Every finding on record at Maple Glen Center

Based on observation, interviews, and a review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents to ensure adequate facility resources to provide resident care and services. These failures had the potential to affect all 122 residents who currently live in the facility during the time of the survey. This deficient practice was evidenced by the following:During the entrance conference on 8/26/25 at 9:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to Facility Assessment (FA). Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 122.On 8/26/25 at 12:19 PM, the LNHA provided the surveyor a 35 page FA which included the following:Resident Population Profile-8/7/23-8/6/24Data included the amount of Admissions/Stays, % of Admissions/Stays and Frequency Relative to Benchmark which was rated as N/A, low, very low, high or very high. Additional data under each area of Sufficiency Analysis Categories for Overall Staffing, Staff Training/Competencies/Skill Sets and Services indicated that each was evaluated. There was no additional information for staffing and a staffing contingency plan.The surveyor asked the LNHA if the FA that was provided was the most up to date and included all the information. The LNHA stated that he would check and provide the surveyor the updated one if the one provided was not the correct one. On 9/2/25 at 11:15 AM, the LNHA provided the surveyor the FA with 8/7/23 to 8/6/24 handwritten on the front page. A review of the provided FA included the original 35 page document provided earlier and additional documents that included reports, meetings, sign in sheets and schedules. The provided documents did not include information about staffing amounts related to the resident population, required staffing ratios or a staffing contingency plan. On 9/2/25 at 11:30 AM, the surveyor notified the LNHA, the DON and the Clinical Lead of New Jersey (CLoNJ) the concern that the FA had not been updated annually and that it did not contain information about staffing amounts related to the resident population, required staffing ratios and a staffing contingency plan. On 9/02/25 at 1:02 PM, in the presence of the DON and CLoNJ, the LNHA stated that the FA had not been updated. The LNHA gave additional staffing reports and schedules. The additional documentation did not include a staffing contingency plan or any information on required staffing ratios. The LNHA did not provide any additional information. A review of the facility's Facility Assessment Policy with a reviewed date of 8/7/24, included the following:PolicyCenters will conduct and document a facility-wide assessment. The Center will review and update the assessment annually and whenever there is, or the Center plans for, any change that would require a substantial modification to any part of the assessment.The FA must address or include:The Center's patient/resident (hereinafter patient) population, using evidence base, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity (level of severity of patients; illnesses; physical, mental and cognitive limitations and conditions), and other pertinent facts that are present within that population that may affect the services the Center must provide;Staff competencies and skill sets necessary to provide the level and types of care needed for the patient population:.PurposeTo determine resources necessary to competently care for patients suring both day-to-day operations and emergencies.3. The Administrator will lead the FA Team to:3.1 Use the findings of the Assessment to:3.1.1 Determine staffing levels to ensure sufficient number of qualified staff are available to meet each patient's needs;.3.1.4 Inform contingency planning for events that do not require activation of the Center's emergency plan, but do have the potential to affect patient care, as such, but not limited to availability of direct care nurse staffing and other resources needed for patient care. N.J.A.C. 8:39-5.1(a); 27.1

Based on observations and interviews on 8/27/25 and 8/28/25 in the presence of the Senior Maintenance Director (SMD) and Maintenance Director (MD), it was determined that the facility failed to ensure that the resident call bell system was properly functioning in all areas. This deficient practice had the potential to affect all (122) residents and was evidenced by the following:Observations on 8/27/25 from 12:44 PM to 12:50 PM, revealed:The call bell system failed to activate for room [ROOM NUMBER] when tested by the MD. The light outside of the room did not turn on, and no audible or visual notification was given at the nurse's station.The call bell system failed to activate for room [ROOM NUMBER] when tested by the MD. The light outside of the room did not turn on, and no audible or visual notification was given at the nurse's station.In an interview at the time, the MD confirmed the observation.The MD then inspected the annunciator panel at the nurse's station. Although the screen was powered on, the call bell system was inactive. Once accessed, the panel displayed a Fault condition for the following locations:410 Bathroom, 409 Pull Station, 406 Bathroom, 414 Bed station, 404-B Bed Station, and 410-A Bed Station.The MD proceeded to restart the system.An observation at 12:50 PM, revealed that the call bell system for room [ROOM NUMBER] functioned properly after the system was reset.An observation at 1:17 PM, revealed that the call bell failed to give audible notification of activation at the nurse's station on Unit 3.In an interview at the time, the SMD confirmed the observation.Two staff members at the nurse's station at the time stated that they typically rely on the annunciator for alerts but confirmed that they could not hear the shower room activation, and they were unaware that we were testing it. Upon further inspection, the SMD discovered that the audio connection was not properly attached. Once corrected by the SMD, the annunciator panel gave audible notifications.An observation at 1:30 PM, revealed that the call bell system on Unit 2 did not correctly identify rooms by their numbers. Activation of the call bell displayed as device 4644-B instead of room [ROOM NUMBER].In an interview at the time, the SMD and MD confirmed the observation.Observations on 8/28/25 from 10:15 AM to 10:20 AM, revealed that the call bell activations of room [ROOM NUMBER] and 106 failed to give audible notification of activation at the nurses' station.In an interview at the time, the MD confirmed the observation.The MD then inspected the annunciator panel at the nurse's station. Although the screen was powered on, the call bell system was inactive. Once accessed, the panel displayed a Fault condition for the following locations:109 Bathroom station, 111-B Bed Station, 101 B- Bed Station, 113-A Bed Station.These faults had been active since 7/30/25 at 8:22:49 AM. Additionally, 106 - A Bed Station showed a fault condition since 8/14/25.Observations from 10:22 AM to 10:25 AM, revealed:. 109 bathroom and 113-A Bed Station failed to produce any audible or visual alerts when tested by the MD. 111-B Bed Station was missing a call bell cord entirely.In an interview at the time, the MD confirmed the observations and stated that the missing cord would be replaced immediately.The facility's Administrator, SMD and MD were informed of the deficient practice at the Life Safety Code exit conference on 8/28/25 at 2:00 PM. N.J.A.C 8:39-31.2(e)

Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 2 of 4 nursing units (Units 2 and 3) observed during environment tour. This deficient practice was evidenced by: 1.On 8/27/25 at 11:35 AM, Surveyor #1 (S#1) with Licensed Practical Nurse #1 (LPN#1) went inside Resident room [ROOM NUMBER] (RR#208) and observed the following: The dresser top area with used coffee cup and plastic wrappers. The 1st drawer of the dresser near the window with peeled wood and there was a coffee cup that was mixed with resident's unfolded clothes. LPN#1 stated that the peeled wood needed a glue. The 2nd drawer of the dresser with small food plastic container (with dried food) that was mixed with unfolded clothes. LPN#1 stated that was probably food that was brought by Resident's Responsible (RR) party and should have been thrown out to garbage. There was a fly inside the resident's room. The bottom drawer with chipped wood and LPN#1 stated that she would notify maintenance department about it. The wall clock was set at 12:07 (the clock was not moving). LPN#1 stated that it was a wrong time and would ask maintenance department for a battery. Inside the toilet room, there was a hole on the ceiling. LPN#1 was unable to state why it was left open. The molding on the toilet floor was peeling off. On that same date and time, LPN#1 stated that she would notify the maintenance department about the environmental concerns inside RR#208. LPN#1 further stated that usually staff enter in computer the work to be done by maintenance department and she was unsure if someone had reported the environment concerns inside RR#208. On 8/27/25 at 11:50 AM, S#1 asked the Registered Nurse/Unit Manager of Unit 2 with regard to facility's practice about reporting environmental concern. The RN/UM confirmed that it was being done electronically, and she stated that she was unaware of those reported concerns with RR#208, unless other staff had reported it. She also stated that it would be maintenance department who can answer those concerns. At that same time, the RN/UM confirmed that the RR were responsible for bringing outside food to RR#208, and the last time probably they were here was over the weekend on Saturday. S#1 asked who was responsible to ensure that there was no garbage mixed in resident's clothes, and she responded it would be the aides. S#1 asked if the aides were responsible for ensuring the resident's dresser was organized and clean, why there was a food container with food residue in the resident's drawer if that was from Saturday, and the RN/UM did not respond. On 8/29/25 at 9:31 AM, Surveyor #2 (S#2) notified the Director of Maintenance (DoM) of the above findings and concerns. The DoM informed S#2 that he was unaware of the issue with furniture of RR#208. The DoM also stated that the facility ordered each month a new set of furniture to replace but he had not been getting recently from the supplier. He further stated that the last order of new furniture was received in March 2025 and last one was delivered on July 3rd. On that same date and time, the DoM stated that the furniture in the facility was about 16 years, the goal was to replace dated furniture, and was able to do for about eight months. He further stated that he would follow up regarding the resident's dresser. In addition, the DoM informed S#2 that the maintenance department checked residents' clock only during day light savings time. He stated that he was unaware of the ceiling tile hole in RR#208's toilet room, and he was trying to figure out when and what happened. He further stated that he fixed the hole after surveyor's inquiry. On 8/29/25 at 11:40 AM, S#1 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ) of the above findings and concerns. On 9/2/25 at 11:04 AM, the survey team met with the LNHA, DON, and CLoNJ, and the LNHA informed the surveyors that the facility was in a process of renovating residents' bathroom. The LNHA stated that in RR#208, deep cleaning, replaced the dresser drawer with torn corner, ceiling was fixed, and checked all clock in the entire building to ensure they were functioning after surveyor's inquiry. 2. On 8/26/25 at 11:14 AM, S#2 observed Resident #112 lying in their bed, alert, and verbally responsive. The resident verbalized that the toilet was loose. Resident #112 also reported that the shower curtain in the shower room was dirty with a dark discoloration. On 8/26/25 at 11:16 AM, S#2 observed in Resident #112's bathroom, the toilet was slightly wobbled with applied pressure and the bathroom floor had a discoloration, black/gray in color, in front of the toilet and sink. The bathroom floor was dry. On 8/27/25 at 11:15 AM, S#2 observed in Resident #112's bathroom the above concerns remained. On 8/27/25 at 11:21 AM, S#2 interviewed Licensed Practical Nurse #2 (LPN#2) from Unit 3, who was assigned to care for the resident. LPN#2 stated staff reported maintenance concerns via a telecommunication maintenance system (TMS; an application used for reporting and tracking maintenance and building work) to maintenance staff who would address the issue. S#2 asked LPN#2 if she was aware of any issue with the bathroom in Resident #212's room. LPN#2 replied that she was not aware of any issue and was not sure if it was a reported issue previously as she was not the regular nurse and work on different units. At that same time, LPN#2 accompanied S#2 to Resident #112's bathroom and the residents in the room were at their bedside. Resident #112 shouted out the toilet rocks as S#2 and LPN#2 entered the bathroom. LPN#2 confirmed the discoloration on the bathroom floor. LPN#2 stated she did not know how it occurred, how long it was there, and did not really notice it before. S#2 and LPN#2 checked the toilet and confirmed the toilet slightly wobbled with applied pressure. S#2 and LPN#2 exited the resident's room. LPN#2 stated the concerns with the toileted had not been previously reported to her. LPN#2 explained the residents in the room were alert and verbalized to staff if there were any concerns. LPN#2 stated she did not know if the issue was previously reported to staff as she was not the regular nurse on the assignment, and it would be in the TMS if it was. On 8/27/25 at 11:50 AM, S#2 accompanied by LPN#2 toured the shower room located in front of unit 3's nurses' station (shower room [ROOM NUMBER]). S#2 observed the shower curtain which had discoloration dark brown to black in color towards the bottom of the curtain and an end of the curtain had a torn corner of material missing. On 8/27/25 at 11:57 AM, S#2 interviewed the Housekeeper (HK) working on the unit. The HK was asked about stain on Resident #112's bathroom floor. The HK stated the discoloration on the floor had been there for a long time and could not recall since when. The HK explained her supervisor, the Environmental Services Manager (ESM), was aware of the discoloration and tried to remove it. The HK stated she thought that the ESM followed up with the Maintenance Director about it but was not sure. The HK was not aware of any issue with the toilet in the bathroom. At that time, S#2 asked the HK about who was responsible for the maintenance and changing of shower curtains. The HK stated she was not sure who was responsible and that she had never changed the shower curtains in the shower rooms. On 8/27/25 at 1:58 PM, S#2 requested from the LNHA the TMS report for the last six months to indicate work order reports. On 8/27/25 at 12:03 PM, S#2 interviewed ESM about the observed concerns in Resident #112's bathroom and the shower room. The ESM stated he was unsure how the discoloration occurred. The ESM explained he tried to remove the discoloration with cleaning agents and degreaser, but it did not come out. The ESM stated he mentioned to the DoM about the issue as the floor would need to be replaced. The ESM further explained that he mentioned the issue to the DoM, but they did not really discuss a plan for the floor. The ESM accompanied S#2 to shower room [ROOM NUMBER] to observe the shower curtain. The ESM confirmed the shower curtain was soiled with discoloration dark in color and a corner of the end of the curtain was missing. The ESM stated the facility's maintenance was responsible for maintaining and changing the shower curtains. S#2 asked the ESM if housekeeping was aware of the issue and if it was reported to maintenance. The ESM stated maintenance was made aware, approximately a couple of weeks ago. On 8/29/25 at 9:31 AM, S#2 interviewed the DoM who stated that if an issue was reported about a shower curtain, a replacement would be ordered, and the maintenance staff would change the curtains. On that same date and time, S#2 discussed and showed the picture of the observed shower curtain. The DoM confirmed the curtain was soiled and that the curtain should not be in that condition. The DoM stated he was not informed by anyone of shower room [ROOM NUMBER]'s curtains and that housekeeping was responsible for checking the curtain's condition and notifying maintenance. At that time, S#2 asked the DoM about Resident #112's bathroom floor discoloration. The DoM stated he was aware of the issue. The DoM explained that if there was a stain on the floor, housekeeping tried to remove, if unsuccessful then a vendor would be called to try to deep clean or replace the flooring. S#2 discussed interview with HK staff about attempts to clean and mentioning to maintenance. The DoM acknowledged it was mentioned by housekeeping and a plan for the floor was never discussed. The DoM further explained that he did not discuss with the LNHA about the plan for the floor which may need to be replaced. The DoM stated regarding the toilet in Resident #112's bathroom, he was not aware of the issue until informed by LPN#2 two days ago, after surveyor's inquiry. On 8/29/25 at 11:30 AM, S#2 reviewed the provided TMS report of the last six months which revealed no work order related to the toilet being loose or the discoloration on the floor of Resident #112's bathroom. There was no work orders noted for shower curtains. On 8/29/25 at 11:39 AM, S#2 notified the LNHA, the DON, and the CLoNJ about the above concerns. The LNHA stated the shower curtains were replaced. S#2 asked who was responsible for maintaining the curtains, and the LNHA stated that housekeeping was responsible for cleaning the curtains and were to inform maintenance if they needed to be replaced. On 9/2/25 at 11:04 AM, the LNHA, the DON, and the CLoNJ met with the survey team. The LNHA stated that the Resident #112's bathroom floor and toilet redone to address concerns. 3. On 8/26/25 at 10:13 AM, S#1 observed Resident #14 lying on the bed, observed a clock hanging on the wall above the resident's bed. The clock's two hands were frozen at 3:31. On 8/29/25 at 12:41 PM, Surveyor #3 (S#3) in the presence of the RN/UM of Unit 2, entered Resident's #1's room and observed the clock on the wall, above the bed with the time stuck at 3:31, and the hands were not moving. The resident entered the room and sat down on the bed and confirmed that the clock was not working. S#3 asked the resident and the RN/UM how long it had not been working, and the resident did not reply. The RN/UM was unable to state how long it was not working. S#3 asked if there was a work order put in for the clock not working and the RN/UM replied, I did not put one myself, but I will let maintenance know now to fix it. On 9/2/25 at 10:23 AM, the LNHA reviewed with S#3 the electronic system for work orders for 7/1/25-8/2/25, and found no work order entered for Resident #14's clock. The LNHA stated We replaced all the batteries in the clocks last Friday. The LNHA further stated that the Housekeeping Director went around and replaced each clock. He also added that he went personally around yesterday to make sure it was completed. S#3 notified the LNHA regarding Resident's #14 clock not working on the initial tour on 8/26/25 by S#1 and was again observed on Friday 8/29/25 (3 days later) by S#3 that the clock was still not working. On 9/2/25 at 11:40 AM, the survey team met with LNHA, DON, RCLoNJ, and the MDS (Minimum Data Set) Coordinator, and S#3 notified the administrative staff regarding Resident #14's clock not working and was confirmed by the RN/UM. A review of the facility's Accommodation of Needs Policy that was provided by the CLoNJ, with revision date of 2/1/23, revealed, the resident has the right to safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.Process:.1.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 1.2.1 Ensure that furniture and fixtures in common areas frequented by patients are accommodating of physical limitations of patients.the Center's efforts to individualize the patient's physical environment. This includes the physical environment of the patient's bedroom and bathroom, as well as individualizing as much as feasible the Center's common living areas . On 9/2/25 at 1:31 PM, the survey team met with the LNHA, DON, and CLoNJ for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-31.2(d)(e), 31.4(a)(f)

REPEAT DEFICIENCYBased on interview and record review, it was determined that the facility failed to submit the Minimum Data Set (MDS) assessments in a timely manner for 2 of 27 residents reviewed (Resident # 74 and Resident #109).The deficient practice was evidenced by the following:On 8/29/25 at 10:16 AM, the surveyor reviewed the most recent MDS's, an assessment tool used to facilitate the management of care, for the timeliness of submission for three system-selected residents.Information in the electronic medical record and additional information provided by the facility revealed the following for two of the residents:1. Resident #74 had a discharge (d/c) MDS with an Assessment Reference Date (ARD) of 3/28/25. The MDS was completed but had not been submitted.2. Resident #109 had a d/c assessment with an ARD of 4/9/25. The assessment had been inactivated after completion and was not submitted.On 8/29/25 at 10:52 AM, the surveyor interviewed the MDS Coordinator (MDSC) regarding the residents' d/c MDS. The MDSC stated that she had started at the end of May. The MDSC stated that a d/c MDS should be submitted (transmitted) as it was completed as much as possible. The MDSC stated that she follows the RAI manual. The surveyor requested information regarding Resident #74 and #109. On 8/29/25 at 12:07 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and Clinical Lead of New Jersey (CLoNJ) the concern that Resident #74's and Resident #109's d/c MDS were not submitted. On 8/29/25 at 12:31 PM, the MDSC stated that the previous MDSC might have just hit no instead of yes to transmit the d/c MDS for Resident #74. She stated that she could not give an answer about Resident #109's d/c MDS. On 9/2/25 at 11:04 AM, in the presence of the LNHA, DON and CLoNJ, the MDSC stated that she transmitted Resident #74's d/c MDS after surveyor inquiry. The MDSC stated that Resident #109's d/c MDS was inactivated in error. She added that the plan was to activate it and transmit it. The LNHA did not provide any additional information.A review of the facility's MDS Remote Completion Policy with a review date of 12/16/24, included the following:PolicyCenters will follow all .System Processes related to MDS 3.0 completion. Centers will also follow the RAI (Resident Assessment Instrument) Manual for instructions for completing the assessment process.PurposeTo ensure compliance with the RAI process and timely completion of the MDS.N.J.A.C. 8:39 -11.2

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to a.) update a physician order for wanderguard with the correct expiration date for 1 of 1 resident, (Resident #12), reviewed for elopement and b.) ensure a medication was administered to a resident and not left at the bedside for 1 of 24 residents (Resident #13).This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case-finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On [DATE] at 9:32 AM, Surveyor #1 (S#1) observed Resident #12 ambulating in the hallway with a wanderguard bracelet (a bracelet or anklet that triggers alarms and can have the capability to lock monitored doors to prevent a resident from leaving a facility unattended) was on the resident's left ankle. S#1 observed the Station 4 Unit Clerk redirect Resident #12 to the resident's room and gave the resident their sweater. A review of Resident #12's admission Record (AR, an admission summary) or face sheet, reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; tracheostomy status (has undergone a tracheostomy procedure, which is a surgical opening in the neck to provide an alternative airway for breathing), vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), and osteoporosis (condition that causes bones to become weak and brittle, increasing the risk of fractures). A review of Resident #12's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, reflected that the resident's cognitive skills for daily decision making was severely impaired. Further review of the qMDS indicated that the resident had a wander/elopement alarm used daily. A review of Resident #12's [DATE] and [DATE] electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) including the following: Wander guard to left ankle due to exit seeking behavior Expiration date: [DATE] every shift check placement with a start date of [DATE] and was signed as checked each shift of each day of the month of July and August until [DATE]. Wander guard to left ankle due to exit seeking behavior Expiration date: [DATE] every night shift check function with a start date of [DATE] and was signed as checked each night shift of each day of the month for July and each day of August until [DATE]. The two orders indicated that the wanderguard had expired at the end of [DATE]. Further review indicated that both orders were discontinued (d/c'd) on [DATE] and the following orders were started on [DATE]: Wander guard to left ankle due to exit seeking behavior Expiration date: [DATE] every shift check placement. Wander guard to left ankle due to exit seeking behavior Expiration date: [DATE] every night shift check function. On [DATE], S#1 interviewed Licensed Practical Nurse #1 (LPN#1) regarding the process for the wanderguard. LPN #1 stated that the wanderguard was checked for placement every shift and the expiration date was checked. S#1 asked LPN #1 if the function of the wanderguard was also checked. LPN #1 stated that she believed that the night shift tested the function. S#1 then asked about the order that had the expiration date of [DATE]. LPN #1 stated that yesterday they changed the order and now it has an expiration of March. S#1 asked if the order should have been updated when the wanderguard expired. LPN #1 stated that it should have been. On [DATE] at 9:44 AM, S#1 interviewed the Registered Nurse/Unit Manager (RN/UM) of Station 4. The RN/UM stated that a new wanderguard had been placed prior to the expiration date when the resident had taken the wanderguard it off and would find out the exact date. S#1 asked about the order that was not updated until [DATE]. The RN/UM stated that she had just updated the order yesterday. S#1 asked if the order should have been updated at the time that the wanderguard was replaced. The RN/UM stated that it should have been. On [DATE] at 10:07 AM, the RN/UM provided the surveyor documentation that the wanderguard was replaced on [DATE]. On [DATE] at 12:07 PM, S#1 notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and Clinical Lead of New Jersey (CLoNJ) the concern that Resident #12 orders for checking the placement and function of the wanderguard had an expiration date that was [DATE] and was being signed as performed until [DATE]. On [DATE] at 11:25 AM, in the presence of the LNHA and CLoNJ, the DON stated that Resident #12's wanderguard was changed on [DATE], prior to the expiration date of [DATE], when the strap was loose but that the order was not updated in the electronic medical record at that time. She added that the device was functioning. The DON stated that staff were educated. The LNHA did not provide any additional information. A review of the facility's Patient Security Bracelet Policy with a reviewed date of [DATE], included the following:PolicyPatients will be evaluated for the need for a wandering security bracelet to serve as a safety measure to prevent elopement and wandering in unsafe areas of the Center. Patients approved for wandering security bracelets will have an individualized plan of care to address wandering and the use of the bracelet as an intervention. Wandering security bracelets will be inspected per manufacturer's recommendations but at a minimum of:Every shift for placement, andDaily for function.The expiration date, placement checks, and function inspections of the bracelet will be documented in the medical record.PurposeTo ensure patient safety. 2. On [DATE] at 10:05 AM, Surveyor #2 (S#2) observed Resident #13 lying in their bed. The resident was alert and verbally responsive. S#2 observed on the resident's bedside table next to their water cup a clear medicine (med) cup which contained two orange-colored capsules (caps). S#2 asked Resident #13 about the med cup and its content. Resident #13 replied it was med from that morning that the nurse administered at breakfast. The resident stated it was their seizure med, and they left the med at the side to take later. Resident #13 stated they forgot to take the med, and the resident was agreeable to wait for the nurse prior to taking the med. On [DATE] at 10:10 AM, S#2 interviewed the DON about med administration protocol, and the DON stated the nurse was to observe a resident take their med, and it should not be left at the resident's bedside. On [DATE] at 10:11 AM, S#2, in the presence of the DON, interviewed LPN#2 who stated it was protocol for the nurses to observe residents take their medications (meds) and they were not allowed to be left at the bedside. S#2 discussed the observation of med at the resident's bedside. LPN #2 confirmed the orange caps were the resident's seizure med, phenytoin (Dilantin, a seizure med). LPN #2 showed the surveyor Resident #13's Dilantin med from the med cart to confirm the orange caps med. There was no additional verbal response from LPN #2 about the meds observed at the resident's bedside. The DON and LPN#2 went to Resident #13's bedside to observe the meds and speak with the resident. Upon exiting the room, the DON confirmed the meds observed at the bedside and stated LPN#2 would be in-serviced. On [DATE] at 1:30 PM, S#2 reviewed the electronic medical record (EMR) of Resident #13. A review of the AR reflected Resident #13 had diagnoses that included but were not limited to, epilepsy (a seizure disorder) and generalized muscle weakness. A review of the qMDS, with an assessment reference date (ARD) of [DATE], reflected a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the physician's order dated [DATE] indicated phenytoin 100 mg (milligram), give 2 caps (a total of 200 mg) by mouth two times a day for seizure. The med was scheduled for 8:00 AM (8 AM) and 8:00 PM (8 PM). A review of the [DATE] eMAR revealed the phenytoin cap entry was signed by the nurse as administered for the [DATE], 8 AM dose. A care plan (CP) with a focus area, Resident #13 exhibits and/or is at risk for seizure activity related to history of seizures, head injury had an initiation date of [DATE]. An intervention of the CP indicated to medicate as ordered and monitor for effectiveness as well as side effects and report to physician as needed. On [DATE] at 1:06 PM, S#2 reviewed the Med Administration Audit Report which revealed for the phenytoin entry on [DATE] at 8 AM, LPN #2 signed the med as administered at 10:08 AM. On [DATE] at 11:39 AM, S#2 notified the LNHA, the DON, and the CLoNJ of the observed concern with med left at the bedside of Resident #13. On [DATE] at 11:04 AM, the LNHA, the DON, and the CLoNJ met with the survey team. The DON stated LPN#2 was interviewed, the resident's physician was notified, there was no adverse effect to the resident and re-education was provided to nurses. A review the facility's Medication Administration Policy with a date of [DATE], revealed under Med Administration:.14. Meds are administered within 60 minutes of scheduled time.20. The resident is always observed after administration to ensure that the dose was completely ingested. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a) administer tube feeding per the physician's order (PO) and b) document the total volume according to PO and standards of clinical practice for 2 of 2 residents (Residents #2 and #9), reviewed for receiving nutrition via tube feeding, and was evidenced by the following:1.On 8/26/25 at 10:32 AM, Surveyor #1 (S#1) observed Resident #2's room was closed with an Enhanced Barrier Precautions (EBP) posted sign outside the door. Inside the resident's room, the resident's privacy curtain was pulled halfway, the resident's eyes were closed, tube feeding (TF, nutrition received through a flexible tube surgically inserted into the stomach) pump was on at 40 ml/hr (milliliter/hour), and Jevity 1.5 container was hung on the pole. S#1 reviewed the medical records of Resident #2, and revealed: A review of the admission Record (AR; an admission summary) or face sheet reflected that the resident was admitted to the facility with diagnoses that included other cirrhosis of liver (late stage of scarring (fibrosis) of the liver caused by many diseases, including hepatitis and chronic alcohol abuse, leading to impaired liver function), other cerebrovascular disease (stroke), vascular dementia, moderate, with mood disturbance, gastrostomy status, and epilepsy, unspecified, not intractable, without status epilepticus. A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/24/25, reflected a brief interview for mental status (BIMS) score of 11 out of 15, which revealed that the resident cognition was moderately impaired. The qMDS revealed that the resident had a TF. A review of the August 2025 Order Summary Report (OSR) revealed a PO: Order date 6/23/25, enteral feed order one time a day downtime 4:00 PM (4 PM) or when total volume (TV) of 800 ml delivered. Order date 6/23/25, enteral feed order one time a day Jevity 1.5 cal. Administer continuous via pump at 40 ml/hr over 20 hours (hrs) or until TV of 800 ml delivered. Order date 7/17/25, flush tube with 80 ml every two hrs during continuous feeding times 20 hrs. TV of flush equals 800 ml/24 hrs. TV of nutrient plus flush equals 1600 ml/24 hrs. Every shift. [The order was plotted for Day shift, Evening, and Night shift. From 8/1 to 8/6/25, day shift, it was documented TV of 1600 ml, from 8/1-8/14/25, evening shift, it was documented 1600 ml, from 8/1-8/25/25, night shift, except 8/15/25, it was documented 1600 ml.] The PO to flush tube 80 ml every two hrs was not followed. Further review of the above, revealed that the PO were transcribed to the August 2025 electronic Medication Administration Record (eMAR) and signed by nurses as administered. On 8/27/25 at 12:12 PM, S#1 and the Registered Nurse/Unit Manager (RN/UM) went inside the resident's room. Both S#1 and RN/UM observed the resident on bed with head of bed slightly elevated and with TF of Jevity 1.2 hung on a pole via pump infusing at 40 ml/hr. The RN/UM confirmed Jevity 1.2 was not according to the PO, and it should have been Jevity 1.5. She also stated that the TV fed was 591 ml and left 209 ml to complete the 800 ml according to the pump monitor. The RN/UM also confirmed that the TF container hung with handwritten information for 8/26/25 at 8 PM. In the nursing station, the RN/UM reviewed the electronic PO and confirmed that the order was for Jevity 1.5 at 40 ml/hr and not Jevity 1.2. She stated that the nurse probably made a mistake last night in hanging the TF. At that same time, S#1 asked about the order for flushing of 80 ml in the eMAR for total of 1600ml/24 hours and what was in the eMAR. The RN/UM reviewed the PO and she stated that what the nurses were documenting every shift were incorrect because the 1600 ml should be the total for 24 hours and not for each shift. On 8/29/25 at 11:42 AM, S#1 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of NJ (CLoNJ) of the above findings and concerns. On 9/2/25 at 11:04 AM, the survey team met with the LNHA, DON, CLoNJ. The DON stated that we interviewed Licensed Practical Nurse (LPN) via phone interview, and she informed us that she was unable to find Jevity 1.5 at that time that was why she hung Jevity 1.2. The DON further stated that there was a Jevity 1.5 supply and the LPN just did not look. The DON also stated that the TF water flushed was via pump and it was set up automatically flush according to the order and that the resident was received the required amount. She further stated the problem was that the nurses were documenting the number of flushes in the eMAR inaccurately. The DON added that the order for flushes were modified to make it clearer. 2. On 8/26/25 at 11:14 AM, Surveyor #2 (S#2) observed Resident's #9 door with EBP sign on the door, alcohol base hand rub (ABHR) on the wall, and personal protective equipment (PPE-equipment worn to minimize exposure like gowns and gloves) by the doorway. S#2 observed the resident sitting on high back wheelchair, and resident alert with confusion. The Registered Nurse (RN) stated that the TF goes up at night and stops at around 6:00 AM-7:00 AM, that the resident also had oral meal (food consumed by mouth), not very good with eating, and was picky. RN#1 also stated that the resident was being followed up by the Dietician and the Speech Language Pathologist (SLP). On 8/27/25 at 10:37 AM, S#2 interviewed the Registered Dietician (RD), who stated that the resident came in with a TF because of dysphagia (swallowing difficulty) from multiple cerebrovascular attack (CVA-a stroke) and seizure disorder. The RD further stated that they tried to get the resident off the TF, but was not getting enough intake. The RD stated the feeding goes up at 8:00 PM, with a total volume of 650 ml/24-hour period and goes down in the morning. A review of the AR revealed diagnoses which included but not limited to; other hereditary CVA disease, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (Cadasil/Carasil- a rare, inherited disorder affecting the brain's small blood vessels, leading to strokes, dementia, and migraines with aura), unspecified sequelae of cerebral infarction (necrotic tissue in the brain), dementia (decline in cognition) in other diseases classified elsewhere severe with mood disturbance, other frontotemporal neurocognitive disorder (brain disorders that damage the frontal and temporal lobes of the brain, leading to changes in behavior), and dysphagia oropharyngeal phase, gastrostomy, status (surgical opening (gastrostomy) has been created in the stomach to provide a direct route for feeding). A review of the modified qMDS, with an ARD of 7/3/25, revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. A review of the PO revealed the following: Flush tube with 200 ml of water every 2 hrs during continuous feeding x 10 hrs. Total volume of flush = 1000 ml/24hrs (excluding medication flushes). TV of nutrient + flush = 1650 ml/24hrs, every evening and night shift, ordered 7/14/25. Enteral feed order one time a day downtime: when TV of 650 ml is delivered -Start Date 7/14/25. Enteral feed order one time a day Jevity 1.5 cal. Administer continuous via Pump at 65 ml per hour over 10 hrs., or until total nutrient of 650 ml delivered. -Start Date 7/14/25. Total nutrient 650 ml/24 hrs. Total Calories 975 Cal/24hours one time a day -Start Date 7/15/25. A review of the eMAR revealed: On 8/1/25 to 8/26/25, except for 8/5/25, on day shift documented 1650 ml; 8/1/25 to 8/26/25, except for 8/5/25, on evening shift documented 1650 ml; and 8/1/25 to 8/26/25 on night shift documented 1650 ml. (The documentation of nutrient and water flushes exceeded the TV of 1650 ml/24 hrs. as ordered by the physician). On 8/28/25 on evening shift documented 200 ml and night shift documented 610 ml; 8/29/25 on evening shift documented 610 ml and night shift documented 610 ml; 8/30/25 on evening shift documented 610 ml and on night shift documented 800 ml; 8/31/25 on evening shift documented 800 ml and on night shift documented 1155 ml. (The documentation of nutrient and water flushes did not add up to the TV of 1650 ml/24 hrs. as ordered by the physician). On 8/29/25 at 11:11 AM, S#2 attempted to interview the primary nurse regarding TF but was not available. On 8/29/25 at12:29 PM, S#2 interviewed the Station 4 Unit Manager (UM) in her office regarding the TF, and she stated the pump will automatically flush the 200 ml of water while the feeding was going. On 9/2/25 at 9:48 AM, S#2 interviewed the RN in the presence of the UM. The UM stated that the order was adjusted and education was provided to nursing to document the correct TV according to PO. The UM confirmed that the order for 8/27/25, the documented amount for evening and night shift were still not correct and the total amount will have to be corrected. RN #1 stated, I will follow through with that once UM updates it. On 9/2/25 at 11:04 AM, the survey team met with the LNHA, DON, CLoNJ, and MDS Coordinator. S#2 notified the above findings and concerns. The DON responded that the flushes were automatic, the resident received the right amount according to PO, but nurses did not document the right amount properly. The DON further stated that the order was modified to make it more clear. S#2 notified the LNHA, DON, and the CLoNJ the concern on the eMAR incorrect documentation of amount of total flush and nutrition and that order was revised on 8/27/25, and was still incorrect which was confirmed by the UM. A review of the facility's Enteral Management Policy that was provided by the DON, with a revision/reviewed date of 7/22/25, revealed, under purpose: to provide safe and effective management of enteral tubes.Practice Standards:.5. The patient's (also known as resident) plan of care will address the use of an enteral feeding tube, including strategies to prevent complications. On 9/2/25 at 1:31 PM, the survey team met with the LNHA, DON, and CLoNJ for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-27.1(a), 27.2(e)

Based on interview, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 27 residents (Resident #2), identified during Medication Regimen Review (MRR). This deficient practice was evidenced by the following:A review of the U.S. FDA (United States Food and Drug Administration) medication (med) guide for prevacid delayed release capsules., revised September 2012, reflected the instructions for use.should be taken before eating. Prevacid delayed release capsules through a nasogastric tube or larger, as prescribed by the doctor:.you can only use apple juice. 1. Open the capsule (cap) and empty the granules into a syringe. 2. Do not break or crush the granules. 3. Mix with 40 ml (milliliters) of apple juice. Do not use other liquids. 4. Attach the syringe to the tube and give the med in the syringe through the tube into the stomach. 5. After giving the granules, flush the tube with more apple juice to clear the tube. Prevacid should not be used in foods or liquids not listed above.On 8/26/25 at 10:32 AM, the surveyor observed Resident #2's room was closed with an Enhanced Barrier Precautions (EBP) posted sign outside the door. Inside the resident's room, the resident's privacy curtain was pulled halfway, the resident's eyes were closed, tube feeding (TF) pump was on at 40 ml/hr (milliliter/hour), and Jevity 1.5 container was hung on the pole. The surveyor reviewed the medical records of Resident #2, and revealed:A review of the admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included other cirrhosis of liver (late stage of scarring (fibrosis) of the liver caused by many diseases, including hepatitis and chronic alcohol abuse, leading to impaired liver function), other cerebrovascular disease (stroke), vascular dementia, moderate, with mood disturbance, gastrostomy status, and epilepsy, unspecified, not intractable, without status epilepticus.A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/24/25, reflected a brief interview for mental status (BIMS) score of 11 out of 15, which revealed that the resident cognition was moderately impaired. The qMDS revealed that the resident had a TF.A review of the August 2025 Order Summary Report (OSR) revealed a physician's orders (PO):Order date 6/21/25, prevacid oral cap delayed release 15 mg (milligram), give one cap via g-tube (gastrostomy tube) once a day for GERD (gastroesophageal reflux disease happens when stomach acid flows back up into the esophagus and causes heartburn). [The med was plotted at 9:00 AM (9 AM) when the resident's TF was ongoing, or the resident was being fed.]Order date 6/23/25, enteral feed order one time a day downtime 4:00 PM or when total volume (TV) of 800 ml delivered.Order date 6/23/25, enteral feed order one time a day Jevity 1.5 cal. Administer continuous via pump at 40 ml/hr (milliliters/hour) over 20 hours or until TV of 800 ml delivered.Further review of the above, revealed that the PO were transcribed to the August 2025 electronic Medication Administration Record (eMAR) and signed by nurses as administered. On 8/27/25 at 12:12 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding the above orders for prevacid that was signed by nurses as administered at 9 AM. The surveyor asked the RN/UM should the med administered in an empty stomach, and she did not respond. The RN/UM confirmed that at 9 AM the resident's TF was ongoing and being fed and that was the time the prevacid was ordered to be administered. On 8/29/25 at 11:42 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Lead of NJ (CLoNJ) of the above findings and concerns. The surveyor asked the LNHA, DON, and CLoNJ, what the expectation was when administering the prevacid. Both the DON and the CLoNJ stated that it should be given in an empty stomach. Both the DON and CLoNJ also acknowledged that the expectation was the consultant pharmacist to identify the irregularity for prevacid. On 8/29/25 at 1:24 PM, the surveyor interviewed the CP about MRR. The surveyor notified the CP of the above findings and concerns with regard to prevacid. The CP stated that usually she would recommend administering prevacid on an empty stomach, and for Resident #2, she did not recommend it because the resident was on TF. The CP also stated that the resident was on TF for a long period of time. She acknowledged that it should be given on an empty stomach.A review of the facility's Enteral Management Policy that was provided by the DON, with a revision/reviewed date of 7/22/25, revealed, under purpose: to provide safe and effective management of enteral tubes.Practice Standards:.5. The patient's (also known as resident) plan of care will address the use of an enteral feeding tube, including strategies to prevent complications.On 9/2/25 at 1:31 PM, the survey team met with the LNHA, DON, and CLoNJ for an exit conference, and there was no additional information provided by the LNHA.NJAC 8:39-29.3(a)(1)

Based on interview and document review it was determined that the facility failed to ensure a Surety Bond was in place to provide coverage to protect resident personal needs account funds held by the facility. The deficient practice could affect all residents who had personal needs funds held by the facility and was evidence by the following:During the entrance conference on 8/26/25 at 9:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to the facility's Surety Bond. On 8/27/25 at 8:53 AM, the surveyor reviewed the facility provided document titled Surety Bond Report for the facility which included under insurance carrier [name redacted] no bond on file which was dated 8/26/25 10:10:13 AM.On 8/27/25 at 9:16 AM, the surveyor asked the LNHA about the Surety Bond Report that was provided. The LNHA stated that the facility had a Surety Bond and that he would provide it. 08/27/25 11:03 AM, the LNHA provided the surveyor two documents which included the following:Power of Attorney dated 12/11/23Verification Certificate for Indefinite Term Surety Bond which included Sufficient premium has been paid to satisfy the requirements of the carrier for this bond to 2/28/25. Signed 12/11/23. On 8/27/25 at 11:34 AM, the surveyor interviewed the LNHA regarding the surety bond provided with the date of 2/28/25. The LNHA stated that corporate had sent the surety bond. The LNHA stated that he called the corporate staff and they said that the surety bond was indefinite.On 8/28/25 at 8:53 AM, the LNHA provide the surveyor an additional two documents which included the following:Power of Attorney dated 8/27/25Verification Certificate for Indefinite Term Surety Bond which did not include a line regarding sufficient premiums and was dated 8/27/25 (after surveyor inquiry). On 8/28/25 at 9:36 AM, the surveyor interviewed the Business Office Manager (BOM) regarding the surety bond. The BOM stated that she was working with the Regional Business Office Advisor since she was new and started in July. She added that when the LNHA asked her for the surety bond that she had to have the Regional print it because she could not locate the surety bond. The BOM stated that she did not know about it [surety bond] as of yet.On 8/29/25 at 12:07 PM, the surveyor notified the LNHA, the DON, and Clinical Lead of New Jersey (CLoNJ) the concern that the facility did not have documented evidence that the facility had a Surety Bond in effect from 2/28/25 until surveyor inquiry. A review of the facility's Resident Funds Policy with a reviewed date of 1/16/23, included the following:13. Surety Bond: The facility will maintain a surety bond in accordance with the Centers for Medicare and Medicaid Services (CMS) regulation 42.CFR 483 and state specific requirements. 13.1 The amount for the surety bond must be reviewed on a quarterly basis by the Administrator and BOM to ensure that the amount is appropriate.13.2 On an annual basis, the facility must receive evidence of renewal from the [company name] Risk Management Department. This notice must be filed along with the facility's surety bond as backup documentation. N.J.A.C. 8:39-9.5(c)3

Based on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents (Residents #71 and #113), reviewed for beneficiary notification. The deficient practice was evidenced by the following:On 9/2/25 at 10:01 AM, the surveyor reviewed the beneficiary notification of three randomly selected residents from a facility provided list of residents who were discharged (d/c'd) from Medicare Part A services in the last six months which revealed the following: 1. Resident #71 had a last covered day from Medicare Part A services of 8/15/25 and remained a resident in the facility. There was no documentation that the resident received a SNF ABN.2. Resident #113 had a last covered day from Medicare Part A services of 8/18/25 and remained a resident in the facility. There was no documentation that the resident received a SNF ABN.On 9/2/25 at 10:33 AM, the surveyor interviewed the Business Office Manager (BOM) who was responsible for providing beneficiary notifications to residents. The BOM stated she was not aware of the SNF ABN, and not aware that it had to be provided to residents who had skilled benefit days remaining when being d/c'd from Part A services and continued to reside at the facility. The BOM confirmed that Residents #71 and #113 did not exhaust their skilled benefit days and remained at the facility. The BOM acknowledged that a SNF ABN was not issued to Resident #71 and Resident #113.On 9/2/25 at 11:23 AM, the BOM provided an undated facility chart related to beneficiary notices titled Valid Forms of Delivery and Required Follow Up. For SNF ABN the chart indicated Medicare Part A only (days remaining and will remain in the center at least one billable day); to be given prior to last covered day and preferably with the Notice of Medicare Non-Coverage (NOMNC).On 9/2/25 at 11:35 AM, the surveyor notified the Licensed Nursing Home Administrator, the Director of Nursing, and the Regional Clinical Lead of the above concern for Resident #71 and Resident #113 not receiving a SNF ABN. There was no additional information provided by the facility. NJAC 8:39-5.1

Complaint #: NJ00181779 Based on interviews, record review and review of pertinent facility documents, it was determined that the facility failed to protect the confidentiality and privacy of a resident (Resident #6)) during an investigation of an alleged sexual incident between the Resident and a staff member that is in accordance with the facility's written abuse prohibition policy. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to the Admission Record (AR), Resident #6 was admitted to the facility with diagnoses that include but not limited to: Abnormalities of Gait and Mobility, Radiculopathy, Lumbar Region, Benign Prostatic Hyperplasia, Chronic Pancreatitis, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Personality Disorder, and Functional Intestinal Disorder. According to the Resident #6's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 03/06/2025, under Section C-Cognitive Patterns showed that the Resident had a Brief Interview for Mental Status (BIMS) Score of 15 indicating Resident's cognition was intact. According to the Resident's Care Plan (CP), [Resident's name] exhibits psychosocial distress related to alleged sexual abuse with the staff member with date initiated 12/20/2024. A review of the Resident's Progress Notes (PN), dated 12/19/2024 6:08:39 PM [evening], documented and e-signed [electronically signed] by the NP [nurse practitioner] [name redacted], Notified by nursing that another resident [name] complained that this resident [Resident #6 name] was half naked with staff member (CNA) [certified nursing assistant] yesterday. No other staff member witnessed to corroborate events. Investigation ongoing. Residents without injuries and at baseline . A review of the Resident's PN dated 12/23/2024 14:25 [2:45 pm] [afternoon] Late Entry documented and e-signed by [name redacted] Social Services, showed in Note: On December 19, 2024 at around 3:20pm, patient [name redacted] reported to the nurse that she had witnessed [Resident #6 name] having sex with the CNA [Certified Nursing Assistant][name redacted]. The social services were immediately notified, and resident [name] was further interviewed. During the initial interview, the resident was having a difficult time pointing to the exact date and time of the alleged sexual interaction between Resident #6 and the CNA .she stated that that happened today at 4:30pm when she was passing by. She was redirected to today's date and time, and she stated, ohh that was probably yesterday then. She stated that she believed the sexual interaction had happened multiple times she stated, you know it's just a woman's intuition and I know something is going on.when interviewed further she stated that [Resident #6 name] was wheeling himself out of the room without his T-shirt on and [CNA name] was laying topless in his bed without any T-shirt or a [undergarment]. Resident stated she did not see an actual sexual act between them .she also verbalized she is in love with [Resident #6 name] and this action had hurt her feelings. The PN further revealed Resident #6 was interviewed and verbalized that he/she had never had any sexual interaction with CNA [name] or any other employee working at [facility name] .CNA [name] stated that on 12/19/24 she did not have any interactions with [Resident #6]. She was in the room assisting other residents [in that room]. [CNA] further stated she never had any sexual interaction with [Resident #6] or any other resident .she further stated she never laid in Resident #6's bed and she had never been undressed without a T-shirt or a [undergarment] in front of Resident #6. She [CNA] stated that on 12/19/24 at around 4-4:30pm [afternoon] she was assisting another resident in that room to get ready for a holiday party A review of the facility submitted document to the New Jersey Department of Health (NJDOH), a facility reportable event (FRE), with attached facility's Summary and Conclusion, December 19, 2024, Abuse-Alleged-sexual-staff, under Investigation and Conclusion, After completion of the interviews .the social services had notified police; and police officer completed his investigation without any suspicion of abuse .[Resident #6 name] agreed on a skin check completed by two nurses and there was no bruising, no skin tears, and no swelling observed; he denied any pain or injury .Social services had interviewed the roommates of [Resident #6] and they stated they did not witness any sexual acts between [Resident #6] and [CNA name] at any time .Based on our investigation, there is no reason to suspect any sexual abuse towards [Resident #6 name] .[Resident #6] will be visited by the social services weekly for a month to ensure that he feels comfortable and safe at [facility name] . On 03/06/2025 at 12:38 pm, the Surveyor interviewed Resident #6. Resident #6 stated that On 12/19/2024 at 3:30 pm he/she was on the telephone when the social worker (SW) [name redacted] came in my room and told me to meet her in the conference room with another resident. In the conference room was the resident (this resident was obsessed with me), the SW, Supervisor in Unit 4 (Supervisor), Unit Manager [name] in Unit 2 (UM), and a front office person [name redacted]. Resident #6 stated he/she felt disrespected that there were a lot of people in the room. He/she further stated the only people that should be there should be my UM, since the LNHA was not around at that time. The SW asked the other resident who accused me in front of other people about the incident and she was descriptive about the incident which was not true. I felt disrespected, humiliated, undignified. I felt like I was garbage even if it was false, I felt embarrassed like other people would make jokes. The SW asked me in front of the other resident and other staff members who I thought should not be involved because they had nothing to do with me. It was an embarrassment. The Resident further stated the interrogation was totally unprofessional, I felt ambushed and totally humiliated because the other resident was saying she/he saw me naked and saw the [CNA] naked and having sex numerous times with me which was ridiculous. They won't let me record in the conference room so I made notes. I still listen to jokes, they [other staff] call me names such as sex machine, love machine. I was embarrassed because the police department had to come and interviewed me and make a police report. I have no idea why SW brought these people in the conference room. I felt it was a violation of my resident rights. On 03/06/2025 at 2:36 pm, the Surveyor interviewed the LNHA regarding Resident #6 incident. LNHA stated on that day he was not in the facility and the SW was here. Surveyor informed LNHA about what Resident #6 stated regarding five people in the conference room when the resident was interrogated. The LNHA stated Resident #6 [name] had accusatory behavior against the SW that was probably the reason why SW [name] called in witnesses but I do not know why SW called so many people. The LNHA agreed to a private and confidential investigation should have been done. On 03/06/2025 at 3:32 pm, the Surveyor interviewed the SW regarding the incident. The SW stated the Assistant Director of Nursing (ADON) came to my office and told me that a resident told her that she saw CNA#1 in bed naked with Resident #6. I took [the other resident] to the conference room but I needed some witnesses, so I got the Supervisor and Unit Manager in unit 2 (UM 2). The resident wanted Resident #6 in the conference room, so I had to go to Resident #6's room and asked him/her to come to conference room. When we got to the conference room, the Supervisor has to stepped out since she had an emergency and since business manager (BM) was here, I asked her to step in the conference room. I asked them (Resident #6 and the other resident) if it is ok to have witness and both agreed with it. I explained to Resident #6 I am not comfortable talking to him alone without witness because he had accused us before. The SW stated Resident #6 was aware that the other resident would be in the conference room. The Surveyor informed SW that Resident #6's statement that he/she felt embarrassed and humiliated because the other resident recounted the alleged sexual incident, very descriptive with a lot of other people in the room. Surveyor asked SW what was the facility's policy in investigating allegations and maintaining confidentiality and residents' privacy. The SW did not provide any answer. A review of the facility's policy titled, Abuse Prohibition, with revision date of 10/24/22, .The Center will implement an abuse prohibition program .Investigation of incidents and allegations .protection of patients during investigations; and .under Federal Definitions: .Mental Abuse includes, but is not limited to humiliation, harassment, threats, and threats of .Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation .; under Process: .8. The Center will protect patients from further harm during an investigation. 8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe .9. The Administrator or designee will: 9.1 Take all necessary corrective action depending on the results of the investigation. 9.2 Report findings of all completed investigations within five (5) working days .9.2.1 All phases of the reporting process will be kept confidential. NJAC 8:39-4.1 a(5)

Complaint #: NJ00175767 Based on interviews, record review, and review of pertinent facility documents on 03/11/2025, it was determined that the facility failed to develop a baseline care plan with a focus [problem area] to address a special procedure, Pleurex Drainage (the process of removing excess fluids from spaces around the lungs) specific for a newly admitted resident (Resident #1) who had diagnosis of pleural effusion (a condition where excess fluids accumulates in spaces around the lungs). Resident #1 was not in the facility during the survey. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to Resident #1's Admission Record (AR), the resident was admitted to the facility with the following diagnoses that included but not limited to: Pleural Effusion, End Stage Renal Disease, Dependence on Renal Dialysis, and Chronic Atrial Fibrillation. According to Resident #1's Minimum Data Set (MDS) dated [DATE], an assessment tool used by facility to facilitate a resident's functional capabilities and management of care, indicated under Section C- Cognitive Skills for Decision Making indicated Resident was independent in his/her decision making. The Resident's MDS further showed under Section GG that Resident required assistance from staff for completion of his/her Activities of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR) with admitted [DATE] revealed a verbal order entry: -Dialysis days: MWF [Monday, Wednesday, Friday] Time for Pick up:4PM Transport to [dialysis center] with order date 07/19/2024. -Drain Pleurex 2x/week [two times a week] one time a day every Tue [Tuesday], Sat [Saturday] with order date 07/19/2024 and start date of 07/20/2024. A review of the Resident's Baseline Care Plan (BCP) initiated on 07/19/2024 showed the following: -Focus [Problem/Need Area]: [Resident's name] requires assistance for ADL care in bathing, grooming, personal hygiene .related to recent hospitalization , resulting in fatigue, activity intolerance, limited mobility and weakness - Date initiated 07/19/2024. -Focus: [Resident's name] has a Full Code Status - Date initiated 07/19/2024. -Focus: [Resident's name] is at risk for falls due to impaired mobility and weakness- Date initiated: 07/19/2024. -Focus: Resident requires assistance/is dependent for mobility related to .- Date Initiated: 07/19/2024. -Focus: [Resident's name] is at risk for alterations in comfort related to occasional body aches and pleurx drainage- Date initiated: 07/19/2024. -Focus: [Resident's name] exhibits and is at risk for impaired renal function and is at risk for complications related to renal insufficiency- Date initiated: 07/19/2024. -Focus: [Resident's name] has Chronic Obstructive Pulmonary Disease (COPD) - Clinical Management - Date initiated: 07/19/2024. -Focus: [Resident's name] at risk for skin breakdown and has an actual skin breakdown related to advanced age (greater than [AGE] years), decreased activity, frail fragile skin on admission: Pleurx R [right], fistula to L [left] forearm, petechia]. The BCP revealed there was no care plan with a Focus/Goal/Interventions created for the Resident's need for special procedure, Pleurex Cath or Drainage, which was indicated for his/her diagnosis of Pleural Effusion. On 03/11/2025 at 2:53 pm, the Surveyor interviewed the Director of Nursing (DON). The DON stated that she knew Resident #1 had pleurex catheter and drainage two times a week on non-dialysis days. The DON further stated that the baseline care plan is created within forty-eight [48] hours a resident was admitted to the facility to identify potential/actual problems of the resident based on whatever the resident had on admissions. The Surveyor showed the DON the Resident's BCP that has not included a focus on the pleurex drainage. The DON stated that the Resident's BCP should include the pleurex catheter drainage as special procedure upon admission. The DON further stated that when a resident was admitted to the facility, the BCP was initiated by the admission nurse on that shift and that after 48 hours the BCP would proceed to comprehensive care planning within seven days. A review of the facility's policy titled, Person-Centered Care Plan, with revision and review date of 10/24/22, under its Policy: The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care . The facility's policy further stipulated under Practice Standards: 1. A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: 1.1 Initial goals based on admission orders; 1.2 physician orders . N.J.A.C 8:39-11.2 (d) N.J.A.C 8:39-27.1(a)

Complaint #: NJ00175767 Based on interview and review of pertinent facility documents, it was determined on 03/11/2025 that the facility failed to ensure that a licensed nurse had the specific competency and skills set necessary to care for a resident's needs involving a Pleurex drainage (the process of removing excess fluids from spaces around the lungs) specific for Resident #1who had a diagnosis of pleural effusion (a condition where excess fluids accumulate in spaces surrounding the lungs). Resident #1 was not in the facility during the survey. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to Resident #1's Admission Record (AR), the resident was admitted to the facility with the following diagnoses that included but not limited to: Pleural Effusion, End Stage Renal Disease, Dependence on Renal Dialysis, and Chronic Atrial Fibrillation. According to Resident #1's Minimum Data Set (MDS) dated [DATE], an assessment tool used by facility to facilitate a resident's functional capabilities and management of care, indicated under Section C- Cognitive Skills for Decision Making indicated Resident was independent in his/her decision making. The Resident's MDS further showed under Section GG that Resident required assistance from staff for completion of his/her Activities of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR) with admitted [DATE] revealed a verbal order entry: -Dialysis days: MWF [Monday, Wednesday, Friday] Time for Pick up:4PM Transport to [dialysis center] with order date 07/19/2024. -Drain Pleurex 2x/week [two times a week] one time a day every Tue [Tuesday], Sat [Saturday] with order date 07/19/2024 and start date of 07/20/2024. A review of Resident #1's Progress Notes (PN), dated 07/20/2024 at 11:06 [morning] documented by [name] Registered Nurse (RN) #1, revealed a note: Pleurex drainage done, output was 5 ml [milliliters]. Vitals . Further review of the Resident's PN dated 07/20/2024 21:37 [9:37 pm] and documented by RN #2 revealed a Note: Pleurx drainage done on the Rt [right] Lung, output was 950ml. Latest V/S Further review of Resident's PN dated 07/21/2024 14:04 [2:04 pm] documented by RN #1 indicated Resident's wife [name] insisted on taking him/her home AMA [against medical advice]. Pt [patient] came on Friday 7/19/24 after 3pm with .and chest tube using pleurex and was on dialysis .Saturday 7/20/24 he/she was drained at 11am, with an output of 5cc .the [Resident's wife] came in the evening and asked about Resident's output. Upon telling [her] that the output was 5cc, [wife] insisted on draining him/her again, the night nurse [name] drained the [Resident's pleurex] at about 7 pm and had an output of 950ml. The [Resident's wife] came in Sunday morning .and expressed that she was unhappy the way [Resident #1] was being taken care of .and the drain was not done . A review of Resident #1's Treatment Administration Record (TAR) dated 7/1/2024 - 7/31/2024 indicated an order entry of Drain Pleurex 2x/week one time a day every Tue, Sat. The TAR further showed it was initialed by a nurse [RN #3's initials] with a numeric entry of 5cc [cubic centimeter, a unit of measurement used to measure liquids]. On 03/11/2025 at 12:41 pm [afternoon], in an interview with the Surveyor, RN #1 stated, I was the one who drained the pleurex of Resident #1. I was with RN #3 who was the charge nurse supervisor. She [RN #3] was the one who signed the TAR. We had the training on Pleurex. Our staff educator (SE) [name] gave the education I forgot when she gave the video, with a hands on demonstration, and we usually sign after the video education or demonstration. On 03/11/2025 at 3:55 pm, in an interview with the Surveyor, RN #2 stated, when I came in at 3-11 shift on that day 07/20/24, the wife was with the patient [Resident #1], the report [nurses' report] said the output was only a small amount. The family member [wife] who knew said that in the hospital it [output] was a lot less than a thousand like nine hundred always. The wife was concerned so I drained it and the output was nine hundred fifty [ml]. The resident [Resident #1] appeared ok and stated he was relieved. RN #2 further stated, the SE did a side by side education with the nurses and would let us sign. On 03/11/2025 at 12:26 pm, the Surveyor attempted to call RN #3. RN #3 did not return the call. The Surveyor was informed by the Director of Nursing (DON) that RN #3 was on a medical leave. On 03/11/2025 at 2:30 pm, the Surveyor interviewed the staff educator.The SE stated on 07/19/24 she sent an email containing the video of the pleurex drainage to all the nurses. The SE further stated she did a bedside return demonstration of the pleurex drainage with the nurses. The Surveyor reviewed the nursing department staff competencies with the staff educator. The Surveyor requested that the SE provide documentation of education and competencies regarding the care of residents specific to pleurex drainage. When asked by the Surveyor for the documentation of mentioned return demonstration with the nurses, the SE was unable to provide documentations of the nurses related to clinical competency specific to pleurex drainage procedure. On 03/11/2025 at 2:47 pm, in an interview with the Surveyor, the DON stated, we had our inserviced thru the [Health System], a set of education modules in the computer, and we do some in paper. The SE would let them sign the education and return demonstration. The DON was made aware by the Surveyor that there were no documents (nurses competencies) provided by the SE related to the aforementioned specific pleurex drainage procedure. No additional information was provided by the facility. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that medication orders that included parameters were not followed by the medication administering nurse. This was observed in 1 out of 3 nurses during medication administration. This was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 3/22/24 at 8:11 AM, the State Surveyor observed the start of medication pass with the Registered Nurse (RN#1) on the X00 unit. RN#1 prepared medication for Resident #186 who had a Physician Order (PO) for Zestril 2.5 mg daily for Hypertension with parameters to hold for Systolic Blood Pressure (SBP) less than (<) 100 and Heart Rate (HR) <55 started on 3/20/24. RN#1 proceeded to review the SBP and HR for Resident #186, that was written on a white piece of paper along with vitals for other residents on the unit. RN#1 informed the surveyor that the documented SBP was 109 and the HR was 86 for Resident #186. RN#1 informed the surveyor that the vitals for Resident #186 were taken early in the morning, in the beginning of the shift and that was not an issue. The surveyor asked that RN#1 retake the vitals, which were SBP 119 and HR 83 prior to administering the Zestril 2.5 mg to Resident #186. A review of the Admission Record for Resident #186 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Heart Disease, Congestive Heart Failure (CHF), Essential Hypertension and Ventricular Tachycardia. A review of Resident #186's Comprehensive Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/24, reflected that Resident #10 had a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. The surveyor reviewed of Resident #186's Care Plan initiated on 3/19/2024 and titled, Resident #186 exhibits or is at risk for cardiovascular symptoms or complications related to diagnosis of Coronary Artery Disease, Cardiomyopathy, CHF, Hypertension, Chronic Obstructive Pulmonary Disease, Iron Deficiency Anemia Epilepsy, Anxiety. The documented Goal was, Resident #186's blood pressure will remain within baseline parameters for 90 days. Interventions included, Assess and monitor vital signs as ordered and report abnormalities to physicians. The surveyor reviewed the facility's Policies and Procedure titled, General Dose Preparation and Medication Administration. Documented under 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 4.1.5 If necessary obtain vital signs. On 3/22/24 at 3:30 PM, the surveyor informed the Licensed Nursing Home Administrator and Director of Nursing of the issue. There was no additional information provided. NJAC 8:39 - 27.1

Based on interview and record review, it was determined that the facility failed to complete the Minimum Data Set (MDS) timely for 1 of 27 residents reviewed, Resident #37 and was evidenced by the following: On 3/21/24 at 12:01 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. Resident #10 was observed to have an Entry MDS with an Assessment Reference Date (ARD) of 9/19/23 and was due to be completed no later than 9/26/23. The MDS was not completed until 9/28/23. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2023) page 2-18 reflected under Entry tracking record with a MDS Completion Date which stated Entry date + 7 calendar days. Further review of Resident #10's MDS assessment revealed that the resident had an Admission MDS with an ARD of 9/21/23 and was due to be completed no later than 10/4/23. The MDS was not completed until 10/6/23. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2023) page 2-16 reflected under Admission (Comprehensive) with a MDS Completion Date which stated admitted + 13 calendar days. On 3/25/24 at 12:15 PM, the surveyor interviewed the facility's MDS Coordinator #2 who was responsible of completing Resident #10's MDS assessments. The MDS Coordinator could not provide an answer and stated that she will get back to me for further information. On 3/25/24 at 12:57 PM, the surveyor discussed the above concern to the facility's Licensed Nursing Home Administrator and Director of Nursing. There was no further information provided. On 3/26/24 at 10:15 AM, the facility's MDS Coordinator #1 provided a copy of the Validation Report of the submitted MDS's which confirmed that Resident #37's above MDS assessments were completed late. NJAC 8:39 - 11.1

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 4 of 30 residents, Resident #32, #33, #95, and #133, reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 3/18/24 at 11:48 AM, the surveyor observed Resident #33 resting in a reclining chair with their eyes closed. The resident was alert and did not verbally respond to the surveyor's questions. On 3/21/24 at 9:40 AM, the surveyor reviewed Resident #33's hybrid (paper and electronic) medical records. The Admission Record (AR) documented the resident had diagnoses that included but were not limited to, unspecified dementia, anxiety disorder, and type 2 diabetes. A review of a Quarterly MDS assessment, dated 2/6/24, indicated the facility completed a Brief Interview for Mental Status (BIMS) with Resident #33. The resident scored a 2 out of 15 which indicated the resident had severe cognitive impairment. In Section P- Restraints and Alarms, under P0100.Physicial Restraints, Resident #33 was coded as using daily bed rails as restraints. A review of the Order Summary Report included a physician's order dated 3/4/22 which read, Two upper side rails up to bed as an enable for turning and repositioning in bed every shift. On 3/21/24 at 12:39 PM, the surveyor interviewed LPN #1 about Resident #33. LPN#1 stated residents had side rails to be used as an enabler for repositioning while in bed. LPN #1 stated the resident was bed bound and was assisted out of bed to the reclining chair daily. The surveyor went with LPN #1 in the room to observe the bed rails. Resident #33 was out of bed in the reclining chair. The resident's bed was observed with upper, quarter length bed rails. LPN# 1 stated the resident had assist side rails used as enabler for repositioning. On 3/21/24 at 1:09 PM, the surveyor interviewed MDS Coordinator #1 who stated bed rails were used to support resident mobility and restraints were not used in the facility. The surveyor reviewed with MDS coordinator #1 the quarterly MDS assessment of Resident #33. MDS coordinator #1 stated the coding was a data entry error and that restraints were not used in the facility. MDS coordinator #1 stated the MDS assessment would be corrected. 2. On 3/18/24 at 11:46 AM, the surveyor observed Resident #95 ambulating in the hallway independently with staff supervision. The resident was alert and verbally responsive. The surveyor observed the resident's bed without bed side rails. On 3/21/24 at 9:40 AM, the surveyor reviewed Resident #95's hybrid (paper and electronic) medical records. The Admission Record (AR) documented the resident had diagnoses that included but were not limited to, Alzheimer's Disease. A review of a Quarterly MDS assessment, dated 2/18/24, indicated the facility completed a Brief Interview for Mental Status (BIMS) with Resident #95. The resident scored a 2 out of 15 which indicated the resident had severe cognitive impairment. In Section P- Restraints and Alarms, under P0100.Physicial Restraints, Resident #95 was coded as using daily bed rails as restraints. A review of the Order Summary Report included a physician's order dated 8/17/22 which read, Two upper side rails up to bed as an enable for turning and repositioning in bed every shift. On 3/21/24 at 12:39 PM, the surveyor interviewed LPN # 1 about Resident #95. LPN # 1 stated the resident was alert with periods of confusion and ambulated independently with supervision. The surveyor went with LPN # 1 to observe Resident #95's bed. The resident's bed had no bed rails in use. LPN# 1 explained the resident was independent with bed mobility and getting in and out of bed. On 3/21/24 at 1:09 PM, the surveyor interviewed MDS Coordinator #1 who stated bed rails were used to support resident mobility and restraints were not used in the facility. The surveyor reviewed with MDS coordinator #1 the quarterly MDS assessment of Resident #95. MDS coordinator #1 stated the coding for bed rails as a physical restraint was an error. MDS coordinator #1 stated the MDS assessment would be corrected. 39399 3. On 3/18/24 at 11:41 AM, the surveyor observed Resident #32 in the room with eyes closed. The resident was also observed with a tracheostomy in place (a medical device inserted into a surgically created opening in the trachea to facilitate breathing) in place. The surveyor also observed that Resident #32 was in the process of receiving their feed of Glucerna at a rate of 75 ml/hr via feeding pump. The surveyor reviewed Resident #32's hybrid medical records. The AR reflected that Resident #32 was admitted to the facility with medical diagnoses which included but not limited to Sepsis, Chronic Respiratory Failure, Dysphagia and Type II Diabetes Mellitus. A review of the Quarterly MDS (Q/MDS), an assessment tool used to facilitate the management of care, dated 12/28/23 reflected that the resident had a BIMS score of 03 out of 15 indicating that the resident had severely impaired cognition. A review of the December 2023 Treatment Administration Record revealed a physician's order dated 5/9/23 for Tracheostomy Care every day and evening shift for trach care which were signed by the nurses indicating that the tracheostomy care was done. Further review of the Q/MDS under Section O0110E1 for Tracheostomy Care which was coded NO. On 3/25/24 at 12:15 PM, the surveyor interviewed the facility's MDS Coordinator #2 who was responsible of completing Resident #32's MDS assessments. The MDS Coordinator could not provide an answer and stated that she will get back to me for further information. On 3/26/24 at 10:15 AM, the DON stated to the surveyor that it was coded in error. 44605 4. On 3/25/24 at 9:42 AM, the surveyor reviewed the closed medical chart for Resident #133 whose discharge MDS was coded for discharge to acute hospital. The surveyor reviewed the Social Workers (SW) Discharge Plan Documentation (DPD) created on 12/20/23 by the SW for Resident #133. The DPD documented that Resident #133 was discharged home with family. Review of the 12/20/2023 Nursing Progress Note (PN), indicated that Resident #133 Picked Up (P/U) by ambulance and transported home. Review of Resident #133's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to fracture of unspecified part of neck of left femur, pain in left leg, and difficulty walking. Review of the A section of the 12/20/23 Discharge MDS for Resident #133 revealed that section A2105 Discharge Status documented, 04. Short-Term General Hospital. On 3/25/24 at 10:39 AM, the surveyor interviewed the MDS coordinator. The MDS coordinator stated, That resident was discharged home. I must have entered that incorrectly; it was a typo. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023). This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. On 3/25/24 at 10:15 AM, the Director of Nursing (DON) provided the surveyors with a facility policy titled, MDS Remote Completion with a revision date of 12/27/21. The policy stated under the purpose section, To ensure compliance with the RAI process and timely completion of MDS. On 3/25/24 at 12:57 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the MDS coding error. The DON acknowledged the errors and stated they would fix errors that were discovered. No further comment made. NJAC 8:39-11.1, 11.2(e)(1)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) implement the appropriate infection control precautions and personal protective equipment (PPE) for a resident actively treated for [MEDICAL RECORD OR PHYSICIAN ORDER] # 47); b.) ensure proper use of personal protective equipment (PPE) for 1 of 4 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control; c.)perform hand hygiene appropriately for 4 of 11 staff; and d.) ensure that residents were offered and provided hand hygiene before and after meals. This deficient practice was evidenced by the following: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) updated 7/26/19 included, As of July 2019, Novel or Targeted MDROs are defined as: Pan-resistant organisms, Carbapenemase-producing Enterobacterales, Carbapenemase-producing Pseudomonas spp; Carbapenemase-producing Acinetobacter baumannii, and [MEDICATION(S)] auris .Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, [CONDITION(S)]/ventilator; Wound care: any skin opening requiring a dressing. Enhanced Barrier Precautions pertain to All residents with any of the following: infection or colonization with a novel or targeted [CONDITION(S)] when Contact Precautions do not apply; Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, [CONDITION(S)]/ventilator) regardless of [CONDITION(S)] colonization status who reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted [CONDITION(S)] resides. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. According to the U.S. CDC guidelines for Clinicians: Information about CRE (carbapenem-resistant Enterobacterales), page last reviewed 1/8/21 included, Based on information from a CDC pilot surveillance system, most CRE infections involve the urinary tract, often in people who have a urinary catheter or have urinary retention. What can clinicians do to prevent CRE transmission? . Whenever possible, place patients currently or previously colonized or infected with CRE in a private room with a bathroom and dedicate noncritical equipment to CRE patients. Wear a gown and gloves when caring for patients with CRE. Perform hand hygiene-use alcohol-based hand rub or wash hands with soap and water before and after contact with patient or their environment. 1. On 11/3/21 at 11:37 AM, the surveyor observed a red and black STOP sign on the resident's door which indicated STANDARD plus CONTACT PRECAUTIONS TO PREVENT THE SPREAD OF INFECTION. The surveyor interviewed the resident's assigned Certified Nursing Assistant (CNA) who stated that the resident has [CONDITION(S)] in the wound and is on contact precautions. On 11/4/21 at 10:23 AM, the surveyor observed the resident and out of bed seated in a chair inside his/her room. There was no STOP sign on the resident's door. On 11/4/21 at 11:21 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated we do not write physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN/UM acknowledged the resident was currently on an antibiotic for [CONDITION(S)]. On 11/4/21 at 11:32 AM, the surveyor conducted a telephone interview with the resident's podiatrist who stated the residents wound culture came back positive for [CONDITION(S)] and was started on an antibiotic because that was the only oral antibiotic sensitive. The doctor further stated, yes he/she should be on contact precautions for [CONDITION(S)]. On 11/4/21 at 11:58 AM, the surveyor interviewed the resident's assigned Registered Nurse (RN) who stated, the day before yesterday (11/2/21), I put the stop sign on the door but then they reviewed it and they said he did not need to be on contact precautions. The RN further stated, I only had to wear PPE when doing his/her wound care. The stop sign was down this morning when I came in. On that same date and time, the surveyor interviewed the assigned CNA for Resident # 47 who stated, No, I did not wear a gown today when I cared for him/her because they took the stop sign down. Yesterday, I wore a gown because of the infection. On 11/5/21 at 12:25 PM, the surveyor observed no STOP sign on the resident's door. On 11/5/21 at 9:50 AM, the surveyor interviewed the infection control preventionist in the Presence of the survey team. The infection control preventionist stated, if we found out of an [CONDITION(S)] we contact the doctor and place a stop sign for contact precautions on the door even before we know if it is contained. Then we discuss as a team if the wound can be contained. If the team decides the wound can be contained; there is no need for contact precautions. I look at the weekly wound round notes and if the wound is contained and the dressing is dry and not saturated and there is no potential for splashes then we determine on those factors and if there is a potential of the dressing opening. She further stated that the team decided that the resident's wound had minimal drainage, no potential for splashes and that the resident would not remove the dressing from the wound. Therefore, the team decided that contact precautions would not be needed for the resident. She also stated that the facility follows infection control guidelines from CDC (Centers for Disease Control and Prevention). On 11/8/21 at 1:17 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and the Regional Nurse. The Regional Nurse acknowledged and spoke to what the aforementioned infection control preventionist stated. The DON confirmed that the resident was not admitted with [CONDITION(S)] and the [CONDITION(S)] was in-house. The Regional Nurse provided the surveyor the CDC's Multidrug-resistant organisms ([CONDITION(S)]) Management dated 2006 and last reviewed 11/5/2015. She also stated that the facility is following this CDC guideline for MDROs. A review of the resident's Face Sheet (an Admission Summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the podiatrist consult dated 10/25/21, indicated to please check R [right] foot sx [surgical] site: still has open area + depth + light drainage not improving well since seen 10/12/21. Area has no redness, but closure is slow .culture taken. Review of the podiatrist consult dated 11/1/21 indicated to cleanse with normal saline, [MEDICATION(S)] packing dressing and [MEDICATION(S)] every 12 hours for 14 days; follow up one week. Review of the culture and sensitivity report dated 10/30/21, indicated moderate growth for [CONDITION(S)]. Review of the Order Summary Report indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/16/21 Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed a Brief Interview for Mental Status (BIMS) score was 02, which indicated the resident's cognition was severely impaired. The MDS further indicated the resident required extensive assistance of one person for bed mobility, extensive assistance of two persons for transferring, extensive assistance of one person for dressing, toileting, and personal hygiene. The resident was totally dependent on staff of one person for bathing. Further review of the MDS indicated the resident had a surgical wound. A review of the resident's individualized comprehensive care plan for risk for complication of wound infection Right foot-[CONDITION(S)] initiated on 9/10/21 and revised on 11/3/21 revealed an intervention for Standard precautions, administer [MEDICATION(S)] as ordered; monitor for adverse reactions and effectiveness; notify MD [medical doctor] as needed. Further review of the resident's care plans indicated a revised care plan dated 11/3/21 for risk for further skin breakdown . 11/2/21 on antibiotic for right foot [CONDITION(S)]. Review of the electronic progress notes dated 11/2/21, timed at 11:36 and documented by an RN indicated Wound cx [culture] is + [positive] for [CONDITION(S)]. Contact precautions initiated. Review of the Interdisciplinary meeting dated 11/3/21 indicated Discuss [CONDITION(S)] + [positive] result of patient. Goal: to determine if patient requires Contact precautions. Team decided due to containment of area with dressing and an improved drainage to wound that we will do care with Standard Precautions. Review of the weekly skin and wound evaluation dated 11/2/21 indicated a surgical wound on the right foot, first digit (Hallux) which was present on admission. Wound measurements indicated 0.4 cm [centimeters] by 0.2 cm and depth 1.0 cm. Light serous exudate. Review of the facility's [CONDITION(S)] line listing indicated Resident # 47 was actively treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Multi-Drug Resistant Organisms (MDROs) policy revised 11/15/20 provided by the infection control preventionist indicated that contact precautions will be followed when there is a high risk for transmission, such as patients who are/have highly draining wounds, with uncontainable drainage. Standard precautions will be followed as long as the source/site of infection/colonization can be contained. Review of the facility's Infectious Disease and Transmission Based Precautions with a review date of 11/15/20, indicated The appropriate types and duration of Transmission Based Precautions will be followed based on patient's condition, Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting 2007- Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions. Review of the facility Contact Precautions policy revised 6/15/19, indicated in addition to standard precautions, contact precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment. The purpose of the policy was to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. 2. On 11/3/21 at 11:18 AM, the surveyor toured Unit 2 and interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that Resident #69 was on Enhanced Barrier Precautions (EBP) for chronic carbapenem-resistant enterobacterales (CRE: are strains of bacteria that are resistant to an antibiotic class (carbapenem) used to treat severe infections) in the urine. She further stated that the CRE in the urine was colonized (having significant quantities of bacteria in the urine, but no clinical signs of inflammation or infection), and the resident will be on precautions for a long time. On 11/3/21 at 11:24 AM, the surveyor observed the resident laying in bed. There was a PPE box and an EBP sign outside the resident's door. The EBP sign indicated that caregivers, staff, and visitors to perform hand hygiene before and after patient contact, contact with the environment, and after removal of PPE. The EBP sign also included wearing a gown and gloves before high-contact resident care activities. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/25/21, Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 12, which reflected that the resident's cognition was moderately impaired. The SCMDS included that the resident had an indwelling catheter. A review of the personalized care plan for CRE revealed that it was created on 4/27/21 and revised on 7/27/21. The intervention for EBP was dated 5/10/21. On 11/5/21 at 11:30 AM, the surveyor observed the Housekeeper (HK) enter Resident #69's room on EBP wearing gloves and a mask. The HK did not wear a gown before entering the resident's room. The surveyor observed the HK mop the floor then exit the room without doffing (removing) gloves, and did not perform hand hygiene. On that same date and time, the surveyor observed the HK exit the resident's room wearing gloves and walk to the cleaning cart which was located in the middle of the hallway across from the resident's room. The surveyor observed the HK remove and discard the gloves into the cleaning cart. The HK then immediately opened the PPE box and removed an isolation gown without performing hand hygiene and donned the isolation gown. At that same time, the surveyor interviewed the HK before she re-entered the residents room. During the interview, the HK acknowledged and confirmed that she was inside Resident #69's room mopping urine from the floor. The HK acknowledged that she did not wear a gown before entering the resident's room. A short time later, during the interview with the HK, the Housekeeping Director (HD) arrived. The HK in the presence of the HD stated that she did not remove her gloves, did not perform hand hygiene before exiting the resident's room, and did not perform hand hygiene before donning a clean isolation gown from the PPE box. The HD told the HK that You should remove your gloves inside the room and wash your hands before going out of the room. The HD further stated that the HK should have worn an isolation gown before entering the room. At the same time, the District Manager (DM) came and was notified of the concerns. The DM informed the surveyor that the HK should not have to wear an isolation gown because she's not providing direct care to the resident. On 11/5/21 at 11:53 AM, the survey team met with the Infection Preventionist Nurse (IPN) and informed the surveyors that she's responsible for facility education with regard to infection control, return demonstration for PPE use, and hand hygiene. The IPN stated that the facility follows CDC, New Jersey Department of Health (NJDOH), and Centers for Medicare & Medicaid Services (CMS) protocol for infection control. On that same date and time, the IPN informed the surveyors that EBP and Contact Precautions included a gown, gloves, and mask when providing care to a resident when there will be potential contact with bodily fluids and secretions, and that included urine. The IPN stated that gloves are removed inside the room, hand hygiene must be performed immediately after PPE removal. She further stated that handwashing should be at least 20 seconds, lathering should be outside the stream of running water. On 11/5/21 at 1:19 PM, the survey team met with the IPN and was informed of the above concerns. The IPN stated that Resident #69 was on EBP for CRE in the urine and CRE was considered a Super [CONDITION(S)] (multidrug-resistant organism is a germ that is resistant to many antibiotics). She further stated that the HK should have worn an isolation gown before entering the resident's room as the HK mopped the urine on the resident's floor. The IPN stated that the HK should have removed the gloves and performed hand hygiene before leaving the resident's room and performed hand hygiene before getting the isolation gown from the PPE box. On 11/8/21 at 1:17 PM, the surveyors met with the Regional Nurse, Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The LNHA informed the surveyors that the HD written explanation on 11/5/21 indicated that the HK stated that Resident #69's room was mopped because there was a smell of urine. Both the Regional Nurse and DON stated that because of the smell of urine, the HK should have worn an isolation gown before entering the resident's room. On that same date and time, the LNHA and the DON stated they had no additional information regarding the aforementioned concern with the HK. A review of the facility's Modified Enhanced Barrier Precautions Policy provided by the LNHA with a review date of 11/14/20 included, Before exiting room, remove and place PPE (e.g. gown and gloves) in a trash and perform hand hygiene upon exiting the room. A review of the facility's Personal Protective Equipment Policy that was provided by the Regional Nurse with a review date of 9/26/19 included All PPE will be removed and disposed of prior to leaving the work area. When PPE is removed, it must be placed in an appropriate designated area or containers for storage, washing, decontamination, or disposal. Staff will perform hand hygiene after removal of PPE Wash hands after removing gloves. A review of the facility's Hand Hygiene Clinical Competency Validation that was provided by the Regional Nurse with a revision date of 11/2017 included, Handwashing: 2. Turns on water at sink. 3. Wet hands and wrists thoroughly. 4. Applies cleanser or soap to hands. 5. [NAME] all surfaces of fingers and hands, including above the wrists, producing friction for at least 20 seconds 2. On 11/3/21 at 11:15 AM, the surveyor observed a Certified Nursing Aide #1 (CNA#1) inside a resident's room on Unit 2 and informed the surveyor that she was waiting for CNA #2 to help her weigh a resident. On that same date at 11:29 AM, the surveyor observed CNA #2 perform handwashing inside a resident's room. She lathered her hands for 12 seconds under a stream of running water, and donned (put on) a new pair of gloves. Afterward, CNA #2 doffed (removed) her gloves after assisting CNA #1 in weighing a resident. On that same date and time, the surveyor observed CNA #2 perform handwashing. CNA #2 did not wet her hands before applying soap and lathered hands for 10 seconds. At that time, the surveyor interviewed CNA #2 who stated she received education and in-services on hand hygiene and handwashing and that handwashing should be done for at least 20 seconds. She stated, I washed my hands too fast. I was wrong. I should have wet my hands first before applying soap.She acknowledged that the lathering of hands should done be outside of the water. On 11/5/21 at 11:53 AM, the survey team met with the IPN and was made aware of the above concerns. The IPN informed the surveyors that she was responsible for education and in-service concerning infection control of all facility staff. The IPN stated that handwashing should be done for 20 seconds and lathering hands outside the stream of running water. 3. On 11/3/21 at 12:11 PM, during the lunch observation in the main dining room, the surveyor observed the Recreation Assistant (RA) perform handwashing, use a clean paper towel to dry her hands. The RA disposed the used paper towel by directly touching the cover of the garbage container with her bare hands. On that same date and time, the RA informed the surveyors that there was no other way to dispose the used paper towel after performing handwashing but to touch the cover of the garbage container. The RA acknowledge that she contaminated her hands when she directly touched the garbage container after performing handwashing. On 11/5/21 at 11:53 AM, the survey team met with the IPN and was made aware of the above concerns. The IPN informed the surveyors that the facility had another container which was a step-on garbage container. The IPN stated that the facility acknowledged that it was an infection control concern using the garbage container that was seen by the surveyors during lunch observation on 11/3/21 that was why the facility decided to change it again to a step garbage container to prevent staff from touching the garbage container with bare hands after handwashing. On 11/5/21 at 1:28 PM, the survey team met with the LNHA, DON, and Regional Nurse and was made aware of the above concerns. On 11/9/21 at 11:00 AM, the survey team met with the LNHA and DON and there was no additional information provided. 4. On 11/3/21 at 12:23 PM, the surveyors observed the RA and the IPN assisting residents in the dining area during lunch. The hand sanitizer that was mounted on the wall inside the dining area was not working. The surveyor observed the RN/UM place a hand sanitizer on top of the dining table at the end of the dining room. On that same date and time, the surveyors observed the food truck was delivered to the dining area and the food trays were distributed to residents at each table by the RA and the IPN. Both the RA and the IPN returned the empty food trays inside the food truck which contained the clean food trays. After lunch, the surveyors did not observe the RA and the IPN provided hand hygiene to residents. Also, the surveyors observed the IPN did not perform hand hygiene before and after handling food to the residents in the dining area. On 11/4/21 at 12:35 PM, the surveyor observed both the RA and the IPN in the dining area assisting residents for lunch. The RA and the IPN did not provide hand hygiene to six residents before eating. Both the RA and the IPN returned the empty food trays to the food truck with other trays with food. The surveyors observed that 5 of 6 residents were not provided hand hygiene after eating and before and exiting the dining room. On 11/5/21 at 11:53 AM, the survey team met with the IPN and informed the surveyors that it was a facility policy and protocol to perform hand hygiene by staff and residents before and after mealtime in the dining area and each resident's room. The IPN further stated that the empty trays should be placed back to the food truck together with the trays with food. The IPN indicated that there was no problem putting together trays with food that was still to be served to other residents. A review of the facility Meal Service Policy with a revision date of 6/1/21 that was provided by the IPN included, Person-centered meal service includes the delivery of a safe, sanitary, and comfortable environment for meals which accommodates patient/resident preference and personal choice. Meal service may occur in dining rooms, patient rooms, and other suitable locations that promote a homelike environment. NJAC 8:39-19.4 (a) (1) (n) (2) (5)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services of a resident who was receiving oxygen and suctioning as needed according to the standard of practice. This deficient practice was identified for 1 of 1 resident (Resident #59) and evidenced by the following: On 11/3/21 at 10:58 AM, during initial pool, the surveyor observed Resident # 59 in bed awake with a [CONDITION(S)] (an opening surgically created through the neck into the trachea). The surveyor observed an oxygen concentrator next to the bed which was not in use. The oxygen tubing and humidification bottle was dated 10/4/21. There was a suction machine on top of the resident's bedside nightstand which had approximately 150 milliliters' (ML) of fluid in the suction canister. The tubing for the suction machine was dated 10/4/21. On 11/5/21 at 11:50 AM, the surveyor observed the resident in bed awake watching television. The oxygen tubing and humidification bottle was dated 11/4/21. The suction machine canister was empty and clean, and the tubing was dated 11/4/21. On 11/8/21 at 11:00 AM, the surveyor interviewed the Registered Nurse (RN) assigned to care for the resident. The RN stated that the oxygen and suction machine tubing are changed weekly. On that same date at 1:00 PM, the Director of Nursing (DON) confirmed that the oxygen tubing should be changed weekly. A review of the resident's Face Sheet (an Admission Summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/20/21 Significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated that the resident's cognition was intact. Further review of the MDS indicated that the resident was on oxygen therapy, suctioning and [CONDITION(S)] care. Review of the October 2021 Order Summary Report indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 Order Summary Report indicted a PO dated 11/8/21 for oxygen tubing/[CONDITION(S)] tubing change weekly label each component with date and initials every night shift. Further review of the November 2021 Order Summary Report indicated a PO dated 8/31/21 for [CONDITION(S)] suctioning as needed; a PO dated 8/31/21 for [CONDITION(S)] care as needed. A review of the resident's individualized comprehensive care plan for risk for respiratory complications related to stage IV [CONDITION(S)], vocal cord mass, [CONDITION(S)] and [CONDITION(S)] initiated on 8/31/21 and revised on 11/4/21 revealed an intervention to suction [CONDITION(S)] as needed and [CONDITION(S)] to [CONDITION(S)] collar with oxygen as needed at 30% 2.5 L/min [liters per minute] and dial on. All water bottle set to 80% compressor assistance as needed for SOB [shortness of breath] or PO2 [pulse oxygen saturation] less than 90 %. On 11/9/21 at 11:00 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and the Regional Nurse. There was no additional information provided. A review of the Oxygen: Nasal Cannula facility policy with a revision date of 6/1/21 provided by the DON indicated to label and date of initial set-up of nasal cannula and if a humidifier is used to label with date. The oxygen facility policy was not specific to [CONDITION(S)] to [CONDITION(S)] collar with oxygen. NJAC 8:39-11.2 (b); 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in three (3) of five (5) medication carts and one (1) of three (3) medication refrigerators that were inspected. This deficient practice was evidenced by the following: On [DATE] at 10:25 AM, the surveyor inspected the Unit-3 low-side in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Glucose test strips that were not dated and an unopened [MEDICATION(S)] Insulin Pen that was stored in the medication cart. The surveyor interviewed LPN #1 who stated that an opened bottle of blood glucose test strips should have been dated and an unopened [MEDICATION(S)] insulin pen should have been stored in the medication refrigerator. On [DATE] at 10:35 AM, the surveyor inspected the Unit-3 high-side medication cart in the presence of LPN #2. The surveyor observed an opened bottle of Blood Glucose test strips that was not dated. The surveyor interviewed LPN #2 who stated that an opened bottle of Blood Glucose test strips should have been dated. On [DATE] at 11:00 AM, the surveyor inspected the Unit-4 medication room refrigerator in the presence of a Registered Nurse (RN#1). The surveyor observed a bag containing ten (10) unopened [MEDICATION(S)] vials that was stored inside the medication refrigerator. The surveyor interviewed RN #1 who stated that unopened vials of [MEDICATION(S)] should have been stored in the medication cart. On [DATE] at 11:10 AM, the surveyor inspected the Unit-4 low-side medication cart in the presence of RN #1. The surveyor observed an opened bottle of Blood Glucose test strips that was not dated and an opened bottle of Blood Glucose control solution with an opened date of [DATE] and was expired (90-day expiration date). The surveyor interviewed RN#1 who stated that an opened bottle of Blood Glucose test strips should have been dated and stated that an expired bottle of Blood Glucose control solution should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Blood Glucose test strips once opened have an expiration day of 180-days 2. Blood Glucose Control Solution once opened have an expiration date of 90-days. 3. Unopened [MEDICATION(S)] insulin pen should be stored in the refrigerator 4. Unopened [MEDICATION(S)] Vial should be stored in room temperature. On [DATE] at 3:15 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON) and no further information was provided by the facility. A review of the facility's policy for Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated [DATE] that was provided by the DON indicated the following: Facility should ensure that medications and biologicals that: (1) have an expired date on the label (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated and stored separate from other medications until destroyed or returned to the pharmacy or supplier. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has shortened expiration date once opened. The facility staff may record the calculated expiration date based on date opened on the medication container. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperatures. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, record review and review of pertinent documentation, it was determined that the facility failed to respond to a tap bell that was rung by a resident to call staff on two survey days. The tap bells were being used by residents in Station 4 after the electronic call light system had malfunctioned. This deficient practice was observed for 1 of 10 residents (Resident #148) in the Admission Operation Unit (AOU) hallway and was evidenced by the following: On 11/03/21 at 11:45 AM, during the initial tour of the facility, the surveyor toured the AOU unit in which all residents were under droplet precautions and had the doors to their rooms closed. The surveyor observed Resident #148 towards the end of the hallway, far from the nurse's station, who had opened the door and was standing in the entry of his/her room. The resident requested that the surveyor turn off the chirping sound (chair alarm) that was sounding in the room. The surveyor asked a housekeeper in the vicinity to intervene. She was able to turn off the chair alarm and another staff member assisted Resident #148 back to the wheelchair after surveyor intervention. Once the resident was seated in the wheelchair and the tab alarm was reattached to the resident's shirt, the surveyor privately interviewed Resident #148, who was not aware of the purpose of the chair alarm. The surveyor observed that the resident was not in reach of the electronic call bell, but had a tap bell on the overbed table positioned in front of the wheelchair. Resident #148 was not aware of the purpose of the tap bell. The surveyor explained to the resident that it was there to call staff. Resident #148 tapped it several times to see if it was functioning from 11:55 AM until 12:03 PM. No one came to see if Resident #148 needed assistance. On 11/04/21 at 11:09 AM, the surveyor visited Resident #148 in the resident's room. The electronic call bell was not working. Resident #148 was seated in a wheelchair in reach of the tap bell. The resident tapped the bell by ringing it. No one responded. At 11:15 AM, the surveyor observed the resident tap the bell by hitting it two times. No one came to answer the bell. At 11:22 AM, the surveyor observed Resident #148 rang the tap bell two more times. There was no response from any staff members. The surveyor reviewed the resident's medical record, which revealed the following: According to the Admission Record (AR), Resident #148 was admitted recently with a diagnosis that included, but was not limited to unspecified dementia with behavioral disturbance and history of falling. Review of the resident's Minimum Data Set (MDS) dated [DATE], an assessment tool used to facilitate the management of care, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating that the resident's cognition was severely impaired. The MDS also indicated that Resident #148 required limited assistance of one person to walk in the resident's room. Review of the Interdisciplinary Care Plan initiated on 10/29/2021 addressed a risk for falls due to cognitive loss, lack of safety awareness, impaired mobility and a history of falls. Interventions included: a tab alarm while in bed and in the wheelchair, place call light within reach and to remind resident to use call light when attempting to ambulate or transfer. On 11/04/21 at 11:46 AM, in the presence of the survey team, the Director of Maintenance (DM) presented the following information: There was a breakdown of call light system that started on 11/03/2021 at approximately 10:00 AM. The DM stated that the system, Seems like an antique. It's so old. I would have to take the whole system apart to fix it. I was able to reset it. It was working fine. I kept checking it yesterday. It was working. It was not working again this morning. He stated that the Unit Manager (UM) reported the call system breakdown to him. The DM also stated that he received information of need for repairs through the on-line TELS work order system. He stated that any staff member who had a problem in their work area could access the TELS system to report it. The DM stated, Only Unit 4 has a problem right now. The DM stated that he began working at the facility recently and was not sure if checking the call lights were part of a monthly audit. He stated he would check if the monthly audits were being done or which department was responsible for such audits. On 11/05/21 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the list of work orders from the TELS system from 10/01/2021 to 11/05/2021. The report included eight instances when the call system was malfunctioning besides the event on 11/3/21. The LNHA later explained that other instances when the call lights were not functioning according to the TELS report, the maintenance department was able to reset the system. On 11/08/21 at 1:10 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) from unit 4. She stated that they were monitoring the residents on unit 4 every 15 minutes. The RN/UM provided copies of the documentation for these 15 minute room checks. She stated that the staff would make sure that the residents were in reach of the tap bells during the checks. The surveyor informed the RN/UM the two days of observation that no staff responded when Resident #148 used the tap bell. The RN/UM stated that she could provide a louder bell for residents at the end of the hallway. On 11/09/21 at 11:03 AM, the LNHA stated in the presence of the survey team that the call bell system was still not working. She stated that they, Ordered a whole new system. She also stated that they ordered more hand held bells that ring more loudly than the tap bells and that they would have to reassess the residents' ability to ring that type of bell. No additional information was provided regarding the call bell system audits. The facility provided their policy regarding Call Lights, which was revised on 6/01/21 and included the following statements: Policy All Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. Purpose To ensure safety and communication between staff and patients. NJAC 8:39-31.8 (c) 9

C NJ 755 Based on observation, interview, and record review, it was determined that the facility failed to a) wash and store dishware in a sanitary manner, b) store potentially hazardous foods in a manner to prevent food borne illness and, c) follow adequate hand washing practices. This deficient practice was evidenced by the following: On 12/30/19 at 9:21 AM, in the presence of the cook, the surveyor observed the following: 1. The cook removed his gloves and did not wash his hands. 2. Inside the deli refrigerator there was a bottle of soy sauce dated 10/26/19 with a use by date of 11/15/19. The bottle of soy sauce was empty. The cook did not know why the bottle of soy sauce was still inside the refrigerator. 3. Inside the same deli refrigerator there was a bottle of white vinegar spice, opened with no expiration date and not dated. There was approximately one-third of vinegar inside the bottle. The cook said he would discard the bottle of vinegar. 4. Inside the same deli refrigerator there was a small clear plastic container with dry spice labeled Lore and dated 8/5/19. There was no use by date. The cook said the spice belonged to an employee and should not have been inside the deli refrigerator. 5. There was a total of nine various size white dishes stored with dried brown food debris. The cook stated, I don't know what that is, but it shouldn't be on there. He could not speak to why the nine dishes were put away with dried food debris. The cook further stated that all the dishes would be rewashed. 6. The oven back splash had visible dripping and stuck on grease. The cook could not speak to when the oven back splash was cleaned or how often. 7. Inside the reach-in freezer, the surveyor observed a large pan of turkey covered with aluminum foil dated 12/12/19 with a use by date of 12/28/19. The cook stated, I don't know why the turkey is inside the freezer. It should not be in there. The cook discarded the turkey in the presence of the surveyor. 8. Inside the same reach-in freezer, the surveyor observed a lemon meringue pie dated 12/19/19 with a use by date of 12/25/19. The cook discarded the pie in the presence of the surveyor. 9. At 9:52 AM, the surveyor observed the cook remove gloves and wash his hands for nine seconds under running water. 10. The large dry storage room floor had a dark brown sticky substance underneath one area of shelves. The floor was visibly soiled inside the small dry storage room. On 1/3/2020 at 12:10 PM, the Regional Food Service Director stated, that a new employee did not follow proper dishwashing procedures and he stacked dry plates with dry food particles on them and put them away. On 1/06/2020 at 10:26 AM, the surveyor interviewed the cook who said that he was in-serviced on hand washing but he was very nervous that day and that was why he washed his hands under running water for only nine seconds. On 1/07/2020 at 9:30 AM, the administrator stated the oven back splash was cleaned daily. The administrator provided the surveyor with a blank cleaning schedule for the kitchen. She said she would find out if there were any cleaning schedule logs kept. On that same day at 10:00 AM, the Regional Food Service Director provided a hand washing, labeling and dating policy, and food storage and retention guide to the surveyor. At that same time, she said the kitchen staff were cleaning the kitchen on a daily basis but it wasn't documented. It wasn't documented because it is a standard of practice to clean the kitchen. She further stated that the blank cleaning schedule was created last week and now implemented. Review of the facility's undated hand washing policy provided by the Regional Food Service Director indicated to wash hands before putting gloves on and after removing gloves and to apply a sufficient amount of liquid soap to hands .using friction, rub hands together until a soapy lather appears. This should be done away from running water so the bubbles are not washed away .continue this for at least 20 seconds .rinse hands thoroughly under warm running water. Review of the facility's undated policy for labeling and dating food which was provided by the Regional Food Service Director indicated the following; Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner . All foods should be dated upon receipt before being stored . Leftovers must be labeled and dated with the date they are prepared and the use by date. There was no additional information provided. NJAC 8:39-17.2(g)

C# NJ Based on interviews and a review of medical records and other facility documentation, it was determined that the facility failed to assess, monitor and provide preventive skin interventions, in a timely manner, for 1 of 3 residents (Resident #1) who developed a facility acquired right foot blister. On 2/18/10, Resident #1, who had a new pair of diabetic shoes, advised the facility Social Worker (SW) about a blister on her foot. Resident #1's concern was not communicated by the SW to any nursing staff until 2/24/11 when the facility was notified by the [MEDICAL TREATMENT] center about an open blister on the resident's right foot which required antibiotic therapy. Subsequently, the resident required hospitalization for further testing/evaluation and treatments. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on 3/8/11 revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 12/27/10, reflected that the resident had moderately impaired cognitive level with a score of "12" and had no pressure sores. She required extensive assistance with dressing, hygiene and bathing. The most recent readmission skin assessment, dated 11/1/10, documented the resident with intact skin. A review of the resident's nursing care plan, created on 10/17/09 with a revision date of 3/1/11, documented the resident as at risk for skin breakdown due to fragile skin and possible moisture secondary to obese physique. Interventions included, but were not limited to, evaluate for any localized skin problems, i.e., dryness, redness, pustules, inflammation, monitor for signs/symptoms of skin breakdown, i.e., redness, cracking, blistering, decrease sensation and skin that does not blanche easily and observe skin condition with ADL care daily and report abnormalities. Additionally, the care plan showed that the resident had no actual skin breakdown until 2/24/11. The care plan indicated that the resident had skin breakdown related to vascular disease. An incident report, dated 2/24/11 at 4:30 PM, documented that, while Resident #1 was at [MEDICAL TREATMENT], an "open blister (was) noted . . ." Additionally, the incident report documented that the resident was "(r)eexamined when she returned with skin tissue covering lateral aspect of right foot measuring 2cm x 2.5cm with redness to surrounding tissue." Further review of the incident investigation report revealed that there were no reports from staff (aides and nurses) assigned to the resident between 2/22/11 to 2/24/11 about any skin breakdown and/or foot blister prior to being found by the [MEDICAL TREATMENT] center. According to the report, Resident #1 stated, "My new shoes were uncomfortable. I got blisters." The investigation summary documented that there were no uncontrollable conditions that contributed to the decline and that the event was "avoidable." The resident was identified with a new, in house acquired Stage II ulcer. During a care tour by the surveyor on 3/8/11 at 10:30 AM with the RN/Unit Manager (RN/UM) from the resident's unit, the resident was not available for observation or interview. The resident was at [MEDICAL TREATMENT] and comes back at 3:30 PM. During an interview by the surveyor on 3/8/11 between 10:30 AM and 10:40 AM, the RN/UM stated that Resident #1 had a recent hospitalization due to a foot blister and complained of her diabetic shoes that did "not fit right." The RN/UM further stated that the resident wore her shoes until they received a call from the [MEDICAL TREATMENT] center that she had an open blister. When the surveyor asked to see the diabetic shoes, they were not in her room. The RN/UM stated that Resident #1 stopped wearing them and that the shoes were fitted and tried with an Orthotist before used by the resident. A Skin Integrity Report, dated 2/24/11 which was initiated for the resident's right foot by the facility, assessed her with a Stage II pressure ulcer (2cm x 2.5cm), inflamed/indurated with no complaints of pain. The Progress Notes by the Social Worker (SW), dated 2/24/11 at 4:41 PM, documented that, on Friday 2/18/11, she spoke with the Orthotist secretary that the resident was complaining of a blister on her foot. The Orthotist "showed up on Tuesday 2/22/11" but the resident was not available. She further documented that the Orthotist felt the problem was because the resident's feet become swollen before [MEDICAL TREATMENT]. The resident's mother appeared angry and was told by the SW to also call the Orthotist for an appointment. The SW again spoke with the Orthotist who said that he ordered another pair of shoes with Velcro. The SW did not communicate to the nursing staff regarding the resident's foot blister complaint or her calls made to the Orthotist on 2/18/11. Further review of the Progress Notes revealed no documentation from any discipline regarding the resident's right foot blister until 2/24/11. A Progress Note by a Nurse Practitioner (NP), dated 2/24/11 at 5:02 PM, documented that the resident received antibiotics at [MEDICAL TREATMENT] for a wound infection. It was further documented that the resident stated that she had a "blister from my shoes." A wound assessment documented an unstageable right foot wound (2cm x 2.5cm) with 75% slough, macerated borders. Peri-wound inflammation extending to dorsal foot with [MEDICAL CONDITION]. The Plan was to get arterial doppler for both lower extremities, Santyl to right lateral ulcer, no weight bearing/pressure to right foot, provide wheelchair for use, non skid socks and podiatry and vascular consult. Further review of the Progress Notes, dated 2/25/11 at 8:44 AM by a Registered Nurse (RN), documented that the resident was sent to the hospital for evaluation and treatment. At 1:53 PM, Resident #1 was admitted with a [DIAGNOSES REDACTED]. Resident #1's Care Plan was not updated until 2/24/11, 6 days after she initially complained of a blister on 2/18/11. A review of the Treatment Record Sheets (TARS) from February 2011 revealed that the resident's skin was monitored weekly and was last assessed on 2/23/11, during the 3-11 shift, with no skin injury/wound noted. During an interview by the surveyor on 3/8/11 at 1:25 PM, the 3-11 RN, who signed the skin assessment on 2/23/11 as intact, revealed that she included Resident #1's feet during her assessment by removing the resident's socks. She denied seeing any skin breakdown. When asked by the surveyor if it was possible for the resident to have a blister/opening on her feet the following day after her assessment, the RN responded that she did not think it was possible but denied seeing anything during her assessment. During an interview by the surveyor on 3/8/11 at 12:40 PM, the SW, who documented the 2/24/11 progress notes, revealed that the resident had the diabetic shoes for about a month prior to receiving her complaint. She corroborated her documentation from 2/24/11 that the resident first came to her on 2/18/11 about the foot blister and that she called the Orthotist's office more than once. Further interview with the SW revealed Resident #1 told her that the shoe was bothering her and thinks that she had a blister. The SW said she instructed the resident to stop wearing her shoes and let nursing know. When asked by the surveyor about her practice when she receives such concerns, the SW stated, "Tell the nurse." She also stated that she should have told one of the 3-11 nurses but it "slipped out of my head." During an interview by the surveyor on 3/8/11 at 12:20 PM with the RN/UM assigned to the resident on 2/24/11, she stated that no one from nursing knew about the blister until [MEDICAL TREATMENT] called on 2/24/11. The RN/UM stated that the resident could not reach her feet and she would need assist from staff with washing feet, applying socks and putting shoes on, but no one reported about the blister even on the day that she left for [MEDICAL TREATMENT]. When questioned by the surveyor about the SW's progress note, the RM/UM corroborated the SW's statement that she was not notified about the blister on 2/18/11. She further stated that if she was told on 2/18/11 about the blister, she would have done a skin assessment, called the physician and implemented new interventions "to prevent it from getting worse." She denied seeing the resident's right foot until 2/24/11. When asked by the surveyor if the SW should have told her about the resident's concern on 2/18/11 and the calls she made to Orthotics, her response was, "I would hope so." A podiatry progress note, dated 2/24/11, documented that the resident was seen due to an open blister on her lateral right foot. During an interview by the surveyor on 3/8/11 at 1:00 PM with the resident's primary Certified Nursing Assistant (CNA) during 7-3 shift, she stated that the resident sleeps with her socks on. She never checked her feet since Resident #1 had no complaints and always had on socks. During an interview by the surveyor on 3/8/11 at 1:10 PM with the Director of Nursing (DON) regarding how the SW should have addressed the resident's complaint on 2/18/11, she corroborated the RN/UM's statement that nursing should have been notified. She further stated that it should have been brought up during their morning meetings. A review of the hospital's physician (MD) History and Physical, dated 2/25/11, documented that Resident #1 had a chief complaint of right foot ulcer with [MEDICAL CONDITION]. She was fine until approximately about 2 weeks ago. She had a new pair of shoes which were rubbing on the right side of the foot. She "developed a blister which has opened up and now with the right there is spreading redness over the top of the right foot. She has no pain. The blister has resulted in an ulcer." It was further documented that she had "progressive worsening of the redness and [MEDICAL CONDITION]." She was admitted through the emergency room (ER) and was seen by an infectious disease doctor. She was started on [MEDICATION NAME] and [MEDICATION NAME] and admitted for further management. A vascular consult from the hospital, dated 2/26/11, documented that the resident had diabetic ulceration on the lateral aspect of the right foot with [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Vascular examination shows nonpalpable pulses of both lower extremities. She also has advanced [MEDICAL CONDITION], with minimal sensorium on both lower extremities. Facility policy, titled Skin Integrity Management, dated 10/1/10, states, "The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed." The purpose of the policy is to "provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds." There was no evidence that this policy was consistently followed by staff. NJAC 8:39-27.1(a)