Every finding on record at Leisure Chateau Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to ensure laundry staff performed hand hygiene immediately after removing personal protective equipment (PPE) worn while handling soiled linen prior to contacting clean laundry equipment and areas. This failure had the potential for contaminated hands to transfer pathogens from soiled linen to clean linen, equipment, and environmental surfaces, placing residents at risk for the development and/or transmission of infections. The facility housed a high-risk population with a census of 187 residents.Findings include:During a tour of the laundry area with the Laundry Manager (LM) on 03/19/26 at 7:38 AM, Laundry Technician (LT) 1 was observed transporting a commercial laundry cart containing soiled washable bed pads and mechanical lift slings, filled above the rim, from the soiled laundry area to the washer.LT1 donned disposable PPE and loaded the items into a front-loading washing machine. After loading approximately two-thirds of the contents, LT1 closed the washer door and started the machine. LT1 then pushed the soiled laundry cart back into the soiled laundry area, removed gloves, gown, and mask, and exited the soiled area. Without performing hand hygiene, LT1 proceeded into the clean laundry area, retrieved a clean laundry cart, and pushed the cart toward a dryer, touching clean equipment and surfaces.During an interview on 03/19/26 at 7:44 AM, the LM stated the proper process after handling soiled laundry included, removing PPE (gloves first, followed by gown and mask) and performing hand hygiene immediately afterward. The LM acknowledged LT1 did not perform hand hygiene after removing PPE. The LM immediately redirected LT1 to wash his/her hands. LT1 initially continued handling the clean laundry cart before stopping and performing hand hygiene after repeated instruction. The LM stated failure to perform hand hygiene after handling soiled laundry created a risk of contamination from dirty to clean areas. During an interview on 03/19/26 at 8:21 AM, the Infection Preventionist (IP) stated the facility follows the Centers for Disease Control (CDC) infection control guidelines, including standard precautions and hand hygiene. The IP stated that failure to perform hand hygiene after handling soiled laundry placed all residents at risk for cross-contamination.Review of an in-service sign-in sheet titled, PPE - Donning, Doffing, Hand Hygiene and Respiratory Illness, dated 02/20/26, included LT1's name and signature.Review of a Hand Hygiene Competency Validation, dated 02/20/26 confirmed LT1 demonstrated proper hand hygiene with soap and water, and it was validated by the LM.Review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen, reviewed and updated 10/2025, indicated, . General Guidelines. Standard Precautions. (2) Wash hands after handling soiled linen and before handling clean linen. (3) Consider all soiled linen to be potentially infectious and handle with standard precautions. 12. Wash hands before handling clean linen (i.e., when moving from washer to dryer, moving from dryer to sorting table, and through the sorting process).Review of the facility policy titled, Personal Protective Equipment, reviewed 09/2025, indicated, . staff are trained on proper PPE use, including donning, doffing, and associated infection control practices. NJAC 8:39-19.4

Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided and that the responsible party was notified for one of three residents (Residents (R) 124) reviewed for beneficiary notification out of a total sample of 40 residents. This had the potential to affect all residents being discharged from services. Findings include:Review of R124's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE].Review of R124's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating severe cognitive impairment.Review of R124's SNF Beneficiary Notification Review (SNF ABN), form revealed the Medicare Part A skilled services start date was 01/21/26 and the last day covered was 03/06/26. Further review revealed that R124 signed her SNF ABN form on 03/04/26.During an interview on 03/20/2026 2:06 PM, the Social Services Director (SSD) revealed residents with a BIMS lower than a 13 should not sign their SNF ABN forms due to their impaired cognition. She stated the resident's daughter told her to allow the resident to sign the form, but she had no documentation for that interview.During an interview on 03/20/26 at 3:38 PM, the Director of Nursing (DON) said she expected it was inappropriate for staff to not allow the representative to sign the SNF ABN for a resident with a BIMS of six. She agreed it was inappropriate for a resident with a BIMS of six to sign. NJAC 8:39-5.1(a)

Based on interviews, record review, facility policy, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for two residents (Resident (R)25 and R163) reviewed for MDS accuracy out of a total sample of 40 residents. This failure placed residents at risk of unmet care needs.Findings include: 1. Review of R25's admission Record, located under the Profile tab in the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type II, chronic multifocal osteomyelitis left foot/ankle, and Charcot's joint left ankle/foot.Review of R25's Nursing Skin/Wound Note, dated 01/26/26 and located under the Notes tab in the EMR revealed, admission skin assessment with [Name of Wound Care company] done this morning. Chronic left lateral malleolus diabetic foot wound with Charcot deformity and chronic osteomyelitis.Review of R25's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/02/26 and located under the MDS tab in the EMR, revealed R25 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Section I for Active Diagnosis did not include the diagnoses of osteomyelitis and Charcot's foot. Section M for skin condition did not assess the resident has having a diabetic foot.During an interview on 03/20/26 at 2:50 PM, the Minimum Data Set Coordinator (MDSC) reviewed the admission MDS for R25's diagnoses with osteomyelitis left foot and ankle and Charcot foot stated it should have been listed on the list for Active Diagnosis, and it must have been an oversight. The MDSC confirmed R25's documentation should have included the venous/arterial ulcers. 2. Review of R163's admission Record, located under the Profile tab in the EMR, revealed the resident initially admitted to the facility on [DATE] with diagnoses that included spinal stenosis of lumbar region, scoliosis, muscle wasting, and morbid obesity.Review of R162's quarterly MDS with and ARD of 06/17/25 and located under the MDS tab of the EMR, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact. Section J for Health Conditions failed to reveal that the resident sustained any falls during the assessment period.Review of R162's Fall Scale Assessment, completed on 06/17/25 and located under the Assessments tab in the EMR identified the resident was at low risk for falling. Review R162's Post Fall Assessment, completed on 06/01/25 and located under the Assessments tab in the EMR identified the resident was at moderate risk for falling.Review R162's Nurses Notes, dated 06/01/25 located under the Notes tab in the EMR indicated the resident slid from the wheelchair to a sitting position trying to get back into bed. No injuries were sustained.During an interview on 03/19/26 at 4:10 PM, Licensed Practical Nurse Unit Manager (LPNUM)1 revealed the resident sustained a fall last year without injuries. The resident has not sustained any falls since that time. During an interview on 03/20/26 at 2:50 PM, the MDSC nurse revealed the resident's quarterly MDS dated [DATE] did not reflect the fall the resident sustained on 6/7/25. The MDSC agreed that since the fall without injury occurred during the assessment period it should have been reflected on that quarterly MDS.A review of the facility policy tilted, Comprehensive Assessments, with a revision date of 10/2025 revealed, .Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.Review of the October 2024 RAI, manual, page 1-5 revealed, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. It is important to note here that information obtained should cover the same observation period as specified by the MDS (minimum data set) items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment. NJAC 8:39-33.2(d)

Based on record review, interview, and document review, the facility failed to ensure three of three residents (Resident (R) 10, R12, and R197) and their resident representatives (RR) reviewed for emergent hospital transfer were provided with a written bed hold policy and transfer notice out of a total sample of 40 residents. This failure had the potential to affect the resident and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following hospitalization for residents transferred to the hospital.Findings include:1.Review of R10's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R10 admitted to the facility on [DATE]. Review of R10's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R10 was cognitively intact. Review of R10's Progress Notes, dated 12/10/25 and located under the Progress Notes tab of the EMR, revealed R10 was transferred to the hospital due to a fall with an abrasion to the left side of the head and returned to the facility on [DATE], later in the morning. According to documentation the facility called a contact on file and left a message, to return the call to the facility. No return call was noted. Review of R10's Progress Notes, dated 12/13/25 and located under the Progress Notes tab of the EMR, revealed R10 returned to the emergency room (ER) at a Psychiatric Emergency Screening service due to increased behaviors on 12/13/25 and returned on 12/13/25, later that day. According to documentation the facility called a contact on file and left a message, to return call to the facility. The Transfer/Bed hold notice was not provided for these visits. 2.Review of R12's admission Record, located under the Profile tab in the EMR, revealed R12 admitted on [DATE]. Review of R12's annual MDS, with an ARD of 12/02/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, indicating R12 was cognitively intact. Review of R12's Progress Notes, dated 02/23/26 and located under the Progress Notes tab of the EMR, revealed that R12 was transferred to the hospital due to being unresponsive to verbal and tactile stimulation and returned to the facility on [DATE]. The Transfer/Bed hold notice was not sent to the Power of Attorney (POA) until 03/10/26 per documentation provided by the facility. According to documentation the facility called R12's power of attorney (POA) and made notification. 3.Review of R197's admission Record, located under the Profile tab in the EMR, revealed the resident admitted to the facility on [DATE]. Review of R197's quarterly MDS, with an ARD of 11/04/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated R197 was cognitively intact. Review of R197's Progress Note, dated 12/26/25 and located under the Progress Note tab of the EMR, revealed R197 had a change in condition. A new order was received to send to R197 to the hospital for evaluation and treatment. Review of the Notice of Emergency Transfer, form dated 12/26/25, and provided by the facility for R197, revealed that the document was sent to the Long-Term Care Ombudsman but not the resident. During an interview on 03/20/26 at 11:35 AM, the Receptionist (RCPT) stated R197 was not provided with a copy of the transfer notice, and one was not mailed to her emergency contact.During an interview on 03/20/26 at 3:38 PM, the Director of Nursing (DON) said the transfer notice should be provided to the resident or representative within 24 hours of discharge. NJAC 8:39-4.1(a)

Based on record review, interview, and policy review, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was submitted timely for two residents (Resident (R) 31 and R13) reviewed for MDS assessments out of a total sample of 40 residents. The failure to submit the discharge MDS did not allow for the closure of the residents' MDS cycle.Findings include:1. Review of R31's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R31 admitted to the facility on [DATE]. Further review revealed R33 was discharged to the hospital on [DATE].Review of R31's discharge MDS, with an assessment reference date (ARD) of 11/27/25 and located under the MDS tab of the EMR, revealed the assessment was completed but not submitted.2. Review of R13's admission Record, located under the Profile tab of the EMR, revealed R13 admitted to the facility on [DATE]. Further review revealed that R13 was discharged to the hospital on [DATE].Review of R13's discharge MDS, with an assessment reference date of 11/16/25 and located under the MDS tab of the EMR, revealed the assessment was completed but not submitted.During an interview on 03/20/26 at 2:41 PM, the MDS Coordinator stated both assessments were missed due to the coding to submit to the Centers for Centers for Medicare and Medicaid Services (CMS) not being updated. He/She stated they should have been submitted after they were completed in November 2025.During an interview on 03/20/26 at 3:38 PM, the Director of Nursing (DON) said He/She expected MDS assessments to be submitted timely after they were completed.Review of the facility policy titled, Comprehensive Assessments, revised 10/2025 revealed, . Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. NJAC 8:39-11.2

Based on interview, record review, and facility policy review, the facility failed to ensure residents were informed of and provided written information, upon admission, regarding their right to formulate advance directives for two residents (Residents (R) 95 and R201) of five reviewed for advance directives out of a total sample of 40 residents. This deficient practice placed residents at risk for more than minimal harm by limiting their ability to make informed decisions and communicate their healthcare preferences, including life-sustaining treatment, in the event they are unable to express their wishes.Findings included:1. Review of R95's admission Record, located under the Profile tab in the electronic medical record (EMR) revealed R95 admitted to the facility on [DATE]. Review of R95's Resident Header did not reflect an Advance Directive.Review of R95's Quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. A Significant Change in Status (SCIS) MDS was completed on [DATE]. R95 previously had a BIMS of 15 out of 15, which indicated intact cognition. Review of R95's Care Plan, initiated [DATE] indicated, .I have requested that CPR [cardiopulmonary resuscitation] measures are to be performed (Full Code Status), with an intervention stating, Please follow my instructions as detailed on my POLST.Review of the Misc, tab, located in the EMR, did not reveal a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) or other advance directives documentation specifying R95's healthcare wishes.There was no evidence to indicate the facility informed R95 of or provided written information regarding advance directives upon admission. 2. Review of R201's admission Record, located under the Profile tab in the EMR, revealed R201 admitted to the facility on [DATE]. Review of R201's Resident Header did not reflect an Advance Directive.Review of R201's Care Plan, initiated [DATE] indicated, I have requested that CPR measures are to be performed (Full Code Status), with an intervention stating, Please follow my instructions as detailed on my POLST.Review of the Misc, tab, located in the EMR, did not reveal a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) or other advance directives documentation specifying R201's healthcare wishes.During an interview on [DATE] at 1:54 PM, R201 stated a preference for Full Code status and reported he/she was not provided with information or resources regarding advance directives upon admission.During an interview and record review on [DATE] at 9:56 AM, Licensed Practical Nurse Unit Manager (LPNUM) 4 stated the admission nurse is responsible for discussing resident preferences regarding life-sustaining treatment during the admission process and documenting those preferences on the POLST form. LPNUM4 stated the POLST must be signed and dated by the resident or representative and the physician to be valid. Review of R95's and R201's medical records with LPNUM4 confirmed the absence of completed POLST forms or other advance directive documentation for both residents.Review of the facility's policy titled, Advance Directive Policy and Procedure, last reviewed 09/2025, indicated: .The resident has the right, and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide residents with a written description of the facility's policy to implement advance directives. NJAC 8:39-4.1(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints for one resident (Resident (R) 125) reviewed for physical restraints out of 40 sampled residents. This failure had the potential to affect all residents' rights at the facility. Findings include:Review of R125's admission Record, located under the Profile tab in resident's electronic medical record (EMR), revealed the resident admitted to the facility on [DATE] with diagnoses which included Huntington's disease. Review of R125's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/26 and located under the MDS tab in the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident's cognition was moderately impaired. Further review revealed the Posey Net Bed was classified as a restraint. Review of R125's Care Plan, dated 01/22/24 and located under the Care Plan tab in the EMR revealed, I am in a posey net bed for increased safety/decrease falls risk.Review of R125's Nurse's Note, dated 02/20/26 at 11:26 PM and located in the EMR under the Notes'' tab, written by Licensed Practical Nurse (LPN) 2 revealed, .Resident caused a disturbance in the hallway by coming out of the room without pants on. Brought back into room and placed pants back on but resident attempted to ambulate out of wheelchair. Resident placed in posey net bed for safety. During an interview on 03/20/26 at 2:43 PM, LPN2 stated Posey Net Beds were considered a restraint. He/She stated staff should attempt different interventions when a resident is being disruptive or unable to be redirected. He/She stated calling R125's wife was usually helpful or offering him/her a snack. He/She also said it was not appropriate to place a resident in a posey net bed because they could not be redirected. LPN2 stated he/she did attempt other interventions prior to placing R125 in the Posey Net bed and did call a supervisor to get guidance, but he/she did not document that, and he/she couldn't remember whom he/she spoke to. LPN2 was unsure if he/she made the decision to place R125 in the Posey Net bed on 02/20/26 or if he/she was told by someone to do so. During an interview on 03/20/2026 at 3:06 PM, Licensed Practical Nurse Unit Manager (LPNUM)3 said it would not be appropriate for staff to place a combative resident in a posey bed. He/She said the posey bed was for safety to prevent falls and not disruptive behavior. LPNUUM3 agreed that it would be a restraint for staff convivence. He/She said staff should always use the least restrictive method and attempt other appropriate interventions and document that in the medical record. During an interview on 03/20/26 at 3:38 PM, the Director of Nursing (DON) said a restraint should never be used for resident behaviors, and it was for safety only and to provide care. Review of the facility's undated policy titled, Use of Restraints, reviewed and updated 11/2025. Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. NJAC 8:39-4.1(a)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents did not have bedrails when they were not assessed to have them for one of four residents (Resident (R) 28) reviewed for side rails out of a total of 40 sampled residents. The lack of appropriate assessment could lead to potential restraint or side rail entrapment. Findings include:Review of R28's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R28 admitted to the facility on [DATE] with diagnosis of Huntington's Disease.Review of R28's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/15/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Review of R28's Care Plan, dated 09/19/23 and located under the Care Plan tab of the EMR, revealed R28 was care planned for top half side rails on the right side of the bed. Review of R28's Physician Orders, located under the Orders tab in the EMR, dated 03/18/26, revealed no current order for side rails.Review of R28's Quarterly/Annual/Significant Change Nursing Evaluation Packet, dated 01/06/26 and located under the Assessments tab in the EMR, revealed side rails were not necessary at this time.During observations on 03/18/26, 03/19/26 and 03/20/26, a side rail was observed on the left side of R28's bed in the up position. During an interview on 03/20/26 at 10:38 AM, the Licensed Practical Nurse Unit Manager (LPNUM)3 said he/she was aware R28's siderail assessment indicated he/she was not supposed to use side rails. He/She said the residents changed units and R28 was placed in a bed that already had a side rail on it but that it should be removed. During an interview on 03/20/26 at 3:38 PM, the Director of Nursing (DON) stated a resident should not have bedrails unless they are assessed to require them. Review of the facility policy titled, Bed Safety and Bed Rails, Reviewed and Updated 11/2025 revealed, . Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/01/2024 from 9:29 to 10:14 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage area on a lower rack of a multi-tiered, wheeled, can storage rack, a can of vegetarian beans had a significant dent on the side of the can. The FSD removed the can to the designated dented can area after agreeing that it was significantly dented. 2. In the meat walk-in on a middle shelf, a previously opened package of sliced turkey was wrapped in plastic wrap. The package had no dates. In addition, a clear plastic bag contained sliced bread. The bag of bread had no dates. The FSD removed the undated foods from the meat walk-in in the presence of the surveyor. 3. The Meat Pot/Pan Storage Drying Rack had six (6) stacks of plates used to serve resident meals were stored on an upper shelf. The plates were not inverted or covered, and the eating surface was exposed. In addition, a red plastic dish rack contained silverware that was cleaned and sanitized. The silverware was not covered and exposed to contamination. Next to the red plastic dish rack two (2) metal, perforated half pans contained various kitchen utensils, including scoops and tongs used to serve food, amongst other utensils. The pans were not covered, and the utensils were exposed to contamination. The FSD stated that the utensils and dishes should be inverted or covered when not in use to prevent contamination. On 10/08/2024 from 10:57 to 11:13 AM, the surveyor, accompanied by the FSD, observed the following in the kitchen: 1. During an observation of the Dish room Storage Rack, the surveyor observed that all dishware was inverted. The surveyor lifted the top plate on a stack of plates used to serve resident meals. The surveyor observed a wet and clear liquid on the plate just below the top plate. The surveyor lifted the next plate on the stack and observed a wet, clear liquid substance. [NAME]/Cook. The cook on interview stated that he had just washed the plates and agreed that he should have air dried the plates prior to stacking. The cook removed the stack of plates to be cleaned and sanitized. The FSD on interview agreed that the cook should have allowed the cleaned and sanitized dish ware to be completely air dried before stacking the plates, a condition known as wet nesting (the practice of stacking wet dishes, pots, or pans together, which prevents them from drying and can lead to bacterial growth). The multiple stacks of plates were to be re-washed, sanitized and air dried according to the FSD who directed the cook to remove the dishes from the storage rack. A review of the facility policy titled Label and Dating, updated 6.22.23, revealed under the heading POLICY: All food items being received or prepared will have a standard label to identify the product name, the received date, the prepared date or the pull date from freezer date, and the expiration or cook by date. All products will be sealed or wrapped tightly with proper labels. All received products will be securely wrapped. In addition, the following was revealed under PROCEDURE: 4. All products that are opened (mayo, dressing, etc.,) are to be labeled with a new expiration date. (please follow label and dating chart system protocol) example-dressing container is opened. It now has a new expiration date of 30 days from open date, Opened on 6.20.23 will be written on the open date on the label, as well as 7.20.23 written in the use by section on the label. All products will be wrapped securely. A review of the facility policy titled Dry Storage and Receiving Foods Policy, undated, revealed under POLICY: Dietary will receive and deliver dry foods in a timely fashion ensuring quality of products and packaging. In addition, the following was revealed under PROCEDURE: 1. All receiving personnel are to check all dry food items upon delivery. Ensure that all packing is intact and marked off against the packing slip. Check all packages for any tears, stains, leaks, missing labels, shortages of order or over deliveries. Ensure product packing is in good condition. A review of the facility policy titled Cleaning Dishes - Manual Dishwashing, 2013, [ company name], revealed the following at POLICY: Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. In addition, the following was revealed under Sink 3: Sanitize: 4. Allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing. A review of the facility provided policy titled Handling Clean Equipment and Utensils, 2013 [company name], revealed under POLICY: Clean equipment and utensils will be handled to prevent contamination. In addition, the following was observed under Procedure: 2. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. Stationary equipment will also be protected from contamination. A review of the facility policy titled Dented Can Policy, undated, revealed under PROCEDURE: 1) All receiving personnel are to check canned items dents, bulging or rust (sic). If a can is identified with these defects, place the can on the dented can section. This section is in the vestibule locker section and labeled as such. Cans are to be returned to the purveyor for credit. Supervisors to check with weekly audits. NJAC 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 2 garbage dumpsters. This deficient practice was evidenced by the following: On 10/03/2024 at 09:07 AM, the surveyor observed the facilities designated garbage area. The surveyor observed two (2) trash only dumpsters in the facility parking lot in an opened but fenced in area. The dumpsters were three (3) yard dumpsters and had two (2) separate black plastic lids to enclose the trash in the dumpster. The front dumpster contained bagged trash/garbage and 2 of 2 lids were open and left the bagged trash exposed. A residential housing complex is located directly behind the designated garbage area. During an interview on 10/03/2024 at 09:11 AM, the surveyor asked who was responsible for the maintenance of the facility designated garbage area the Food Service Director (FSD) told the surveyor, It's a joint effort between dietary, maintenance and housekeeping. On further interview the FSD stated that, I agree with you 100%. The doors should be closed. A review of the facility policy titled Garbage Storage Area, September 2023, revealed the following under the policy title: A garbage storage area is a necessity to provide a safe and sanitary environment for residents. It provides a specific place for the disposal of garbage and must be maintained properly to prevent the spread of bacteria, pests and odor. The following was revealed at 4. Garbage storage area must be maintained in a sanitary condition to prevent the harboring and feeding of pests. In addition, the following was revealed at 6. Dumpsters must be covered and gates closed when the garbage storage area is not being utilized. NJHAC 18:39-19.3(b)

C# NJ172982 Based on observation, interview, and record review, it was determined that the facility failed to provide all the items that were on the menu. This deficient practice occurred during one lunch meal that was observed in the conference room of the facility during a test tray evaluation by the survey team and was evidenced by the following: On 10/08/2024 at 11:28 AM, the surveyor requested the main and alternate meal for lunch on 10/8/2024. According to the [facility name] Week at a Glance - New Menu 2020 the main entree for week 4 consisted of creamy carrot soup, cheese quesadilla, zucchini stuffed tomato, and cinnamon rice pudding. The alternate meal at lunch according to the menu consisted of grilled eggplant and roasted pepper sandwich, and potato salad, in addition the creamy carrot soup. The Food Service Director (FSD) delivered the lunch meal trays to the facility conference room for the surveyors to sample as there had been resident complaints concerning residents not receiving items at meals that were listed on the menu. Observation of the main entree revealed that no zucchini stuffed tomato and the vegetable provided was yellow squash with diced tomato. The alternate meal consisted of grilled eggplant and roasted pepper sandwich with yellow squash and diced tomato as the vegetable. There was no zucchini stuffed tomato or potato salad as the menu indicated. During an interview with the surveyor on 10/08/2024 at 11:51 AM, the surveyor asked the FSD if the kitchen staff had potato salad available as it was a listed item on the lunch menu for Tuesday week 4 according to the facility menu. The FSD stated, Ill check with the cook. The FSD asked the cook who was serving on the tray line if they had potato salad available and the cook responded, No. I didn't see it on the sheets, so we didn't make any today. The surveyor also pointed out to the FSD that the vegetable served consisted of yellow squash and diced tomato and not a tomato stuffed zucchini. The FSD agreed that the vegetable served was not a tomato stuffed with zucchini, as indicated on the lunch menu. The FSD on interview agreed potato salad should be on the menu. The FSD further stated, I'll get some made now. We don't want any complaints from residents. We missed it, I don't want to lie. A review the facility policy titled Garbage Storage Area, dated September 2023, revealed under the policy title: A garbage storage area is a necessity to provide a safe and sanitary environment for residents. It provides a specific place for the disposal of garbage and must be maintained properly to prevent the spread of bacteria, pests, and odor. In addition, the policy reveled the following at and 4. and 6. Garbage storage area must be maintained in a sanitary condition to prevent the harboring and feeding of pests. Dumpsters must be covered and gates closed when the garbage storage area is not being utilized. The facility did not provide a policy concerning menus. NJAC 8:39-17.2(b)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 05/02/23 at 09:51 AM, in the presence of the Food Services Director (FSD), the surveyor toured the kitchen and observed the following: 1. In the dairy freezer, there was one (1) knotted clear plastic bag which contained several frozen brown coated squares of meat, which the FSD identified as breaded fish squares, with no label and no dates. The FSD acknowledged there was no label and stated that he did not know how old the food was and stated that the bag should have been marked when it was opened and what the contents were. There was a large metal tray which contained white pieces of meat that were partially covered with clear plastic wrap. The meat was visible and exposed to air on both sides of the tray. The FSD identified the meat as flounder filets and stated that the plastic wrap should have completely covered the fish to prevent contamination. There was one (1) large knotted blue plastic bag which contained brown coated square pieces of meat, that the FSD identified as vegan chicken patties, with no label and no dates. There was a large round hole observed in the bag with the meat visible and exposed to air. The FSD acknowledged that there should have been a label and a use by date and stated that the hole should not have been in the bag. There was one (1) knotted clear plastic bag with several round flat yellowish pieces of dough, that the FSD identified as crepes, with no label and no dates. There were two (2) knotted large blue bags with several round white and tan pieces of dough, that the FSD identified as pizza shells, with no label and no dates. The FSD was unable to state how old the food items were and acknowledged that the crepes and the pizza shells had no labels and no dates. The FSD further stated that it was important that the food was labeled and dated so that everyone would have known what the food was and how old the product was. The FSD removed the bags from the freezer. 2. In the walk-in refrigerator, there was one (1) opened bag of shredded yellow cheddar cheese wrapped in clear plastic wrap with no opened or use by date. The FSD acknowledged that he did not know when the cheese was opened and stated that it should have been marked with the date when it was opened. In a metal half pan, there were 15 small plastic plates of fruit covered with clear plastic wrap, with no labels and no dates. The FSD acknowledged that he did not know how old the undated plates of fruit were and that they should have had a label and a use by date. The FSD removed the cheese and the fruit from the refrigerator. 3. In the meat freezer, there was one (1) knotted clear plastic bag that contained several brown circular patties, that the FSD identified as beef patties, with no label and no dates. When the surveyor inquired as to how old the beef patties were, the FSD stated, You wouldn't know by looking at it. The FSD acknowledged that the beef patties should have had a label and use by date and that it was important to label and date the food products because contamination could have caused sickness. The FSD discarded the meat into the garbage. 4. In the dry storage room, there was one opened bag of chocolate pudding wrapped in clear plastic wrap with no open or use by date. There was one opened bag of quick rolled oats wrapped in clear plastic wrap with no open or use by date. The FSD stated he was unsure how long the pudding and the oats were good for and that they should have been dated when they were opened. In the can section on a metal rack, there was one (1) 115 ounce can tomato ketchup with a large dent, one (1) 100 ounce can cut sweet potatoes with a large dent and six (6) 108 ounce cans diced potatoes with large dents. On the top shelf on a large metal rack there was one (1) 66.5 ounce can chunk light tuna with a large dent. The FSD acknowledged the dents and stated that the dented cans should have been put on the dented can shelf. There were two (2) opened bags of confectioner sugar each wrapped in clear plastic wrap with no open or use by dates. There was one (1) large opened brown bag in an opened clear plastic bag, that contained visible white flakes that were exposed to air, with no label and marked 4/18/23. The FSD identified the white flakes as potato flakes and stated that he was unsure if the marked date indicated if the bag was opened at that time. The FSD further stated that the bag should have been wrapped and closed and have had a label and a use by date. 5. On the meat side of the kitchen, under a metal food prep area, there was a red bucket that contained a white rag and clear liquid. The FSD identified the bucket contents as sanitizer and stated that the bucket was made at the start of the shift and it was used to wipe down the prep area. The FSD used a chlorine paper test strip to test the sanitizer which revealed a light grey color. The FSD stated it read nothing and that it should have read 200 parts per million (ppm.) The FSD then used a QT10 paper test strip to test the sanitizer which revealed a light orange color which the FSD stated read more like 100 ppm and that it should have read 200 ppm. The FSD acknowledged that the sanitizer bucket did not contain enough sanitizer and instructed the cook to add sanitizer to the bucket. 6. On the drying rack there were two (2) large red cutting boards with black smudges and gouges. The FSD acknowledged that the smudges and gouges should not have been there and used his finger to scrape at the smudges. The FSD stated that it was important to use clean equipment to prevent cross contamination. 7. In the three-compartment sink, the sanitizer sink was filled with clear liquid. The FSD tested the liquid with a QT10 paper test strip which matched 300 ppm. The FSD acknowledged the 300 ppm and stated that the liquid should have been 200 ppm and added more water to the sink. 8. On the dairy side of the kitchen, in the three-compartment sink in the dish washing area, the sanitizer sink was filled with clear liquid. The FSD tested the liquid with a QT10 paper test strip which revealed a dark green color that matched 400 ppm. The FSD acknowledged the 400 ppm and stated that the liquid should have been 200 ppm and instructed the dish washer to empty some liquid from the sink and add more water then retest. On 05/05/23 at 10:52 AM, in the presence of the FSD, the surveyor observed the door to the dietary cart room opened and held ajar with a five-gallon bucket. 9. In the dietary cart room on the top shelf of a metal five-tiered cart, which contained paper and plastic products, there were several large coffee filters resting on the shelf which were exposed to air. The FSD acknowledged that the coffee filters should not have been stored that way and that they should have been in a bag to prevent contamination. The FSD discarded the coffee filters into the garbage. On 05/05/23 at 11:00 AM, in the presence of the FSD, the surveyor toured the kitchen and observed the following: 10. On the meat side of the kitchen, there was a red bucket labeled sanitizer which contained a rag and clear liquid. The FSD tested the liquid with a QT10 paper test strip which revealed a dark green color which matched 400 ppm. The FSD acknowledged the strip read 400 ppm and stated that it should have read 200 ppm. The FSD emptied some of the liquid into the sink and added more water then retested the liquid with a QT10 paper test strip which matched 200 ppm. 11. On the dairy side of the kitchen, there was a red bucket marked sanitizer which contained a rag and clear liquid. The FSD tested the liquid with a QT10 paper test strip which matched 400 ppm. The FSD acknowledged the strip read 400 ppm and stated that it should have read 200 ppm. The FSD emptied some of the liquid into the sink and added more water then retested the liquid with a QT10 paper test strip which matched 200 ppm. The FSD stated that after any meal prep that the counters were washed with soap and water and then the sanitizer was used. The FSD further stated that it was important to have the correct amount of sanitizer so that there was an optimum level of chemical to clean any bacteria. A review of the undated facility policy, Cleaning and Disinfection of Kitchen Equipment, revealed, Policy Interpretation and Implementation 2. All Kitchens, kitchen areas and dining areas shall be kept free clean .3. Sanitizing of Environmental surfaces must be performed with one of the following solutions . b. 150-200 ppm of approved sanitizing solution which is the one used here in Leisure Chateau. A review of the facility document, Sanitizer Buckets, with a revision date 5/23, revealed, 3. Buckets should be filled and checked and fixed until the test strip reads 200 ppm of solution, which is the optimal cleaning reading. A review of the undated facility policy, Cleaning Instructions: Cutting Boards, revealed, Policy: Cutting boards will be cleaned and sanitized after each use. Procedure: 2. After each use, wash cutting in hot soapy water. 3. Rinse and sanitize A review of the facility policy, Dented Can Policy,, with a revision date of 8/2022, revealed, Procedure: 1. Identify an acceptable/unacceptable dented can. Unacceptable: Any dent, crease, bulge, swelling, or rust. 2. Upon discovery, place dented can in the designated Dented Can area. A review of the facility policy, Receiving and Storage, dated 2/2020, revealed Procedure: 2. d. All foods are dated as they are placed in storage and dated using a first in-first out system. 3. a. i. Dented cans-Not acceptable and should be stored in designated area for pick up from the vendor at a later time. A review of the facility policy, Receivable and Storage Policy, with a revision date of 7/2022, revealed, Procedure: 8. Ensure that all foods are securely covered, dated, and labeled. NJAC 8:39-17.2(g)

Based on observation, interview and review of medical records and other pertinent facility documentation it was determined that the facility failed to assure that a resident received oxygen as ordered by the physician. This deficient practice was identified for 1 of 3 residents (Resident #25) reviewed for respiratory care and was evidenced by the following: According to the Admission Record, Resident #25 was admitted to the facility with the diagnoses which included but was not limited to atelectasis (collapsed lung), Huntington's Disease (genetic neurological disease) and heart failure. The quarterly Minimum Data Set (MDS-an assessment tool utilized to facilitate the care of a resident), dated 03/03/2023, indicated that the resident was cognitively intact and required extensive assistance with activities of daily living. The MDS also indicated that the resident was on oxygen. On 05/02/23 at 10:20 AM, the surveyor was conducting a tour on the Florida Unit and observed Resident #25 in their room and was being administered oxygen (O2) by way of (via) nasal cannula at 2 liters per minute (l/min). The surveyor observed that the O2 was hooked up to a portable liquid O2 tank that was located on the back of the resident's chair. The portable O2 tank gauge reading indicated that the O2 tank was empty. Resident #25 was not in any distress and there was no evidence that he/she was short of breath (SOB). The resident was observed moving about the room in the wheelchair. Resident #25 was interviewed at this time, and he/she indicated that he/she could not feel the O2 coming through the nasal cannula tubing and did not know when the portable liquid O2 tank was last filled with oxygen. On 05/02/23 at 10:57 AM, the surveyor reviewed the Resident's Physician Order Summary (POS) which reflected orders for: - O2 at 2 l/min via nasal cannula and may titrate to maintain O2 saturation of 92% or greater every shift. -Check O2 liter flow (2 liters) and O2 tubing placement/integrity every shift for SOB. The surveyor reviewed the Treatment Administration Record (TAR) dated 05/01/2023-05/31/2023 which reflected a physician's order for O2 at 2 l/min via nasal cannula and may titrate to maintain O2 saturation of 92% or greater every shift and check O2 liter flow (2 liters) and O2 tubing placement/integrity every shift for SOB. On 05/02/23 at 11:36 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she had been employed in the facility for the last [AGE] years. The RN stated Resident # 25 had been on routine oxygen at 2 liters for quite some time. She explained that she had not yet checked the resident's portable liquid O2 tank that was hanging on the back of the resident's wheelchair. The surveyor asked the RN who was responsible to assure that the portable liquid O2 tank was filled with O2, and she explained that the Certified Nursing Assistant (CNA) was responsible to assure that the portable O2 tank was filled. The RN accompanied the surveyor to the resident room, and she confirmed that the portable tank was empty, and that the resident was not receiving the oxygen that was ordered by the physician. On 05/02/23 at 11:43 AM, the surveyor interviewed the CNA who was caring for Resident #25. The CNA stated that she thought that the resident was on the O2 concentrator that was in the resident's room and did not realize that the resident was on the portable liquid tank that was on the resident's wheelchair. She stated that she did not know that the resident's portable O2 tank was empty, and that the resident was not receiving the O2 that was ordered by the physician. The CNA stated that the nurses and the CNAs were responsible to assure that the portable O2 tank was filled with O2. She stated that the resident would usually tell her that the tank was empty, but the resident did tell her anything that morning. On 05/03/23 at 11:43 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that Resident # 25 usually used the O2 concentrator while in the room and utilized the portable O2 tank when out of the room. She stated that the CNA's were responsible to check the portable liquid O2 tanks every couple hours to make sure they were filled. She explained that the nurses and the CNAs did not have to sign any paperwork that indicated that they were checking the portable O2 tank to assure that it was filled with O2. On 05/03/23 at 11:47 AM, the surveyor observed the resident sitting in the room and was wearing O2 at 2 l/min via the portable liquid O2 tank that was hanging on the back of the resident's chair. The portable O2 tank was filled, and the resident stated that she felt the O2 coming out of the nasal cannula tubing. On 05/10/23 at 12:40 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses and the CNAs were responsible to assure that the portable liquid O2 tanks were filled and explained that they all knew how to fill it and they all knew that they should have checked that it was filled. On 05/12/23 at 10:23 AM, the surveyor in the presence of the survey team, interviewed the DON who stated that the nurses and the CNAs were trained on liquid O2 and knew how to care for residents on liquid oxygen. She explained that the nursing staff knew how to fill the portable liquid O2 tanks. The DON stated that she spoke with the CNA that was caring for Resident #25 on 05/02/23 7:00 AM- 3:00 PM shift and that the CNA stated that the O2 tank was approaching the 0 mark which would have indicated that the tank was empty but did not feel that it would have emptied that quickly. The DON stated that there was no paperwork that the CNAs filled out when they checked the portable O2 tanks. The surveyor reviewed the facility policy, Liquid Oxygen, dated October 29, 2022, which indicated that the facility utilized liquid oxygen technology to supply its residents with their oxygen needs. It's the facility policy to ensure safe transportation, use and storage of both liquid oxygen based units and portable units; ensure that the filling of oxygen, herein referred to as trans-filling, from the liquid oxygen base unit to the portable unit id done properly and complied with the State Department of Health and Federal Regulation and maintains the safety precautions in the transportation, use, storage, trans-filling of units and handling of oxygen. The policy also indicated that the residents using oxygen will utilize concentrators in their rooms and while outside of their rooms, residents will be transferred to a portable tank. Prior to this transfer, the caregiver-nurse and or CNAs will check the oxygen gauge to determine how much O2 is left; if not a full tank, the nurse and or CNA should fill the tank utilizing the procedure for trans-filling of a portable tank. NJAC 8:39-19.4(a)

Based on observation, interview, record review and review of pertinent facility documentation it was determined that the facility failed to appropriately store an indwelling urinary catheter drainage bag in a manner to prevent against infection. This deficient practice was identified for one (1) of 1 resident, (Resident #4) reviewed for urinary catheter care. This deficient practice was evidenced by the following: On 05/02/23 at 11:10 AM, the surveyor entered Resident #4's vacant room and observed a blue privacy bag attached the resident's bed frame. The blue privacy bag was empty. The surveyor knocked on the door to the resident's unoccupied bathroom and observed a plastic bag tied to the handrail in the bathroom. Inside of the plastic bag, the surveyor observed an indwelling urinary catheter drainage bag with a blue cap attached to the end of the foley catheter tubing. The indwelling urinary catheter bag was dated 05/02/23. On 05/03/23 at 12:25 PM, the surveyor entered Resident #4's vacant room and observed an empty blue privacy bag attached to the resident's bed frame. The surveyor then entered the resident's unoccupied bathroom and observed a plastic bag tied to the handrail in the bathroom. Inside of the plastic bag, the surveyor observed an indwelling urinary catheter bag. The tubing to the indwelling urinary catheter was uncapped and in direct contact with the plastic bag. The indwelling urinary catheter bag was dated 05/02/23. On 05/04/23 at 12:13 PM, the surveyor entered Resident #4's unoccupied bathroom and observed the resident's indwelling urinary catheter drainage bag stored inside of the plastic bag attached to the handrail in the resident's bathroom. The tubing to the indwelling urinary catheter drainage bag was observed to be uncapped and in direct contact with the plastic bag. The surveyor further observed clear, yellow urine inside of the indwelling urinary catheter tubing. The indwelling urinary catheter bag was dated 05/02/23. On 05/04/23 at 12:18 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert and oriented with confusion at times. The CNA stated that he changed the resident's indwelling urinary catheter drainage bag to a leg bag every morning and that he would empty the indwelling urinary catheter bag after use and store the bag that the resident wore at night in a plastic bag in the resident's bathroom. The surveyor asked the CNA if he capped the tubing on the indwelling urinary catheter drainage bag. The CNA stated that he would put the cap on the tubing, sometimes and the purpose for putting the cap on the tubing was so the bag would not leak and that it would have been protected against contamination. The CNA further stated that he had cared for the resident during the 7:00 AM - 3:00 PM day shift the day before (05/03/23). On 05/04/23 at 12:22 PM, the surveyor entered the resident's bathroom with the CNA. The CNA put on a pair of gloves in the presence of the surveyor, touched, and observed the resident's indwelling urinary catheter drainage bag and confirmed that the tubing to the bag was uncapped. At that time the CNA stated, the tubing should have been capped. On 05/04/23 at 12:24 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she was not very familiar with the resident. The LPN further stated that the resident was alert and oriented with confusion, could make needs known, and ask for help. The LPN told the surveyor that the staff performed catheter care for the resident and that the resident had a suprapubic catheter (a hollow flexible tube surgically inserted into the bladder from an opening by a person's lower abdomen that is used to drain urine from the bladder) for urinary retention (a condition where your bladder doesn't empty all the way or at all when you urinate). The LPN stated that she thought maybe the tubing to the indwelling urinary catheter bag should have a cap on it. 05/04/23 12:28 PM, the surveyor entered the resident's bathroom and observed the indwelling urinary catheter drainage bag in the presence of the LPN. The LPN stated that she did not see a cap on the foley catheter tubing and was unsure if the tubing needed one because she had never seen one on them before. On 05/04/23 at 12:30 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the indwelling urinary catheter bags came with a blue cap. The LPN/UM further stated that if the blue cap was not on the indwelling urinary catheter drainage bag while it was being stored and not in use, then the drainage bag should be thrown away and the staff would be required to utilize a new bag for the resident. On 05/04/23 at 12:33 PM, the surveyor entered the resident's bathroom with the LPN/UM. The LPN/UM observed, in the presence of the surveyor, that the indwelling urinary catheter bag was dated 05/02/23 and was uncapped. At that time the LPN/UM stated that the cap should have been placed on the foley catheter tubing for infection control purposes. On 05/04/23 at 2:04 PM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that sometimes the cap would go at the end of the indwelling urinary catheter bag tubing when the bag was not in use. The LPN/IP stated that the facility's practice was to change out the indwelling urinary catheter drainage bag weekly and store the bag in a plastic bag when not in use. The LPN/IP told the surveyor that the purpose of the cap was to prevent anything from getting inside the tubing that could have potentially caused an infection. On 05/04/23 at 02:16 PM, the surveyor interviewed the LPN/IP who stated that Resident #4 had not had a history of a urinary tract infection in the last four (4) months. On 05/05/23 at 11:15 AM, the surveyor observed Resident #4 walk with a cane into the smoking section on the unit. The resident was observed wearing loose, long pants. The surveyor interviewed the resident who stated that the CNAs helped him/her with the care of his/her catheter. The resident further stated that he/she could not remember the last time they had a urinary tract infection. On 05/09/23 at 09:01 AM, the surveyor conducted a follow up interview with the LPN/IP who stated that moving forward, the facility was going to dispose of the indwelling urinary catheter drainage bags and privacy leg bags after each use. The LPN/IP further stated that the instructions for indwelling urinary catheter drainage bag and the leg bag indicated to dispose of the bags after one use to prevent against microbial growth within the catheter tubing. The surveyor reviewed the medical record for Resident #4. A review of the resident's Admission Record (an Admission Summary) reflected that the resident had resided at the facility for over five (5) years and had diagnoses which included but were not limited to anemia, hyperlipidemia, essential hypertension, obstructive and reflux uropathy (abnormal flow of urine from the bladder into the ureters), and benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlargement that causes difficulty urinating). A review of the resident's most recent annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/01/23, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. A further review of the resident's MDS, Section H - Bladder and Bowel reflected that the resident had an indwelling catheter. A review of the resident's May 2023 Order Summary Report (OSR) reflected a Physician's Order (PO) dated 05/06/23 to change foley catheter stabilizing device weekly. Date and initial device. Rotate application site every night shift on Sundays for protection. A further review of the May 2023 OSR did not reveal a PO for changing the indwelling urinary catheter drainage bag to a privacy bag daily or for the storage of the indwelling urinary catheter drainage bag. A review of the May 2023 Medication Administration Record (MAR) did not reflect that nurses were signing that the resident's indwelling urinary catheter bag was changed to a leg bag daily or for the storage of the indwelling urinary catheter drainage bag. A review of the May 2023 Treatment Administration Record (TAR) indicated that on 05/07/23 the nurses signed on the night shift that the resident's foley catheter stabilizing device was changed for prevention. A further review of the May 2023 did not reveal that the nurses were signing that the resident's indwelling urinary catheter bag was changed to a leg bag daily or for the storage of the indwelling urinary catheter drainage bag. A review of the resident's Care Plan (CP), revised on 02/23/23, indicated a focus area that the resident had potential for urinary tract infection related to suprapubic catheter and obstructive uropathy. The goal of the resident's CP was that the resident's suprapubic catheter would remain intact and the resident would be free from signs and symptoms of a urinary tract infection. The interventions in the resident's CP included to provide proper pericare, monitor suprapubic catheter site for signs and symptoms of infection during routine care, ensure patency of all tubing, change foley drainage bag weekly, and empty drainage bag every shift. A review of the facility's, Indwelling Urinary Catheter Policy and Procedure, dated 05/04/23, indicated that every attempt should be used to maintain a closed urinary drainage system. The Policy and Procedure further indicated to change tubing and drainage bag when catheter was changed and when changing from a straight drainage bag to a leg bag as ordered by physician. The Policy and Procedure instructed staff to use a new drainage bag every time the drainage tubing was disconnected, label the bag with the date and the resident's room number, discard the used bags, do not wash, or disinfect drainage bags to reuse them. NJAC 8:38-27.1(a)

Based on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to provide a resident who was a smoker with a smoking apron. This deficient practice was identified for one (1) of five (5) residents, (Resident #65), reviewed for safe smoking practices and was evidenced by the following: On 05/02/23 at 10:24 AM, the surveyor observed Resident #65 self-propelling in his/her wheelchair from the smoking section on the Florida unit to their room. At that time, the surveyor interviewed the resident whose speech was slightly garbled. The resident stated that he/she smoked cigarettes and the staff held his/her lighter and cigarettes for them. On 05/05/23 at 10:17 AM, the surveyor observed Resident #65 seated in his/her wheelchair in the outside smoking section on the Florida unit with the smoking attendant present. The surveyor observed the resident appropriately holding his/her cigarette. The cigarette had a smoking extender (device attached to the end of the cigarette to make it longer) attached to it. The surveyor observed the resident was bent at the waist, resting his/her elbows on their knees. The cigarette was observed positioned in front of the resident's body. The surveyor did not observe a smoking apron worn by the resident. At that time, the surveyor conducted an interview with the resident who told the surveyor that he/she always used the smoking extender and never wore the smoking apron. On 05/05/23 at 10:20 AM, the surveyor interviewed the smoking attendant who stated that Resident #65 never wore a smoking apron, just the extender. The smoking attendant then showed the surveyor a piece of paper which included a list of the resident's names who smoked on the unit. The surveyor reviewed the piece of paper in the presence of the smoking attendant. Next to the list of the resident's names who smoked, was a second list of identifiers for residents who smoked electronic cigarettes and residents who were required to utilize an apron/extender. Resident #65's name was included under the list of names for residents who were required to wear an apron/extender. The surveyor asked the smoking attendant, How do you know which residents wear the apron or the extender? The smoking attendant stated that the resident had always just used the smoking extender. The surveyor reviewed the medical record for Resident #65. A review of the resident's Admission Record (an Admission Summary) reflected that the resident had resided at the facility for over five years and had diagnoses which included but were not limited to Huntington's disease (an inherited disease in which nerve cells in the brain break down over time), major depressive disorder, anxiety disorder, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlargement that causes difficulty urinating). A review of the resident's most recent annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/04/23, indicated that the resident had a Brief Interview for Mental Status score of 03 out of 15 which indicated that the resident's cognition was severely impaired. A review of the resident's Safe Smoking Assessment, dated 03/07/23, indicated that the resident had impaired judgement, impaired decision making skills and impaired short-term memory. The resident's Safe Smoking Assessment further revealed that the resident did not have any physical limitations which could impact smoking or a history of other smoking related issues. The Safe Smoking Assessment indicated that the resident required a smoking apron and extender while smoking. A review of the resident's Care Plan (CP), revised on 04/12/23, reflected a focus area that the resident was at an increased risk of injury related to smoking. The goal of the resident's CP was that the resident would remain free from injuries from smoking. The interventions in the resident's CP included to monitor clothing for any burns from cigarette ashes, to wear a smoking apron during smoking, to use smoking extenders during smoking, and to monitor smoking apron prior to leaving the smoking area. The resident's CP did not indicate that facility staff observed burn holes in the resident's clothes, that the resident had a history of being hurt during smoking or had dropped the cigarette on himself/herself while smoking. On 05/05/23 at 10:30 AM, the surveyor interviewed the resident's Nursing Assistant (NA) who stated that she worked at the facility since December and always shared an assignment and performed care with a Certified Nursing Aide (CNA) present. The NA stated that the resident was alert and had never showed signs of confusion when she cared for him/her. The NA further stated that she got the resident up and dressed in the morning so the resident could go outside and smoke cigarettes. The NA stated that she would bring the resident to the smoking section and the smoking attendant was responsible for supervising the area. The NA told the surveyor that the resident could feed himself/herself and to her knowledge the resident had never dropped a cigarette. On 05/05/23 at 10:44 AM, the surveyor interviewed the resident's CNA who stated the resident was alert, oriented, and could make needs known. The CNA explained that the resident was a smoker, and she was unsure if the resident was required to wear a smoking apron because the smoking attendant who worked for the recreation department was always outside supervising. The CNA further stated that to her knowledge, the resident never burned himself/herself while smoking. On 05/05/23 at 12:09 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident was alert, oriented, and a very nice person. The LPN further stated that the resident smoked cigarettes and had never burned himself/herself while smoking. On 05/09/23 at 10:24 AM, the surveyor interviewed the Director of Activities (DOA) who stated that the facility had four (4) separate smoking locations and the residents were monitored twice daily during the scheduled smoking times by the smoking attendant. The DOA told the surveyor that the times were scheduled so the smoking attendant could observe and help all the residents who smoked at the facility. On 05/09/23 at 11:17 AM, the surveyor interviewed the resident's Licensed Practical Nurse/Unit Manger (LPN/UM) who stated that the smoking attendant was responsible for making sure the residents were provided with smoking extenders and smoking aprons as a safety precaution. The LPN/UM stated that Resident #65 had never burned himself/herself while smoking and the smoking apron was an additional intervention to protect the resident. A review of the facility's Smokeroom document, revised 05/01/23, indicated that Resident #65 was to wear an apron and an extender while smoking. A review of the facility's Smoke Room Policy, revised 05/23, indicated, 7. Safety is the number one priority; smoking aprons and/or cigarette extenders will be offered to all patients/residents who smoke and provided to those patients/residents who have the potential to burn themselves and/or clothing secondary to their disease process (i.e. choreic [a movement disorder that causes sudden, unintended and uncontrollable jerky movements of the arms, legs, and facial muscles] and/or Parkinsonism movements). These aprons will also be provided to any resident who request to use it. 8. Smoking aprons will be monitored by the smoking attendant to be in good condition. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined the facility failed to apply a physician ordered splinting device to a resident with contractures. This deficient practice was identified for 1 of 2 residents' (Resident #41) reviewed for position and mobility and was evidenced by the following: On 05/02/23 at 11:00 AM, during the initial tour of the facility Resident #41 was observed out of bed in the room in a reclining chair. The residents right hand appeared contracted, and the surveyor did not observe a hand splint or palm guard. Review of the Admission Record indicated that Resident #41 was admitted to the facility on [DATE]. Medical diagnoses included, but were not limited to traumatic brain injury, calorie malnutrition, major depressive disorder, stiffness of unspecified joint, and hypertension (high blood pressure). The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 03/23/23 which showed the residents Brief Interview of Mental Status was incomplete due to severe cognitive impairment. On 05/02/23 at 11:46 AM, the surveyor reviewed the physician orders which revealed the following active order dated 05/20/22 patient will tolerate wearing a resting hand splint on right hand for improved joint integrity and decrease risk contractures for four hours in the morning and four hours in the afternoon. Skin checks in between donning and doffing (applying and removing). On 05/02/23 at 11:54 AM, the surveyor reviewed the Treatment Administration Record (TAR), the splint was signed as applied for 05/02/23 for the morning shift. On 05/03/23 at 09:40 AM, the surveyor reviewed the care plan which showed the following focus: I will maintain current level of physical and functioning abilities. The care plan included the following intervention regarding upper extremity range of motion: o passive range of motion to bilateral upper extremities and lower extremities. The care plan was initiated 06/20/2020. On 05/03/23 at 09:53 AM, the surveyor reviewed the residents TAR. The order for the hand splint being applied was signed by the nurse as being completed, meaning the hand splint was applied on the resident. On 05/03/23 at 11:24 AM, the surveyor observed Resident #41 in the room in a reclining chair. The surveyor did not observe a splint to the residents right upper extremity. On 05/03/23 at 12:13 PM, the surveyor reviewed the most recent MDS a quarterly assessment tool dated 3/23/23. Under section G, titled functional status, it indicated that the resident had impairment of an upper extremity of one side. On 05/04/23 at 09:49 AM, the surveyor reviewed the TAR. The TAR was signed for right upper extremity splint as if it was applied on the resident. On 05/04/23 at 09:55 AM, the surveyor observed the resident in the room in a reclining chair. The resident did not have a splint to the right upper extremity. On 05/04/23 at 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) caring for Resident #41 regarding the signed TAR as the splint was applied. In the presence of the surveyor the nurse viewed the residents TAR. The section for the right upper extremity splint was reviewed by the surveyor and the LPN. The surveyor asked if it was signed did it mean the splint was applied and the LPN stated yes, it's on, we can go look now. The surveyor entered the room in the presence of the LPN and the splint was not on the resident. The surveyor then observed the LPN look in the resident's nightstand drawer and reach to the back of the drawer to retrieve the splint. The LPN said, there it is, it should be on, and proceeded to get the help of a Certified Nursing Assistant (CNA) to apply the splint. On 05/08/23 at 12:24 PM, the surveyor reviewed the policy titled, Splint/Adaptive Devices dated January 2022. The policy sated that splints/adaptive devices are to be applied as ordered by the physiatrist, attending physician, or nurse practitioner. Under number 12 of the procedure section of the policy, it indicated nursing will document splint application and or removal of the splint on the residents Treatment administration record. Number 13 indicated that nursing will discuss with therapy and/or Medical Doctor if the resident refuses the splints/adaptive devices. On 05/12/23 at 10:31 AM, the surveyor met with the Director of Nursing (DON). The DON told the surveyor that the nurse who was caring for Resident #41 told me, She did not put the splint on, she was very anxious. The DON told the surveyor that the resident will be reassessed by physical therapy to ensure that there was no negative affect by not wearing the splint. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review 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, in accordance with federal guidelines for three (3) of 38 residents, (Resident #65, Resident #104, Resident #144) reviewed for accuracy of MDS coding. This deficient practice was evidence by the following: 1. On 05/02/23 at 10:24 AM, the surveyor observed Resident #65 self-propelling in his/her wheelchair from the smoking section on the Florida unit to their room. At that time, the surveyor interviewed the resident whose speech was slightly garbled. The resident stated that he/she smoked cigarettes and the staff held his/her lighter and cigarettes for them. The surveyor reviewed the medical record for Resident #65. A review of the resident's Admission Record (an Admission Summary) reflected that the resident had resided at the facility for over five (5) years and had diagnoses which included but were not limited to Huntington's disease (an inherited disease in which nerve cells in the brain break down over time), major depressive disorder, anxiety disorder, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlargement that causes difficulty urinating). A review of the resident's most recent annual MDS, dated [DATE], indicated that the resident had a Brief Interview for Mental Status score of 03 out of 15 which indicated the resident's cognition was severely impaired. A further review of the resident's MDS, J1300 - Current Tobacco Use indicated that the resident did not smoke. A review of the resident's Safe Smoking Assessment, dated 03/07/23, indicated that the resident had impaired judgement, impaired decision making skills and impaired short-term memory. The resident's Safe Smoking Assessment further revealed that the resident did not have any physical limitations which could impact smoking or a history of other smoking related issues. A review of the resident's Care Plan (CP), initiated on 04/09/21 and revised on 04/12/23, reflected a focus area that the resident was at an increased risk of injury related to smoking. The goal of the resident's CP was that the resident would remain free from injuries from smoking. The interventions in the resident's CP included to monitor clothing for any burns from cigarette ashes, to wear a smoking apron during smoking, to use smoking extenders during smoking, and to monitor smoking apron prior to leaving the smoking area. On 05/05/23 at 10:44 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert, oriented, and could make needs known. The CNA told the surveyor that the resident was a smoker. On 05/05/23 at 11:05 AM, the surveyor made the Registered Nurse/Minimum Data Set Coordinator (RN/MDSC) aware that section J1300 was not filled out correctly. The RN/MDSC stated that she would review the resident's medical record and modify the annual MDS dated [DATE]. On 05/05/23 at 12:09 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident smoked cigarettes. On 05/09/23 at 11:17 AM, the surveyor interviewed the resident's Licensed Practical Nurse/Unit Manger (LPN/UM) who stated that the resident smoked cigarettes. 40744 2. On 05/08/23 at 10:26 AM, the surveyor interviewed Resident #104. The resident told the surveyor that when he/she came to the facility they were allowed to smoke three times a day, and few months ago it was changed to twice a day, about six months I think. The surveyor asked if the resident was a smoker since being admitted to the facility and the resident replied, yes. A review of the resident's Admission Record indicated that Resident #104 was admitted to the facility in 06/2020. Medical diagnoses included, but not limited to, Huntington's Disease (an inherited disease in which nerve cells in the brain break down over time), diabetes (high blood sugar), lack of coordination and muscle weakness. The resident had a Brief Interview of Mental Status of 15 out of 15, meaning the resident was cognitively intact. On 05/10/23 at 10:30 AM, the surveyor reviewed the resident CP which showed a focus of smoking, with potential risk for injury related to smoking. The CP was initiated on 01/29/21. On 05/10/23 at 10:50 AM, the surveyor reviewed Resident #104's annual MDS, dated [DATE]. Section J1300, titled health conditions was marked zero for tobacco, meaning the resident was not a smoker. The surveyor then reviewed the annual MDS dated [DATE], section J1300 was marked zero for tobacco, meaning the resident was not a smoker. On 05/10/23 at 11:15 AM, the surveyor interviewed the MDS coordinator regarding Resident #104. The surveyor asked the MDS coordinator how she would find out if a resident was a smoker. The MDS coordinator told the surveyor, We look at documentation, but now we are verbally asking because of the lack of documentation. The surveyor then asked the MDS coordinator to look at Resident #104's annual MDS dated [DATE], section J1300 the tobacco section. The MDS coordinator said, After it was reviewed, a modification was completed for both the annuals from 7/2021 and 7/2022. The surveyor asked when the modifications were completed, and the MDS coordinator said, yesterday 5/9/23, originally they were done incorrectly but then a modification was done on 5/9/23, after surveyor inquiry. 41679 3. On 05/02/23 at 01:07 PM, the surveyor observed Resident #144 returning from the smoking area and was sitting in his/her room with a blanket over their head seated in a wheelchair. Resident #144 confirmed with the surveyor that he/she was a smoker but did not want to talk any further. The surveyor reviewed the medical record for Resident #144. On 05/02/23 at 01:37 PM, a review of the resident's Admission Record (an Admission Summary) reflected that the resident was admitted ,d+[DATE] and had diagnoses which included but were not limited to Huntington's disease (an inherited disease in which nerve cells in the brain break down over time), pneumonia, dysphagia, psychiatric/mood disorder (anxiety disorder/psychotic disorder), muscle weakness, obstructive and reflux uropathy, and implants and grafts. On 05/12/23 at 12:53 PM, a review of the resident's most recent annual MDS, dated [DATE], indicated that the resident had a Brief Interview for Mental Status score of 13 out of 15 which indicated the resident's cognition was cognitively intact. A further review of the resident's MDS, Section J1300 under Current Tobacco Use was coded 0 and indicated that Resident #144 was not identified as a smoker on the MDS, which was coded incorrectly. At that same date and time, the surveyor reviewed the resident CP which showed a focus of smoking, with potential risk for injury related to smoking. The CP was initiated on 12/30/22. On 05/12/23 at 11:05 AM, the surveyor interviewed the Social Worker (SW) in the MDS Coordinator's absence and made the SW aware that Section J1300 of the MDS did not identify Resident #144 as a smoker and was not coded correctly. The SW confirmed the MDS was initially not coded correctly but provided the surveyor with a copy of the modified annual MDS dated [DATE]. A review of CMS RAI Version 3.0 Manual, Section J - Health Conditions indicated in J1300: Current Tobacco Use, that the negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life. In planning for care, this item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed. Facility staff is to conduct an assessment and ask the resident if he or she used tobacco in any form during the seven (7) day look-back period. If the resident states that he or she used tobacco in some form during the 7-day look-back period, code 1, yes. If the resident is unable to answer or indicates that he or she did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions indicated to code 0 for no, indicating the resident did not smoke and 1 for yes, indicating that the resident did smoke. NJAC 8:39-11.2(e)1

Based on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident # 124), reviewed for hospitalization s. This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident # 124. Review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to coronary artery disease, heart failure, diabetes, and hyperlipidemia. Review of the New Jersey Universal Transfer Form (NJUTF) dated 01/30/23 indicated the resident was transferred to the hospital for lethargy and weakness, abnormal labs and low pulse OX. Review of the Minimum Data Set (MDS) dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the NJUTF dated 02/21/23, indicated the resident was transferred to the hospital for fever. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the NJUTF dated 03/22/23, indicated the resident was transferred to the hospital for an elevated temperature and an increase in weakness. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. On 05/11/23 at 12:29 PM, the surveyor interviewed the front desk receptionist (FDR) who stated she was responsible for notifying the residents and resident representatives of the facility's bed-hold policy and notice of transfers. She stated she began her position as the FDR approximately 2 years ago and started sending the notifications out about 4 weeks ago, in April. The FDR stated before her the Social Worker (SW) was the staff who sent out the last notifications. On 05/11/23 at 12:33 PM, the surveyor interviewed the SW who stated she began her position as the SW, [AGE] years ago. The SW confirmed that she was one of two staff responsible for notifying the Long-Term Care Ombudsman (LTCO) office of emergency transfer(s) and discharges on a monthly basis but confirmed the facility had not completed them for a long time before March 2023 due to staffing. On that same date at 12:48 PM, the FDR provided the surveyor with one Notice of Transfer for Resident #124 dated 03/22/23. The FDR could not provide any documented evidence of the Notice of Transfer notices sent to the resident representative or the LTCO for 01/30/23 and 02/21/23. On 05/11/23 at 12:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the above findings. There was no additional information provided. Review of the facility's policy for Notice Requirements for Transfer/Discharge of a Long-Term Care Resident include that the notice of transfer or discharge form will be completed by the nursing/social services department. The resident/responsible party will be notified. Resident discharge list will be emailed to the Ombudsman office on a monthly basis. NJAC 8:39-5.3; 5.4

Complaint # NJ00163390 Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) maintain a clean, comfortable, homelike environment on the Florida unit, b.) maintain privacy curtains free from stains in a resident's room c.) maintain cleanliness behind the blinds in a resident's room, and d.) paint over the spackle in a resident's room. This deficient practice was identified for two (2) of 36 resident's, (Resident #4 and Resident #33) and on one (1) of four (4) nursing units, (Florida unit) reviewed for clean, comfortable, homelike environment. The deficient practice was evidenced by the following: 1.) On 05/04/23 at 10:39 AM, the surveyor toured the Florida unit and observed that the gold-colored wallpaper to the right of room [ROOM NUMBER] was ripped from the wall leaving a white mark. On 05/05/23 at 11:49 AM, the surveyor toured the Florida unit in the presence of the Maintenance Director (MD). The MD observed the area and stated that it was hard to patch the wallpaper, but he would fix it as soon as he could. On 05/04/23 at 10:43 AM, the surveyor observed on the Florida unit in between rooms [ROOM NUMBERS], scratches in the wall underneath the handrail. [NAME] indentations and holes were observed on the wall. On 05/05/23 at 11:50 AM, the surveyor toured the Florida unit with the MD who observed the scratches in the wall in between rooms [ROOM NUMBERS]. The MD stated that the wall needed to be spackled and painted. On 05/04/23 at 10:45 AM, the surveyor observed on the Florida unit, white indentations and scratches at the bottom part of the wall, underneath the handrail between room [ROOM NUMBER] and the day room. On 05/05/23 at 11:52 AM, the surveyor toured the Florida unit with the MD who observed the scratches and indentations at the bottom part of the wall, underneath the handrail between room [ROOM NUMBER] and the day room who stated that the wall was patched up, less than a year ago, last May, but needed to be touched up again. On 05/04/23 at 10:47 AM, the surveyor toured the Florida unit and observed a hole in the brown molding attached to the wall by the floor in between rooms [ROOM NUMBERS]. The surveyor further observed scratches and white indentations on the wall underneath the brown molding. On 05/05/23 at 11:53 AM, the surveyor toured the Florida unit in the presence of the MD who observed the hole in the brown molding attached to the wall by the floor in between rooms [ROOM NUMBERS]. At that time, the MD stated that he didn't know how long it had been that way. The MD looked at the scratches and indentations in the wall and stated that, it needed to be patched up. On 05/04/23 at 10:51 AM, the surveyor toured the Florida unit and observed scratches and holes in the wall, slightly above the brown molding attached to the floor in between rooms [ROOM NUMBERS]. On 05/05/23 at 11:55 AM, the MD observed the scratches and holes in the wall, slightly above the brown molding attached to the floor in between rooms [ROOM NUMBERS] in the presence of the surveyor. The surveyor observed the MD touch the wall and white debris was observed falling onto the floor. The MD stated that the wall needed to be patched up too. On 05/04/23 at 10:52 AM, the surveyor observed on the Florida unit underneath the handrail in between rooms [ROOM NUMBERS] brown and white indentations throughout the wall. On 05/05/23 at 11:56 AM, the MD observed the brown and white indentations in the wall between rooms [ROOM NUMBERS] with the surveyor and stated that the wall needed to be spackled and painted. On 05/04/23 at 10:54 AM, the surveyor observed in the day room on the Florida unit dents throughout the white trim in the room. The surveyor further observed wallpaper peeling underneath the light switch. On 05/05/23 at 11:57 AM, the surveyor entered the day room on the Florida unit with the MD who stated that if he painted the bottom of the trim in the day room, it would be dented in three (3) days and that the material of the trim should be plastic and not wood, due to the resiliency of the plastic. The MD told the surveyor that he could patch up the wallpaper with tape. On 05/04/23 at 10:55 AM, the surveyor observed scratches halfway up the door on the shower room door on the Florida unit. On 05/05/23 at 11:58 AM, the MD observed the scratches on the shower room door on the Florida unit and stated that he could use paint to fix it and put a water based poly (polyurethan, a material that coats an area making the area more durable) to seal the paint. On 05/04/23 at 10:56 AM, the surveyor observed on the Florida unit white, red, and brown discolorations throughout the tile in front of the nurse's station. The surveyor further observed scratches throughout the brown exit doors towards the right of the nurse's station. On 05/05/23 at 12:00 PM, the MD observed the tile in the presence of the surveyor and stated that the housekeeping department was responsible for cleaning the tile. The MD further stated that he was unsure what the white [NAME] on the door were, the door wasn't painted often, but could probably use a touch up. On 05/04/23 at 12:06 PM, the surveyor observed white stains in the center of the right door in the front hall of the Florida unit On 05/05/23 at 12:01 PM, the MD observed the white stains on the doors in the presence of the surveyor and stated that the doors needed a touch up. On 05/05/23 at 08:41 AM, the surveyor observed on the Florida unit white [NAME] and scratches on the wallpaper in between room [ROOM NUMBER] and room [ROOM NUMBER]. On 05/05/23 at 12:05 PM, the MD observed the white [NAME] and scratches on the wallpaper between rooms [ROOM NUMBERS] in the presence of the surveyor. On 05/05/23 at 08:45 AM, the surveyor toured the Florida unit and observed an indentation in the wall to the left of room [ROOM NUMBER]. There was a rectangular white box observed over the indentation and the area surrounding the white box was observed to be caving into the wall. On 05/05/23 at 12:04 PM, the MD observed the indentation in the wall in the presence of the surveyor. The MD told the surveyor that the facility used to have lights there and the hole got too big, so they had to put a bigger plate there for now before the unit was redone. On 05/09/23 at 11:11 AM, the surveyor interviewed the Florida unit Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the maintenance department was responsible for fixing anything that was broken. The LPN/UM told the surveyor that if staff working on the unit identified that anything was broken, they would call maintenance to notify them and put it in the maintenance book on the unit. The LPN/UM explained that the Administration and Infection Preventionist rounded the unit monthly and made a list of things that needed to be fixed. Once the list was constructed, it would then be delegated to the different departments to delegate who was responsible for fixing what. The LPN/UM further stated that the maintenance department was responsible for fixing scratches, holes in walls, paint discoloration, and broken furniture. The LPN/UM stated that the expectation would be to hopefully fix things when they came up or monthly. The LPN/UM stated that, it had been quite a few years since the Florida unit had been renovated and the unit takes quite a beating. On 05/09/23 at 12:25 PM, the surveyor interviewed the Housekeeping Director (HD) who stated that he made rounds on the unit daily. On 05/12/23 at 11:01 AM, the Administrator stated in the presence of the survey team that the maintenance department was short on staff, and he was in the process of hiring more staff. The Administrator stated that the Florida unit needed someone there to fix it very often and that sometimes they would fix something and then have to fix it again right away. A review of the May 2023 Florida unit Maintenance Log did not include any of the above observations documented in the log that needed repair. A review of the Maintenance Director's Job Description and Performance Standards dated 07/12/22 indicated that the purpose of the position was to, develop and implement facility maintenance policies and procedures in an efficient, cost-effective manner to meet safely meet resident's needs in compliance with federal, state, and local requirements. A further review of the Maintenance Director's Job Description revealed that the MD was responsible for developing and implanting repair and maintenance schedules for all the areas of the facility grounds and supervising the schedule for repair and maintenance by contractors. 2.) On 05/02/23 at 10:26 AM, the surveyor observed Resident #21 in their room. The surveyor observed that the privacy curtain between Resident #21 and his/her roommate was light peach in color and had light brown stains throughout. On 05/03/23 at 12:08 PM, the surveyor observed the resident in their room seated in a high back wheelchair. The surveyor observed that the privacy curtain between Resident #21 and his/her roommate was light peach in color and had light brown stains throughout. 05/04/23 11:42 AM, the surveyor observed the resident in his/her room seated in their high back wheelchair. A staff member was in the room feeding the resident, seated next to the resident's wheelchair. At that time the surveyor observed that the privacy curtain between Resident #21 and his/her roommate was light peach in color and had light brown stains throughout. The surveyor further observed that the bottom part of the privacy curtain by the door in the resident's room had a red stain on it and browns stains throughout. The surveyor reviewed the medical record for Resident #21. A review of the resident's Admission Record (an Admission Summary) reflected that the resident had resided at the facility for over a decade and had diagnoses which included but were not limited to Huntington's disease (an inherited disease in which nerve cells in the brain break down over time), COVID-19, anxiety disorder, essential hypertension (high blood pressure), and dysphagia (difficulty swallowing). A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment toll used to facilitate the management of care dated 03/14/23 indicated that the resident's Brief Interview for Mental Status (BIMS) score was 03 out of 15 which indicated the resident's cognition was severely impaired. On 05/05/23 at 09:55 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that they changed the privacy curtains in the resident's room the night before (05/04/23). On 05/05/23 at 11:35 AM, the surveyor interviewed the housekeeper working on the Florida unit who stated that it was her job to change the privacy curtains in the resident's rooms. On 05/09/23 at 10:52 AM, the surveyor conducted a follow up interview with the resident's LPN who stated that it was the responsibility of the housekeeping department to change the privacy curtains in the resident's rooms. The LPN told the surveyor that if the nursing staff noticed that the privacy curtains were dirty, the nursing staff would tell the housekeeper verbally when they saw them or document in the housekeeping communication book on the unit. The LPN further stated that if she directly spoke with the housekeeping staff, she would not document the request in the housekeeping book. On 05/09/23 at 11:09 AM, the surveyor interviewed the Florida unit LPN/UM who stated that if staff noticed that the privacy curtains in the resident's room were dirty, the staff would call and notify the HD or document it in the housekeeping book for the unit. The LPN/UM further stated that the housekeeping department had a routine schedule where every room on the unit was deep cleaned once monthly and at that time the privacy curtains in the resident's rooms would be changed. On 05/09/23 at 12:25 PM, the surveyor interviewed the HD who stated that he made rounds on the Florida unit every day and would look at everything including the cleanliness of medication carts, resident's wheelchairs, and the floors. The HD told the surveyor that the resident's rooms were deep cleaned every month and the privacy curtains in the resident's rooms would be changed at that time and when a resident was discharged from the facility. The HD explained that it was the housekeeping departments responsibility to change the privacy curtains and the Administration was aware that some of the privacy curtains were stained. A review of April 2023 and May 2023 housekeeping book did not indicate that the nurses documented that the privacy curtain needed to be changed in Resident #21's room. A review of the HD Job Description and Performance Standards dated 12/20/22 indicated, the purpose of this position is to implement effective, efficient systems to operate the housekeeping department in a cost-effective, efficient manner to safely meet residents' needs in compliance with federal, state, and local requirements. A review of the facility's House Keeping In-Service, Complete Room Cleaning dated 01/01/00, indicated, cubicle curtains - check and report any soil or damage to supervisor. 40744 3.) On 05/08/23 at 1:14 PM, the surveyor entered room [ROOM NUMBER] on the [NAME] Unit at the request of Resident #33. The surveyor observed a wall in the room with an area of spackle, approximately 4 feet long by six inches wide. The surveyor asked the resident if the facility recently started working on the wall and the resident told the surveyor, Been like that since I came in the room in 2020. The surveyor also noticed multiple sections of peeling wallpaper, which was a decorative border on three of the four walls. On the window blinds one small section of a blind slat was missing, approximately 5 inches on the right side, and when the blind was moved there was a buildup of a black substance on the back of the window blind. On 05/09/23 at 11:30 AM, the surveyor interviewed Maintenance Worker #1 (MW#1) and Maintenance Worker #2 (MW#2) and asked if there was a process of routine maintenance in the resident rooms or routine maintenance rounding. The MW #1 told the surveyor there was a binder that staff would write down what needed to be fixed and the binder was checked in the morning and again later in the day. The surveyor asked what would happen if there was an urgent need for a repair and MW#1 said, the staff would page us overhead. The surveyor entered room [ROOM NUMBER] on the [NAME] Unit with MW #1 and MW #2 with Resident #33 permission. The surveyor asked about the spackled areas on the wall. MW#1 said, the guy who worked here before must have done that, maybe two months ago. MW#2 told surveyor that maybe it was done 5 months ago. MW#1 told the surveyor The maintenance director should know; he is on the roof right now. The surveyor asked MW#1 to provide more information if available. No further information was provided to the surveyor. NJAC 8:39-31.2(e), 31.4 (a)(f)

NJ00154373 Based on interview and review of facility documentation, it was determined that the facility failed to follow upcoming policy changes within the timeframe provided to residents. This deficient practice was identified for 1 of 5 residents reviewed for smoking (Resident #104) and was evidenced by the following: On 05/08/23 at 10:26 AM, the surveyor interviewed Resident #104. The resident told the surveyor that when he/she came to the facility residents were allowed to smoke three times a day, and a few months ago it was changed to twice a day, about six I think. Resident #104 said, There are days when we can't smoke at all, maybe every other month because the staff doesn't show up. The resident could not give specific dates when the smoking was suspended. At the same time, the surveyor reviewed the residents complaint which indicated the residents were not allowed to smoke on 04/27/22. Review of the Admission Record showed that Resident #104 was admitted to the facility on ,d+[DATE]. Medical diagnoses included, but not limited to Huntington's disease (a condition that damages nerve cells in the brain), diabetes mellitus (high blood sugar), Covid 19 (respiratory illness caused by a virus), unspecified lack of coordination, and muscle weakness. Review of the quarterly Minimum Data Set, (an assessment tool) dated 4/2/23 indicated the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 05/08/23 at 10:37 AM, the surveyor reviewed Resident #104's paper chart. The surveyor reviewed the quarterly smoking assessments which indicated the resident was a safe smoker since admission to the facility 06/2020. The last quarterly smoking assessment that was reviewed was on 4/23/23. On 05/09/23 at 10:29 AM, a surveyor interviewed the Director of Activities (AD)regarding smoking. The AD told the surveyor that at one point in time, the residents were smoking three times a day. The surveyor asked the AD when the times changed, and the AD was unsure of specific dates but said it's been well over a year. The AD said when the smoking times changes, all the residents were educated, and a trial run was done prior so they could get used to it, and to see if they had any questions. The residents all signed agreements acknowledging the new rules, and it was also reflected in the resident's care plan. On 05/09/23 at 10:54 AM, the surveyor reviewed Resident #104's care plan which showed the following focus regarding smoking: The smoking program will be reduced from 3 sessions a day to 2 sessions a day. We will be eliminating the afternoon session. If the current staff that were to call out from work for the day, we will do our utmost to cover the position for that day but if we are unsuccessful, we may have to suspend the program for that day. The care plan had a revised date of 04/19/23. On 05/10/23 at 10:36 AM, the facility provided progress notes from the social worker stating she met with Resident #104 on 4/19/22 to inform the resident of a change in smoking policy. The social worker explained to the resident that the changes would take effect in 30 days. The resident was told that there might be days when smoking would be eliminated if there were not staff available for supervision. It was documented that the resident understood although displeased with the change. The administrator also sent an email regarding the changes which were to take effect 30 days from 04/19/22. At the same time, the resident's care plan was revised to include the changes. On 05/10/23 at 11:00 AM, the surveyor reviewed an email sent to resident representatives informing them of the upcoming smoking changes to take place 30 days from 04/19/22. The email read that the notification on April 19, 2022, was a 30-day notice and the new smoking schedule would go into effect after 30 days. On 05/10/23 at 11:15 AM, the surveyor reviewed the Smoke Room policy, dated January 22, 2021. The policy did not include a statement saying that if no staff were available smoking would be suspended for the residents. The surveyor then reviewed the revised policy, dated May 13, 2022, which then included that if a smoke room attendant is unable to work their shift and coverage is unattainable, no smoking will be provided for the day. NJAC 8:39-31.6 (e, 3)