Every finding on record at Meadow Lakes

Based on interview and record review it was determined that the facility failed to consistently ensure Minimum Data Set (MDS) assessments were submitted within the required time frame. This deficient practice occurred for 8 of 8 system selected residents (Resident #4, #6, #19, #22, #36, #42, #48, and #53) reviewed for timely submission of MDS and was evidenced by the following: On 3/12/25 at 11:01 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RNMDS) regarding the MDS'. The surveyor provided a list of MDS and requested a validation report regarding timeliness. The RNMDS stated she knew she had late MDS submission. On 3/12/25 at 1:24 PM the RNMDS provided the following validation reports: 1. Resident #6; Target Date: 11/3/24: Message: Assessment Completed Late: Z0500B (12/28/24) is more than 14 days after A2300 (Assessment Reference Date). 2. Resident #4; Target Date: 10/31/23: Message: Assessment Completed Late: Z0500B (12/4/24) is more than 14 days after A2300 (Assessment Reference Date). 3. Resident #19; Target Date:11/6/24 : Message: Assessment Completed Late: For this Admission assessment Z0500B (11/20/24) is more than 13 days after (Entry Date). 4. Resident #33; Target Date: 10/31/24: Message: Assessment Completed Late: Z0500B (12/4/24) is more than 14 days after A2300 (Assessment Reference Date). 5. Resident #36; Target Date: 11/9/24: Message: Assessment Completed Late: Z0500B (12/30/24) is more than 14 days after A2300 (Assessment Reference Date). 6. Resident #42; Target Date: 10/17/24: Message: Assessment Completed Late: Z0500B (11/4/24) is more than 14 days after A2300 (Assessment Reference Date). 7. Resident #48; Target Date: 11/6/24: Message: Assessment Completed Late: Z0500B (12/29/24) is more than 14 days after A2300 (Assessment Reference Date). 8. Resident #53; Target Date: 10/2824: Message: Assessment Completed Late: Z0500B (11/15/24) is more than 14 days after A2300 (Assessment Reference Date). On 03/18/25 at 10:05 AM, the survey team met with the Director of Nursing and Licensed Nursing Home Administrator and no additional information was provided. NJAC 8:39-11.1

Based on interview and document review it was determined that the Facility Assessment (FA) failed to identify and include the staff competencies and skill sets necessary to provide the type of care required for the resident population. This deficient practice had the potential to affect all residents and was evidence by the following: On 3/12/25 at 11:20 AM, the Licensed Nursing Home Administrator (LNHA) provided a copy of the FA dated July 23, 2024 which revealed an attendance sheet with an Agenda that included, but was not limited to; Data- Disease/Conditions/Physical Behaviors needs/ Cognitive disabilities/Acuity and Staff Competencies and Skill Sets. The body of the document included Staff Competencies/Skill Sets, 40% Alzheimer's/Dementia; Resident Count and Acuities: .Short term stays are 100% joint replacement are hips, Pressure ulcers . report show a higher rate of occurrence at 12.8 % compared to 8.7 % for state average . Staffing Plans: .Staff competencies are conducted annually and when new skill sets are required based on resident care needs . The [facility name redacted] can provide services for the following diagnosis/care categories: Common Diagnosis, Psychosis .Congestive Heart Failure, Coronary Artery Disease .Parkinson's Disease .Fractures .Renal Insufficiency, Nephropathy .Renal Failure, End Stage Renal Disease .Skin Ulcers, Injuries . Special Treatments: IV medications -20/year; Dialysis-3/Year . Specific Care or Practices: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Other special care needs included Dialysis. The document failed to include any staff competencies related to the specific care identified for the resident population. On 03/18/25 at 9:57 AM, the surveyor interviewed the LNHA regarding the FA and asked the LNHA if she was aware of the revised regulations related to the FA. The LNHA confirmed she was aware and stated the FA was is compliance, and was also reviewed by the corporation. The surveyor reviewed the FA in the presence of the LNHA and asked if the FA identified the specific staff competencies that were needed to care for the resident population. The surveyor asked specifically about any competencies related to care, including hemodialysis, and wound care. The LNHA looked through the FA and stated, I don't see it there. On 03/18/25 at 10:05 AM, the survey team met with the Director of Nursing and Licensed Nursing Home Administrator and no additional information was provided. NJAC 8:39-13.4(b)

Based on interview and document review it was determined that the facility failed to self-identify all areas for improvement, then develop, implement and maintain a comprehensive, measurable, data driven Quality Assurance and Performance improvement (QAPI) program to address all systems and review significant events at QAPI. The deficient practice had the potential to affect all residents and was evidenced by the following: Refer to F550, F677, F678 On [DATE] at 9:22 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI program. The surveyor asked the LNHA to identify all the current QAPI plans. The LNHA stated that call bell response was identified from the resident council, and from grievances and the LNHA provided the surveyor with the QAPI plan which was reviewed in the presence of the LNHA. The Problem Statement revealed: Staff are to answer call lights.; The SMART Goal revealed: To respond residents need and request expeditiously and appropriately at all times.; The Root Cause/s: What are the contributing factors that cause the problem? Staff not mindful of the call lights and Staff forget to turn off the call lights after answering their needs.; What is the importance of this goal? To respond resident's needs appropriately in a timely manner.; Barrier/s: What difficulties will you encounter implementing your goal? The surveyor asked the LNHA since the date of the goal is [DATE], where is the measurable progress documented. The LNHA reviewed the QAPI in the presence of the surveyor and stated, I don't see the SMART goal is measurable. When asked what SMART meant the LNHA stated, we are not making it measurable. When asked what the remaining QAPI plans were, the LNHA stated, that the facility identified that the staff were not all completing the online education system. When asked to provide the QAPI, the LNHA stated they were in the middle of it. When asked about a specific and measurable goal, the LNHA stated she did not have a document to show the surveyor, but the performance had improved from 40 to 70%. The LNHA stated the facility had a QAPI on the inconsistent availability of the resident weights. The surveyor asked if the goal was specific and measurable and the LNHA stated, I don't have it, maybe the Dietitian, had it? The LNHA stated there was a QAPI with falls with major injury. The surveyor asked if falls with major injury was an adverse event? The LNHA stated, yes, and it went into the internal risk management system. The surveyor asked if adverse events were reviewed in QAPI and she stated, no, I don't see it here, I cannot show it to you. The surveyor asked the LNHA if hand hygiene during meals and standing and cutting resident meals has been identified as a concern per surveyor observations. The LNHA stated, that has not been identified as an issue or had any concerns regarding that brought to her attention. The surveyor then asked if the LNHA was aware of staff placing two incontinence briefs residents as observed during the survey. The LNHA stated, no, the Aides (Certified Nurse Aides) never brought it to my attention. The surveyor asked was placing a double incontinent brief on a resident, okay? The LNHA stated, no, I expect the primary nurses to be checking from time to time. The surveyor asked the LNHA if there were any audits or documents to show that care was monitored, and she stated, No. On [DATE] at 12:07 PM, the survey team interviewed a Registered Nurse (RN) regarding when on [DATE] 6:00 PM, staff observed Resident #18 sitting in recliner not breathing, no pulse, no respiration . Resident expired at 6:00 PM. The RN stated that the resident was found unresponsive and she had confirmed that she was the RN supervisor that day. The surveyor asked the RN if her Cardiopulmonary Resuscitation (CPR) training was up to date. The RN proceeded to look at her phone and looked up her CPR certification and stated, it is expired, I thought it was due in September. The surveyor requested all the CPR education for the nursing staff. On [DATE] at 1:56 PM, during an interview with the LNHA, the surveyor asked if she had been aware that the RN's CPR certification was expired. The LNHA confirmed the RN's CPR certification was expired and was unable to provide a list of all the CPR certifications of the nurses because only the former Director of Nursing had access to it. On [DATE] at 1:59 PM, the surveyor asked the Director of Nursing (DON) how the facility would ensure that there was a CPR certified staff member on each shift. The DON stated that the RN was incorrectly listed as having a current CPR certification. NJAC 8:,d+[DATE]XXX,d+[DATE]

Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide a dignified dining experience by failing to a) provide incontinence care to a resident prior to providing the lunch meal, and b) appropriately provide dining assistance in a dignified manner, and ensure appropriate resident engagement during the lunch meal. This deficient practice occurred for 4 of 4 residents (Resident #13, #27, #29 and #46) reviewed for dining and was evidenced by the following: 1. On 3/12/25 at 12:06 PM, the surveyor observed Resident #13 in the day room next to a Certified Nursing Aide (CNA) #1 who was preparing to assist the resident with the lunch meal. The surveyor smelled an odor of feces and then observed Resident #13's incontinence brief was bulging. At that time, CNA #1 stated that the resident required total care and had been provided with incontinence care that morning. The surveyor then inquired if the resident had been provided with incontinence care prior to serving the meal. CNA #1 confirmed that they had not provide incontinence care prior to serving the resident the meal, and proceeded to assist Resident #13 with the meal without first changing the resident's incontinent brief. On 3/12/25 at 12:37 PM, CNA #1 transferred the resident to bed with a mechanical lift. Upon observation of the resident, the surveyor observed that Resident #13 was soiled with feces. A review of the Face Sheet for Resident #13 revealed diagnoses which included but were not limited to; Alzheimer's disease, Hemiplegia (paralysis on one side of the body), Dysphagia (difficulty swallowing), and muscle weakness. A review of the individual comprehensive care plan (ICCP) dated 6/7/24 to present, included a focus area of at risk for skin impairment secondary to being dependent with Activities of Daily Living (ADL)s and incontinent of bowel and bladder. Interventions included to provide incontinence care and maintain my dignity during episodes of incontinence. A review of the Monthly Summary Evaluation completed 3/7/25, included but was not limited to; limited ability to make concrete requests, always incontinent of bowel and bladder, and was dependent on the staff for ADLs. A review of the facility provided policy, Incontinent Care revised 4/3/24, included but was not limited to; Policy: to provide cleansing . and to maintain skin integrity incontinent care will be provided as needed and according to the resident's care plan. 31654 2. On 3/12/25 at 12:04 PM, the surveyor observed CNA #2, was assisting Resident #29 with the lunch meal, and while assisting the resident she conversed with another CNA who was also assisting another resident with the meal and was behind Resident #29. CNA #2 then spoke over Resident #29 and began complaining about the kitchen staff, and stated they never get it right, CNA #2 then without saying anything to Resident #29, stood up in the middle of assisting Resident #29 and walked to the back table, and then picked up the utensil for Resident #46 and handed it to the resident and returned to assist Resident #29. On 3/12/25 at 12:14 PM, CNA #2 again stood up from assisting Resident #29 and began removing dirty dishes, and then went back to Resident #29 and offered a drink to Resident #29 and stated, you gonna eat? On 3/12/25 at 12:22 PM, CNA #2 again stood up from assisting Resdient #29, walked to another table and picked up Resident #27's knife, and while standing at the opposite side of the table began to cut Resident #27's food with one hand. CNA #2 then again returned to sit next to Resident #29. On 3/12/25 at 12:38 PM, CNA #2 began to assist Resident #29 with a spoonful of food and Resident #29 put their hand up in front of the spoon and CNA #2 stated, you don't want? and CNA #2 proceeded to give the resident the spoonful of food. On 3/12/25 at 12:50 PM, the surveyor interviewed CNA #2 regarding speaking over Resident #29, and leaving, assisting other residents. CNA #2 stated, no we cannot talk over the resident, and the resident is a feeder. CNA #2 stated there was supposed to be four people in the dining room and I don't know what happened. On 3/12/25 at 1:30 PM, the surveyor reviewed the medical record for Resident #29 which revealed a Care Plan Problem, I have dementia and am dependent for my care needs due to functional and cognitive decline . Interventions, undated, included approach in a calm manner and explain what you are doing to me. Another Problem, revealed Nutrition under Hospice Care, resident with increased nutrient needs due to wound healing, requires set up and assistance at meals On 3/14/25 at 12:58 PM, the survey team met with the facility to discuss the above concerns. On 3/18/25 at 10:05 AM, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) met with the survey team. The DON stated the staff was educated to include toileting scheduling and that incontinence care was to be done as soon as resident needs the care. The DON further stated that definitely no matter where and what, that if a resident needed incontinence care, it should be done immediately. In referencing the dining room observations, the DON stated that there were not enough people in the dining room. The Resident Rights Policy, Revised 12/3/24, revealed the facility will treat its resident in a manner that promotes and enhances the quality of life of each resident, ensuring dignity, choice and self determination. NJAC 8:39-4.1(a); 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to provide adequate supervision for a resident who was identified at risk for falls and sustained multiple falls. This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for falls and was evidenced by the following: On 3/13/25 at 8:31 AM, the surveyor observed Resident #47 in their room and was being assisted by a Certified Nursing Aide (CNA). The resident was non verbal and did not open their eyes upon approach. At the CNA then wheeled Resident #47 in into the dayroom, then shortly after returned the resident to their room and left the resident unattended in their room. On 03/13/25 at 8:45 AM, during an interview with the surveyor the Hospice Aide (HA) stated that she cared for Resident #47 and left the resident alone in their room. The surveyor then went to the room with the HA and the resident was not there. The HA and surveyor encountered another staff member that stated Resident #47 was escorted to sensory room at the Assisted Living. On 3/14/25 at 9:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that Resident #47 was cognitively impaired and exhibited agitated behavior manifested by screaming and throwing themselves on the floor. The LPN also stated that Resident #47 had a history of falls. On 3/14/25 at 9:40 AM, the surveyor observed Resident #47 in bed. A floor mat was noted on the right side of the bed and at that time. The surveyor reviewed the medical record for the resident. The Admission Record reflected that Resident #47 was admitted to the facility with medical diagnoses which included, but were not limited to; unspecified dementia, anxiety disorder, unspecified psychotic disorder, unspecified repeated falls. A review of the Quarterly Minimum Data Set (MDS) a comprehensive assessment tool, dated 12/15/24, indicated that Resident #47 was moderately cognitively impaired. Resident #47 received a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). The assessment indicated that Resident #47 required extensive assistance of 1 person for bed mobility and transfers, and was totally dependent on staff for all activities of daily living, used the wheelchair as the primary method of locomotion and was unable to self-transfer. A review of the progress notes revealed that Resident #47 sustained multiple falls at the facility for the last 120 days. On 3/14/25, the facility provided the following fall reports. On 12/10/24 at 4:03 PM, Resident #47 fell in the hallway next to the activity room. Resident #47 sustained a skin tear to the left eyebrow which measured 2 centimeters (cm) x 0.3 cm. A review of the IDT (Interdisciplinary Team) fall note dated 12/12/24 timed 9:57 AM, indicated that the resident was confused. The IDT recommended that Resident #47 be kept within staff eyesight, and to refer to Physical Therapy. On 12/14/24 at 2:44 PM, Resident #47 sustained a fall in the room. The IDT's recommendation were to refer to rehab for screen and keep personal belongings within resident reach. On 12/20/24 at 3:00 PM, Resident #47 fell in the hallway while being transferred by the CNA, and sustained a skin tear to the bridge of their nose with moderate bleeding. The IDT recommendations were to refer Resident #47 to rehab for screen and anticipate needs. On 12/29/24 at 4:00 PM, Resident # 47 was found on the floor in the room. Resident #47 sustained a skin tear with moderate bleeding to the bridge of their nose and bruises to the right arm. The IDT again recommended to refer the resident to rehab screen. Keep the resident within eyesight during waking hours. On 1/14/25 at 11:AM, Resident #47 sustained another fall in the room. Resident #47 was found on the floor by the the therapist calling out for help. No injury sustained. The recommendation was to continue to monitor. On 2/5/25 at 3:18 PM, the resident attempted to get up from the recliner and fell . According to the fall report, staff was across the room and could not get in time to the resident. The recommendation was for staff to monitor closely while awake. On 2/10/25 at 6:20 AM, Resident #47 was found on the floor next to the closet. Resident #47 did not have non skid socks on. Resident #47 sustained a skin tear to the left shin measuring 2 cm x 2 cm. There was no recommendation made by the IDT regarding the fall. On 2/12/25 at 10:15 AM, Resident #47 was found on the floor mat next to the bed, sustained bruises to the right wrist. Recommendations: Increase resident monitoring. Involve in activities. Educate CNA to use redirection method. On 3/10/25 at 9:30 AM, Resident #47 was found on the floor in the bathroom. Recommendation: Continue all current fall recommendation in care plan. Continue frequent monitoring of the resident, and anticipate needs. Further review of the medical record revealed that Resident #47 had a care plan for falls initiated 4/17/24. The goal was for Resident #47 will not have any fall related injuries through the review date. The interventions were to place call bell within reach. Remind and encourage to call for assistance. Staff to leave the bed against the wall. Floor mat to right side of bed. Frequent rounding during the day and night. Increase activity and supervision after family visits. Staff re-educated to increase rounding and check the resident every 1 hour. On 3/14/25 at 1:05 PM, the facility was made aware of the concerns regarding the multiple falls and surveyor observations. On 3/18/29 at 12:30 PM, the Director of Nursing (DON) informed the survey team that she agreed that Resident #47 should not be left unsupervised, and she would formulate a plan to address Resident #47's behavior and the falls. A review of the facility's titled, Falls Management Program last revised 1/27/24 revealed the following under policy and procedure: Residents at high risk for falls must have an appropriate intervention protocol established immediately upon admission documented on the baseline care plan, and continued onto the comprehensive care plan. Procedure #4 The resident's fall risk and appropriate interventions will be reflected on the baseline care plan to be completed within 48 hours and continue to the comprehensive care plan as appropriate. Procedure # 12 All falls are investigated and trended for possible causative factors utilizing the Risk Watch Analysis and reported to the community Improvement Committee along with appropriate action plans. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to administer pain medication as ordered by the physician. This deficient practice was identified for 1 of 3 residents reviewed for pain management (Resident # 33) and was evidenced by the following: On 3/12/25 at 9:30 AM, during the initial tour of the facility, Resident #33 reported to the surveyor that they were experiencing constant pain and did not receive their pain medications for a few days. On 3/13/25 at 8:52 AM, the surveyor interviewed the resident in their room. The resident informed the surveyor that there was a lack of communication among staff and no teamwork. The resident stated that they did not receive their Hydrocodone (opiod used to treat severe pain) prescribed for pain for 3 days, and they experienced excruciating pain on their right shoulder at that time. On 3/14/25 at 9:26 AM, the surveyor again visited the resident and they revealed that about 4 weeks ago, the Hydrocodone was not administered for 3 days, When asked if they experiencing pain at that time, Resident #33 stated, I am always in pain, I have excruciating pain on my shoulders. I do not have any cartilage, they are bone to bone. The nurse stated that they run out of the medication. My doctor always has my scripts. On 3/14/25 at 9:21 AM, the surveyor interviewed the Physician Assistant (PA) in charge of the resident's care. The PA stated that the resident informed her that morning of the missing medication as she just returned to work today. She was not made aware and could not comment on the omissions. On 3/14/25 at 10:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). She stated that she was aware of the missing medication and would provide the investigation. On 3/14/25 at 12:40 PM, the surveyor reviewed the Medication Administration Record (MAR) and confirmed that the Hydrocodone 7.5 milligrams (mg)/300 mg Acetaminophen was not administered on the following dates: 2/18/25, 2/19/25 and 2/20/25. The investigation was not provided and there was no documentation that the physician was notified. A review of the Face Sheet (an admission summary) reflected that Resident #33 was admitted to the facility with diagnoses which included but were not limited to; acute respiratory failure, general anxiety and other chronic pain. A review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/31/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of intact cognition. The assessment included that the resident was receiving scheduled and as needed pain medication, and had pain in the last five days that would occasionally interfere with day-to-day activities. A review of the resident's individualized comprehensive care plan dated 7/26/24, reflected a Focus: I have chronic pain, I have pain to my shoulders, especially my right shoulder. The goal indicated that the resident will be comfortable and If I have pain, it will be managed through the next review period. Interventions included the following: My nurse will administer my pain medication as ordered by my physician. (Hydrocodone-Acetaminophen). Offer me PRN (as needed) medications when I complain of mild pain. Monitor the effectiveness of my pain medication. A review of the Physician's Orders sheet (POS) for February 2025 reflected a physician's order (PO) dated 12/18/24 for the narcotic analgesic Hydrocodone 7.5 mg/Acetaminophen 300 mg. The order specified to administer 1 tablet orally every 12 hours for severe pain as of 12/24/24. The order also reflected an order to check for pain every shift A review of the electronic Medication Administration Record (eMAR) for Resident #33 for February 2025, revealed the pain medication Hydrocodone with scheduled administration times of 0900 (9:00 AM) and 2100 (9:00 PM). On the following dates and times, there was no documentation to indicate that the medication was administered as ordered: 2/18/25 at 0900 and 2100 2/19/25 at 0900 and 2100 2/20/25 at 0900 and 2100 The resident did not receive 6 doses of the medication. The February 2025 non PRN [as needed] medications notes for pain monitoring reflected that on 2/18/25 the resident reported generalized pain pain level was 4, evening shift pain level was 3. On 2/19/25 the resident reported pain to the left shoulder. Pain level was 3. On 2/20/25 the resident reported generalized pain, pain level was 4. On 3/13/14 at 1:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) # 1, who worked on 2/21/25. She stated that the medication was not available and she informed the Unit Manager (UM). On 3/18/25 at 9:16 AM, the UM confirmed again that she was made aware on 2/18/25, she informed the Nurse Practitioner and a script for the medication was forwarded to the provider pharmacy. She could not provide documentation of any communication with the pharmacy. On 3/18/25 at 9:31 AM, the surveyor contacted the provider pharmacy and the pharmacist informed the surveyor that they received a script for the Hydrocodone on 2/20/25. On 3/18/25 at 10:36 PM, LPN #2 who did not administered the medication on 2/21/25, informed the surveyor that staff were to order the Hydrocodone when at least 8 tablets were left on the Bingo card (medication delivery system). She informed the surveyor that she informed the UM that the medication was not available at that time. She stated she did not contact the physician. The surveyor and LPN # 2 reviewed the February 2025 MAR [medication administration record]. She confirmed that Resident #33 did not receive the Hydrocodone as ordered by the physician. On 3/18/25 at 12:56 PM, the surveyor interviewed the physician and he confirmed that he was not made aware that Resident #33 did not receive/have the Hydrocodone since 2/18/25. The physician added, had he been made aware, he would have contacted the provider pharmacy and ordered a 3 day supply. The physician confirmed that he was made aware on 2/20/25 and he sent the script to the pharmacy on 2/20/25. The facility was made aware of the above concerns on 3/14/25. On 3/18/25, the facility confirmed that the physician was contacted on 2/20/25 and ordered a stat (immediate) delivery. A review of a facility policy titled, Administering Medications with a revised date of 1/10/25 included: Policy: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. The individual administering the medication must initial the resident's EMAR/MAR on the appropriate line and date for that specific day before administering the next resident's medication. A review of a facility policy titled Pain Management with a revised date of 6/19/23, included under policy: The resident will be provided with the most effective pain relief methods, and their response to the treatment plan will be monitored and adjusted as needed. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) consistently complete the Dialysis communication form (CF) for the residents on hemodialysis (HD) a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure), and b) monitor, assess and document the care of a hemodialysis access site pre and post HD treatment. This deficient practice was identified for 1 of 1 resident (Resident #15) and was evidenced by the following: On 3/12/25 at 12:56 PM, the surveyor did not observe Resident #15 in their room. The Licensed Nurse Practical (LPN) informed the surveyor that the resident was in the salon. On 3/12/25 at 11:04 AM, the surveyor reviewed the hybrid medical records (combination of electronic medical record and physical chart) of Resident #15. A review of Resident #15's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dependence on renal dialysis (a state of chronic dependence on a machine and medical professionals to maintain life when the kidneys are no longer able to function properly), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), and hypertension (high blood pressure). A review of Resident #15's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/9/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that Resident #15's had moderately impaired cognition. Further review of the MDS indicated the resident received HD. A review of Resident #15's individualized comprehensive care plan (ICCP) created on 11/4/24 included a focus care area that the resident had a diagnosis of chronic kidney disease Stage 5 and had elected to receive HD. The interventions included to monitor right arm AV Fistula (An arteriovenous (AV) fistula is a medical condition where an artery and a vein connect directly, causing blood to flow between them) for signs and symptoms of infection; check bruit (a sound, especially an abnormal one, heard through a stethoscope) and thrill (a vibratory movement) every shift; Review dialysis communication form (CF) for completion. A review of the physician's Order Summary Sheet revealed the following orders: hemodialysis schedule Tuesday, Thursday and Saturday with a start date 11/21/24; Check bruit and thrill [B&T]- check right arm AV fistula for positive bruit and thrill every shift (three times daily) with a start date 11/21/24; and collect dialysis communication book every Tuesday, Thursday, and Saturday, post dialysis. Observe toleration dialysis vitals, new orders sign/initial book and date that this has been done with a start date 1/30/25. The above order to check B&T three times daily was transcribed in Treatment Administration Records (TARs) with a start date of 11/21/24. A review of the February and March 2025 Treatment Administration Record (TARs) reflected that B&T order was signed by the LPN, who worked per diem (as needed) at the facility, as completed who was not able to explain how to assess the AV fistula site correctly. There were 2 entries in February for 2/23/25 and 2/24/25 and 3 entries in March for 3/12/25, 3/13/25, and 3/14/25. On 3/12/25 at 12:47 PM, the surveyor interviewed the LPN regarding the process for a resident that received HD services. The LPN stated that Resident #15 was on HD. The LPN stated the nurses check the resident's vital signs (VS; blood pressure, heart rate, respirations, temperature, etc) before and after the HD, assessed right arm AV fistula site for any signs of bleeding, checked B&T. The LPN further stated the nurses would write down the VS and the fistula site assessment findings on the CF before the resident would leave for their HD session. On 3/12/25 at 1:00 PM, the surveyor reviewed Resident #15's HD binder (a binder on the unit which contained a resident's status on HD treatment days between the facility and the dialysis center) contained two separate areas to be filled out; the top section was to be completed by the facility nurse prior to the resident leaving the facility for the dialysis treatment and the bottom section was to be completed by the Dialysis center staff after treatment and last line needed to be signed by the receiving nurse at the facility when the resident returned. The binder contained the HD CF's which indicated the following: CFs dated 2/8/25, 2/11/25, 2/18/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, and undated CF, did not have VS, access site status and facility nurse signature to acknowledge that this section was completed before the resident left the facility for their HD session. The CF dated 2/8/25 and an undated CF was missing receiving nurse's signature and date at the bottom. The CF did not have a section on the form for an assessment of VS and disposition of dialysis site post dialysis. On 3/12/25 at 1:35 PM, the LPN reviewed the HD binder in the presence of the surveyor and the LPN stated the nurses are responsible to complete the top part of the CF. The LPN further stated the nursing supervisor (NS) and/or the Unit Manager (UM) checked the HD binder for completion after the resident returned to the facility. The LPN stated and demonstrated that she checked resident's right arm for B&T by palpation (a method of feeling with the fingers or hands during a physical examination) at the access site before the resident left for their HD. On 3/14/25 at 9:29 AM, during an interview with the surveyor, the Registered Nurse (RN)/UM stated the top portion on the CF was completed by the nurses at the facility before the resident left for HD and the HD binder would be taken with the resident, by the transport staff. The RN/UM stated that it was important to complete the top portion of the CF so that the HD center knows about resident's VS before the resident left the facility. The RN/UM further stated when the resident returned to the facility, the NS had to sign the CF as a receiving nurse in charge. Then the NS would check for any signs for bleeding at the access site. The RN/UM further stated the NS would check B&T after the dressing was removed from the access site after 4 hours. The RN/UM stated B&T would be checked by palpating at the site. The RN/UM reviewed the HD binder in the presence of the surveyor and observed the incomplete CFs. The RN/UM acknowledged the information was missing on the forms and stated the CFs should be completed prior to the resident leaving the facility for HD. The RN/UM further stated she would educate and provide in-service to the nurses. On 3/14/25 at 9:46 AM, during an interview with the surveyor, the NS stated the process was to check resident's VS, B&T, and if the resident received any pain medication before they left, that would be written down on the CF. The NS stated when the resident returned from HD center, she would check the CF and sign it as a receiving nurse. The NS further stated, If I am not there then the assigned nurse can sign the CF. The NS started the UM was responsible to make sure the CFs were completed. The NS stated to check for B&T, she would place her hand at the AV fistula site and feel for the pulse. On 3/14/25 at 12:58 PM, the survey team met with the administration team and notified the above-mentioned concerns regarding Resident #15. On 3/18/25 at 10:05 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON presented an in-service meeting and training sign-in sheet for assessment of an AV fistula site that was completed after surveyor inquiry. A review of the facility provided Dialysis Treatment-Communication policy revised on 1/25 included a statement: To assure continuity of care and treatment for the resident receiving hemodialysis, the facility will communicate with the hemodialysis center and interdepartmentally. C. Education and training to include: a. Upon orientation the nurses will be taught the care of grafts and fistulas through assessment. NJAC 8:39- 27.1(a)

Based on observation, interview, record review and document review, it was determined that the facility failed to a.) follow appropriate infection control protocols during a wound treatment observation. This deficient practice was identified for 1 of 2 residents (Resident # 54) reviewed with wounds, b.) perform hand hygiene (HH) between serving food, removing dirty dishes, and when assisting residents. The deficient practice was identified in 1 of 1 dining room meal observation, for 3 of 4 residents (Resident #27, #29 and #46) reviewed for dining and was evidenced by the following: 1. On 3/14/25 at 10:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to the sacral area of Resident #54, two certified Nursing Aides (CNA) assisted the LPN during the wound treatment. The LPN prepared the over bed table and gather the needed supplies to complete the treatment. The LPN placed the supplies on the overbed table. At 10:45 AM, the surveyor observed the LPN removed the soiled dressing, dispose of the soiled dressing, removed the soiled gloves and placed them in the trash can inside the room. The LPN then, without first performing HH, donned (put on) a clean pair of gloves and cleaned the wound with [name redacted] Wound solution (topical wound care product that contains hypochlorous acid) soaked gauze pads and patted the wound dry. The LPN did not wash her hands or used Alcohol Based Hand Rub (ABHR) to cleanse her hands after removing the soiled dressing. The LPN then donned gloves, applied the treatment inside the wound, then attempted to pack the wound with the Calcium Alginate (absorbent wound dressing) packing that was not cut to size. With the gloved hand the LPN attempted to retrieve a pair of scissors from her pants pocket. The LPN then could not reach the scissors and asked the CNA to assist. The CNA with her gloved hand reached for the scissors and gave them to the LPN. The LPN picked up the scissors and cut the Calcium Alginate. The LPN was about to insert the Calcium Alginate to pack the clean wound when the surveyor asked the LPN if the scissors were clean or had they been disinfected. The LPN then, donned a clean pair of gloves, disinfected the scissors, cut the Calcium Alginate to size and packed the wound. The LPN then applied a foam dressing for optimum coverage and protection. The LPN did not disinfect the overbed table after disposing of the unused supplies into the trash can. The LPN then signed the resident's Treatment Administration Record (TAR) for completion of the wound treatment. On 3/14/25 at 11:30 AM, the surveyor reviewed the observed treatment with the LPN. The LPN confirmed that she missed some steps during the wound care. The LPN stated that she should have washed her hands after removing the soiled dressing prior to applying a clean pair of gloves. The surveyor reviewed Resident #54's electronic medical record. The admission Face Sheet reflected that Resident #54 had diagnoses which included but were not limited to; difficulty in walking, personal history of other malignant neoplasm of bronchus and lung, pressure ulcer of sacral region, stage 4 (deep wound reaching the muscles, ligament and bone). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/01/24, reflected that the resident was at high risk for developing pressure ulcers and had a stage 4 pressure ulcer to the sacral area. A review of the Care Plan initiated 2/5/25 reflected a problem for alteration in skin impairment related to overall decline. The goals were the resident's skin alterations will continue to improve without complications. The interventions included: wound care treatment as ordered, monitor for pain and provide incontinence care as needed. A review of Physician's Orders sheet (POS) for March 2025, reflected an order dated 3/13/25 for the sacral wound to be cleansed with [name redacted] wound solution -Remove Zinc with mineral Oil-.Apply Collagen wound powder to wound bed-Pack with Calcium Silver alginate-apply Zinc to periwound and cover with bordered gauze dressing every day and as needed. A review of the facility's policy titled, Clean Dressing last revised 1/28/25, revealed the following: Policy: The licensed nurse will use clean techniques for all dressing changes unless otherwise ordered by the physician. The policy did not address the steps to follow for packing a wound. A review of the treatment observation document attached to the facility policy reflected that staff were to wash their hands, after setting the clean field, after disinfecting the over bed table and after removal of the soiled dressing. 31654 38079 2. On 3/12/25 at 11:49 AM, two surveyors observed the lunch meal in the dining room and observed the following: The remote kitchen was adjacent to the dining room and the surveyors observed through an open door that there was one dietary staff (DS) serving food in the kitchen and two CNAs were assisting residents in the dining room. On 3/12/25 at 12:04 PM, the DS entered the dining room wearing gloves and served soup to the residents. The DS returned to the kitchen and failed to remove her gloves or perform HH. The surveyor then observed CNA #2, was assisting Resident #29 at the lunch meal, CNA #2 then Resident #29 got up in the middle of assisting Resident #29 and without first performing HH, walked to the back table and picked up the utensil for Resident #46 and handed it to the resident. CNA #2, without first performing HH, then returned to assist Resident #29. On 3/12/25 at 12:13 PM, the DS plated lunch plates and entered the dining room wearing the same gloves and served residents their lunch meal. At that time the surveyor observed that the HH dispenser adjacent to the dining room panty entrance was empty. The surveyor informed the food service supervisor (FSS) who was also present and the FSS placed her hand under the dispenser and confirmed that the HH did not work. She reentered the kitchen at 12:17 PM, failed to remove gloves or perform HH and plated meals for the residents. On 3/12/25 at 12:13 PM, On 3/12/25 at 12:23 PM, CNA #2 who was assisting a resident with feeding, stopped feeding the resident and walked over to a table with three residents and was handling their cups and utensils (Resident #46 and #27) and used a knife cut Resident #27's food, then without first performing HH returned to assist Resident #29 with their meal. On 3/12/25 at 12:14 PM, CNA #2 again got up from assisting Resident #29 and began removing dirty dishes from Resident #46 and without first performing HH went back to Resident #29 and used the resident's cup to offer a drink to Resident #29. On 3/12/25 at 12:19 PM, the DS delivered three more meals, and then removed two dirty soup bowls. The DS then returned to the kitchen still wearing the same gloves and without performing HH after removing the soiled dishes. At 12:22 PM, the DS delivered two more meals while still wearing the same gloves that were used to remove dirty dishes and plate up other meals. On 3/12/25 at 12:24 PM, CNA #2 walked over to Resident #27 and held that resident's hand while asking that resident if they wanted ice cream. CNA #2 then, without first performing HH, returned to resident #29 and continued to assist with feeding. On 3/12/25 at 12:26 PM, the DS was observed wearing the same gloves, delivered one meal to a resident, returned to the kitchen and began placing desserts on a cart. She did not change remove her gloves or perform HH. At 12:28 PM, the DS removed her gloves and put on new gloves without first performing HH, and then passed desserts from a cart to the resident in the dining room. On 3/12/25 at 12:32 PM, the DS returned to the pantry wearing the same gloves, proceeded to open up packages of crackers, placed the non-sealed crackers on a saucer, and served soup with the crackers to a resident in the dining room. On 3/12/25 at 12:33 PM, CNA #2 stopped assisting Resident #29 when another resident entered the dining room, and without first performing HH she assisted the newly arrived resident to sit, and then handed them their utensils. On 3/12/25 at 12:36 PM, the DS while wearing gloves, pushing the cart into the dining room, then simultaneously provided residents with desserts while removing dirty dishes and placed on the same cart, then placed a tea bag in water opened and then used the same gloved hands to open Jello for a resident. There was no HH performed between providing food items and removing soiled items and at 12:42 PM, the DS then walked into the kitchen while pulling up her pants wearing the same gloves. The DS did not remove her gloves or perform HH and obtained a meal for a resident, and then delivered the meal, removed more dirty dishes while wearing the same gloves. On 3/12/25 at 12:46 PM, upon interview the DS stated she did not change the gloves because I go fast. She further stated that she did not need to perform HH because it was only her, and she was not leaving the dining room. When asked about performing HH between delivering meals and removing dirty dishes, the DS stated she did not need to change her gloves just to deliver food and that there was usually another staff member there to assist her. On 3/12/25 at 1:08 PM, the Food Service Director (FSD) stated that the kitchen staff should not be using the same gloves and should use HH between tasks. The FSD further stated that the DS had been educated and usually would have others to help in the dining room. A review of the facility provided policy, Hand Hygiene revised 1/22, included but was not limited to; Policy: all associates handling food shall wash hands with soap and water at the following times (included) before handling good or clean utensils/dishes/equipment; before putting on gloves; after touching clothing; after handling soiled silverware/utensils; after handling garbage; after removing gloves; and after activities that may contaminate the hands. On 3/14/25 at 12:58 PM, the above concerns were presented to the facility. On 3/18/25 at 10:05 AM, the DON presented documentation that the DS had been in serviced on hand hygiene on 2/13/25. NJAC 8:39 -19.4 (a) Surveyor: [NAME], [NAME] Surveyor: LAW, [NAME]

Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide appropriate incontinence care for a resident (Resident #13) who was dependent on staff for Activities of Daily Living (ADL) for 1 of 1 residents reviewed for ADLs. This deficient practice was evidenced by the following: 1. On 3/12/25 at 12:06 PM, the surveyor observed Resident #13 in the day room next to a Certified Nursing Aide (CNA) #1 who was preparing to assist the resident with the lunch meal. The surveyor smelled an odor of feces and observed Resident #13's incontinence brief was bulging. At that time, CNA #1 stated that the resident required total care and had had incontinence care that morning. The surveyor inquired about the resident requiring incontinence care. CNA #1 did not provide incontinence care and assisted Resident #13 with lunch. On 3/12/25 at 12:37 PM, CNA #1 transferred the resident to bed with a mechanical lift. Upon assessment of the resident, it was observed that Resident #13 was soiled with feces and was wearing two incontinence briefs. A review of the Face Sheet revealed that Resident #13 had diagnoses which included but were not limited to; Alzheimer's disease, Hemiplegia (paralysis on one side of the body), Dysphagia (difficulty swallowing), and muscle weakness. Resident #13 was newly admitted and the Minimum Data Set (MDS) an assessment tool used to facilitate care, had not been completed yet. A review of the individual comprehensive care plan (ICCP) dated 6/7/24 to present, included a focus area of being dependent with ADLs due to cognitive and functional decline. Interventions included to anticipate needs and being dependent on staff for toileting. A review of the Monthly Summary Evaluation completed 3/7/25, included but was not limited to; limited ability to make concrete requests, always incontinent of bowel and bladder, and was dependent on the staff for ADLs. On 3/12/25 at 12:40 PM, the CNA stated that the heavy wetter usually wore two incontinent briefs and that residents should be changed every 2 hours. A review of the facility provided policy, Incontinent Care revised 4/3/24, included but was not limited to; Policy: to provide cleansing . and to maintain skin integrity incontinent care will be provided as needed and according to the resident's care plan. A review of the facility provided policy, Incontinent Care revised 4/3/24, included but was not limited to; Policy: to provide cleansing . for a resident who has been incontinent and to maintain skin integrity incontinent care will be provided as needed during the delivery of personal care services. Equipment included adult brief. On 3/14/25 at 12:58 PM, the survey team met with the facility to discuss concerns. On 3/18/25 at 10:05 AM, the Director of Nursing (DON) stated the staff was educated to include toileting scheduling and that incontinence care was to be done as soon as resident needs the care. The DON further stated that, definitely no matter where and what, that if a resident needed incontinent care, it should be done immediately. She stated that it was unfortunate that the CNA applied two incontinent briefs and that it was not the facility practice. NJAC 8:39-4.1(a); 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to a) consistently ensure physician orders for residents' wishes for life-sustaining treatment were documented in the medical records. This deficient practice was identified for 1 of 1 closed record reviewed for cardio-pulmonary resuscitation (CPR-a medical procedure involving repeated compressions of a person's chest, performed in an attempt to restore blood flow to and breathing of a person whose heart stopped) and was evidenced by the following: A review of Resident #18's closed medical record revealed that Resident #18 was admitted to the facility for short term rehabilitation. Review of the Physician Order Summary (POS) dated February 2025, did not include an order for DNI/DNR (do not resuscitate/do not intubate (to insert a tube into a person's throat, to help with breathing). A nurses progress note dated [DATE] timed 6:00 PM, revealed that the resident was found unresponsive in the recliner chair in the room at 6:00 PM. The note further revealed that the resident was transferred to bed and post mortem care was rendered. Resident was a DNI/DNR. The surveyor reviewed the Physician Order Summary dated February 2025 and could not identify a physician Order for DNI/DNR. A Physical examination dictated and signed by the physician on [DATE] at 12:22 AM reflected the following: General; Appears well and no acute distress. Neurologic: Alert, awake, oriented to place time and forgetful and no focal deficit Plan of care. Plan: Clinically stable. Continue with Physical Therapy. Continue with present medications. Continue diuretic and monitor Basic Metabolic Profile (BMP). There was no DNR/DNI status. On [DATE] at 10:30 AM, the surveyor shared the above concerns with the Licensed Nursing Home Administrator (LNHA) and requested the entire closed record for Review. On [DATE] at 1:15 PM, the LNHA provided the closed record along with the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) dated [DATE], which contained the following order: Do not attempt resuscitation, allow natural death, and do not intubate. Use Oxygen manual treatment to relieve airway obstruction, medications for comfort. On [DATE] at 1:00 PM, during an interview with the surveyor, the LNHA stated that Resident #18 was a DNR/DNI. The surveyor reviewed the closed chart with the LNHA and could not identify a physician order for DNR/DNI. On [DATE] at 11:20 AM, during an interview with a surveyor, a Licensed Practical Nurse (LPN) who recently began working at the facility, stated that a resident's code status would show up when the resident's record was displayed on the computer screen. The LPN pulled up a random resident and showed the surveyor two areas where the DNR/DNI (code) status would be easily identifiable. On [DATE] at 11:34 AM, during an interview with the Registered Nurse (RN) who pronounced Resident #18's death, she admitted that she did not administer First Aid or perform CPR. The RN stated while the nurse went to check the code status in the paper chart, she called the son immediately to verify the code status. She stated that the (POLST) was in the paper chart. She confirmed that the code status should have been easily identified in the electronic medical record. On [DATE] at 1:05 PM, the surveyor interviewed the physician in charge of the resident's care. He stated clearly that the code status should have been in the electronic medical record and easily accessible. He added, Staff should not have to look and check for the order. The process is to initiate CPR and call 911. That is not practical. The Director of Nursing (DON) should educate or continue to reeducate the staff. A review of the facility's policy titled, Electronic Health Record (EHR) last reviewed [DATE] indicated the following: This policy establishes the expectation that every clinician will use the EHR to access and retrieve information, enter data, and respond to clinical decision support interventions at the point of care. Procedure: The EHR is designed to be used at the point of care to support timely access and retrieval of information, accurate and complete capture and documentation of information, clinical decision-making, and communication with all stakeholders in the care process As such: 1 All clinicians are expected to use the EHR as the primary means to access and retrieve information, capture data, and be guided by clinical decision. Review of the facility's Advanced Directive policy last revised [DATE] the policy revealed under #4 the following: Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. NJAC 8:,d+[DATE].6(b)

Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure a resident received their physician ordered medication. This deficient practice was identified for 1 of 5 residents (Resident #48) observed during medication administration. This deficient practice was evidenced by the following: On 3/12/25 at 8:20 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications to administer to Resident #48. The LPN and surveyor observed that the container for the medication Risperdal (an antipsychotic) 2 milligrams (mg) was empty. The LPN stated that medications were to be reordered when there were 10 doses left. A review of the Admission Face Sheet revealed that Resident #48 had diagnoses which included, but were not limited to; Bipolar disorder. A review of the March 2025 Physician Order Sheet documented an order dated 7/31/24, for Risperdal (generic) 2 mg to be administered at 9:00 AM and 9:00 PM. A review of the individual comprehensive care plan (ICCP) effective 5/1/24 to present, included a focus area of a diagnosis of bipolar disease . take medications to manage my symptoms. Interventions included but were not limited to; the nurse will administer medications as ordered by the physician. On 3/12/25 at 11:30 AM, the surveyor approached the LPN and inquired regarding the missing Risperdal. The LPN stated that she had not called the pharmacy yet. When asked if she notified the Unit Manager (UM), she stated no. The surveyor approached the UM and inquired regarding the missing Risperdal. The UM stated that she was not made aware of the missing Risperdal and that if she had been made aware, she would have checked to see if the medication was available in the facility back up supply. The UM further stated that the protocol for reordering medications was for the staff to request the refill when 5 pills were remaining. At 11:35 AM, the UM accompanied the surveyor to the backup medication supplies and retrieved the Risperdal. The UM stated all staff were aware that they should check for missing medications in the backup supply. The UM further stated that medications could be reordered via computer. A review of the facility provided policy, Administering Medications revised 1/17/25, included but was not limited to: Policy: Medications will be administered on time and per physicians order. Should a drug be given other than the scheduled time, an explanatory note must be entered. On 3/14/25 at 12:58 PM, the facility was made aware of the above concern. On 3/18/25 at 10:05 AM, the Director of Nursing (DON) acknowledged that the LPN did not act at the time and that the Risperdal was in the backup medication supply. NJAC 8:39-27.1(a); 29.2(d); 29.3(a)5

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist were acted upon in a timely manner and documented for 4 of 5 residents (Residents #11, #14, and #39) reviewed for unnecessary medications. This deficient practice was evidenced by: 1. According to the Face Sheet, Resident #11 had diagnoses that included, but were not limited to: respiratory failure (a condition that makes it difficult to breathe on your own), iron deficiency anemia (a condition in which the blood doesn't have enough healthy red blood cells), and congestive heart failure (a condition in which the heart doesn't pump blood as well as it should). Review of Resident #11's Electronic Pharmacist Information report (EPIC) revealed a Consultant Pharmacist (CP) recommendation, dated 12/01/22, to Please separate the administration of multivitamin from Ferrous sulfate (iron supplement) by at least 2 hours. Simultaneous administration times of these medications may reduce the absorption. Review of Resident #11's Resident Medication Profile Physician Order Sheets (POS) revealed a 09/22/22 physician order (PO) for Ferosul (iron) 325 milligram (mg) tablet and to administer one tablet daily. The POS revealed a second order, dated 09/22/22, for a Multivitamin tablet and to administer one tablet daily. Review of Resident #11's Medication Administration Record (MAR) for 12/22 and 01/23 revealed that both the Ferosul 325 mg and the multivitamin was scheduled to be administered at 9:00 AM. The EPIC revealed a second CP recommendation, dated 12/01/22, that The recommended dose of Fluticasone (nasal spray) nasal is 2 sprays per nostril once daily or 1 spray per nostril twice daily. If continuing the present dosage, document the rationale. Review of Resident #11's CP recommendation, dated 12/29/22, revealed that the CP repeated the 12/01/22 recommendation that The recommended dose of Fluticasone nasal is 2 sprays per nostril once daily or 1 spray per nostril twice daily. If continuing the present dosage, document the rationale. The 12/29/22 CP recommendation further revealed that the physician reviewed and accepted the CP recommendation on 01/05/23. Review of Resident #11's POS revealed a 09/22/22 PO for Fluticasone Propriate 50 microgram/actuation and to administer two sprays into both nostrils every 12 hours. Review of Resident #11's 12/22 and 01/23 MAR on 01/09/22 revealed the aforementioned PO with the administration times of 9:00 AM and 9:00 PM. The resident's MARs reflected that the Fluticasone dosage continued at the same dosage despite the physician accepting the CP recommendation on 01/05/23. 2. According to the Face Sheet, Resident #14 had diagnoses that included, but were not limited to: heart failure, hypertension (high blood pressure), and cardiac electronic device (pacemaker). Review of the Resident #14's Consultant Pharmacist's Monthly Report (CPMR), dated 11/29/22, revealed that the CP made a recommendation that Metoprolol Tartrate (blood pressure medication) is recommended to be scheduled and given with or immediately following a meal. However, if the prescriber wants to give every 6, 8, or 12 hours despite manufacturer recommendation, then clarify with prescriber and update order to read without regard to meals. The CP made the same recommendation on 12/28/22. Review of Resident #14's POS revealed an 11/05/22 PO for Metoprolol Tartrate 25 mg every 12 hours and included instructions to Hold for HR [heart rate] less than 55; SBP [systolic blood pressure] less than 100. Review of Resident #14's 11/22 MAR on 01/06/23 revealed a 11/05/22 PO for Metoprolol Tartrate 25 mg every 12 hours with the administration times of 9:00 AM and 9:00 PM. The PO included the following under the instructions, Recommended to be given with or immediately following a meal. However, per provider give every 12 hours without regards to meals. The PO was discontinued on 11/05/22. Review of Resident #14's POS did not include the aforementioned PO. Further reviewed of the 11/22 MAR revealed a second PO, dated 11/05/22, for Metoprolol Tartrate 25 mg every 12 hours. The PO included the following under the instructions, Hold for HR [heart rate] less than 55; SBP [systolic blood pressure] less than 100. The PO did not include the notation of that per the provider, give every 12 hours without regards to meals. Review of the 12/22 and 01/23 MAR revealed the aforementioned 11/05/22 PO which did not include the notation of that per the provider, give every 12 hours without regards to meals. During an interview with the surveyor on 01/11/23 at 1:56 PM, the Regional Nurse Consultant (RNC) stated they were unable to locate documentation of Resident #14's 08/22 and 09/22 CP Medication Regimen Reviews reports. 44834 3. According to the Admission Record, Resident #39 had diagnoses that included, but were not limited to: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), systemic sclerosis (a condition that causes skin and the connective tissue to harden), hypertension (high blood pressure), and gastroesophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting the mouth and stomach). Review of Resident #39's CPMR revealed a CP recommendation, dated 09/28/22, Cilostazol (an antiplatelet medication) is best administered on an empty stomach, preferably 1 hour before or 2 hours after meals. The CPMR reflected that the CP made the same recommendation on 10/31/22, 11/29/22, and 12/28/22. Review of Resident #39's Physician Order Sheets (POSs) for 10/22, 11/22, 12/22, and 01/23 all revealed a 03/21/22 PO for cilostazol 50 mg tablet (1 tab) given two times a day. Review of Resident #39's MARs for 10/22, 11/22, 12/22, and 10/23 all revealed that cilostazol 50 mg was scheduled for 9:00 AM and 5:00 PM. Review of the facility document, Meal Times for Healthcare Unit indicated that breakfast was served on the resident's unit between 7:35 AM and 7:45 AM and that dinner was served between 4:35 PM and 4:45 PM. The CPMR revealed another recommendation, dated 10/31/22, Please separate the administration of Ferrous sulfate (iron) from Carbidopa-levodopa (medication to treat Parkinson's disease) by at least 2 hours. Simultaneous administration of these medications may reduce absorption. The CPMR reflected that the CP made the same recommendation on 11/29/22 and 12/28/22. Review of Resident #39's POS for 11/22, 12/22, and 01/23 all revealed a 06/08/22 PO for ferrous sulfate 325 mg (65 mg iron) tablet (1 tablet) given once a day and a 07/11/22 PO for carbidopa 25 mg levodopa 100 mg tablet (2 tabs) given four times a day. Review of Resident #39's MARs for 11/22, 12/22, and 01/23 all revealed that ferrous sulfate 325 mg was scheduled at 5 PM and that carbidopa 25 mg levodopa 100 mg was scheduled at 9 AM, 1 PM, 5 PM, and 9 PM. The CPMR revealed another recommendation, dated 10/31/22, Please update PRN (as needed) artificial tears to include the frequency. The CPMR reflected that the CP made the same recommendation on 11/29/22 and 12/28/22. Review of Resident #39's POS for 11/22, 12/22, and 01/23 all revealed a 04/20/22 PO for artificial tears (pg400-hypromell-glyerin) 1%-0.2%-0.2% eye drops (1 drop) both eyes as needed. The PO did not indicate a frequency for the drops to be given. Review of Resident #39's MARs for 11/22, 12/22, and 01/23 all revealed that artificial tears eye drops were ordered as needed and failed to reveal an indication for how frequently the drops could be given. The CPMR revealed another recommendation, dated 11/29/22, Please separate the administration of Ferrous sulfate from Tums (calcium antacid) by at least 2 hours. Simultaneous administration of these medications may reduce absorption. The CPMR reflected that the CP made the same recommendation on 12/28/22. Review of Resident #39's POS for 12/22 and 01/23 both revealed a 06/08/22 PO for ferrous sulfate 325 mg (65 mg iron) tablet (1 tablet) given once a day and a 11/16/22 PO for Calcium Antacid 300 mg chewable tablet (1 tab) given one time daily. Review of Resident #39's MARs for 12/22 and 01/23 both revealed that ferrous sulfate 325 mg tablet was scheduled for 5:00 PM and that calcium antacid 300 mg chewable tablet was scheduled for 5:30 PM. The CPMR revealed a final recommendation, Please clarify the order for fluticasone (allergy spray) nasal. Please indicate in the order, 1 spray and remove 1-2 sprays. Review of Resident #39's POS for 01/23 revealed a 06/22/22 PO, fluticasone propionate 50 mcg/ actuation nasal spray, suspension (1-2 spray), suspension intranasal to be given one time a day. Review of Resident #39's MAR for 01/23 revealed that fluticasone propionate 50 mcg had instructions to administer 1-2 sprays in both nostrils in the morning. On 01/10/23 at 10:40 AM, the surveyor reviewed Resident #39's progress notes (PN) from 09/11/22- 01/3/23. The PN revealed no documentation that the CP recommendations were discussed or addressed with the physician. The PN further revealed no documented rationale or response to the CP's recommendation. 46889 During an interview with the surveyor on 01/10/23 at 10:13 AM, the VP of Health Services (VPHS) state the CP sends the recommendations via email to the Director of Nursing, the Licensed Nursing Home Administrator (LNHA), and the Unit Manager (UM). The VPHS added that it was the responsibility of the UM to follow up with the CP recommendations. The VPHS further stated they recently had a lot of changes in staff and that they were trying to find the CP recommendations now. During an interview with the surveyor on 01/10/23 at 10:48 AM, the Licensed Practical Nurse (LPN) stated that the nursing supervisors and Director of Nursing (DON) were responsible to make sure that CP recommendations were addressed with the physician. The LPN stated that the nurses on the unit do not look at the CP recommendations. During an interview with the survey team on 01/10/23 at 1:23 PM, the RNC stated the CP recommendations should be addressed by the responsible party to see if the medical director agrees and there should be documentation of when the recommendations are accepted or rejected. The facility policy, Consultant Pharmacist Services-Requirements dated 2020 indicated, Upon receipt of the consultant's recommendations, the facility utilizes the information to complete the Resident Care Plan, takes any action to remedy problems identified, and places required reports in the resident's medical record. The facility policy also indicated, Communicating to the responsible physician potential or actual problems detected relating to medication therapy orders or found within the resident's medical record. NJAC 8:39-29.3(a)(1)

Based on observation and interview, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 01/04/22 at 10:30 AM, the surveyor observed the emergency water storage area in the presence of the Director of Dining Services (DDS). The resident census on the day of observation was 44. The surveyor observed 2 cases that contained six (6) 1-gallon bottles each, plus an additional one (1) gallon of water for a total of 13 gallons. The DDS stated that they should have 3 gallons of water per resident for 3 days in storage. He further stated it was important to have the water in storage because you never know what mother nature will do. The DDS then confirmed that this was the only water stored for the facility. Review of the facility's policy, Recommendations for safe practices during water supply disruption and/or Contamination in Health Care Facilities effective date 04/01/01, revealed A. Procurement of Water from Alternate Sources/Use of Well Water: 1. Bottled Water: a. Determine amount of water needed for patients and personnel (1 to 2 Liters per person per day, depending on patient population); .d. An emergency supply of bottled water should be maintained on premises. NJAC 8:39-31.6 (n)

Based on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to perform new admission COVID-19 testing per facility policy and in accordance with the Centers for Disease Control and Prevention guidelines (CDC) for infection control to mitigate the spread of COVID-19 for 7 out of 10 residents reviewed that had been admitted in the last 30 days. According to the U.S. CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022 .3. Setting-specific consideration .Nursing Homes Managing admissions and residents who leave the facility: o Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. In general, admissions in counties where Community Transmission levels are high should be tested upon admission; admission testing at lower levels of Community Transmission is at the discretion of the facility. o They should also be advised to wear source control for the 10 days following their admission. Residents who leave the facility for 24 hours or longer should generally be managed as an admission. This deficient practice was evidenced by the following: During an interview with the survey team on 01/06/23 at 10:27 AM, the Infection Preventionist (IP) stated that the Community Transmission level was high. She stated new admissions were COVID-19 rapid antigen tested regardless of their vaccination status on day 1 of admission and then again on day 5 through 7. When asked what guidance the facility was following, the IP stated the facility's policy. On 01/09/23 at 11:30 AM, the surveyor requested the COVID-19 testing for the new admissions from the last 30 days from the IP. Review of the facility provided 30-day new admission testing revealed the following: -Resident #49 was admitted to the facility on [DATE]. Review of the December 2022 Physician Order Sheet (POS) revealed a 12/20/22 physician order (PO) for COVID POC (Point of Care) Test as needed, starting 12/20/22. Review of the nursing note dated 12/20/22 at 10:53 PM, revealed the resident had a rapid COVID test on admission. Review of the December 2022 Non-PRN Medication Notes the resident received a COVID test on 12/25/22. -Resident #149 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/21/22 PO for COVID Test on Admission one time daily for one day starting 12/21/22 and PO for COVID Test 5 days after Admission one time daily for one day starting 12/26/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/21/22 and 12/26/22. -Resident #37 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/21/22 PO for COVID Test on Admission one time daily for one day starting 12/21/22 and a PO for COVID Test 5 days after Admission one time daily for one day starting 12/26/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/21/22 and 12/26/22. -Resident #8 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/20/22 PO for COVID Test on Admission one time daily for one day starting 12/20/22 and a PO for COVID Test 5 days after Admission one time daily for one day starting 12/25/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/20/22 and 12/25/22. -Resident #152 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/16/22 PO for COVID Test on Admission one time daily for one day starting 12/16/22 and a PO for COVID Test 5 days after Admission one time daily for one day starting 12/21/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/16/22 and 12/21/22. -Resident #38 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/09/22 PO for COVID Test on Admission one time daily for one day starting 12/09/22 and a PO for COVID Test 5 days after Admission one time daily for one day starting 12/14/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/09/22 and 12/14/22. -Resident #13 was admitted to the facility on [DATE]. Review of the December 2022 POS revealed a 12/13/22 PO for COVID Test on Admission one time daily for one day starting 12/13/22 and a PO for COVID Test 5 days after Admission one time daily for one day starting 12/18/22. Review of the December 2022 Non-PRN Medication Notes revealed the resident received a COVID test on 12/13/22 and 12/18/22. During a meeting with the survey team and the administrative staff on 01/10/23 at 01:22 PM, the Regional Nurse Consultant (RNC) stated the facility followed the New Jersey Department of Health, Local Health Department and the CDC guidelines, which was to test the resident on day of admission and then preferably day 5 and 7. The surveyor requested a copy of the guidance they were following. During a meeting with the survey team on 01/11/23 at 01:52 PM, the IP stated there was no additional information to present for the new admission testing and that she submitted the Medication Administration Records (to the survey team) that reflected testing on Day 1 and Day 5. Review of the facility's policy COVID-19 Universal Testing for Residents (Skilled Nursing and Assistant Living) revised 1/4/2023 revealed the Purpose: To mitigate the spread of COVID-19 in Springpoint communities; 5. All new admissions, readmissions, and residents who leave the facility for 24 hours or longer: a) testing immediately on admission; b) Test after 48 hours after 1st negative; c) Test again after 48 hours after the 2nd negative; 9. Follow all current CDC guidance pertaining to COVID-19 Management. NJAC 8:39-19.4 (a)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 01/04/23 between 09:57 AM and 10:42 AM, the initial tour of the kitchen was completed in the presence of the Director of Dining Services (DDS), the surveyor observed the following: 1. Cook #1 was observed leaning over to observe the contents inside the tilt skillet. The surveyor observed that Cook #1 had a tall white hat on top of his head with exposed hair on the side and back of his head. He was not wearing a hair net. During an interview with the surveyor at that time, Cook #1 stated, I thought because I had a hat on I did not need to wear a hair net. He further stated that the purpose of a hair net was to keep hair from falling in food. The DDS identified the contents of the tilt skillet as the soup of the day. He then confirmed that Cook #1 should have had a hair net on. 2. Dishwasher #1 was observed on the clean side of the dishwasher wearing a baseball hat with exposed hair on the sides and back of his head. The surveyor did not see a hair net. During an interview with the surveyor at that time, Dishwasher #1 stated he had a hair net on, he lifted his hat and showed the surveyor the hair net that had slipped up under his hat leaving his hair exposed. The DDS confirmed Dishwasher #1's hair was uncontained, and it should be contained in the hair net to keep hair from falling onto the dishes. 3. During review of the emergency supply storage the surveyor observed the following: -1 case of 12 cans of 50 ounces of minestrone soup with 02/22/22 stamped on the top of the cans. -1 case of 12 cans of 50 ounces of chicken noodle soup with 03/04/22 stamped on the top of the cans. -1 case of 12 cans of 50 ounces of chicken noodle soup with 02/02/22 stamped on the top of the cans. -3 cases of 12 cans of 50 ounces of cream of mushroom soup with 01/09/22 stamped on the top of the cans. -1 case of 12 cans of 50 ounces of tomato soup with 02/02/22 stamped on the top of the cans. During an interview with the surveyor at that time, the DDS confirmed that the date stamped on the top of the cans, were the expiration dates. On 01/10/23 from 11:15 AM to 11:36 AM, the surveyor observed the following during a revisit in the kitchen: 1. Cook #2 was observed by the ovens wearing a hat with exposed hair around the sides and back of his head and exposed facial hair around his mask. Cook # 2 walked past the surveyor, exited the kitchen and entered the DDS's office. The surveyor followed Cook #2 and observed him donning (putting on) a hair net. During an interview at that time, he stated he realized I did not have a hair net on and came out to get one. The surveyor asked about his facial hair, he stated it has to be covered at all times. 2. Salad Prep #1 was observed stocking salad, she was wearing a hat with exposed hair around the side and back of her head. During an interview at that time she stated, I forget to put the hair net on, it was a woopsie on my part. She further stated the purpose of the hair net was to keep everything clean. 3. Cook #3 was observed wearing gloves, cutting meat. He had a black mask tucked under his chin. Cook # 3 had a significant amount of exposed facial hair on and around his chin. He reached up to pull his mask up with visibly soiled gloves. He pulled his mask up over his nose and mouth, removed the gloves, and donned another pair. During an interview at that time, Cook #3 stated he was told that if facial hair was short enough they didn't have to worry about it and that surgical masks are encouraged to be worn. When the surveyor asked him about handwashing, he stated it should be performed upon entering and exiting kitchen and before and after donning gloves. He confirmed that he did not wash his hands after removing the visibly soiled gloves and donning new gloves. On 01/10/23 at 11:22 AM, the surveyor reviewed the above observations with the DDS. He stated that surgical masks should be worn all day long and facial hair should not be exposed, it should be covered. He stated he would have to check the facility's policy on the length of the facial hair that should be covered. During a follow up interview with the surveyor on 01/10/23 at 11:30 AM, the DDS stated he was responsible for maintaining the emergency food supplies and ensuring it was up to date. On 01/10/23 at 12:08 PM, the DDS provided the surveyor with the facility's policy on Hand Hygiene and stated that he was unable to find a policy on the length of facial hair. The surveyor reviewed the previously provided policy E006, Uniform Dress Code with the DDS. The DDS reviewed the policy and confirmed that all facial hair should be covered and that it was not done. Review of the facility's policy E006, Uniform and dress Code revised 1/22, revealed Associates working with food should wear the approved hair restraint when on duty regardless of the length of presence of hair and to restrain all facial hair with a beard net/restraint. Review of the facility's policy B003, Food and Supply Storage revised 1/22, revealed that most, but not all, products contain an expiration date. The policy further revealed that foods past the use by, sell-by, or enjoy by date should be discarded, date and rotate items first in, first out (FIFO), and discard food past the use-by or expiration date. Review of the facility's policy E007, Hand Hygiene revised 1/22, indicated to wash hands with soap and water at the following times: .before putting on gloves; after touching hair, skin, beard or clothing; after handling soiled silverware/utensils; after removing gloves, after any other activity that may contaminate the hands. NJAC 8:39-17.1(a);17.2(g)

Based on interview and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Resident #14, 1 of 15 residents reviewed for an evaluation of a significant change in the resident's condition. The deficient practice was evidenced by the following: The surveyor reviewed Resident #14's medical record and noted the following: According to the Face Sheet, Resident #14 was readmitted to the facility with diagnoses that included but were not limited to: displaced fracture of left femur, (a fracture where the pieces of your bone moved so much that a gap formed around the fracture where the bone broke) lack of coordination and fall. The Admission Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, dated 08/11/22, revealed that the resident had a brief interview for mental status (BIMS) score of 14 which indicated that the resident was cognitively intact. The MDS showed that the resident required supervision with bed mobility, transfers, walk-in room and corridor, locomotion on unit, toileting, personal hygiene, and bathing. The Quarterly MDS, dated [DATE], revealed the resident had declined and required extensive assistance in bed mobility, transfers, toileting, personal hygiene, and bathing. The resident was coded as 8 for walk-in room and corridor which meant that the activity did not occur. There was no documented evidence that a significant change assessment was initiated when a significant decline in function were identified on the 11/11/22 assessment. During an interview with the surveyor on 01/10/23 at 11:44 AM, the Corporate MDS/Registered Nurse (CMDS/RN) stated that a Significant Change MDS (Sig change MDS) assessment would be completed within 14 days of identifying the change in condition. The CMDS/RN further stated that a Sig change MDS would automatically be completed if the resident was admitted to hospice, had a decline or improvement in two areas of function, and if the change in condition would not self-resolve within 14 days. The CMDS/RN added that if the resident went on therapy and had some improvement but was not back to baseline, then the completion of a Sig change MDS would depend on the number of functional areas affected. During a follow up interview with the surveyor on 01/11/23 at 11:22 AM, the CMDS/RN stated the resident met the criteria for a decline in more than two areas and had a revision to the Care Plan. The resident was placed on physical therapy due to a hip fracture sustained on 10/29/22 and that the biggest areas affected were walking, transferring, and bed mobility. The CMDS/RN added that a Sig change MDS was not completed because the resident was on therapy with a goal to return to the prior level of function, supervision level. The CMDS/RN added that Resident #14 was still receiving therapy services and was making progress but had not yet reached baseline. Review of Resident #14's Care Plan revealed a Problem, initiated on 11/17/22, that I need help with ADL's due to my overall decline in my strength. The CP included interventions initiated on 11/17/22, that I need assistance of one staff for dressing, bed mobility, transfers, toileting, bathing, locomotion on/off unit and maintaining my hygiene. Review of Resident #14's 09/12/22 Physical Therapy (PT) Discharge summary indicated that the resident required supervision with bed mobility, transfers and ambulating. Review of Resident #14's 11/07/22 PT evaluation indicated that prior to hospitalization , the resident was independent with bed mobility, transfers, ambulating with rollator, (rolling walker) (RW) and toileting. The PT evaluation further indicated that now, Resident #14 required moderate assistance for bed mobility, transfers, and ambulating using RW. Review of Resident #14's 11/05/22 Occupational Therapy Evaluation and Plan of Treatment documents indicated the resident's new baseline was substantial/maximal assistance with toilet transfers, lower body dressing, and bathing. The resident required partial/moderate assist with upper body dressing. During an interview with the surveyor on 01/11/23 at 11:44 AM, the Director of Therapy/PT, (DT) stated that Resident #14 required more assistance upon readmission to the facility. The DT added that the resident was hesitant and that the resident indicated that he/she required more assistance due to the surgery. The DT reviewed the 11/07/22 PT evaluation with the surveyor and stated the resident required partial to moderate assist which meant that Resident #14 required 50% or more assistance. Review of the facility's MDS Policies and Procedures, revised October 1, 2019, indicated 6. A Significant Change in Status Assessment (MDS) will be done on return from the hospital, when a determination has been made that the resident meets the criteria of a significant change. (Based on comparison of resident's pre and post hospital status.) 8:39-11.2(i)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to clarify as needed pain medication orders in accordance with professional standards. This deficient practice was identified for Resident #11, one of 5 residents reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During tour of the C-unit on 01/04/23 at 11:54 AM, the surveyor observed Resident #11 sitting in the recliner. The resident was awake, alert, and able to verbalize needs. According to the Face Sheet, Resident #11 had diagnoses that included, but were not limited to: osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), iron deficiency anemia (a condition in which the blood doesn't have enough healthy red blood cells), and muscle weakness. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], an assessment tool utilized to facilitate the management of care, reflected that Resident #11 Brief Interview for Mental Status (BIMS) score was 15 which indicated that the resident was cognitively intact and had received as needed (prn) pain medication in the last five days. The MDS further indicated that the resident had frequent pain and had to limit his/her day-to-day activities because of pain. Review of Resident #11's Resident Medication Profile Physician Order Sheet (POS) revealed a prn physician order (PO) dated 09/22/22, for acetaminophen (pain medication) 500 milligrams (mg) and to administer two tablets prn every six hours for pain. The PO included an instruction notation that: No more that 5 grams in 24 HRS [hours]. The POS revealed a second prn PO, dated 11/09/22, for tramadol (pain medication) 50 mg and to administer one half tablet [1/2 tablet=25 mg] every 12 hours prn for pain. The prn pain medication orders did not include instructions on which medication to administer depending on the resident's pain level. Review of Resident #11's 11/22 and 12/22 Medication Administration Record (MAR) revealed that the resident was administered acetaminophen 1000 mg on: -11/05/22 at 9:28 PM for a pain level of 8 out of 10. -11/10/22 at 3:00 AM for a pain level of 4 out of 10. -11/10/22 at 1:42 PM for a pain level of 8 out of 10. -11/11/22 at 9:14 AM for a pain level of 7 out of 10. -11/17/22 at 1:30 PM for a pain level of 5 out of 10. -11/24/22 at 4:52 PM for a pain level of 7 out of 10. -12/24/22 at 8:07 PM for a pam level of 7 out of 10. -12/25/22 at 5:58 PM for a pain level of 5 out of 10. -12/31/23 at 12:47 AM for a pain level of 6 out of 10. Review of Resident #11's 11/22 and 01/23 MAR revealed that the resident was administered tramadol 25 mg on: -11/09/22 at 10:02 PM. The assessment did not include a pain level. -11/10/22 at 10:00 AM. The assessment did not include a pain level. -11/10/222 at 9:30 PM. The assessment did not include a pain level. -01/02/23 at 8:46 PM for a pain level of 7 out of 10. -01/07/23 at 9:00 AM. The assessment did not include a pain level. -01/09/23 at 9:29 AM. The assessment did not include a pain level. During an interview with the surveyor on 01/10/23 at 12:36 PM, the Licensed Practical Nurse (LPN) #1 stated that she would assess the resident's pain level when administering prn pain medications. LPN #1 further stated she would review the resident's POs to see if the resident had prn pain medications ordered. LPN #1 added that there were instructions within the PO that indicates which prn pain medication to administer depending on the resident's pain level. The surveyor questioned what the facility's practice was if there were no instructions in the prn pain PO. LPN # 1 stated that she would assess the resident's pain level and if the resident's pain level was mild, she would offer the Acetaminophen. LPN #1 added that she would administer the other medication if the resident's pain level was severe. LPN #1 did not indicate that she would clarify the prn pain medication orders with the physician. During an interview with the surveyor on 01/10/23 at 1:10 PM, LPN #2 stated the nurse should check the resident for pain every shift. LPN #2 stated if the resident had more than one prn pain medication, the PO would include additional instructions indicating which medication to administer depending on the resident's pain level. LPN #2 stated that she considered a resident pain scale of 1-4 was mild pain and 5-10 was moderate to severe pain. LPN #2 added that if there were no additional instructions in prn pain medication orders, she would clarify the prn pain medication orders with the physician. During an interview with the surveyor on 01/10/23 at 1:50 PM, the Regional Nurse Consultant (RNC) stated that prn pain medications should have a sequence and indications in the PO instructing which prn pain medication to administer depending on the resident's pain level. During a follow-up interview with the surveyor, the RNC stated he expected the nurses to clarify Resident #11's prn pain medication orders with the physician. NJAC 8:39-29.2(d), 29.3(a)

Based on interview and record review, it was determined that the facility failed to evaluate the performance of Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 4 of 5 randomly sampled CNAs whose personnel records were reviewed and was evidenced by the following: On 01/09/23 at 08:47 AM, a review of the personnel records for the selected CNAs that were provided by the facility revealed the following: CNA #1 was hired on 12/12/05. A Performance Enhancement Program for Staff dated 05/03/21. CNA #2 was hired on 09/28/87. A Performance Enhancement Program for Staff dated 12/20/17. CNA #3 was hired on 12/27/17. A Performance Enhancement Program for Staff dated 05/03/21. CNA #4 was hired on 10/08/10. A Performance Enhancement Program for Staff dated 05/03/21. On 01/09/23 at 09:08 AM, the surveyor requested the most recent employee evaluations. During an interview with the surveyor on 01/09/23 at 10:48 AM, the Director of Human Resources (DHR) stated that CNA performance evaluations should be done yearly but due to the many recent changes at the facility, the evaluations may not have been completed. During a follow-up interview with the surveyor on 01/09/23 at 12:19 PM, the DHR confirmed the employee evaluations that had been provided were the most recent evaluations. He then stated that evaluations should be done yearly but they had not been completed until surveyor inquiry. He further stated that the Director of Nursing (DON) and the administrator were responsible for completing them. The DHR added that the evaluations should be done yearly so employees know where they stand and what needs to be improved on. During an interview with the surveyor on 01/09/23 at 12:42 PM, and in the presence of the DON, the administrator stated that evaluations should be done annually and that she realized some of the evaluations were overdue. She then stated that evaluations were important for feedback and to keep open dialogue especially if there were areas of improvement needed. Review of the facility's Performance Management policy, revised on 03/01/12, indicated it is the policy of Springpoint Senior Living, Inc. (SSL) to review the job performance of each employee .at least every 12 months thereafter The policy revealed that the purpose of the Performance Management process was to review the employee's competencies or performance criteria, completion of goals and objectives and the implementation of a step by step development plan. NJAC 8:39-43.17(b)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for a floor mat for 1 of 3 residents (Resident #39) reviewed for accidents. The deficient practice was evidenced by the following: During the tour of the B unit on 01/04/23 at 10:20 AM, the surveyor observed Resident #39 sitting on the side of their bed with their legs hanging towards the floor. The surveyor observed that there was no floor mat near the resident's bed or visible anywhere in the resident's room. When interviewed, Resident #39 stated that they had several medical diagnoses and that they had been in the facility's healthcare unit for about 2 years. According to the Admission Record, Resident #39 was admitted to the facility with diagnoses that included, but were not limited to: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), systemic sclerosis (a condition that causes skin and the connective tissue to harden), acute osteomyelitis (bone infection) of the left ankle and foot, and a history of falling. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/02/22, revealed staff identified Resident #39 as cognitively intact. The MDS also indicated that the resident had two or more falls that resulted in no injury since the resident's prior MDS was completed. Review of Resident #39's fall incident report dated 09/29/22 indicated that, the resident got up from their bed to pick up an item from the floor when they slipped from their bed and sat on the floor. The incident report indicated that the fall resulted in a minor cut to the resident's lip. Review of Resident #39's fall incident report dated 11/06/22 indicated that the staff member found the resident in the room in a sitting position between their wheelchair and the bed. Further review of Resident #39's incident reports indicated that the resident also had falls from their wheelchair on 11/07/22 and 11/08/22. Review of the January 2023 Physician Order Sheet revealed a 03/18/22 physician order (PO) for mat on the floor along the bed while in bed, for safety. Review of the January 2023 Treatment Administration Record (TAR) revealed the aforementioned PO with administration times of day, evening, and night. The TAR further revealed that nurses signed daily that the floor mat was in place while the resident was in bed. Review of the fall risk care plan (CP) initiated on 03/29/22 indicated that the aide would put a mat on the floor alongside the resident's bed at night, for safety. On 01/05/23 at 10:35 AM, the surveyor observed Resident #39 sitting in a wheelchair in their room. The surveyor did not observe a floor mat in the resident's room. During an interview with the surveyor at this time, Resident #39 stated that they had several falls and that they never had a floor mat. Resident #39 added that the floor mat, might be a good idea. On 01/06/23 at 8:14 AM, the surveyor observed Resident #39 in bed with their eyes closed. The surveyor observed that there was no floor mat beside the resident's bed. During an interview with the surveyor on 01/06/23 at 12:03 PM, the Certified Nursing Assistant (CNA) stated that the resident did not have a floor mat in their room. During an interview with the surveyor on 01/06/23 at 12:17 PM, the Licensed Practical Nurse (LPN) stated that Resident #39 has had a history of falls. The LPN further stated that the resident had an order for a floor mat and that it was put in place in the evening before the resident went to sleep. The LPN and the surveyor entered the resident's room, and the surveyor asked the LPN to show her the resident's floor mat. The LPN stated that there was no floor mat in the resident's room. On 01/06/23 at 12:33 PM, the LPN approached the surveyor and stated that all the staff were responsible to check for placement of the floor mat and that it was not in place that morning. During an interview with the surveyor on 01/06/23 at 12:37 PM, the Registered Nurse (RN) Supervisor stated that Resident #39 fell a few times getting out of bed to their wheelchair. The RN Supervisor stated that she thinks that the resident had a floor mat in their room. The RN supervisor further stated that a floor mat should be in place at night until the morning and that the importance of having a floor mat was so the resident did not get hurt. On 01/09/23 at 2:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA stated the importance of having a floor mat in place while Resident #39 was to follow the PO and CP, and to avoid potentially catastrophic injury for the resident. During an interview with the survey team on 01/10/23 at 1:23 PM, the Regional Nurse Consultant stated that the resident's floor mat had spillage on it and that it went out to be cleaned but acknowledged that a replacement mat should have been in place per the PO. The facility policy, Medication and Treatment Orders with a revised date of 02/2018 failed to indicate how PO should be administered or documented. NJAC 8:39-27.1 (a)

Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to a.) identify all residents exposed to COVID-19 as persons under investigation (PUI) and b.) implement mitigation strategies to prevent the transmission of COVID-19. This deficient practice was identified for 8 of 8 residents (Resident #5, #6, #7, #8, #9, #10, #11, and #12) reviewed for a known exposure to COVID-19 on 2 of 2 nursing units during a survey conducted on 12/9/2020. On 12/6/2020, the facility became aware that CNA #1 tested positive to COVID-19 on 12/4/2020. The CNA was assigned to both COVID-19 positive and negative residents on both the B and C wing nursing units on 12/2/2020, 12/3/2020, and 12/4/2020. The facility identified through contact tracing that CNA #1 had direct contact with seven COVID-19 negative residents (Resident #5, #6, #7, #9, #10, #11, and #12). Surveyor review of CNA #1's assignment sheet on 12/3/2020 revealed that Resident #8 was also exposed. The facility failed to identify these eight residents exposed to COVID-19 as PUI. Upon known exposure these residents remained on the well non exposed nursing unit and were not placed on transmission-based precautions (TBP) in an effort to mitigate the spread of [MEDICAL CONDITION]. During the survey conducted on 12/9/2020, the surveyors observed staff on the well non exposed sections of both nursing units wearing at minimum a N95 (respirator) mask as the only personal protective equipment (PPE). There was no signage that indicated any residents on the well non exposed nursing units were on TBP as well as no readily available PPE. In addition, staff were unaware of the appropriate TBP or protocol that should have been implemented for exposure to [MEDICAL CONDITION]. The facility's failure to identify residents on the well non exposed nursing units as exposed to COVID-19 or implement strategies to prevent the spread of COVID-19. This failure posed a serious and immediate threat to safety and wellbeing of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/6/2020 when the facility was notified of the confirmed positive CNA. The facility Administration was notified of the IJ on 12/9/2020 at 4:29 PM. The immediacy was removed on 12/10/2020 at 1:22 PM based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 12/15/2020. The evidence was as follows: Part A. 1. On 12/09/2020 at 9:15 AM, the surveyors met with the Executive Director, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Registered Nurse/Infection Preventionist (RN/IP). The RN/IP informed the surveyors that the facility had two nursing units (B and C) that shared a connected COVID-19 positive unit. The RN/IP indicated that residents were on TBP in the COVID positive unit so staff in that section of the unit donned (wore) PPE which included N95 mask with a surgical mask covering, coveralls (tear and puncture resistance full body jumpsuit), gown, bonnet (hair covering), booties (shoe coverings), and eye protection. The remaining sections of both B and C nursing units housed residents who were well non exposed. Staff donned at minimum a N95 mask with no surgical mask covering. The RN/IP stated that the facility currently had no PUIs that required TBP. The RN/IP stated that if a staff member was to become COVID-19 positive, that staff member would immediately be removed from work for a minimum of ten days. The RN/IP stated that the facility utilized a form to identify the residents that the COVID-19 positive staff member had come in close contact to within seventy-two hours of testing positive for COVID-19. The RN/IP further stated that all residents that the COVID-19 positive staff member had come in contact with would be placed on TBP for fourteen days. At 10:15 AM, the surveyors reviewed the facility's COVID-19 outbreak resident and staff line list, infection data tracking/surveillance sheets with the LNHA, DON, and RN/IP. The survey team identified that a nursing staff member had tested positive to COVID-19 on 12/4/2020. The RN/IP identified this staff member to be CNA #1. The RN/IP stated that the facility became aware of the positive test results on 12/6/2020. The CNA was not at the facility at the time and was instructed to remain out of the facility on quarantine. The RN/IP stated that the CNA had worked on the nursing units on 12/2/2020, 12/3/2020, and 12/4/2020. The survey team requested CNA #1's assignments for those days as well as any contact tracing completed. At 10:51 AM, the surveyors toured the well non exposed section of B wing nursing unit. The surveyors observed that there was no signage on any of the residents' doors to indicate TBP requirement or usage direction or visible PPE supply bins on the unit. At 11:02 AM, the surveyors interviewed the Lead CNA who stated that she was assigned for the day to residents on both the well non exposed side and the COVID-19 positive side of B wing nursing unit. The Lead CNA stated that she worked from well to ill residents and donned full PPE (coveralls, gown, gloves, booties, bonnet, eye protection, and a surgical mask covering the N95 mask) for the COVID-19 positive residents. The Lead CNA stated that no residents on the well non exposed section of B wing nursing unit were on TBP. Staff did not have to don additional PPE to enter any of these rooms. At 11:08 AM, the surveyors interviewed Housekeeper (HK) #1 who stated that she cleaned both the B and C wing nursing units. The HK stated that when she cleaned the COVID-19 positive section, she donned full PPE. The HK stated that the rooms on the well non exposed sections of the nursing units were considered non-isolation rooms, so she did not have to don additional PPE besides her N95 mask. At 11:21 AM, the surveyors interviewed HK #2 who stated that her primary role was clean and deliver laundry. The HK identified the COVID-19 positive section of the nursing units. The HK stated that those residents were on TBP. The HK stated that none of the residents on the well non exposed section of B wing nursing unit were on TBP. The HK stated that there would be a sign outside the resident's door which indicated TBP and additional PPE was required for that room. There would also be a PPE bin outside that door which contained the additional PPE. The HK stated that she donned only a N95 mask for resident rooms not identified to be on TBP. At 11:31 AM, the surveyors interviewed the Licensed Practical Nurse (LPN) who stated that she was assigned today to residents on both the well non exposed section of B wing nursing unit as well as COVID-19 positive residents. The LPN stated that she worked from well residents to COVID-19 positive residents. The LPN stated that she donned full PPE with COVID-19 positive residents because they were on TBP. The LPN confirmed that there were no residents on the well non exposed section of the B wing nursing unit who were on TBP and required additional PPE prior to entering their rooms. At 11:33 AM, the surveyors toured the well non exposed section of C wing nursing unit. The surveyors observed that there was no signage indicating residents to be on TBP or PPE supply bins. At 12:10 PM, the surveyors interviewed the Occupational Therapist (OT) who stated that she worked with both well non exposed and COVID-19 positive residents on both the B and C wing nursing units. The OT stated that she worked with well residents first before any COVID-19 positive residents. The OT stated that the residents on the COVID-19 positive section were on TBP and she was required to don full PPE. The OT stated that residents in the well non exposed rooms on both B and C wing nursing units were all considered non-ill residents who were not on TBP. The OT stated that she donned only a N95 mask with no surgical mask covering and optional eye protection for those residents. At 12:12 PM, the surveyors interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that no residents on the well non exposed sections of B and C wing nursing units were currently on TBP. The RN/UM further stated that if a staff member tested positive for COVID-19, the facility would identify the residents the staff member had contact with and then perform a rapid [MEDICATION NAME] COVID-19 test (a nasal swab test that detected a body's immune response to COVID-19 which results were known in fifteen minutes) on all of these residents to rule out an infection. The RN/UM did not provide a time frame or look back period for staff to resident contact. The RN/UM further stated that the residents would be monitored for signs and symptoms of COVID-19 in addition to monitoring their vital signs every shift. The RN/UM stated that if the resident who had contact with a COVID-19 positive staff member had a negative rapid test result, were being monitored with no signs and symptoms of COVID-19, then there would be no need to place residents on TBP since residents did not leave their rooms. Review of the PCR lab results (PCR test for qualitative detection of nucleic acid from [DIAGNOSES REDACTED]-CoV-2/COVID-19) revealed the following: CNA #1's swab was collected on 12/4/2020 and reported as positive detected for SAR-CoV-2 on 12/5/2020. Review of the facility's staff line listing revealed that CNA #1 was placed on quarantine out of the facility on 12/6/2020. Review of CNA #1's assignment sheets for 12/2/2020, 12/3/2020, and 12/4/2020 which reflected the following: On 12/2/2020, the CNA was assigned to provide care for one COVID-19 positive resident and nine COVID-19 negative residents. On 12/3/2020, the CNA was assigned to provide care for seven COVID-19 positive residents and three COVID-19 negative residents. On 12/4/2020, the CNA was assigned to provide care for eight COVID-19 positive residents and one COVID-19 negative resident. Out of the eleven COVID-19 negative residents CNA #1 cared for from 12/2/2020 through 12/4/2020, three residents tested COVID-19 positive on 12/4/2020. The remaining eight COVID-19 negative residents (Resident #5, #6, #7, #8, #9, #10, #11, #12) remained negative and not on TBPs according to the facility's resident outbreak line list. At 2:14 PM, the surveyors re-interviewed the RN/IP who explained the facility's contact tracing process. The RN/IP stated that she was not assigned the responsibility of contact tracing, that the head of that department would be responsible. The RN/IP stated that for nursing either the RN/UM or the DON would be responsible for that contact tracing. At 2:17 PM, the LNHA and DON joined the RN/IP and the survey team. The RN/IP continued that for example, if a CNA had tested positive for COVID-19, the facility went back seventy-two hours from the date that CNA tested positive to see who they were in contact with. The RN/IP stated that they were verbally instructed from their Local Health Department (LHD) to do this. Any resident that the CNA was in close contact (within six feet for a cumulative of fifteen minutes in a twenty-four-hour period), would be considered a PUI and placed on TBP for fourteen days and COVID-19 tested routinely. Staff would, during this time, monitor for any signs and symptoms that might develop for COVID-19. Staff would place TBP signage outside the resident's room, as well as place a PPE bin to provide staff with the additional PPE needed. There would be limited movement of staff in and out of that room. During this interview, the surveyors asked why the residents who were COVID-19 negative and exposed to CNA#1 from 12/2/2020 through 12/4/2020 were not placed on TBP for fourteen days. The LNHA responded that the COVID-19 positive results kept coming in. The LNHA acknowledged that the facility was aware that CNA #1 was COVID-19 positive on 12/6/2020. The DON responded that CNA #1's assignment was to COVID-19 positive residents only. At 2:25 PM, the surveyors reviewed with the LNHA, DON, and RN/IP the undated contact tracing sheet for CNA #1 provided by the facility that identified that CNA was in contact with seven out of the eight residents on the CNA's assignment sheets. The surveyor than reviewed the CNA's assignment sheets form 12/2/2020 through 12/4/2020 that reflected that the CNA cared for both COVID-19 positive and negative residents on all three days. The CNA cared for eight identified COVID-19 negative residents. The RN/IP stated that there was no immediate contact tracing completed for CNA #1. At 2:30 PM, the LNHA, DON, and RN/IP acknowledged that all eight residents should have immediately been placed on TBP on 12/6/2020. The DON stated that Resident #5 was discharged home from the facility on 12/7/2020, but the other seven residents remained in the facility and not on TBP. The IJ was identified on 11/19/2020 and the LNHA, DON, and RN/IP were notified of the IJ at 4:29 PM. A removal plan was accepted on 12/10/2020 which included that residents who were identified in coming into close contact with CNA #1 remained in their rooms and placed on TBP. The family of Resident #5, who was discharged home, was notified of the exposure. All licensed staff were re-inserviced on PUI isolation, COVID testing, and investigation of an outbreak. The implementation of the removal plan was verified on-site on 12/15/2020. On 12/15/2020 at 10:12 AM, the surveyors toured the PUI unit and verified through observations, interviews with facility staff, and review of in-service education and revised facility documents that the Removal Plan had been implemented. A review of the facility's Emergency Preparedness Policies and Procedures COVID-19 Contact Tracing dated effective 11/10/2020 included that contract tracing will be done to identify and provide support to staff/residents that may have been infected through exposure to an infected person. This process prevents further transmission of disease by separating people who have (or may have) an infectious disease from people who do not. The importance of contract tracing after exposure is critical to stop the spread of COVID-19. The policy also included that contact tracing will be conducted by the Infection Preventionist, LNHA, Department Manager, Manager on Duty or designee for persons who have been in close contact up to 48 hours prior to the person who has a laboratory-confirmed or probable COVID-19 exposure. The close contact to the person should be notified of their exposure as soon as practicable. The policy also included that close contacts are required to self-quarantine at home for fourteen days after your last contact with that person. A review of the guidance of the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 included that cohort 2 COVID-19 negative, exposed consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. These individuals should be quarantined for fourteen days from the last exposure, regardless of test results. The guideline further included that residents in cohort 2 should be placed on TBP using the COVID-19 recommended PPE of a N95 mask, eye protection, gloves, and isolation gowns. F880 remains a deficiency, at a scope and severity level of a D based upon the following: Part B Based on observation, interview and record review it was determined that the facility failed to perform appropriate hand hygiene in accordance with the Center for Disease Control (CDC) guidelines. This deficient practice was identified during 1 of 3 direct hand hygiene observations and was evidenced by the following: 1. On 12/09/2020 at 10:54 AM, the surveyor interviewed HK #3 working on the non COVID-19 unit. The HK told the surveyor that she had difficulty sometimes speaking English. The HK stated that she worked on both the COVID-19 positive and non COVID-19 positive nursing units. The HK explained that she cleaned the non-ill resident's rooms first and then cleaned the COVID-19 positive rooms last. The HK stated that she performed hand hygiene before and after entering all the residents' rooms and washed her hands for four to five seconds. At 10:59 AM, the surveyor observed HK #3 turn on the faucet to the sink with a paper towel. The HK was observed wetting her hands with water and then applied soap. The surveyor observed the HK rinse and rub her hands together under the running water for twenty-two seconds. The HK was not observed lathering her hands with friction outside of the running water. After the HK rinsed her hands, she used a paper towel to turn off the faucet and then dried her hands with a clean paper towel. The surveyor further interviewed the HK who confirmed that she washed her hands under running water. At 2:10 PM, the surveyors interviewed the RN/IP who stated that the appropriate method to perform hand hygiene in accordance with the CDC guidelines was to wet hands, apply soap, and lather hands in a downward position outside of the running for twenty seconds. The RN/IP further stated that after lathering the hands for twenty seconds, the individual was to rinse their hands with water, use one to two paper towels to dry their hands and then take a clean paper towel to turn off the faucet of the sink. A review of the facility's Handwashing/Hand Hygiene Policy and Procedure dated revised 7/18/18 included that this facility considers hand hygiene the primary means to prevent the spread of infections. The policy further included for the procedure for washing hands to 1. Turn the faucet on. Avoid splashing your uniform. If you touch any surface after turning the water on, including the sink or the faucets, you must begin again. Adjust water to acceptable warm temperature. 2. Angle your arms down, holding your hands lower than your elbows. Wet your hands and wrists. 3. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of twenty seconds (or longer) away from the stream of water. 4. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. 5. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. 6. Discard towels into trash. NJAC 8:39-19.4 (a)(b)(c)(d)

C# NJ Based on observation, interviews, review of medical records, and pertinent facility documents, it was determined that the facility failed to do a fall risk assessment and implement appropriate safety interventions to prevent falls, for 1 of 3 sampled residents (Resident #1), who had a history of [REDACTED]. This deficient practice is evidenced by the following: The surveyor interviewed staff and residents, and reviewed the medical records on 3/16/12 unless otherwise specified. 1. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no fall risk assessment completed on day of admission. A Reportable Event Record/Report (FRE) was received by the New Jersey Department of Health and Senior Services on 3/1/12. The FRE indicated that on 2/28/12 (Resident #1 arrived on the unit during the 3:00 p.m.-11:00 p.m. shift. No care plan was developed because the resident had just been admitted to the unit. He was sent to the hospital.) The Incident/Accident Report dated 2/29/12, revealed that at 2:30 a.m. staff heard the resident holler out and he was found lying on the floor at the bottom of the bed. He was found lying on his abdomen and staff were unable to move the resident. The resident stated that he hit his head and was placed on a back board by the emergency response team. The Nurse's Notes (N.N.) dated 2/29/12, indicated that Resident #1 was admitted to the facility at 4:20 p.m. on 2/28/12, status [REDACTED]. He was asked to call for assistance before ambulation, and call bell was within reach. "He was sent out last night (2:30 a.m.) after sustaining a fall. He was admitted to (hospital) for fracture of C4. Will assess upon return." On 3/1/12 (while the resident was hospitalized ), a N.N. revealed that resident was admitted to the unit on 2/28/12 and was found on the floor in room after sustaining a fall. 911 was called because he reported that he hit his head. The Medical Doctor (MD) and the family were notified. Resident #1 was admitted to the hospital for Cervical 2 Spine Fracture per nurses report. The N.N. also documented that it was suggested to the family to secure a private duty aide for the resident during the 3:00 p.m.-11:00 p.m. and 11:00 p.m.-7:00 a.m. shifts. The 24 Hour Report/Change of Condition Report dated 2/28/12, indicated that the resident: was restless, was repositioned, and settled down and fell asleep at 1:00 a.m. He was found on the floor. He was a status [REDACTED]. The Care Plan Report dated 2/28/12 and printed on 3/2/12 indicated that the following interventions were in place for potential falls: call bell within reach at all times, remind/orient resident of use of call bell during contact, Physical Therapy (P.T.) and Occupational Therapy (O.T.) as ordered, Transfer in and out of bed with assist for toileting/ambulation/to wheelchair, monitor every two hours. According to the FRE, there were no interventions in place for potential falls. The Skilled Unit Incident Statement dated 3/2/12, indicated that the 4:00 p.m.-12:00 a.m. Nursing Supervisor (N.S.) for 2/28/12 observed the resident closely during the 3-11p.m. shift and had to go into his room several times and ask him not to try and stand or ambulate without assistance. "He did not seem to understand why he couldn't return to his apt (apartment)." The 4:00 p.m.-12:00 a.m. N.S. gave report to the oncoming N.S. at 2:00 am and documented that the need for a bed alarm was communicated to that supervisor and the floor nurse. The Skilled Unit Incident Statement dated 3/2/12 also indicated that the 11:00 p.m.-7:00 a.m. Certified Nurse Assistant (CNA) observed the resident asleep at 1:55 a.m. and that the 11:00 p.m.-7:00 a.m. Licensed Practical Nurse (LPN) heard the resident holler out and found him on the floor at 2:30 a.m. A post hospitalization Fall Risk assessment dated [DATE] reflected a score of 13 which indicated that he was at a high risk for falls. On 3/16/12 at 10:25 a.m., a care tour was conducted on the Skilled Nursing Unit (C wing) by the surveyor accompanied by the Acting Director of Nursing (ADON). Resident #1 was observed with a functioning sensor pad alarm on his bed, and functioning tab alarm on his wheelchair. 1:1 staff was observed to be present. An interview was conducted by the surveyor on 3/16/12 at 10:00 a.m., with the Vice President (VP), who stated that the facility was attempting to find out the reason the resident did not have an alarm in place. She said that resident was impulsive, and further stated that it was the primary nurse or the 4:00 p.m.-12:00 a.m. N.S. responsibility to apply the alarm. The VP further explained that the facility was aware that he was a fall risk because he fell while living in the Assisted Living (A.L) facility. She said that normal procedure would be to do a fall risk assessment and then decide what interventions would have been implemented and that an alarm would have been implemented upon admission. Resident #1 was readmitted to the facility with an alarm for his bed and has 24 hour 1:1 staff. An interview was conducted by the surveyor on 3/16/12 at 11:50 a.m., with the 4 p.m.-12 a.m. N.S. who stated that the resident was admitted to the facility at 4:00 p.m. She further explained that the 8:00 a.m.- 4:00 p.m. N.S. would do the assessment. She stated that she was unsure if the assessment was done and that the resident did not have an alarm in place. However, she oriented him to the use of the call bell. She explained that she did not get a chance to apply an alarm because she had two other new admissions to assess. She further explained that she did not delegate for any other staff to implement an alarm and that she and the primary nurse were aware of his need for an alarm. She further stated that it was the primary nurse and her responsibility to apply the alarm. She explained that she observed him attempt to get out of the bed on several occasions, and encouraged him to call for help. She further explained that she was unsure of what interventions were implemented to prevent him from falling. She stated that she reported to the in-coming primary nurse and N.S. the need for an alarm. She was unsure if this need was documented on the 24 Hour Report. A telephone interview was conducted by the surveyor on 3/16/12 at 11:55 a.m., with the 12:00 a.m.-8:00 a.m. N.S. who stated that the evening N.S. did not inform her of the need of an alarm until 2:00 a.m. and that she did not realize that he did not have an alarm until after he fell at 2:15 a.m. The N.S. said that they were busy finishing orders for the new admissions. She explained that she did not get a chance to get an alarm for the resident. A telephone interview was conducted by the surveyor on 3/16/12 at 12:05 p.m., with the 11:00 p.m.- 7:00 a.m. LPN who explained that the evening N.S. did not inform her of the need for an alarm until 15 minutes prior to Resident #1 falling. She further explained that she was completing orders, and did not get a chance to get an alarm. An interview was conducted by the surveyor on 3/16/12 at 12:37 p.m., with the ADON. She stated that the nursing admission assessment has to be done within 24 hours of admission. However, she was unable to provide the surveyor with a policy indicating such. She further stated that the fall risk assessment was not done on the day of admission. The facility policy titled, "Falls Management Program" included but was not limited to completing a fall risk assessment on admission. There was no evidence that this policy was consistently followed. A review of the Hospital Records obtained post survey, indicate that per the "History & Physical Result Report" dated 2/29/12, Resident #1 had a recent history of fall with fractured ribs and" at 2:30 a.m., the patient came out of his bed by himself where he is not supposed to do that and had a fall. "The report also revealed that" a CAT scan revealed odontoid C2 neck fracture." NJAC 8:39-27.1 (a)