to the bathroom was closed. The LPN stated that the resident had a mechanical sit to stand lift (a mechanical medical device that promotes movement from seated to a standing position). The surveyor reviewed the medical record for Resident #27 The Admission Record (AR; or facesheet; an admission summary) reflected that the resident had been admitted with diagnoses which included hemiplegia and hemiparesis (weakness or the inability to move on one side of the body) following cerebral brain infarction, affecting non-dominant side, type 2 diabetes mellitus without complications ((a disease of inadequate control of blood levels of glucose), unspecified dementia (impairment of memory loss and judgment), with unspecified severity without behavioral disturbance, and benign prostatic hyperplasia (enlarged prostate, symptoms include difficulty and sudden urge to urinate) without urinary tract symptoms and unspecified depressive disorder. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated 8/02/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) out of 15, which indicated the resident had a moderate impaired cognition and needed/wanted an interpreter to communicate with a doctor or healthcare staff. Further review of the qMDS developed by the facility to identify the resident's needs and implemented care interventions revealed that Resident #27 required extensive assistance (resident involved in activity; staff provide weight-bearing support) with two person assistance for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and toilet use (how the resident uses toilet room). The individualized Care Plan (CP) revealed a focus that included, Resident #27 had an actual fall on 6/23/23, related to impaired gait and mobility, paralysis, and weakness. The interventions included: A referral to an Ear Nose and Throat (ENT) Orthopedist. The resident was offered toileting before meals, at bedtime and as needed since the resident frequently attempted to get out of bed to go to the bathroom initiated on 6/23/23 and revised on 10/10/23. The resident frequently attempted to get out of bed to go to the bathroom and was on early up, the resident was offered toileting before meals, at bedtime and as needed initiated on 6/23/2023, and revised on: 10/10/2023. A review of the Progress Note for Resident #27, created on 6/23/23 at 10:49 AM, by the LPN, documented the following: Resident #27's roommate had called this nurse (LPN) and said the resident was on the floor, the resident was wheeling the chair and fell forward. The resident was on the floor, lying on their right side, bleeding from the nose, resident alert, saying get me up .walnut size bump over the right eyebrow, resident was able to move all extremities except the stroke arm, dark purple bruising over bridge of nose, updated daughter. The resident was sent out via 911 to the hospital for evaluation . A review of the Risk Management Report dated 6/23/23 at 11:46 AM, reflected the following: Incident description by the nurse: the resident's roommate called for help. The resident was on the floor [NAME] down on the right side, blood coming from nose, resident self-propelling forward and fell forward. Incident description by the resident: I fell frontways. Immediate action description: Resident was in a sitting position, nose and face cleansed. The bridge of the nose was purplish, and bleeding continued. The physician was informed. The resident was sent to the emergency room for possible nasal fracture. Level of pain was blank. Mental status was blank. Injuries report post incident: No injuries observed post incident Predisposing environmental factors was blank. Predisposing physiological factors was blank. Predisposing situation factors was blank. Witness was blank. Family member and physician were notified. Notes: On 6/26/23, team note review, the resident had not had a fall in greater than ten months, it appears the toileting schedule had worked. The incident although not witnessed the roommate with BIMS of 15 and the resident were able to state what had happened. A review of the Consultation note dated 7/21/23 indicated the report was a follow up for the resident's nasal fracture from a fall four weeks ago. The resident's septum was ok, and no significant deformity. No intervention was required. A review of the electronic Medical Record, Assessment tab, under Interdisciplinary Team Conference (group of health care professionals working together to set goals and make decisions) reflected the team met on the following dates: -1/31/23 -5/2/23 -8/7/23 There was no documented meeting after Resident #27's fall on 6/23/23 that resulted in a nose fracture. A review of a facility provided unsigned and undated document indicated the Resident fell on [DATE] in which the resident and sustained a fractured nose. The resident was sent to the hospital for evaluation and returned to the facility. The resident was in their room self-propelling, leaned forward and fell forward. Roommate did not see [Resident #27] fall. The resident preferred to stay in their room and do their own activity. Was seen by ENT 7/21/23 as follow up. Healing well no congestion, will heal on own. On 10/12/23 at 11:23 AM, during a meeting with the surveyors, Registered Nurse (RN)/ Infection Preventionist (IP), and the Director of Nursing (DON), the [NAME] President of Clinical Services (VPoCS) stated that incidents of falls and risk management were discussed during the morning meeting with the team. At that time, the DON explained their process for investigating incidents and accidents. The team reviewed the particulars of the incident and accidents with or without a witness statement from the resident. When an injury occurred from an incident or an accident the rehabilitation department (therapy) was involved to conduct a screening. A medical work up was conducted, and a member of the facility communicated with the medical doctor. The results of the screen and evaluation were documented on the notes section of the risk management report (RMR; also known as the Accident/Incident Report). The witness/staff statements were also uploaded into the electronic Medical Record (eMR). The DON stated the process could be a lot tighter. On 10/12/23 at 01:06 PM, in the presence of two surveyors, the DON stated there was not a need for a witness statement from the resident since she documented what she learned from the resident and the roommate. The DON could not explain while utilizing the RMR, the root cause of the fall, why the resident was leaning forward, where the resident was propelling to, and exactly where in the room the resident fell . At that time, the DON did not have a signed witness statement(s). The DON stated she would ask the LPN who documented on the PN to see what she recalled. On 10/13/23 at 11:28 AM, during a meeting with the surveyors, and the VPoCS, the DON stated the incident was not reported to the State Agency because the fall was witnessed by the roommate. At that time, the DON stated she obtained a signed statement from the nurse yesterday [after surveyor inquiry] about the fall that occurred on 6/23/23. The DON learned the resident fell on the right-side foot of the bed and the roommate with a BIMS of 15 (cognitively intact) informed the same nurse that the roommate saw the resident fall. The nurse had mistakenly entered the incorrect information and checked unwitnessed fall on the RMR. The DON was unable to explain from the statement and the report why the resident fell forward or where the resident was propelling to and the discrepancies from the investigation between the unwitnessed summary on the RMR and the witnessed signed statement provided that day. 45208 2. The surveyor reviewed the medical records of Resident #208. A review of the the facility provided investigations showed incomplete investigations and missing witness statements for the following dates: -Un-witnessed fall 01/14/2022 -Un-witnessed fall 01/26/2022 -Un-witnessed fall 01/30/2022 -Un-witnessed fall 06/04/2022 -Bruise of unknown origin 06/18/2022 -Bruise of unknown origin 11/17/2022 -Un-witnessed fall 08/22/2022 -Un-witnessed fall 09/24/2022 -Injury of mouth from unknown origin 10/14/2022 -Un-witnessed fall 10/29/2022 -Un-witnessed fall 11/05/2022 -Un-witnessed fall 11/16/2022 -Un-witnessed fall 12/25/2022 -Un-witnessed fall 02/09/2023 Resident #208's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, chronic atrial fibrillation, unspecified lack of coordination, cognitive communication deficit. A review of Resident #208's comprehensive MDS (cMDS) dated [DATE], reflected that the resident had a BIMS score of four out of 15, which indicated the resident had a severely impaired cognition status. Further review of the cMDS developed by the facility to identify the resident's needs and implemented care interventions revealed that Resident #208 required extensive assistance (resident involved in activity; staff provide weight-bearing support) with two person assistance for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and toilet use (how the resident uses toilet room). The individualized CP revealed a focus that included, Resident #208, revealed resident was high risk for falls, initiated on 8/05/2021 and revised on 3/19/2023. A review of the undated facility policy provided Incident/Occurrence Investigation policy included the following: Policy Statement 1. All incidences of alleged abuse, mistreatment, or neglect of a resident by staff, other residents, visitors, etc. will be investigated. 4. The results of investigations that indicates that abuse, neglect, or mistreatment has occurred, or cannot be conclusively ruled out, will be reported to the DOH utilizing standard reporting procedures. Procedure: 1. Following an occurrence or notification or a complaint the RN Manager or RN Supervisor will submit to the DON - Nursing/Designee a copy of the Accident/Incident report [RMR] with staff statements. If Social Services is notified regarding a complaint or occurrence, the DON - Nursing/Designee and Administrator will be promptly advised. If event occurs on the weekend the RNM or RN Supervisor will initiate an investigation and will advise the Administrator on Duty that an that an investigation is underway. 5. Administrator, DON- Nursing/Designee will meet to review the summary of the investigation and make a decision if an event is reportable to the DOH. The Medical Director or Director of Social Services may be asked to participate in the decision making process depending on the type of event that has occurred. A file with an investigation summary will be kept in all occurrences or complaints that meet criteria for requiring an investigation. On 10/16/23 at 12:06 PM, during a meeting with the survey team, the VPoCS, the DON and LNHA informed the surveyors that all the staff were educated along with the Interdisciplinary team about the risk management documentation and the expectation was to thoroughly document the record, collect witness statements, and root cause analysis would be completed at the time of investigation. The LNHA stated that his lawyer did not want him to acknowledge the investigation was incomplete. At that time, the VPoCS stated we have identified the need to update the process as identified by the surveyors. The issue regarding thorough documentation was incorporated within the Quality Assurance Performance for Improvement (QAPI). Our process is for continued improvement. NJAC-8.39-4.1(a)5 38327

Based on interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner. This deficient practice was identified for three (3) of six (6) residents reviewed for physician visits, Residents #1, #8, and #18. This deficient practice was evidenced by the following: 1. On 10/17/23 at 8:51 AM, the surveyor and the Licensed Practical Nurse both observed Resident #1 lying on the bed. The surveyor reviewed Resident #1's medical records. The Admission Record (AR; or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts communication between the brain and the body. MS causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), other muscle spasm, and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 9/20/23, Section C Cognitive Patterns had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which reflected that the resident's cognitive status was moderately impaired. A review of Resident #1's PN showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN revealed that there was no Physician Note after 6/30/23. 2. On 10/06/23 at 11:04 AM, the surveyor observed Resident #8 inside their room with a Certified Nursing Assistant providing care. The surveyor reviewed the resident's medical record as follows: The AR showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes mellitus without complications (a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels), neuromuscular dysfunction of bladder unspecified (lack bladder control due to a brain, spinal cord or nerve problem), and depression unspecified. The qMDS with an ARD of 8/09/23 had a BIMS score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) 3. On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with a trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dependence on supplemental oxygen, gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) status, hypoxic ischemic encephalopathy (a type of brain damage), dysphagia unspecified (a disorder characterized by difficulty in swallowing), chronic obstructive pulmonary disease unspecified (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and anoxic brain damage not elsewhere classified (caused by a complete lack of oxygen to the brain, which results in the death of brain cells due to oxygen deprivation). The most recent qMDS with an ARD of 9/04/23 revealed that the resident had a BIMS score of 00 which indicated that the resident's cognitive status was severely impaired. A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS) and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x3 months. The VPoCS stated that it was an expectation that the face to face visit notes of the physician then will be every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, then the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyors that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months notes of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and entered the notes late. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy and that the facility followed the regulations. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. NJAC 8:39-23.2(d)

Based on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify residents in need of, offer a Pneumococcal vaccine for four (4) of six (6) residents, (Residents #13, #82, #84, and 95), and offer the subsequent Pneumococcal vaccine for two (2) of six (6) residents, (Residents #28 and #30) and b) follow the facility Pneumococcal vaccine policy in accordance with the Advisory Committee on Immunization Practices and the CDC (Centers for Disease Control and Prevention) guidelines. This deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: Age [AGE] years or older who have: -Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive Pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23. 1. On 10/06/23 at 10:44 AM, the surveyor observed Resident #82 inside their room seated in a wheelchair while watching television. The resident stated that there was no concern with care. The surveyor reviewed the medical records of Resident #82. The Admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), essential hypertension (occurs when abnormally high blood pressure that's not the result of a medical condition), type two diabetes mellitus without complication (It is characterized by high levels of sugar in the blood. Type 2 diabetes is also called type 2 diabetes mellitus and adult-onset diabetes), and adjustment disorder with mixed anxiety and depressed mood (Feeling both anxious and depressed). A review of Resident #82's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) 7/26/23, Section C Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which reflected that the resident's cognitive status was moderately impaired. Section O Special Treatments, Procedures, and Programs included that the resident's pneumonia vaccine was not assessed and there was no information. The immunization record in the electronic medical record showed that the resident consent was refused. Further review of the medical records showed that there was no pneumonia vaccine consent documentation that the resident declined the vaccine. On 10/13/23 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified the facility management of the above findings. 45208 45449 2. On 10/10/12 at 01:45 PM, during an interview with the surveyors, the AiT/RN/IPN stated that she was waiting for her reciprocity from another state, and was the acting RN/IP (also the AiT/RN/IPN) since April of 2023. At that time, the RN/IP explained the process for the Pneumococcal (PNA) Vaccination for the facility to the surveyors. She stated that upon admission the resident should have been offered the PNA vaccine, if there was no history the resident should have been offered the PNA vaccine and administered if they wanted it. Ideally it should be re-offered quarterly or biennially. At that time, the RN/IP stated that the surveillance was conducted by running a report on the [electronic medical record (eMR)/brand redacted] as to who needed or wanted the PNA vaccine. At that time, the surveyors had asked the RN/IP if she had run the report. The IP stated that she did not recall but should have as part of the surveillance to ensure better resident outcomes. At that time, the RN/IP stated that the facility protocol was dependent on the physician's order and what was available at the pharmacy. The surveyor reviewed the medical records for Resident #13. The resident's AR reflected that Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) without behavioral disturbance, dysthymic disorder (chronic low level depression), chronic atrial fibrillation (a longstanding irregular heart rhythm), and vascular syndrome of brain in cerebrovascular diseases (condition that affects the blood vessels in the brain). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The MDS record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #13's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's Care Plan (CP) and Order Summary Report (OSR) did not indicate the resident was care planned or had an active order for immunizations. 3. The surveyor reviewed the medical record for Resident #95. The resident's AR reflected that Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia without behavioral disturbances, bipolar disorder (a mental health condition that causes unusual shifts in mood ranging from extreme high to lows), type 2 diabetes mellitus (high blood sugar), and chronic kidney disease, stage 2 ( the damage to the kidneys was still mild). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #95's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. 4. The surveyor reviewed the medical record for Resident #28. The resident's AR reflected that Resident #28 was admitted to the facility with diagnoses that included but were not limited to unspecified dementia with other behavioral disturbance, chronic diastolic (congestive) heart failure (heart does not pump enough blood to the body), hypertension (high blood pressure), cardiac pacemaker, and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, indicated yes. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] A review of the Resident #28's eMR under Immunizations record did not indicate a record for Pneumococcal vaccination indicated the resident received Pneumovax/PPSV23 on 01/01/15. A review of the Resident #28's eMR under Immunizations record did not indicate a subsequent offer or declination of an offer for the PNA vaccine. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. A review of the Resident #28's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. 5. The surveyor reviewed the medical record for Resident #30. The resident's AR reflected that Resident #30 was admitted to the facility with diagnoses that included but were not limited to dementia without behavioral disturbances, bipolar disorder (a mental health condition that causes unusual shifts in mood ranging from extreme high to lows), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism). According to the qMDS dated [DATE] with a BIMS score of 12 out of 15, indicating that the resident had moderately impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was marked yes. The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #30's eMR under Immunizations record revealed a recorded Pneumovax Dose one (1) given on 3/29/2021. It did not indicate that the subsequent Pneumococcal vaccine was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. 6. The surveyor reviewed the medical record for Resident #85. The resident's AR reflected that Resident #85 was admitted to the facility with diagnoses that included but were not limited to depression (serious medical illness that negatively affects how you feel, the way you think and how you act.), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and other schizoaffective disorder (relating to, characterized by, or exhibiting symptoms of both schizophrenia and a mood disorder (such as major depression or bipolar disorder). According to the comprehensive MDS dated [DATE] with a BIMS score of eight (8) out of 15, indicating that the resident had moderately impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The MDS record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #85's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. On 10/12/23 at 12:31 PM, during a follow-up interview with the surveyors, the RN/IP stated that the facility had a Group A Streptococcal (GAS) disease outbreak from 5/23 to 8/23 and the facility has been cleared since by the State Agency. At that time, the RN/IP stated that she had a working relationship with the Medical Director (MD) who was not comfortable to administer the PNA vaccines to the residents at that time of the GAS disease outbreak. The MD and the RN/IP did not document this discussion on the eMR of the residents who did not receive the PNA vaccines. The RN/IP also stated that se did not want to risk exposure to the resident by administering the PNA vaccine. The RN/IP did not provide documentation regarding the guidelines used for the decision to not offer the administration of the appropriate PNA vaccination based on the CDC's guidelines. At that same time, the RN/IP informed the surveyors that she followed the CDC guidelines for the PNA vaccination. Furthermore, the RN/IP stated that she would revisit the consent. If it was not uploaded into the eMR the resident or resident representative was not given the consent form. Moving forward we will revisit the offering of the PNA vaccine quarterly and update tracking of the consent, vaccinations. She further stated that the concern would be included into the Quality Assurance Performance for Improvement (QAPI). A review of the RN/IP surveillance report revealed Resident (#13, #95, and #85) were without consent forms. On 10/16/23 at 10:03 AM, during a meeting with the survey team, RN/IP, the DON, LNHA, and the VPoCS, the surveyor discussed the concern regarding the missing consent forms (proof of offer and/or declination), the surveillance of who needed PNA vaccination Resident (#13, #95, and #85), the surveillance of who needed the subsequent dose, Resident #28 and #30 and the concern regarding the facility policy. On 10/16/23 at 12:05 PM, the survey team met with the VPoCS, DON, and LNHA. The DON stated that we (facility management) went around and offered PNA vaccination to all residents and informed the family. The LNHA stated that a QAPI (Quality Assurance and Performance Improvement) plan and tracking was started after surveyor's inquiry. A review of the facility provided policy Pneumococcal Vaccination, dated 5/18/23 included the following: It is the policy of this facility to provide vaccination against Pneumococcal Disease for all residents who are [AGE] years of age or older in accordance with the Recommendations of the Advisory Committee for an Immunization Practices and the Centers for Disease Control, unless such vaccination is medically contraindicated or the resident has refused the vaccine. Under, procedure included, The the facility will provide the provisions of Pneumococcal vaccinations for all residents [AGE] years of age or older, who have not been previously immunized prior to admission unless the resident refuses offer of the vaccine, or the vaccine is medically contraindicated. Pneumococcal Vaccinations will be recorded in the resident medical record under immunizations, or it will be documented that the resident did not receive the vaccine due to medical contraindication or refusal. NJAC 8:39-19.4 (a) (i)

Based on observation, interview, record review, and review of pertinent facility provided documents it was determined that the facility failed to provide a physically impaired resident a specialized call bell according to the resident's limitation and preference. This deficient practice was identified for Resident #1, one (1) of two (2) residents reviewed for the limited range of motion, and was evidenced by the following: On 10/13/23 at 11:47 AM, during the courtesy meeting with the facility's Volunteer Advocate (VA), the VA informed the survey team that she was the one who recommended to the facility for the resident to have a specialized call bell due to the resident's limitations to upper extremities as per resident's preference. The surveyor reviewed Resident #1's medical records. The Admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts communication between the brain and the body. MS causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), other muscle spasm, and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 9/20/23, Section C Cognitive Patterns had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which reflected that the resident's cognitive status was moderately impaired. The qMDS also reflected in Section G Functional Status, G0400 Functional Limitation in Range of Motion that the resident was coded 1 (one) for the limitation that interfered with daily functions on the upper extremity and 2 (two) for lower extremities limitations. A review of the personalized care plan with a focus that the resident had a limited ADL (activities of daily living) function, physical mobility r/t (related to) contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), MS, and weakness that was initiated on 7/04/18 and was revised on 8/11/23. The limited ADL care plan's interventions/tasks did not include information about the specialized call bell. Further review of the care plan showed that the resident had a focus care plan for at risk for falls r/t gait/balance problems, a diagnosis of MS that was initiated on 7/04/18 and was revised on 10/12/23. The interventions/tasks included call the light is within reach, encourage the resident to use it for assistance as needed, and needs a prompt response to all requests for assistance that was created on 7/04/18 and revised on 10/03/22. The personalized care plan interventions did not specify where to put the call bell according to the resident's limitations and preferences. In addition, the resident had a care plan focus that the resident has MS/quadriplegia and spends most of their time in bed and depends on staff for solid and liquid administration that was initiated on 3/28/23 and revised on 9/24/23. The IDCP (Interdisciplinary Care Planning)- Team Conference for quarterly assessment dated [DATE] and was locked (closed) on 10/07/23. The information included that the resident was dependent on staff for solid and fluid administration and that the resident requires total care for all aspects of care self-feeding, hygiene, dressing, toileting, and all mobility require total assist. In addition, it included that the resident could follow short cues to participate in tasks and was currently on PT/OT (Physical Therapy/Occupational Therapy) services. A review of the electronic Progress Notes (PN) dated 10/02/23 by the Social Worker (SW) showed that the resident was issued a last cover date of 10/06/23 because the resident met the goals for Skilled PT and OT and that the resident could not sign the NOMNC (Notice of Medicare Non-Coverage; is a notice that indicates when your care is set to end from a skilled nursing facility (SNF) example skilled PT and OT) due to MS. On 10/17/23 at 8:49 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) in the 200-wing nursing station. LPN#1 informed the surveyor that LPN#2 was the assigned nurse of Resident # 1. On 10/17/23 at 8:51 AM, the surveyor interviewed LPN#2. LPN#2 informed the surveyor that she was a per diem nurse and assigned nurse of Resident # 1. The surveyor asked the LPN to go with the surveyor inside the resident's room. In the resident's room, the surveyor and the LPN both observed the flat call bell attached/pinned to the left part of the head bed approximately (two) 2 inches away from the pillow where the head of the resident was. The specialized call bell was placed where the resident was unable to use the call bell. The surveyor observed the resident with bilateral hands/arms limitations. On that same date and time, the surveyor asked LPN#2 if that was where the call bell should be and the LPN stated that definitely not, and the LPN took it and placed it just above the xiphoid process (xiphoid process is a small extension of bone just below the sternum) and grabbed the residents hands to be able to touch the call bell. The surveyor then asked the LPN should the call bell was there, and the LPN stated yes and that the resident could use it with the resident's hand. At this time the resident said it should be under the resident's chin. Then, the surveyor observed the LPN went outside the room and took a towel before entering the resident's room again. On 10/17/23 at 8:53 AM, the surveyor interviewed the assigned Certified Nursing Assistant (CNA) of the resident. The CNA informed the surveyor that he was the regular CNA in the 200 wing, worked 7-3 and 3-11 shifts, and had been working in the facility for [AGE] years. He further stated that he was assigned to the resident and he was familiar with the resident. At that same time, the CNA stated that the resident's specialized call bell should be placed in the resident's chest so the resident could reach it with their hand. He further stated that, lately the resident was not able to use the call bell and the CNA was unable to state how long and why. The surveyor asked the CNA how he knew that it should be placed in the resident's chest and who educated him about the proper placement of the resident's call bell, and the CNA stated that he just knew. The CNA was unable to state who informed him that it should be in the resident's chest. On 10/17/23 at 9:48 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and [NAME] President of Clinical Services (VPoCS) of the above findings. On 10/17/23 at 11:00 AM, the surveyor interviewed the Rehab Director/OT (RD/OT) in the presence of the survey team. The RD/OT acknowledged that he knew Resident #1 and that he recently treated and discharged (d/c) the resident from Skilled OT. The RD/OT informed the surveyor that the resident was d/c with no significant changes, and remained in total care with ADLs except for the left hand/extremity have some movement. On that same date and time, the surveyor asked about the resident's specialized call bell. The RD/OT claimed he called it a pancake call bell the way it looked, flat and circular. He stated that the pancake call bell should be placed on the left breast area of the resident. The surveyor asked the RD/OT if education was provided to the staff regarding the proper use of the pancake call bell and who provided the call bell. The RD/OT stated that he discussed with the Registered Nurse Unit Manager (RN/UM) verbally how to use it. The surveyor then asked how other nurses and CNAs were educated, and he stated that he did not talk to nurses and CNAs. The RD/OT further stated that generally, it should be nurses who document for care plan for the use of the call bell. On 10/17/23 at 11:55 AM, the surveyor interviewed the RN/UM in the presence of the survey team. The RN/UM informed the surveyor that when she was promoted as a UM beginning of May 2023, that was the same time she observed that the resident had the specialized call bell. The RN/UM stated that she was not sure who provided the call bell. She further stated that it was the VA who recommended the specialized call bell since the resident had limitations on both hands/arms. The RN/UM stated that the call bell should be placed under the left breast. She further stated that it was her and the RD/OT who assessed the resident that the resident can use their left hand in using the specialized call bell. On that same date and time, the surveyor asked the RN/UM if education was provided to the staff including the aides on the proper placement of the specialized call bell, the UM stated that just verbal instructions to the aides in the morning shift. The surveyor then asked how about other shifts, 3-11 and 11-7, the UM stated that she told the nurses in the morning, and that they do shift reports, and probably the nurses notified other staff. The RN/UM acknowledged that in-service or education should have been provided to all staff and all shifts on the proper placement of the call bell. In addition, the surveyor also asked if should it be in the care plan. The UM stated that it should be documented in the care plan the proper placement of the call bell. She further stated that the preference of the resident should be consider on where to put the specialized call bell and it should be in the care plan interventions. The RN/UM informed the surveyor that the resident was cognitively intact, not confused, and had no unusual behavior. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), DON, and VPoCS, and notified of the above findings. On 10/18/23 at 12:00 PM, the surveyor reviewed the typewritten explanation that was provided by the LNHA included that the staff education and care plan was updated about the pancake call bell after the surveyor's inquiry. Included in the typewritten explanation also was that the maintenance provided a call bell at the request of the Ombudsman on 6/14/23. The pancake bell was on the premises and supplied on 6/15/23. A review of the updated care plan showed an intervention/task dated 10/17/23 for a geri call within reach Patient prefers under the chin. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and the team could proceed with decision making. NJAC 8:39- 4.1 (a), 12

Based on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to a) notify in advance and in writing of a resident's new roommate change for a cognitively impaired resident in accordance with federal and state regulations. This deficient practice was identified for one (1) of three (3) residents reviewed for room change (Resident #81) and was evidenced by the following: On 10/17/23 at 10:07 AM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident's room change were discussed during the morning clinical meeting with the Interdisciplinary team. The team was comprised of the Certified Nursing Assistant (CNA) to the resident, Social Services, the Licensed Practical Nurse (LPN) or the Registered Nurse (RN) assigned to the resident, the Infection Preventionist (IP), the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The conversation involved discussing the resident's personality differences, comfort. We also wanted the resident in the room to be comfortable along with the new resident who was going to be moved into the room. At that time, the DSS stated that the conversation was not documented anywhere. The team meetings were documented but not our conversations. We did document the notification to the family and guardian [as applicable]. At that time, the DSS informed the surveyor that she recalled the Resident who was being moved into Resident #81's room was documented as the aggressor but did not see the report before it was sent to the State Agency. As the social worker I thought it was ok to move the resident into Resident 81's room. When I placed the resident in the room, I did not think the new roommate to be was the aggressor. I effectuated the room changes [05/02/23] after a team conversation to determine the room change. At that time, the DSS stated that she had notified the guardian of the Resident who was being moved into Resident #81's room. At that time, the DSS stated that she had not provided a written notification to Resident #81's family. The surveyor reviewed Resident #81's medical record. A review of the resident's Admission Record (an admission summary) reflected that Resident #81 was admitted to the facility with diagnoses that included vascular dementia (problems with reasoning, planning, judgement, memory, and other thought process caused by impaired blood flow to the brain) without behavioral disturbance, depressive episodes, and personal history of transient ischemic attack (stroke that lasts a few minutes) and cerebral infarction (a result of decreased blood flow to the brain) without residual deficits. According to the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate management of care dated, 9/12/23, Resident #81 was documented as having a Brief Interview for Mental Status score of two out of 15, indicating that the resident had a severely impaired cognition. A review if the Census (total number of residents) list reflected Resident #81 had been in the room since 8/06/22. There was no documentation that Resident #81 was notified of a new roommate, or their representative was notified in writing. On 10/18/23 at 12:32 PM, during a meeting with the surveyors, the [NAME] President of Clinical Services (VPoCS) and the LNHA, the surveyor discussed the concern regarding the missing written notification of a new roommate for Resident #81. On 10/19/23 at 11:52 AM, during a meeting with the surveyors, the DON, the LNHA, and the RN/IP/Interim LNHA, the VPoCS stated the SSD was educated on the process of roommate notifications. At that time, the RN/IP/Interim LNHA stated that they did not have a facility policy on room changes. N.J.A.C. 8:39-4.1(a)(13)

Based on observation, interview, and review of pertinent facility documentation it was identified that the facility failed to provide residents with a clean, safe, comfortable, and home like environment. This deficient practice was identified in one (1) of two (2) dining areas where morning activities for the English-speaking residents were also held. A review of the Material Safe Data Sheet for [brand name redacted] under Section 7: Handling and Storage included the following: Provide good ventilation. Do not use in confined spaces without adequate ventilation and/or respirator. Avoid contact with skin and eyes. Do not eat, drink, or smoke when using the product. Methods of Clean-up: Small spillages: Absorb with sand or other inert absorbent. Large spillages: Dam and absorb. Collect spillage in containers, seal securely and deliver for disposal according to local regulations. Wear necessary protective equipment. Storage: Keep separate from food, feedstuffs, fertilizers and other sensitive material. Store in closed original container at temperatures between 5 Cand 30 C/ 40 F and 86 F. Protect from freezing and direct sunlight. On 10/06/23 at 01:20 PM, the surveyors observed Resident #95 walking the hallway adjacent to the dining area without assistance. The resident was cognitively impaired and conversant. At that time, the surveyor walked with Resident #95 towards the Recreation/Activities Director's (R/AD) office. The Activity Director (AD) stepped outside her room and assisted the resident towards their wing. On 10/11/23 at 10:28 AM, the surveyor met with the AD in the main dining room to commence the meeting with the resident council president and representatives. At that time, the AD stated that the resident council meeting was always held in the main dining room. The main dining room had two entrance and exit doors from the hallway and across the entrance/exit doors was the entrance to the kitchen. At that time, the surveyor observed a heavy-duty flatbed [NAME] cart with handles and wheels, a hand truck, a fan, a mop, a palette of wood flooring, and multiple gallons of vinyl flooring adhesive (construction materials) next to one of the entrances/exit doors in which one of the resident council representatives (Resident #50) entered from. Resident#50 parked their mechanical sit and stand lift (a mechanical medical device that promotes movement from seated to a standing position) next to the palette of construction materials. At that time, the resident council member(s) who did not want to be identified stated that the floor construction where we had our resident council meeting was new. They were unsure exactly when. On 10/11/23 at 12:16 PM, the surveyor observed residents in the dining area waiting for lunch to be served. The construction materials were still in the corner of the dining area next to the entrance/exit and adjacent to a dining table where residents were seated. On 10/11/23 at 01:09 PM, the surveyor met with the Facility Maintenance Director (FMD) and walked into the dining area together. The FMD confirmed observing the construction material with visible seepage from the vinyl glue adhesive gallon container. The FMD informed the surveyors that he did not put the construction materials into the dining area. I just noticed it was there. The FMD stated that the facility had a contractor who did not report to him. At that time, the FMD stated that the facility did not have space to put the construction materials. The Administrator had hired the contractor and reported to the administrator directly. The FMD stated he was in -charge of water, the hood in the kitchen, painting, temperature, and water testing. The materials purchased by the FMD were not in bulk and could be kept downstairs. On 10/11/23 at 01:25 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and discussed the concern regarding the construction materials and the visible seepage from the vinyl glue adhesive gallon container stored inside the dining area where residents ate and had activities. At that time, the LNHA stated it did not occur to him that it was a problem. The LNHA stated yes, the area is a resident area, yes, he did see the residents in the area, and yes, food was served there. The LNHA confirmed he had knowledge that he had wandering residents living in the facility and yes, it can be a hazard. At that time, the LNHA stated that it did not occur to him that it was a problem. The LNHA informed the surveyors that he would move the construction materials from the dining area. On 10/13/23 at 10:19 AM, the surveyor observed the dining area was cleared of the construction materials. At that time, during the meeting with the survey team, the LNHA stated he was ultimately responsible for the construction. He did not see that it was a contradiction to a homelike or safety environment. On 10/13/23 at 11:28 AM, during a meeting with the surveyors, the [NAME] President of Clinical Services (VPoCS), Director of Nursing (DON), Registered Nurse (RN)/Infection Preventionist (IP), and the LNHA, the surveyor discussed the concern regarding safety, homelike environment (similar to those found in a private residence or apartment) and storing construction materials in an area where confused wandering residents, residents that required assistance with daily living, and all the residents who had access to dining area. On 10/16/23 at 12:06 PM, during a meeting with the surveyors, the VPoCS, and the DON, the LNHA stated the supplies were not a danger, a resident would have to use a crowbar to open the vinyl adhesive glue gallon containers. The LNHA did not discuss the palette of wood, the heavy-duty flatbed [NAME] cart with handles and wheels, the hand truck, the fan stored next to the entrance/exit of the dining area and the decrease in dignity for the residents who used the dining/activities area. At that time, the LNHA stated we moved it immediately. Based on the regulations it was not against homelike environment. It was appropriate to keep it there for a few days. It was a big process to remove the palette. It took 45 minutes to remove from the dining area. It was there for a short period of time. At that time, the LNHA informed the surveyors that the facility did not have a Policy and Procedure for homelike environment. A review of the undated/unsigned facility provided job description for the facility Maintenance Director under position summary included. The Maintenance Director follows established safety rules and policies and procedures of the maintenance department, keeps required records and submits them to the administrator and director of property management when required and cooperates with other employees and department heads. Under responsibilities/accountabilities included performs overall supervision of the maintenance department including hands on performance of maintenance and repair work. Concerns his/ herself with safety of all facility residents in order to minimize the potential for fire and accidents. Also ensures that facility adheres to the legal, safety, health, fire, and sanitation codes by being familiar with his/ her role in carrying out the facilities fire, safety, disaster plans and by being familiar with current MSDS. A review of the undated/unsigned facility provided job description for the Administrator (LNHA) included the following: Position Summary The administrator is responsible for planning and is accountable for all activities and department of the facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The administrator administers directs and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. Responsibilities 2. Interprets personal practices within policy guidelines and recommends changes as necessary; 5. Super intense physical operations of the facility; 9. Concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. Also, ensures that the facility adheres to the legal safety health fire and sanitation codes by being familiar with his/her role in carrying out the facilities fire safety disaster plans and by being familiar with the current MSDS. NJAC 8:39-31.4(a)(f)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of nine (9) newly hired staff reviewed, (Staff #1, #4, and #6) and was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 7/06/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. Staff #4, a Speech Therapist, hired 01/01/23, did not have a New Jersey Division Consumer Affairs license verification printout for license verification. There was no documented evidence that Staff #4's license was verified. Staff #6, a CNA, hired 3/21/23, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. On 10/18/23 at 11:59 AM, the surveyor interviewed the Human Resources Director (HRD) regarding the process for license verification. The HRD stated that she would go online and verify the employee's license. The HRD confirmed that Staff #1 and #6 did not have a date on their license verification printout. The HRD confirmed that Staff #4 did not have a license verification printout in their employee file. On 10/18/23 at 01:02 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Clinical Services (VPoCS) the concern that three newly hired employees did not have documented evidence that their licenses were verified prior to their date of hire. On 10/19/23 at 10:59 AM, in the presence of the survey team, LNHA and DON, the VPoCS stated that the HRD now knows how to print the date on the printout. The surveyor asked if licensed employees should have their licenses verified prior to hire and that if the date should be on it. The VPoCS confirmed that they should be. A review of the undated facility provided policy titled, New Hire And Onboarding Process included the following: Prior to a start date: Valid NJ State License (RN, LPN, C.N.A., etc.) A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 5/18/22, included the following: Employee and Volunteer Screening 2. Inquiry of State Nurse Aide Registry for CNA applicants 3. Inquiry of licensing authorities for all licensed/certified positions N.J.A.C. 8:39-43.15(a)

Complaints # NJ00158985, NJ00156816 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for three (3) of 21 residents, (Resident #26, Resident #208, Resident #209) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified October.20.2023, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of the source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. 1. On 10/18/23 at 12:17 PM, the surveyor observed and interview Resident #26. The surveyor observed the resident had jagged teeth and brown discoloration when he/she smiled. The resident stated that there was no pain at this time. The surveyor asked if the resident had seen a dentist or had been offered since he/she was admitted . The resident stated no, neither. On 10/16/23 at 11:46 AM, surveyor interviewed the assigned aide of the resident, Certified Nursing Assistant (CNA). The CNA stated that Resident #26 was a set-up for morning (AM) care including care of resident's teeth. The aide further stated that the resident did not have a complete set of teeth and had some broken teeth. On 10/10/23 at 9:45 AM, the surveyor reviewed Resident #26's electronic medical record (eMR). A review of Resident #26's Admission Record (AR; or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high. Blood glucose is your main source of energy and comes mainly from the food you eat), moderate protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function ), need for assistance with personal care (the range of services put in place to support an individual with personal hygiene and toileting, along with dressing and maintaining your personal appearance.). The Order Summary Report dated 8/25/23 through 10/10/23 revealed that there was not an order for a dental consultation. A review of the Nutrition Assessment, dated 8/29/23, #12, Teeth /Dentures, letter J, indicated broken or carious teeth? Was answered Yes. A review of the Comprehensive Minimum Data Set (CMDS), dated [DATE], revealed the resident had Brief Interview for Mental Status (BIMS), score of five out of 15 which reflected that the resident had a severe cognitive impairment. It further revealed under. -section L, Oral/Dental status none of the above were present. -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance, (helper does less then half the effort.) A review of the resident's personalized Care Plan (CP), dated 8/24/23, revealed a focus resident has an ADL self-care performance deficit related to (r/t) activity intolerance and impaired balance. date initiated 8/29/23, revision date of 10/07/202. The individualized care plan did not reflect a focus for teeth impairment and care. There was no documentation that Resident #26 was offered and refused dental care services. 2. On 10/10/23 at 10:02 AM, the surveyor reviewed Resident #208's closed medical record. A review of Resident #208's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified severe protein-calorie malnutrition, cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). A review of the Quarterly MDS (QMDS), dated [DATE] revealed: -section L, Oral/Dental status as left blank -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was left blank - section G, Functional Status was coded as 3 (Extensive Assistance, resident involved in activity, staff provided support) self-performance and 2 (one-person physical assist) Support Further review of the QMDS, dated [DATE], revealed the resident had BIMS) score of four out of 15 which reflected that the resident had a severe cognitive impairment. In addition: -section L, Oral/Dental status was left blank -section G, Functional Status was coded as 3 (Extensive Assistance, resident involved in activity, staff provided support) self-performance and 2 (one-person physical assist) Support -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was left blank The resident's personalized CP, dated 8/31/21, revealed a focus resident has oral/dental health problems (oral laceration) r/t refuses assist with dental care. Poor oral hygiene. date initiated 10/14/2022, revision date of 01/02/2023. There was no documentation that Resident #208 was offered and refused dental care services. 3. On 10/10/23 at 10:20 AM, the surveyor reviewed Resident #209's closed medical record. Resident #209's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, unspecified protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), vitamin B deficiency, Vitamin D deficiency. A review of the Nursing admission assessment, dated 5/05/2022 revealed section #12 Teeth and Dentures; a) own teeth? No, b) partial upper (blank) c) partial lower (blank) d) full upper (blank) e) full lower (blank) f) has dentures but does not wear them (blank) A review of the Order Summary Report, dated 5/11/22 through 8/01/22 revealed that there was an order for a dental consult, initiated on 5/05/2022. A review of the Nutrition Assessment, dated 5/10/2022, revealed in the assessment and plan section; resident has been put on list to see the dentist as resident doesn't wear them due to poor fit. It also revealed #12 Dentures answered as #5 edentulous (lacking teeth). A review of a Social Worker progress note (PN), date 5/12/2022, labeled as 72-hour meeting revealed resident was on a diet of; no added salt (NAS) pureed texture and thin liquids. It did not reflect the residents oral standing of having dentures but not using because of poor fit. A review of the CMDS dated [DATE], revealed the resident had BIMS score of four out of 15 which reflected that the resident had a severe cognitive impairment. It further revealed under. -section L, Oral/Dental status none of the above were present. -Section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance, (helper does less than half the effort.) A review of the resident's personalized CP, dated 5/05/22, revealed a focus Resident does not wear dentures due to poor fit. Resident receives consistency modifications. Eats fairly with acceptable BMI (body mass index [BMI] is a measure of body fat based on height and weight that applies to adult men and women) on admit. date initiated 5/18/22, revision date of 5/18/2022. There was no documentation that the resident declined dental services. Surveyor requested MDS policy 10/12/2023. The facility was unable to provide a policy. The VPOCS stated, they refer to the RAI manual by CMS guidelines. A review of the Dental Services policy, dated 1/2018, revealed; statement; To ensure a resident's diet is appropriate, optimal hydration and nutritional status are maintained and risk of choking is avoided. Speech therapy (via screen) and dietary (via alert) must be notified of the following circumstances: -Missing/ broken dentures -Recent extractions -Refusal to wear dentures -New dentures If a resident's dentures are lost or damaged, they must be referred to a dentist within 3 days for services. If a referral does not occur within 3 days, supportive documentation of what was done to ensure the resident could still eat and drink adequately and the extenuating circumstances behind the delay of services will be noted. A review of the policy Interdisciplinary Care Planning Protocol revealed; #3. Activities and Dietary provide an overview of their assessment of resident needs and problems. #8. Problems established by the team with the resident/ family input MUST be specific and individualized. On 10/19/23 at 11:36 AM, the surveyor interviewed the [NAME] President of Clinical Services (VPoCS) who stated, the MDS coordinator was unavailable and out on personal leave and she could answer surveyor's question regarding coding. She stated coding of the MDS was based on what is found in the record and Interdisciplinary Care Plan (IDCP) note. The IDCP should be a synopsis of the MDS. NJAC 8:39-33.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; and b.) ensure an individualized comprehensive care plan interventions were developed and implemented to a Stage 1 pressure injury wound; and c.) ensure an individualized comprehensive care plan with interventions were developed and implemented in a timely manner after a skin impairment occurred for one (1) of three (3) residents reviewed for PU (Resident #81). This deficient practice was evidenced by the following: On 10/16/23 at 10:00 AM, the surveyor observed Resident #81's assigned Licensed Practical Nurse (LPN #1) perform a wound treatment. Prior to handwashing (HW), LPN #1 pulled the lever on the paper towel dispenser downward and upward multiple times to dispense the paper towel. LPN #1 then performed HW for 20 seconds. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. LPN #1 donned (put on) gloves and proceeded to wipe the top of the treatment cart with a disinfectant wipe. LPN #1 then wiped the bedside table with a new disinfectant wipe. She doffed (took off) her gloves. LPN #1 performed HW for 20 seconds. She then used her elbow to move the lever downward and upward to dispense the paper towel from the towel dispenser. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. She put a blue disposable barrier sheet on the bedside table, gathered the supplies needed for the treatment and placed them on top of the barrier sheet. At 10:16 AM, LPN #1 dispensed the paper towel from the dispenser then performed HW for 20 seconds. After the she dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. LPN #1 donned a new pair of gloves and removed the dressing that was on Resident #81's sacrum. She doffed her gloves. After LPN #1 dispensed the paper towel with her hand, she performed HW for 20 seconds. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. At 10:22 AM, the Certified Nursing Assistant (CNA) doffed her gloves and performed HW for 20 seconds which was mostly under the flow of water. She then dried her hands with a paper towel that she had dispensed prior to HW. Afterward, she used her right hand to dispense more paper towels by pushing the lever downward and upward. She then dried her hands with the additional paper towel and then used the used wet paper towel to turn off the faucet. She did not use a clean dry paper towel to turn off the faucet. She then donned gloves and continued to hold the resident. At 10:24 AM, LPN #1 donned a new pair of gloves and then wiped Resident #81's sacral wound with a 4 X 4 gauze dressing that was moistened with normal saline solution. She then patted dry the wound with a dry 4 X 4 gauze dressing. LPN #1 then used a cotton tipped applicator to place medihoney paste (medication used on acute and chronic wounds and supports the removal of necrotic tissue and aids in wound healing) on the wound and then used a second applicator to place additional medihoney paste on the wound. LPN #1 applied a border gauze dressing over the wound. LPN #1 did not change her gloves or perform HW after she cleansed the wound prior to applying the medication and dressing. She doffed her gloves and performed HW for 20 seconds. After drying her hands, LPN #1 used the used wet paper towel to turn off the faucet. She did not use a clean dry paper towel to turn off the faucet. At 10:26 AM, after removing the used supplies from the bedside table and placing them in the garbage, LPN #1 performed HW and again turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. She then signed off the treatment as being performed in the computer. At 10:29 AM, the surveyor asked LPN #1 if she was finished with the wound treatment. LPN #1 stated yes. LPN #1 had not wiped the used bedside table with a disinfectant wipe. The surveyor then asked if she would wipe the bedside table at the end of a wound treatment. LPN #1 stated that she did not usually wipe the bedside table after because the barrier sheet was there. The surveyor then asked if she always used the used wet paper towel to turn off the faucet. LPN #1 stated that she usually used the wet paper towel and that she was probably not supposed to use it. She added that she was supposed to use a clean one. She then confirmed that she had done it wrong and that she was supposed to use a clean one. She added that she just had an inservice. The surveyor then asked LPN #1 if she should have changed her gloves after cleaning the wound and before applying the medication and dressing. LPN #1 stated the she did not usually change her gloves between cleaning the wound and applying the medication. At 10:46 AM, the surveyor interviewed the CNA regarding her HW. The CNA stated that she does it inside the sink under the water. A review of Resident #81's Admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), hypertension (high blood pressure) and cerebral infarction (circumscribed focus or area of brain tissue that dies as a result of localized hypoxia/ischemia due to cessation of blood flow). A review of Resident #81's Significant Change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/05/23, indicated a Brief Interview for Mental Status (BIMS) score of 02 out of 15, which reflected that the resident's cognition was severely impaired. Further review of Section M-Skin Conditions indicated that Resident #81 had 1 Stage 2 pressure ulcer. A review of Resident #81's entry MDS dated [DATE], indicated that Resident #81 was readmitted to the facility after an unplanned discharge to the hospital. A review of Resident #81's Discharge Return Anticipated MDS dated [DATE], indicated that the resident had an unplanned discharge to an acute hospital. Further review of Section M-Skin Conditions indicated that Resident #81 did not have an unhealed pressure ulcer/injury. A review of Resident #81's Quarterly MDS dated [DATE], Section M-Skin Conditions indicated that Resident #81 did not have an unhealed pressure ulcer/injury. Section M1200 Skin and Ulcer/Injury Treatments indicated that a pressure reducing device for bed was being utilized. A review of the facility provided Order Summary Report, dated 10/17/23 included the following orders: 1. Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to sacral wound topically every day shift for wound healing clean sacrum w/ (with) NSS (normal saline solution), pat dry, apply layer of medihoney to sacral wound bed and cover with border dressing. 2. Turn every two hours while in bed every shift for relief of pressure Turn every two hours while in bed with a start date of 10/05/23. A review of Resident #81's individualized care plan (CP) included the following: 1. At risk for: Potential for altered skin integrity related to: disease process with an initiated date of 6/15/2023 and a revision on 8/04/2023. The interventions included: Consult wound care prn (as needed) and follow MD (physician) orders Date Initiated: 10/10/2023 Revision on: 10/10/2023 Monitor for bruising daily with am (morning) care and PRN Date Initiated: 6/15/2023 Instruct staff/family on fragile skin. Date Initiated: 6/15/2023 2. Impaired Skin Integrity R/T (related to) Poor nutritional status Moisture/Incontinence, Immobility/CVA (cerebrovascular accident or stroke, which is damage to the brain from interruption of its blood supply) with an initiated date of 10/14/2023 and a revision on 10/14/2023. The interventions included: Encourage nutrition and hydration Date Initiated: 10/14/2023 Keep skin clean and dry Date Initiated: 10/14/2023 Monitor for signs of infection Date Initiated: 10/14/2023 Perform necessary wound care as per MD's ordered Date Initiated: 10/14/2023 Provide pressure reduction mattress. Date Initiated: 10/14/2023 Wound care consult in place to treat and evaluate wound Date Initiated: 10/14/2023 A review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/22/23 indicated a score of 16 and that Resident #81 was at risk. A review of the Skin Observation Tools dated 9/22/23 and 9/29/23 indicated that Resident #81 had an observation of the Coccyx that had a stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area) redness with a measurement of 3 cm length and 3 cm width. A review of the Skin Observation Tools dated 10/03/23 indicated that Resident #81 had an observation of the sacrum with a type of pressure which measured 3 cm length and 2 cm width but did not indicate the stage. A review of the Skin Observation Tools dated 10/04/23 indicated that Resident #81 had an observation of the sacrum with a type of pressure that measured 3 cm length, 2.3 cm width and 0.2 cm depth and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). A review of the September 2023 CNA Task documentation, that was provided by the facility, did not include any intervention of turning or applying a skin protectant cream. A review of the October 2023 CNA Task documentation, that was provided by the facility, included an intervention of roll left and right q (every) shift. The intervention was started on 10/05/23. There was no documented evidence that the CP was updated with any additional interventions to prevent Resident #81's redness from becoming a Stage II pressure ulcer when the resident was readmitted to the facility on [DATE]. There was no documented evidence that the CP for the skin impairment was initiated in a timely manner when Resident #81 was found to have the impairment on 10/04/23. There was no documented evidence that Resident #81 was being turned from 9/22/23 to 10/05/23. On 10/16/23 at 10:55 AM, the surveyor interviewed the Unit Manager (UM) of the 200 wing unit, regarding the process of HW and wound treatment. The UM stated that after the person washes their hands for 20 seconds, they would dry their hands with a paper towel and throw it in the garbage. The UM stated that the person should take another paper towel to turn off the water. The surveyor asked the UM if the hand washing part was outside the flow of water. The UM stated that it was outside the flow of water. The surveyor asked the UM if a nurse should change gloves and perform hand hygiene after the wound is cleaned and before applying medication. The UM stated that after the wound is cleaned, the nurse should remove the gloves, wash their hands and put on clean gloves before medication is placed. The surveyor asked the UM if the bedside table should be cleaned at the end of the treatment. The UM stated that the bedside table should be washed at the end because you do not know what fell on table. She added that the resident is going to use the table after, so you would make sure it is clean. On 10/17/23 at 10:08 AM, the surveyor interviewed the assigned CNA regarding the care of Resident #81. The CNA stated that she did everything for the resident. She added that she would put the resident back to bed after lunch and that she would reposition the resident when the resident was in bed. The surveyor asked the CNA if Resident #81 had a pressure ulcer. The CNA stated that the resident had a small opening and that it was getting smaller. The surveyor asked the CNA if she documented the care of the resident. The CNA stated that she would document on the laptop. On 10/17/23 at 10:27 AM, the surveyor interviewed the assigned LPN #2 regarding the process for preventing pressure ulcers and CP. LPN #2 stated that for person at risk for pressure ulcer, the resident would be turned every couple hours. The surveyor asked what the process was if a resident was a readmission to the facility and had redness on their skin. LPN #2 stated that all residents have a general assessment when they come to the facility. She added that a skin check, full body check, is performed and if there is redness it is documented on the skin observation tool. She then stated that she would also document it in a progress note. The surveyor asked if a CP with interventions would be initiated. LPN #2 stated that of course it would be but that she did not do anything with the CP. She stated that she believed it was the UM that did the CP. On 10/17/23 at 10:38 AM, the surveyor interviewed the UM regarding the process related to a resident's skin when there was redness noted. The UM stated that when a nurse checked the skin and there was redness, the nurse would contact the physician and get an order for a skin barrier and measure the redness and document it. She added that there would be a CP for risk of skin breakdown and interventions may include turning when in bed and a cushion for the wheelchair. The UM stated that she would do the CP and that also the MDS coordinator and Director of Nursing (DON). On that same date and time, the UM added that anyone that has redness there would be an order for turning every 2 hours. The surveyor asked about Resident #81's CP. The UM stated that the resident had an order for turning but that she just did not update the CP. The surveyor asked the UM if the order to turn every 2 hours should have been done prior to 10/05/23. The UM stated that it should have been ordered the first day the redness was found (9/22/23). The surveyor asked the UM how the tasks on the CNA documentation are put in the system. The UM did not know and stated that she would have to check with the Director of Nursing (DON). On 10/17/23 at 11:53 AM, the surveyor interviewed the DON regarding the process of CP for a resident's skin. The DON stated that it was done by the interdisciplinary team. She stated that if someone was at risk for a pressure ulcer that there would be a CP with preventative interventions that might include turning, positioning, air mattress and heel pads. The surveyor asked what the expectation would be if a resident had redness. The DON stated that the expectation would be that they would be turned and repositioned and that with each incontinent change, a barrier cream would be applied. The surveyor asked if those interventions would be listed on the CP. The DON stated yes. At that same time, the surveyor asked about the documentation of the CP and the CNAs. The DON stated that the nursing staff put in interventions. She added that if you put an intervention in the CP, it gives you an option to put it in the tasks for the CNA documentation. She added that it is not an automatic entry but that it has to be prompted by individual that is adding to the CP. The DON stated that not everything was always on the CP and that some were standards of practice like the barrier cream. The surveyor asked if the barrier cream was an order and if it was documented anywhere. The DON stated that it was not an order and that it was not documented anywhere. Furthermore, the surveyor asked the DON about the process of the wound treatment and HW. The DON stated that the HW process of lathering was mostly outside the flow of water, but that if you did not have enough lather that you could add a little water. She stated that after you dried your hands, you would take another paper towel to turn off the faucet. The DON stated that after cleaning the wound the nurse should change gloves before placing medication. On that same date and time, the surveyor notified the DON about the concern of Resident #81's CP that there were no interventions to prevent an impairment. The DON stated that interventions were being done and that they just were not documented. She added that Resident #81 was being turned and position, had barrier cream and had an air mattress. She then stated that the wound was getting better. On 10/17/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Administrator in Training/Registered Nurse/Infection Preventionist (AIT/RN/IP) and [NAME] President of Clinical Services (VPoCS) the concerns that Resident #81 did not update the at risk CP to include interventions to prevent a Stage I to develop into a Stage II, the actual impairment of skin integrity CP was not initiated at the time of the impairment and the infection control issues that were observed during the wound treatment. On 10/19/23 at 11:28 AM, in the presence of the survey team, LNHA, AIT/RN/IP and VPoCS, the DON stated that she educated the nurse on the wound treatment and HW. She added that the nurse should have used a clean towel, changed her gloves after cleaning and wiped the bedside table. The surveyor asked if the facility had a response regarding the CP and if Resident #81's should have been updated. The AIT/RN/IP stated that the staff would be inserviced on the proper CP and timely updating. The surveyor then asked how often the CP should be updated. The DON stated as needed and quarterly. The LNHA stated that any change that warrants the CP to be changed. A review of the undated facility provided policy titled, Wound Care Protocol included the following: 1. Use disposable towel to establish a clean field on resident's over-bed table. 2 .Wash and dry your hands thoroughly following standards of practice . 4. Put on gloves . 5. Apply treatments and dress wound as indicated. 6. Discard disposable items into the designated container. 7. Remove gloves and wash hands following standards of practice. A review of the undated facility provided policy titled, Handwashing/Hand Hygiene included the following: Washing Hands Procedure 2. Wet hands with warm (not hot) running water. 3. Apply soap and vigorously rub hands together, creating friction to all surfaces, for at least twenty (20) seconds. 4. Rinse hands thoroughly under running water 5. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. A review of the undated facility provided policy titled, Pressure Ulcer Prevention, included the following: The Nursing Department's goal is to ensure that a resident does not develop pressure ulcers unless clinically unavoidable and provide care to: Promote the prevention of pressure ulcer development; Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcers The licensed nurse on admission will complete a comprehensive skin assessment within 2 hours, initiating interventions based upon the resident's risk level and risk factors. Interventions will be documented on the care plan . The Certified Nursing Assistant will reposition residents according to their needs and based on their ability to reposition themselves to promote circulation and prevent as much as possible skin breakdown/or to aid in the healing of any skin breakdown . A review of the undated facility provided policy titled, Interdisciplinary Care Planning Protocol, included the following: Interdisciplinary Care Planning 2. Nursing provides overview of medical and nursing care regimes. Nursing Assistants must provide input especially related to ADL (activities of daily living), skin, weights, and safety needs . 7. CAA Summary triggers are reviewed by the team to decide whether or not to proceed with care planning for each triggered area. 9. Problems established by the team with resident/family input MUST be specific and individualized. N.J.A.C. 8:39-27.1

Based on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of five (5) residents reviewed for falls (Resident #22). This deficient practice was evidenced by the following: On 10/10/23 at 12:12 PM, the surveyor observed resident #22 in their room, seated in a wheelchair eating lunch. Resident #22 did not want to be bothered at this time. The surveyor reviewed Resident #22's medical records. The Admission Record (or face sheet; an admission summary) reflected that Resident #22 was admitted to the facility with diagnoses that included but not limited to asthma (a chronic condition that inflames and narrows the airways in the lungs), atherosclerosis heart disease (or hardening of the arteries -- is the leading cause of heart attacks, strokes, and peripheral vascular disease.), unspecified systolic (congestive) heart failure (a specific type of heart failure that occurs in the heart's left ventricle). A review of the facility Incident/Accident Report dated 3/02/23 indicated that the resident had an unwitnessed fall. The investigation documentation revealed the fall was with injury and the resident was transferred to acute care for further evaluation. Further review of the facility Incident/Accident Report dated 5/20/23 indicated that the resident had another unwitnessed fall. The investigation documentation revealed there were no injuries noted. The Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/21/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which reflected a severely impaired cognition. The Fall Risk Evaluation (an assessment tool) reflected that anytime there was a total score of 10 or greater, the resident should be considered at HIGH RISK for potential falls. It also indicated that a prevention practice should be initiated immediately and recorded on the resident's care plan. A review of the resident's fall risk assessment score dated 3/04/23 revealed the resident score of 14. Further review of the resident's fall risk assessment score dated 4/21/23 revealed the resident score of 14. Upon review of the resident's care plan (CP) which included that the resident at risk for falls related to (r/t) disease process, date initiated: 7/21/2023 and was revised on: 8/04/2023. The CP was not updated or revised to include new interventions for fall incidents that happened on 3/02/23 to prevent further fall on 5/20/23. During Interview on 10/16/23 at 11:30 AM with the Director of Nursing (DON) she stated, a CP should have been initiated immediately following the investigation of the fall and interventions should have been adjusted with the second fall. The DON and facility management were unable to provide a fall policy upon surveyor request. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that tracheostomy (trach) care and services were provided according to the standard of clinical practice for one (1) of one (1) resident (Resident #18) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's Admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dependence on supplemental oxygen, gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) status, hypoxic ischemic encephalopathy (a type of brain damage), dysphagia unspecified (a disorder characterized by difficulty in swallowing), chronic obstructive pulmonary disease unspecified (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and anoxic brain damage not elsewhere classified (caused by a complete lack of oxygen to the brain, which results in the death of brain cells due to oxygen deprivation). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an assessment reference date (ARD) of 9/04/23 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident's cognitive status was severely impaired. The qMDS also showed that the resident had trach care for the last 14 days. A review of the October 2023 orders showed that there was an order to change the tracheostomy tube inner cannula daily on days one time a day with a start date of 6/13/2023. Further review of the above 6/13/23 order showed that it was signed by nurses daily. The order for the inner cannula did not include the size. On 10/11/23 at 11:01 AM, the surveyor observed the Licensed Practical Nurse (LPN) performed handwashing inside the resident's room, introduced himself to the resident, and explained that he will be doing trach care. The resident was at the geri chair at this time, then the LPN left the room and read the order in the electronic treatment administration record (eTAR) in his treatment cart as follows: change tracheostomy tube inner cannula daily on days one time a day. The LPN informed the surveyor that the order was to change the inner cannula daily and that he does it every day. On that same date and time, the LPN performed handwashing inside the resident's toilet room, donned gloves, and placed a blue liner on top of the table without disinfecting the table first. The garbage container inside the toilet room was full. LPN then removed gloves, performed handwashing, dried his hands with a paper towel, and discarded the used paper towel on top of the full garbage slightly pressing the garbage. The LPN then took the supplies from the treatment cart that was outside of the resident's room and opened the NSS bottle, packets of gauze, and trach mask on top of the blue liner. The LPN opened the trach kit and put the white liner on top of the blue liner. The LPN accidentally dropped the paper cover of gauze inside the sterile kit container and stated to the surveyor that he had to discard it and get another sterile trach kit. The LPN discarded the first sterile trach kit and performed handwashing, dried his both hands with a paper towel, and slowly placed directly the used paper towel on top of the garbage that was full to prevent it from spilling. After discarding the first sterile trach kit, the LPN opened another sterile kit. The LPN opened the inner cannula container. The LPN informed the surveyor that he would change the inner cannula with this (showing opening the inner cannula). The surveyor asked the LPN what was the size order for the inner cannula for the resident. The LPN asked the surveyor where he could find that information in the inner cannula container. He further stated Is it in the expiration date? The LPN was unable to state the complete order and what size of the inner cannula. At that time, the LPN informed the surveyor that he always changed the resident's inner cannula and he knew that it was the same inner cannula even though he was not aware of the size of the inner cannula. He further stated that it was the Respiratory Therapist who provided the supplies for trach care of the resident that included the inner cannula. The surveyor asked the LPN, as a standard of practice, if should there be an order for what size to use for the resident's inner cannula. The LPN had no response. On 10/11/23 at 11:34 AM, the surveyor immediately interviewed the [NAME] President of Clinical Services (VPoCS) regarding the inner cannula order and what should be included. The VPoCS informed the surveyor in the presence of another surveyor that there should be an order for the size of the cannula. This time the surveyor notified the VPoCS of the above findings. The VPoCS further stated that she will talk to the LPN right now. On 10/11/23 at 12:25 PM, the Director of Nursing (DON) in the presence of the survey team confirmed to the surveyor that the order for inner cannula size should be part of the resident's order as a standard of practice. On 10/13/23 at 9:22 AM, the surveyor interviewed the LPN regarding the trach care observation on 10/11/23. The surveyor asked the LPN why he did not disinfect the table prior to putting the blue liner and treatment supplies? The LPN stated I could but since I put another sterile liner on top of the blue chux (excellent absorbency, comfort, and moisture control pad), he thinks that would be fine not to disinfect the table. The surveyor asked what the Infection Preventionist (IP) education provided to him and other staff about disinfecting frequently touched surfaces, does he include the table as frequently touched surfaces? The LPN stated that he did not consider the resident's table as frequently touched surface because the resident was a total care and did not get out of bed to be able to reach the table and touch it. The surveyor then asked the LPN how about the Certified Nursing Assistants (CNAs) who take care of the resident do they not use the table or touch the table when providing care, or how about visitors and other facility staff who enter the room? On that same date and time, the LPN acknowledged that the CNAs use at times the table for providing care, that the resident received visitors, and that the resident's responsible party visits almost every day. In addition, he indicated that other staff entered the room as well. The LPN also stated that he can not remember the education provided to him about disinfecting tables, maybe he had but can not remember because there was a lot of education provided already. Furthermore, the LPN acknowledged that the garbage receptacle of the resident inside the toilet room at that time was full. On 10/13/23 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), and VPoCS. The surveyor notified the facility management of the above findings. A review of the undated facility's Tracheostomy Care Policy that was provided by the AiT/RN/IPN included in the procedure guidelines to check the physician's order and to remove gloves and discard them into the appropriate receptacle. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and survey team could proceed with decision-making. NJAC 8:39-25.2(b),(c)4

Based on observation, interview, and record review, it was determined that the facility failed to: a) consistently monitor the resident's vital signs (VS) and dialysis access site and b) complete the Hemodialysis Communication Record (HCR) according to the facility's policy and standard of clinical practice. This deficient practice was observed for one (1) of one (1) resident reviewed. The deficient practice was evidenced by the following: On 10/06/23 at 9:48 AM, the surveyor observed that Resident #60 was not in their room. The Unit Clerk stated that the resident was at the dialysis center. On 10/10/23 11:48 AM, the surveyor observed the resident in bed asleep. The surveyor reviewed the hybrid medical records (a combination of paper, scanned, and computer generated record) of Resident #60. The Admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life, dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) and chronic combined systolic and diastolic heart failure (abnormalities of hemodynamic compression pump performance). A review of the Annual Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 9/05/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 8 out of 15 which indicated that the resident's cognitive status was moderately impaired. The Physician Order Set (POS), dated 8/11/2023 revealed an order that resident #60 dialysis days were on a Monday, Wednesday, and Friday (M, W, F). The dialysis days order was discontinued (d/c) on 10/08/2023. On 10/10/23 at 9:20 AM, the surveyor reviewed the Dialysis Communication Log (a binder on the unit which contains a resident's HCR forms) of Resident #60. The surveyor reviewed the communication book documents from 9/12/22 through and including 10/06/23. The facility provided the documentation that was scanned into the computer from the Dialysis log. (The resident was discharged from dialysis on 10/07/23 and started on hospice services on 10/09/23.) The facility also provided a manual progress notes as part of dialysis communication. There were missing information in the provided manually written progress notes as part of dialysis communication as follows: -signature of sending nurse to dialysis, communication of pre dialysis, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), pre dialysis weight, signs, and symptoms (s/s) of resident or implanted device, medications given, and body weight. -communications from the dialysis center VS, and post dialysis vitals, post dialysis weight, new orders for labs, medications, diet order, and signature of dialysis nurse. According to the provided Dialysis Communication Record Policy that was provided to the surveyor, the HCR forms must be utilized as communication record between the facility and the dialysis center. On 10/11/23 at 9:31 AM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that the communication between the facility and the dialysis center documentation should be completed upon the residents return to the facility. The DON also stated that the HCR form that was provided to the surveyor with the facilities Dialysis Communication Book policy was not being used for this resident since 9/22/22. The LNHA provided the surveyor with the facility policy titled Dialysis Communication Book Policy, updated 5/18/2022. During review, it revealed: Policy: It is the policy of this facility to maintain an ongoing communication between the dialysis center and [facility] regarding the resident's care and progress. Procedure: 2. The book will be initiated from the facility to include but not limited to the following: a. Residents name b. Vital signs prior to leaving. c. medication changes since last visit d. lab work and results since last visit e. any notes or comments 3. Upon return from dialysis treatment, the dialysis center will provide the following: a. weight at start/ending weight. b. fluid removed. c. Blood Pressure (BP) at start / ending BP. d. notes /comments: (i.e.) medications, labs, any unusual occurrences Attached to the facilities Communication Book Policy was a [facility] Dialysis Communication Record it was in grid format to include residents' name / room # /Extension of the nurses station / date / VS prior to leaving the facility/ Medications changes since last visit / lab work since last visit / any notes or comments. N.J.A.C. 8:39-2.7(a)

Based on observation, interview, and record review, it was determined that the facility failed to limit restraint use to circumstances in which the residents had a medical condition or symptom that warranted the use of restraints; failed to utilize the least restrictive devices based on facility policy and procedures; failed to obtain a physician's order for restraints based on facility policy and procedure; and failed to identify and evaluate the risk of restraint use prior to providing residents with bilateral full side rails and buckled seat belts. This deficient practice resulted in a fracture for Resident #8; ecchymosis and a laceration that required sutures for Resident #16; bruises and abrasions for Resident #11; and a fall out of bed for Resident #17. This deficient practice was evidenced for 9 of 10 residents reviewed for the use of restraints, Residents #4,#6, #8, #19, #20. #16, #17, #11, and #15. Evidence is as follows: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/22/15 the Interdisciplinary (IDC) team assessed Resident #4, utilizing a Quarterly Minimum Data Set (MDS), an assessment tool. The IDC team assessed that Resident #4 was severely cognitively impaired . The IDC team further assessed that the resident required extensive assistance with activities of daily living including bed mobility. Resident #4 participated in the Restorative Nursing Program (RNP) and ambulated between 100-150 feet with a rolling walker and assistance daily. The IDC team documented in the MDS that the resident used side rails on his/her bed. The IDC team did not document the use of any other type of restraint. However, on 07/15/15 at 8:40 a.m. the surveyor observed the resident out of bed in a wheelchair with a buckled seat belt in use. In the presence of facility staff, the surveyor asked the resident if s/he could open the buckled seat belt and s/he said, no. The staff member encouraged the resident to open the belt but s/he could not, which indicated that the seat belt was a restraining device. On 07/16/15 at 7 a.m. the surveyor observed the resident asleep in bed with 2 full side rails up. The surveyor reviewed the July 2015 Physician's Order Sheet (POS) and observed that on 7/24/14 the Physician ordered a buckled alarmed seat belt in wheelchair for poor safety awareness. The Physician had not ordered side rails. The Side Rail Assessment Form completed by the nurse on 01/21/15 indicated the side rails were used for safety and to promote independence. The surveyor reviewed the Monthly Restraint Assessment Sheets from 09/24/14 through 07/15/15, under the section entitled Behavior Problems. The IDC team documented that the resident attempts independent transfer but the team did not indicate from bed or wheelchair. The IDC team also documented that the resident had previous falls but did not document how the resident fell and/or the cause of the falls. The surveyor observed that each month the assessment sheets had the exact same data. The surveyor reviewed the Nurses Notes (NNs) for entries that indicated the facility attempted restraint reduction. The surveyor found no documentation. The surveyor also reviewed the NNs for documentation on Resident # 4's attempts to transfer independently. The resident had one fall in January 2015 and one fall in June 2015, both from the wheelchair. The resident did not sustain an injury. On 07/21/15 at 11 a.m., the surveyor spoke with the Director of Nurses (DON) regarding attempted restraint reduction of side rails and the seat belt for Resident # 4. She said that it was not done because the daughter wanted the resident to have side rails and seat belts. A thorough assessment was not done to show the need for the use of restraints. The DON said the same data was just copied from month to month if no change occurred. The surveyor reviewed the Education Material for Physical Restraints implemented 3/16/2006. The Policy indicated that a restraint was an intervention to prevent/protect residents from injury to themselves and others and was used when and if necessary; to maintain safety and good body alignment; to promote independence and ambulation; to prevent contractures and functional deterioration; and to promote and maintain optimal levels of physical and emotional function. The facility policy entitled Policies Regarding the Use of Restraints dated 3/16/06 indicated in element number 3 that the facility implemented a progressive range of restraining procedures from least restrictive to the most restrictive, as was clinically indicated. The surveyor reviewed the Restraint Use Policy and Consent Form dated 03/16/06 and observed that the facility policy stated restraint use shall be implemented only as a direct order from the Attending Physician. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/27/15, the IDC team assessed the resident as being cognitively intact utilizing an Annual MDS. The IDC team further assessed that the resident required extensive assistance with activities of daily living including bed mobility. Resident #6 participated in the RNP and was ambulated between 75 and 100 feet with a rolling walker daily. The MDS indicated that the resident used 2 side rails on his/her bed. On 07/16/15 at 7:30 a.m. the surveyor observed Resident #6 in bed asleep with 2 full side rails up. The surveyor reviewed the July 2015 POS and observed that the Physician did not order side rails. The surveyor noted the Side Rail Assessment Form dated 09/03/14 was signed by the nurse but no other information was entered on it. On 07/16/15 at 1 p.m. the surveyor spoke with the resident about the use of the side rails. S/he said that they were always raised, no one ever asked him/her whether s/he wanted them or not. S/he did not feel s/he needed both of them. 3. On 07/14/15 at 9 a.m. on the initial tour of the facility with the Licensed Practical Nurse (LPN), the surveyor observed Resident #8 seated in a wheelchair with a knee immobilizer brace on the right leg. The LPN stated that the resident fell out of bed the prior month and sustained a [MEDICAL CONDITION] right leg. The LPN further stated that although the resident did not require surgery, s/he spent a few days in the hospital. On 07/15/15 at 7:45 a.m. the surveyor reviewed the medical record of Resident # 8 who was originally admitted to the facility on [DATE]. The resident fell out of bed on 06/20/15, was sent to the hospital and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/15/15 at 8:15 a.m. the surveyor observed the resident seated out of bed in a wheelchair in his/her room having breakfast. The right leg was extended on the footrest of the wheelchair with a knee immobilizer brace on it. The surveyor asked the resident about the fall and s/he replied that it happened outside on the concrete. S/he further stated that the leg was painful sometimes but did not know if s/he received pain medication for it. On 07/16/15 at 7:30 a.m. the surveyor observed the resident in bed asleep with 2 full side rails up. The height of the bed was not in the lowest position, instead it was slightly elevated. The bedside table, over bed table, and wheelchair were all placed at the right side of the bed. On 07/21/15 at 9:45 a.m. the surveyor measured the full side rails on Resident # 8's bed. They were 68 ¾ inches long. The distance from the end of the side rail to the footboard was 8 inches. The distance from the end of the side rail to the headboard was 5 inches. The Interdisciplinary (IDC) team assessed the resident on 5/13/15 utilizing a Quarterly Minimum Data Set (MDS), an assessment tool. The IDC team documented that the resident was moderately cognitively impaired, required extensive assistance of 1 person for all activities of daily living including bed mobility, and used side rails on his/her bed. The MDS also indicated that the resident received restorative nursing services daily. A review of the Restorative Nursing Flow Sheet from June 1 through June 20 revealed that the resident was to ambulate with a rolling walker to and from the bathroom daily with minimum assist of 1 and to ambulate with a rolling walker 50 to 75 feet with minimum assist of 1 daily. The IDC team developed a fall prevention care plan for Resident #8 and identified that the resident was at risk for falls due to the following: use of full side rails; resident attempted to get out of bed and had an unsteady gait; resident attempted independent transfers and ambulation; and the resident had poor safety awareness, poor judgement, a [DIAGNOSES REDACTED]. Additionally, the care plan also noted under the section entitled Interventions that the resident attempted independent ambulation when in need of toileting. The surveyor reviewed the medical record which revealed the resident had 1 fall and sustained a [MEDICAL CONDITION] tibia/fibula. The surveyor reviewed an Incident and Accident report dated 06/20/15 and found that on 06/20/15 at 12:45 a.m. the resident climbed out of bed with the 2 full side rails elevated and was found on the floor at the foot of the bed. The resident stated, I tried to go to the bathroom. The resident complained of pain and was noted to have a hematoma with swelling on the right lower leg approximately 8 cm by 8 cm. The nursing staff notified the physician and transferred the resident to the hospital at 2 a.m. for evaluation and admitted with the [DIAGNOSES REDACTED]. The resident was treated with a knee immobilizer brace and pain medication and returned to the facility on [DATE]. The surveyor reviewed the lower extremity CT scan from the hospital dated 06/23/15 and noted that the resident sustained [REDACTED]. The resident returned to the facility on [DATE] at 8 p.m. with a knee immobilizer and pain medication. The Incident/Accident Report indicated that bed rails were ordered, bed rails were present and bed rails were up. A review of the June 2015 Physician's Order Sheet prior to hospitalization did not include an order for [REDACTED].>The surveyor reviewed the Restraint Use Policy and Consent Form dated 03/16/06 and observed that the facility policy required that restraint use shall be implemented only as a direct order from the Attending Physician. Although the facility failed to obtain a physician's order for side rails, the Director of Nursing (DON) told the surveyor on 7/18/15 at 10:10 a.m. that a physician's order was necessary. A review of the Physician's Orders upon returning from the hospital indicated that the resident was routinely receiving [MEDICATION NAME] (a narcotic pain reliever) 25 mg at hour of sleep and Tylenol 650 mg three times a day. In addition, the resident had an order for [REDACTED]. On 07/18/15 at 10:10 a.m., the surveyor reviewed the facility policy for Side Rails. According to the policy the resident should be assessed on admission and quarterly or as necessary. Additionally, before the use of side rails, less restrictive measures should be tried. The facility policy entitled Policies Regarding the Use of Restraints dated 3/16/06 indicated in element number 3 that the facility implemented a progressive range of restraining procedures from least restrictive to the most restrictive, as it was clinically indicated. The facility was unable to provide the surveyor with a Side Rail Assessment Form prior to the date of the fall. A Side Rail Assessment Form completed on 06/23/15 at the time of readmission after the fall indicated that the resident would continue to use 2 full side rails. On 07/21/15 at 12 p.m. the surveyor spoke with the DON and discussed the potential for serious injury with the use of bilateral full length side rails for confused residents who ambulated only with assistance, as they may attempt to exit a bed over or around raised side rails. Although the DON did not dispute this fact, the DON did not offer the surveyor a reason why they were used prior to or after the resident's fall with fracture. On 07/22/15 at 11 a.m. the DON had no response when the surveyor questioned if the side rails were assessed as contributing to the fall with fracture. On 07/23/15 at 9:30 a.m. the surveyor asked the DON if she disputed the fact that the use of side rails could have contributed to the fall on 06/20/15. She said, no. The surveyor reviewed the June POS prior to the fall and observed that the physician did not order side rail use. A review of the June POS at the time of readmission did not include an order for [REDACTED].>4. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/17/15 the IDC team assessed the resident as being severely cognitively impaired utilizing a Quarterly MDS. The team further assessed that the resident was totally dependent on staff for all activities of daily living including bed mobility. The MDS indicated that the resident used side rails and no other type of restraint. On 07/20/15 at 7:40 a.m., the surveyor observed Resident #19 awake in bed with 2 full side rails up. On 07/20/15 at 9:50 a.m. the surveyor observed the resident out of bed in a wheelchair with a buckled seat belt loosely in place. The surveyor asked the resident if s/he could open it and s/he made no attempt to try to open it. The surveyor reviewed the July POS. The Physician on 10/22/12 ordered a buckled seat belt. There was no order for side rails. The Side Rail Assessment Form dated 06/17/15 was not completed in its entirety. The surveyor reviewed the Monthly Restraint Assessment Sheets from 01/21/15 through 06/15/15 which noted under the section entitled Behavior Problems that the resident attempted independent ambulation with fall and had dementia. No other information or assessment was provided. A review of the Restraint Assessment Sheet dated 07/15/15 indicated that the resident leaned forward in the wheelchair and slid at times. The buckled seat belt was not considered a restraint but used for positioning. On 07/20/15 at 10:30 a.m. the surveyor spoke to the DON regarding the use of a seatbelt as a positioning device to manage a resident leaning forward or sliding in a chair. The surveyor discussed the safety issues of seatbelt use for Resident #19 who leaned forward or slid in the chair with regard to entrapment under the seatbelt and strangulation by a loosely secured seatbelt. The DON did not disagree. In addition, the resident had no physician's order for 2 full side rails. 5. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/08/15 the IDC team assessed the resident as severely cognitively impaired utilizing a Quarterly MDS. The resident required extensive assistance with all activities of daily living including bed mobility. The MDS indicated that the resident used 2 side rails and no other restraint. On 07/20/15 at 10:30 a.m. the resident was in bed with 2 full side rails up and padded. The head of the bed was elevated and the resident was toward the bottom of the bed. The surveyor notified the nurse on duty. At 11:15 a.m. the surveyor observed the resident out of bed in the wheelchair with a buckled seat belt in place. The resident was unable to open the seatbelt when asked to by the surveyor. S/he was confused and disoriented when spoken to. The resident was leaning forward in the wheelchair. Resident #20 was admitted on [DATE]. On 04/15/15 the resident had a seat belt alarm applied. There was no documentation in the nurse's notes that indicated why the resident required a seat belt alarm. The Restraint Assessment Sheet indicated that the resident had a history of [REDACTED]. The Side Rail Assessment indicated the bilateral full side rails were needed for safety. There was no physician's order for side rails. The facility lacked restraint reduction documentation. The surveyor reviewed the IDC notes and noted that on 07/03/15, the resident tried to stand up in the wheelchair with the seat belt in place. On 07/11/15, the resident attempted to stand up and down in the wheelchair with the seatbelt in place. On 07/13/15 the resident attempted to stand with the seatbelt in place in the wheelchair. On 07/14/15 the resident attempted to stand up in the wheelchair with the seatbelt in place. On 07/22/15 at 12 Noon the surveyor discussed these observations with the DON and asked if the facility addressed the appropriateness of the seat belt restraint. The DON had no response. 6. On 7/15/15 at 9:25 a.m. the surveyor observed Resident #11 in the dining room folding towels. The resident sat in a regular chair with an alarm attached and was sitting near the edge of the chair. An activity aide sat next to the resident. At 9:40 a.m. the surveyor observed the resident ambulating in the hall with an activity aide. On 7/15/15 at 10:25 a.m. the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/6/15 the IDC team, utilizing a Quarterly MDS, an assessment tool, assessed that the resident was severely cognitively impaired, required limited assistance of 1 person for ambulation, locomotion, and toilet use, and had behavior symptoms not directed towards others. The IDC team further assessed that the resident had 2 falls. On 7/15/15 at 11:05 a.m. the surveyor reviewed a fall report of 5/21/15 at 8:06 p.m. A CNA heard an alarm and went to the resident's room. The resident was on the floor on his/her left side. According to the interpreter the resident was looking/calling for somebody and got out of bed. The resident got out of bed through the right lower corner of the bed. The fall report did not include anything about side rails being up or down. The resident sustained [REDACTED]. On 7/15/15 at 1:25 p.m. the surveyor reviewed the CNA plan of care that noted the resident had 2 side rails up when in bed. At 2:12 p.m. the surveyor reviewed a side rail assessment dated [DATE] and one dated 6/13/14. The surveyor could not locate a current side rail assessment. The assessment of 4/5/12 noted that the son agreed to have the side rails raised for safety. The assessment of 6/13/14 noted that the side rails were up for safety. The surveyor reviewed the July 2015 Physician's Order Sheet and observed that the resident did not have a physician's order for side rails. At 1:40 p.m. a CNA told the surveyor that the resident used 2 side rails when in bed. The CNA also said that the resident ambulated with assistance daily. On 7/16/15 at 11:45 a.m., utilizing a translator, the surveyor attempted to ask the resident if s/he wanted to have the side rails up when in bed. The resident did not answer the question appropriately. A staff member said that the resident was confused. On 7/16/15 the surveyor spoke with the Director of Nursing regarding the use of full bilateral side rails and the absence of a physician's order that included the reason for use. On 7/15/15 at 9:25 a.m., the surveyor observed Resident #11 in the dining room folding towels. The resident sat in a regular chair near the edge of the chair with an alarm attached to the resident. An activity aide sat next to the resident. At 9:40 a.m. the surveyor observed the resident ambulating with an unsteady gait in the hall with an activity aide. 7. On 7/14/15 at 8:37 a.m. the surveyor observed Resident #16 at a table in the dining room sitting in a wheelchair with a loosely buckled seat belt. The resident had a black and blue right eye with gauze above the right eye. The resident told the surveyor they did not know what happened. On 7/16/15 at 10 a.m., the surveyor observed the resident sitting in his/her wheelchair with a buckled seat belt on. At 11:10 a.m. the resident's family member told the surveyor s/he did not know how the resident fell . The family member received a call at 4:30 a.m. to inform him/her that the resident had a fall and was on his/her way to the emergency room . When the family member went to the facility the next day the family member was told that the resident got out of bed by him/herself attempting to go to the bathroom and fell . The family member said that Resident #16 used bilateral full side rails when in bed. On 7/14/15 at 8:55 a.m. the Unit Manager (UM) said that the resident was in bed and fell when attempting to toilet him/herself. She also said that the resident's side rails were up because the resident was at risk for falls. The resident was sent to the hospital, received stitches, and came back to the facility. On 7/16/15 at 9:30 a.m. the DON said that the resident attempted to toilet him/herself and was unable, resulting in the resident having a fall. The DON agreed that the resident used 2 full side rails. The DON was unaware that bilateral side rails could be a hazard for residents and viewed side rails as a safety device. At 11:30 a.m., the surveyor observed the resident in his/her room sitting in a wheelchair with the seat belt buckled. The resident's bed was against the wall and had 2 full side rails on it. A Registered Nurse (RN) was in the room and said that the resident always used 2 full side rails when in bed, used a seat belt when in the wheelchair with brakes always on, and that the call bell was always in reach. Resident #16 was in the wheelchair next to the bed and the call bell was behind the resident on the bed and s/he could not reach it. The surveyor handed the call bell to the resident and s/he demonstrated that s/he was able to use it. The surveyor asked the resident if s/he wanted to use side rails on his/her bed and the resident was unable to answer. On 7/16/15 at 12:25 p.m., the surveyor reviewed Resident # 16 's fall care plan which included that the resident used full side rails when in bed. The Physician's Order Sheet did not include an order for [REDACTED]. On 6/5/15 the nurse assessed the resident's potential for falls. The resident had a fall risk score of 18 with 10 or above representing a high risk of falling. On 7/20/15 at 9:30 a.m. the surveyor reviewed Resident #16's resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/12/15 the IDC team, utilizing an admission MDS, an assessment tool, assessed that the resident on was severely cognitively impaired, required extensive assistance of 2 persons for transfers, ambulation, and toileting. The IDC team further assessed that the resident used bed rails, which were considered a restraint. The MDS included that the resident had falls in the month prior to admission, in the last 6 months prior to admission, and a fracture related to a fall in the 6 months prior to admission. On 7/20/15 at 10:11 a.m. the surveyor reviewed the resident's fall report of 7/14/15. The fall occurred at 4:15 a.m. The alarm sounded and the staff went to the resident's room and found the resident sitting on the floor near the bed with bleeding at the right eye with the side rail of the bed up. Resident # 16 verbalized that s/he had attempted to toilet him/herself. The resident was sent to the hospital and received 5 sutures near his/her right eye. A nurse's note of 7/14/15 revealed that the resident returned to the facility with 5 sutures intact to the outer right eye area with a 4 x 6 centimeter (cm) dark purple bruise surrounding the eye, a 2 x 1 cm contusion area below the sutures, and a 5.5 x 4 cm right elbow bruise. The surveyor could not locate any nurse's notes about the need for the continued use of side rails. On 7/22/15 at 12:43 p.m. the DON said that the nurses do not document information about assessing the need for side rails but they do perform side rail assessments. A review of the Certified Nursing Assistant's (CNA) Plan of Care revealed that the resident used 2 side rails and a Velcro seat belt alarm. The surveyor could not locate any information or documentation on attempts to reduce or remove Resident #16's side rails. When asked, the DON could not provide any documentation. The surveyor also could not locate information about interventions attempted before the resident was restrained with side rails. The surveyor did not find a doctor's Progress Note that indicated the presence of a specific medical symptom that warranted the use of side rails and/or how side rails would maintain the resident's safety. The surveyor reviewed the current Physician's Order Sheet and observed that the physician did not order side rails. 8. On 7/14/15 at 8:15 a.m. during the initial tour of the facility the RN said that Resident # 17 was confused, got out of bed daily, sat in the wheelchair, and had falls. On 7/16/15 at 11:48 a.m. the surveyor observed the resident in the dining room sitting in a wheelchair with a loosely buckled seat belt on. The resident demonstrated that s/he could remove the seatbelt and said that s/he does not try to get up by him/herself because s/he knows that s/he cannot walk by him/herself. On 7/15/15 at 11:08 a.m. the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The IDC team assessed the Resident on 3/13/15 utilizing an Admission MDS, an assessment tool. They noted that the resident had short and long term memory problems and had some difficulty in new situations only with his/her cognitive skills for daily decision making. The IDC team further assessed that the resident required extensive assistance for transfers, bed mobility, ambulation, and toilet use. The nurse assessed the resident's fall risk on 6/8/15. The resident had a fall risk score of 11,with a score of 10 or above representing a high risk for falls. On 7/16/15 at 9:30 a.m. the surveyor reviewed the resident's fall report of 5/14/15. On 5/15/14 at 4:30 a.m. the staff heard the resident's bed alarm sound and found him/her sitting on the floor in his/her room. The resident reported that s/he put the side rail down so s/he could get up and toilet him/herself. The resident did not sustain injuries. Although the resident had a fall while attempting to get out of bed by putting his/her own side rails down, the surveyor found no documentation that the resident was reassessed for the continued use of the bilateral side rails. The Summary of the Investigation Report included that the bed would be changed for a different type of rail, the staff would work on teaching the resident to use a urinal, and the resident would be placed on a toileting schedule. However, these interventions were not added to the resident's care plan. The care plan did include that the resident used a chair alarm and full side rails. The surveyor could not locate a care plan that addressed the resident's toileting needs. A nurse documented in the nurse's note of 5/14/15 at 9:15 a.m. that the nurse informed the resident's family member that the resident had a fall. The nurse also informed the family member that they changed the side rails to ensure that the resident could not get them down by him/herself. On 5/14/15 the Therapist evaluated the resident after the fall. The therapist indicated that the resident continued to transfer with a 1 person assist and ambulated on the unit with the restorative nursing assistant. The therapist did not indicate that the resident required side rails for safety. The resident's side rail assessment dated [DATE] included that poor safety awareness was due to a cognitive decline. However, the resident did not demonstrate poor bed mobility or difficulty moving to a sitting position on the side of the bed. The resident did not express a desire to have side rails up. Side rails were indicated to provide safety, even though the resident climbed out of bed and fell with the side rails raised. On 7/21/15 at 11:40 a.m., 2 surveyors observed the resident's side rails. The side rails were raised at the foot of the bed higher than the at the head of the bed. The surveyors raised and lowered the side rails multiple times. Although the side rails were a little difficult to lower and raise, they were in good working condition. The Activity Director of this unit said that they purposely put the bottom higher because the resident climbs over the side rails. Resident #17 did not have a physician's order for bilateral full side rails or a physician's note that justified the use of these side rails. The nurse's notes did not contain information that indicated the resident displayed symptoms that required the use of bilateral full side rails. The surveyor found no documentation that the facility professional staff periodically assessed the resident for continued use of the side rails, which presented a safety hazard for Resident #17, who climbed out of bed with the side rail raised and fell . 9. On 7/14/15 at 8 a.m. during the initial tour, the RN told the surveyor that Resident #15 had a [DIAGNOSES REDACTED]. The resident used a wheelchair to ambulate due to weakness after [MEDICAL TREATMENT]. The resident was alert and oriented to person, place and time. On 7/14/15 at 1:30 p.m. the surveyor observed Resident #15 during the Group Interview with 4 other alert and oriented residents. The resident was an active participant during the interview. On 7/20/15 at 8 a.m. Resident #15 was observed in bed with bilateral full side rails up and eyes closed. At 9:15 a.m. the surveyor returned to Resident #15's room and observed the resident dressed, out of bed and seated in a wheelchair reading a book on the over bed table. A bedside commode was observed against the wall at the foot of the resident's bed. The surveyor asked the resident about the bilateral side rails that were both up when the surveyor observed the resident in bed. The resident stated that the staff automatically put the side rails up at night but s/he would like at least one side rail down so s/he could use the bedside commode. The resident stated s/he only used the wheelchair on [MEDICAL TREATMENT] days due to weakness after [MEDICAL TREATMENT] was completed. S/he stated that a few hours after [MEDICAL TREATMENT] and on non-[MEDICAL TREATMENT] days s/he was able to stand, transfer and walk short distances. On 7/20/15 at 11:05 a.m., the surveyor reviewed Resident #15's signed Physician's POS for July 2015 which failed to include an order for [REDACTED].>On 7/20/15 at 7:10 a.m., 2 surveyors toured the facility for the use of bilateral side rails. The surveyors observed 45 residents in bed with 37 of those residents having bilateral side rails up. Refer to F-323 NJAC 8:39-27.1(a); -27.1(c)1.2.3.i,ii.,4.