Every finding on record at Oaks at Denville, The

Complaint #: 3008061 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a staff member, Unidentified Person (UP #1), who was providing resident direct care as a Certified Nursing Aide (CNA) was a.) certified as an nursing aide and b.) had the appropriate competencies and skills sets to provide resident care in a manner to assure resident safety and ensure each resident attained or maintained their highest practicable physical, mental, and psychosocial wellbeing. This deficient practice had the potential to affect all residents who resided on 2 of 3 nursing units. On 4/29/2026 at 6:36 PM, the Staffing Coordinator called Agency CNA #1 with the phone number listed on the online staffing agency platform seeking CNA coverage for 4/30/2026. The woman who answered the phone identified herself as Agency CNA #1 and informed the Staffing Coordinator that she was currently out on disability and not working. The Staffing Coordinator identified that Agency CNA #1 had worked at the facility the day before (4/28/2026), and she was currently signed in at the facility as working. The Staffing Coordinator called back Agency CNA #1, who stated that her sister had the same name as her, but spelled differently, and that her sister used Agency CNA #1's phone number on the online staffing agency. The facility indicated that they searched the online state registry and could not find a second license with Agency CNA #1's name spelled differently as her sister. UP #1 was immediately removed from her assignment and the local police came in to question her. Upon police questioning, it was identified that UP #1 was not certified and was posing as Agency CNA #1. An interview with the Staffing Coordinator on 5/18/2026, revealed that UP #1 had worked three shifts at the facility from 4/28/2026 through 4/29/2026, on two nursing units, and she rendered care on sixteen residents. The facility's failure to ensure all staff members who were providing direct resident care which included but was not limited to; bathing, mobility, ambulation, feeding assistance, toileting, showering, dressing, and transfers using a mechanical lift, had the appropriate certification, competencies, and skills sets needed to provide resident care. This posed the likelihood for serious harm, impairment, or death from an incompetent staff member rendering care. This resulted in an Immediate Jeopardy (IJ) situation which the immediacy ran from 4/28/2026 at 7:00 AM, when UP #1 began working as a CNA until 4/29/2026 at 7:30 PM, when UP #1 was removed from the nursing unit and the local police confirmed she was impersonating Agency CNA #1. The IJ was Past Non-Compliance (PNC). The facility's Administration was notified of the F 726 IJ and was provided with the IJ template on 5/18/2026 at 3:30 PM. The facility submitted an acceptable Removal Plan (RP) on 5/19/2026 at 12:16 PM. The facility was back in compliance when the facility addressed the situation by removing UP #1 from the nursing unit, calling the local police, conducting complete body checks and interviews of all residents who were provided care from UP #1, and implementing a new policy requiring two forms of identification be shown to the supervisor prior to working for all agency staff and all nursing staff were in-serviced on the policy. The survey team verified the completion of the Removal Plan, and that the facility self-corrected the deficient practice on 4/30/2026, during an on-site survey on 5/19/2026 at 12:20 PM. It was determined that the IJ was PNC. The evidence was as follows:A review of the facility's Temporary Contracted Staff Verification policy, dated effective 4/30/2026, included for procedures, 2. Facility staff must verify credentials through appropriate state registry prior to the start of shift. 3. All temporary staff must check in with a supervisor or designated staff before beginning work. A) The temporary contracted staff must present at least 2 forms of ID, and it must exactly match the pre-approved documentation: a) Government issued photo ID, b) Agency badge. A review of the facility's Abuse, Neglect and Exploitation policy, dated 5/12/2026, included, Screening.C. Professional Licensing and Credentialing: a) License/Certification Verification: Subacute Nursing Facilities (SNFs) must independently verify the active status of any required professional licenses. A review of the Facility Reportable Event (FRE) dated 5/01/2026, submitted to the New Jersey Department of Health (NJDOH), revealed on 4/29/2026 at 6:36 PM, the Staffing Coordinator called Agency CNA #1 with the phone number listed on the online staffing agency platform seeking CNA coverage for 4/30/2026. The woman who answered the phone identified herself as Agency CNA #1 and informed the Staffing Coordinator that she was currently out on disability and not working. The Staffing Coordinator identified that Agency CNA #1 had worked at the facility the day before (4/28/2026), and she was currently signed in at the facility as working and notified the Director of Nursing (DON). The Staffing Coordinator called back Agency CNA #1, who stated that her sister had the same name as her, but spelled differently, and that her sister used Agency CNA #1's phone number on the online staffing agency. The facility indicated that they searched the online state registry and could not find a second license with Agency CNA #1's name spelled differently as her sister. UP #1 was immediately removed from her assignment and placed in the break room until the local police came to question her. Upon police questioning, it was identified that UP #1 was not certified, was posing as Agency CNA #1 who was her sister, and Agency CNA #1 knowingly let UP #1 use her certification to work. On 5/18/2026 at 9:31 AM, the surveyor interviewed the Staffing Coordinator, who stated the facility had been using the online staffing agency for over five years, and the agency application required individuals to upload photo identification, cardiopulmonary resuscitation (CPR) card, a professional license, and annual background checks. The Staffing Coordinator confirmed that UP #1 had worked three shifts from 4/28/2026 through 4/29/2026, and she was responsible for the care of sixteen residents. The Staffing Coordinator stated that UP#1 provided the following direct care resident activities; bathing (the immersion or washing of the body or specific body parts using water), mobility/ambulation (refers to the help provided to individuals who have difficulty walking due to various medical conditions, injuries, or age-related decline), feeding assistance (including tasks such as cutting food, guiding utensils, and monitoring swallowing), toileting (involves guiding resident to a toilet, bedside commode, bedpan, urinal, or using incontinence products such as adult incontinence briefs), showering, dressing (providing assistance with robing and disrobing with resident's clothes), and transfers using a mechanical lift (also known as a patient lift, a medical device designed to assist in transferring individuals with limited mobility from one surface to another). The Staffing Coordinator further revealed that agency staff did not have to provide a secondary identification to the facility staff upon entering the facility. At that time, the Staffing Coordinator provided the surveyor with a list of sixteen residents that UP#1 provided direct care to during her shifts. Furthermore, the Staffing Coordinator confirmed that the individual used their sibling's information to work in the facility as a CNA. On 5/18/2026 at 2:27 PM, the DON provided the surveyor with a breakdown per resident of the direct care provided by UP #1 which included the following: On the 7:00 AM to 3:00 PM (7-3) shifts on 4/28/2026 and 4/29/2026, UP #1 provided direct care for: Resident # 7 which included bathing, mobility/ambulation assistance, toileting, dressing and mechanical lift transfers.Resident #31 which included bathing, mobility/ambulation assistance, feeding, toileting, dressing, and mechanical lift transfers.Resident #44 which included bathing, toileting, and dressing.Resident #65 which included bathing, mobility/ambulation assistance, meal tray set up, toileting, lower body dressing and mechanical lift transfers.Resident #28 which included supervision for bathing, mobility/ambulation assistance, toileting, dressing, and transfers.Resident #42 which included bathing, meal tray setup feeding, toileting, dressing, and stand lift transfers (medical device that helps a person move from one seated surface to another by bringing them to a supported standing position).Resident #20 which included bathing, toileting, dressing, and mechanical lift transfers.Resident #21 which included meal tray set up and toileting. On the 3:00 PM to 11:00 PM (3-11) shift on 4/29/2026, UP #1 provided direct care for: Resident #32 which included toileting.Resident #56 which included meal tray set up and toileting.Resident #74 which included meal tray set up and toileting.Resident #64 which included toileting.Resident #63 which included meal tray set up and toileting.Resident #50 which included meal tray set up and toileting.Resident #75 which included meal tray set up and toileting.Resident #18 which included meal tray set up. On 5/18/2026 at 3:26 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON to review concerns regarding UP#1. The DON revealed the staffing agency used their own identification card, clock in system, and that the facility did not complete a secondary identification check when agency staff entered the facility. The LHNA revealed that after the incident on 4/29/2026, the facility had updated their policy for agency staff to include providing a secondary identification check. The facility submitted an acceptable Removal Plan (RP) on 5/19/2026 at 12:16 PM, which indicated the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice which included UP #1 was immediately removed from the nursing unit, the local police were notified and came to the facility and verified UP #1 was impersonating Agency CNA #1. On 4/29/2026, the DON, Unit Manager, and Unit Nurse completed body assessments and resident interviews on all residents who were given care by the impersonator (UP #1) and the NJDOH was notified. UP #1 and Agency CNA #1 were reported to the Health Care Reporting Unit. On 4/30/2026, the facility implemented a new policy, Temporary Contracted Staff Verification, which required two forms of identification to be presented to the supervisor for all agency staff entering the building, and the Unit Manager began in-servicing all nursing staff on this policy. On 4/30/2026, a sign was put up near the time clock which indicated all agency staff were to report to management and present identification upon arrival. The facility self-corrected the deficient practice, and it was determined that the IJ was Past Non-Compliance (PNC), and that the facility corrected their non-compliance on 4/30/2026. The survey team verified the implementation of the Removal Plan during the continuation of the on-site on 5/19/2026. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a 14-hour gap between dinner and breakfast. This deficient practice was identified for 5 of 5 residents sampled for bedtime snacks (Resident #13, # 17, #26, #36, and #50) and was evidenced by the following:On 05/18/2026 at 10:34 AM, the surveyor conducted a Resident Council meeting, which included five residents (Resident #13, #17, #26, #36, and #50). All five residents informed the surveyor during the meeting that bedtime (HS) snacks were not offered every night. All five residents stated that it would be nice if the facility automatically provided each resident with an HS snack. The surveyor reviewed the Meal Times document provided by the Licensed Nursing Home Administrator (LNHA), which indicated that the first dinner cart was served to the 4th-floor Nursing unit at 5:00 PM and the first breakfast cart was served to the 4th-floor Nursing unit at 8:00 AM. This was a 15-hour time span between dinner and breakfast. On 5/19/26 at 9:40 AM, during an interview with the surveyor, the Food Service Director (FSD) stated that the kitchen would send a variety of snacks to the nursing units, which included crackers, Jello, cookies, and sandwiches, but that snacks were not labeled and not every resident was provided with a snack. The FSD confirmed that she was aware of the 15-hour time span between dinner and breakfast and that her expectation was that the nursing staff would provide snacks to the residents at HS. The surveyor reviewed the HS Snack Reports from April and May 2026 for the five residents. The reports indicated that none of the residents consistently received an HS snack. On 5/20/26 at 11:34 AM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator and the Director of Nursing (DON). On 5/21/26 at 10:00 AM, the surveyor showed the HS Snack Reports to the DON. The DON confirmed that all five residents were not consistently offered or provided HS snacks. A review of the facility's HS Nourishment policy reflected .To assure that all residents able to have nourishment are offered a substantial snack at HS (hour of sleep) daily .The percentage consumed is to be documented electronically by the aides for all residents after all nourishments are offered. On 5/21/26 at 1:45 PM, no further information was provided. NJAC 8:39-17.2 (f)(1)(I-ii)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure that a specialty low air loss mattress was accurately set and monitored according to the resident's weight for 1 of 3 residents (Resident #2) and b.) failed to provide a resident with a pressure ulcer the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 3 residents reviewed for pressure ulcers (Resident #2). This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, and this should be done outside the water when rubbing your hands, then rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take approximately 20 seconds. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. a. On 5/15/26 at 11:15 AM, the surveyor observed Resident #2 in bed and a specialty mattress in place. The resident's air mattress pump was set at 140 pounds (lbs.). On 5/18/26 at 11:10 AM, the surveyor observed Resident #2 in bed and a specialty mattress in place. The resident's air mattress pump was set at 300 lbs. The surveyor reviewed the electronic medical record (E-mar) for Resident #2. A review of the admission Record (AR) reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; fractured left hip femur (break in the upper thigh bone), hypertension (high blood pressure) and congestive heart failure (heart muscle becomes too weak to pump blood efficiently which causes the blood and fluid to back up and leads to congestion in the lungs, liver and extremities). A review of the admission Minimum Data Set (MDS), an assessment tool dated 4/9/26, reflected that Resident #2's Brief Interview for Mental Status (BIMS) score was 3 out of 15 indicating a severe cognitive impairment. The MDS further assessed Resident #2 had a stage 2 pressure ulcer with treatments that included but were not limited to; pressure reducing device for their bed and applications of ointment/medications. A review of the current Physician Order Sheet revealed a physician order (PO) for an Air Mattress to bed dated 5/11/26. A review of the resident vitals sign revealed the resident's last known weight was 89.6 lbs. on 4/21/26. On 5/18/26 at 2:00 PM, the surveyor showed the Registered Nurse/Unit Manager (RN/UM) the air mattress pump setting. The RN/UM confirmed that the gauge was set to 300 lbs. and stated that it should be set to the resident's weight. At that time the RN/UM turned the setting to 120 lbs even though the resident's weight was 89.6 lbs. b. On 5/18/26 at 11:34 AM, the surveyor observed the RN perform the treatment to Resident #2's stage 2 pressure ulcer (an open sore with partial thickness skin loss), while the Certified Nursing Assistant (CNA) assisted with the positioning of the resident. The surveyor and RN reviewed the physician's order which included a treatment order for a Stage 2 wound to the upper thoracic back. The order included cleanse the wound with wound cleanser, apply zinc oxide to the periwound, apply Medihoney (medical-grade, antibacterial honey used to manage wounds and burns); cover with a bordered gauze dressing daily and as needed (PRN).The surveyor observed the RN perform hand hygiene. The RN applied soap to her hands and immediately placed them under running water without first lathering. The RN then disinfected the over-bed table (OBT) and applied a clean barrier.The RN assembled the needed supplies from the treatment cart and placed them on the OBT in the resident's room. Among the supplies were an unopened tube of zinc oxide ointment, foam dressing, gauze sponges, normal saline solution bullets, and a 2x2 skin [NAME] pad. The RN stated, We don't have Medihoney in backup, so they called the pharmacy. The RN removed and discarded the soiled dressing and then performed hand hygiene. The RN applied soap to her hands and immediately placed them under running water without first lathering. The RN cleansed the wound and applied the zinc oxide to the wound bed and periwound without using an applicator. The RN did not apply Medihoney to the wound bed as per the PO. The RN then covered the wound with a border dressing and stated that she had forgotten her pen. The RN left the resident's room and returned with a pen. The RN wrote directly on the dressing after it had already been applied to the resident rather than labeling the dressing prior to its application. The surveyor observed the CNA perform hand hygiene. The CNA applied soap to her hands and immediately placed them under the running water without first lathering. The CNA turned off the faucet with her bare hands. When the RN exited the resident's room, she brought out the tube of zinc oxide and placed it back into the treatment cart.On 5/18/26 at 1:45 PM, the surveyor discussed the infection control breaches with the RN, in the presence of the RN/UM. The RN confirmed that she should have washed her hands and lathered outside of the stream of water for 20 seconds. The RN further acknowledged she should only bring the supplies needed for the treatment into the resident's room, should have used an applicator to apply the zinc and should have notified the physician when she discovered that there was no Medi Honey. On 5/18/26 at 1:55 PM, in the presence of the RN/UM the surveyor discussed hand hygiene concerns with the CNA. The CNA acknowledged that she should wash outside the stream of water for 20 seconds and stated, I'm sorry I thought I did. On 5/19/26 at 1:21 PM, during an interview with the surveyor, the Infection Preventionist (IP) confirmed that hands should be lathered for at least 20 seconds outside of the stream of water. The IP also confirmed that nurses should only bring treatment supplies that will be used for that one treatment into the resident's room and that it is an IC concern bringing the entire tube of zinc oxide into the room and then placing it back into the multiuse treatment cart. On 5/20/26 at 11:57 AM, the survey team discussed the above observations and concerns with the LNHA and DON. A review of the facility's General Guidelines Wound and Skin Care policy dated 6/23/25 reflected.Objective. to maintain the integrity of residents skin admitted without wounds and promote wound healing on residents admitted with skin breakdown. A review of the facility's Handwashing/Hand hygiene policy dated 3/12/25 reflected.Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) away from the stream of water.Dry hands thoroughly with paper towels and then turn off the faucet with a clean, dry paper towel. On 5/21/26 at 1:45 PM, no further information was provided. NJAC 8:39-19.4(a)

Refer to F686 D Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to establish and maintain a system of records for controlled medications in sufficient detail to enable accurate reconciliation for the dispensing of controlled medications. This deficient practice was identified for 1 of 1 staff members (Registered Nurse) (RN) observed during a wound treatment observation involving the administration of a controlled medication. This deficient practice was evidenced by the following: On 5/18/26 at 11:44 AM, during a wound treatment observation, the surveyor observed an RN prepare and administer a controlled medication to Resident #2. The surveyor observed the RN reviewed the physician's order for morphine concentrate 100 milligrams (mg) in 5 milliliters (mls) administer 0.25 ml by mouth every 3 hours as needed, with a start date of 4/18/26.The RN removed the morphine concentrate from the medication cart, measured 0.25 mL, and administered the medication to Resident #2. Following administration, the RN returned to the medication cart and signed the Controlled Drug Declining Inventory Sheet (CDDIS). The surveyor observed that the RN did not document the removal of the medication on the controlled substance accountability record at the time it was removed from the medication cart. On 5/18/26 at 12:05 PM, after completing the wound treatment, the surveyor observed the RN prepare and administer Lorazepam Intensol 2mg/ml/ml 0.25ml to Resident #2. The surveyor observed the RN prepare and administer the controlled medication prior to signing the CDDIS. On 5/18/26 at 1:45 PM, in the presence of the RN Unit Manager (UM), the surveyor discussed the above observations and concerns with the RN. The RN stated she was not aware that the CDDIS should be signed prior to administering the controlled medication. The RN further stated that she intentionally waited to sign the CDDIS until after administration because she was concerned the resident might refuse the medication. The RN/UM confirmed that, per facility policy, the RN should have documented the removal of the medication on the CDDIS prior to administering the controlled substance. The RN/UM further stated that if the resident refused the medication after it had been signed out, the medication would then require wasting in accordance with controlled substance procedures.On 5/18/26 at 3:15 PM, during an interview with the surveyor, the Regional Nurse confirmed that best practice was to sign the CDDIS at the time the controlled medication was removed from the medication cart and prior to administration. On 5/20/26 at 11:57 AM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that nurses should sign the CDDIS at the time the controlled medication is removed from the medication cart to ensure accountability and accurate tracking of controlled substances. The DON further stated she would need to review the facility's policy to verify the specific procedure. A review of the facility's policy titled, Administering Medications dated 2/12/26 reflected.The nurse will document immediately on the controlled declining inventory sheet when administering controlled medications. On 5/21/26 at 1:45 PM, no further information was provided. NJAC 8:39-29.7(c)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in 1 of 3 medication carts (medcarts) on 1 of 3 nursing units.This deficient practice was evidenced by the following: On 5/20/2026 10:22 AM, the surveyor began inspecting the low side medcart located on the facility 4th floor in the presence of the Registered Nurse (RN) assigned to the medcart. The surveyor observed an opened foil package containing budesonide inhalation suspension (an inhaled steroid used to treat asthma). The surveyor did not observe a date when the vial was opened marked on the vial or the box. The surveyor asked the RN what the package was from and if it should have a label and a date when it was opened. The RN stated that the foil pack must have been from a discontinued medication (med) and should have been disposed of. The RN also stated that the box the pack came in would have a date on it. The surveyor completed the observation. On 5/20/26 at 11:57 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns. The surveyor notified the DON of the concern with the budesonide foil pack with no resident label or date opened. On 5/21/26 at 9:08 AM, the survey team met with the LNHA and DON for responses. The DON stated that they had the supervisor check the cart for further information, and the assumption was that the foil pack fell out of the box that was previously removed from a discharged resident's supply. The surveyor asked if the staff should be sure all unlabeled meds should be removed from the cart. The DON stated yes. The facility did not provide any further pertinent information. The surveyor reviewed the manufacturer package insert (PI) for budesonide inhalation suspension. The PI revealed, under 16. Storage and Handling: .should be stored upright. When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. The surveyor reviewed the facility policy titled Storage of Medications, dated revised 3/20/26, that was provided by the DON. The policy reflected under 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned. The policy did not reflect anything relating to dating of medications. NJAC 8:39-29.4 (a)(h)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe, clean, and homelike environment in 1 of 3 nursing units, the fourth floor nursing unit, affecting one resident (Resident #8) in room [ROOM NUMBER]. The deficient practice was evidenced by the following:On 5/18/26 and again on 05/21/2026, the surveyor observed that the overhead light located in the middle of Resident #8's room was not functioning. During an interview with the surveyor, Resident #8 stated that he/she had reported the nonfunctioning light to the Registered Nurse/ Unit Manager (RN/UM) approximately four weeks earlier.On 5/21/26 at 12:20 PM, during an interview with the surveyor, the RN/UM confirmed that she was aware that the light in Resident #8's room was not working. The RN/UM stated that she had submitted a work order approximately four weeks earlier for the repair.On 5/21/26 at 12:45 PM, during an interview with the surveyor, the Director of Maintenance confirmed there were no completed work orders related to Resident #8's room.The surveyor requested the facility's policy and procedure regarding maintaining a homelike environment. On 5/21/26 at 1:15 PM, no additional information was provided. NJAC 8:39-31.4(a)

Repeat deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/27/25 at 9:55 AM, while on the 4th floor in the kitchenette the surveyor observed the following: in refrigerator #1 had an individual cheesecake without a cover and missing a use by date, an open jar of molasses without an open/use by label, and in freezer #2 a paper cup with a brown frozen substance not dated and without a use by label. On 1/27/25 at 10:15 AM, while on the 2nd floor in the kitchenette the surveyor observed the following in refrigerator #1: a zip lock bag of sliced pickles and red cup with oatmeal-like substance both missing labels and use by dates. On 1/27/25 at 10:20 AM, the surveyor interviewed the Unit Manager (UM), who stated all items in the refrigerator and freezers should be covered as well as have a label with an open and use by date. The UM further stated the kitchenette areas are checked by the nurses and certified nursing assistants, but unable to explain why those items had not been labeled. On 1/29/25 at 12:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Food Storage with reviewed date of 10/2024. Under the policy section it states, All leftovers are labeled, dated, and used within three days and then discarded. If there is any question about a product's storage or expiration, discard the product. On 1/29/25 at 12:32 PM, the survey team met with the LNHA and Director of Nursing (DON) to review concerns. The DON stated all the refrigerator and freezers in the three kitchenettes have been checked and any foods that did not have a label have been discarded. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 15 residents reviewed (Resident #35 and #13). This deficient practice was evidenced by the following: 1. On 1/27/25 at 11:00 AM, the surveyor observed Resident #35 sitting in the wheelchair inside the recreation room, unable to answer the surveyor's inquiry. On 1/27/25 at 1:25 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #35, which revealed the following: A review of the Face Sheet (FS; an admission summary) reflected that Resident #35 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 6/18/24 indicated that the facility assessed the residents' cognitive status, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating that the resident had severe impairment in cognition. A further review of the Q/MDS revealed that the resident received anti-anxiety and antidepressant medications on a routine basis. A review of the most recent Physician Order Sheet (POS) reflected a physician's order of the following medications: 1. Risperidone 0.5 mg. by mouth daily with an order date of 2/23/24 and discontinued on 3/16/24. 2. Xanax 0.25 mg. by mouth daily with an order date of 4/7/24 for anxiety. A review of the resident's individualized person-centered care plan (CP) with an effective date of 12/11/23 to 8/28/24 reflected under problems that I am at risk for complications related to the use of psychotropic medication. I am on Risperidone. The goal reflected that the resident would have no complications related to the use of Risperidone in the next 90 days. Further review of the CP does not reflect the discontinued use of Risperidone on 3/16/24 and the use of the anti-anxiety medication Xanax, with a start order of 4/7/24. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern but did not provide further information. 2. On 1/27/25 at 11:35 AM, the surveyor observed Resident #13 lying in bed, alert and awake. The surveyor observed that the resident had a cup of water on the table. Resident #13 stated they have dialysis every Tuesday, Thursday, and Saturday pick-up at 10:00 am. On 01/30/25 at 09:05 AM, the surveyor observed Resident #13 awake and had just finished breakfast. The surveyor observed that the resident had a 16-ounce cup of water on the table. The resident was aware that they were under a fluid restriction and added that they were noncompliant and disagreed with the restriction. On 1/29/25 at 1:18 PM, the surveyor reviewed the hybrid medical record of Resident #13, which revealed the following: A review of the FS reflected that Resident #13 was admitted with diagnoses that included but were not limited to chronic kidney disease (CKD-kidney stopped working), Stage 4 (severe), and dependence on dialysis (a treatment for the failing kidney). A review of the recent Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 14 out of 15, which indicated that the resident had intact cognition. A review of the most recent POS reflected a physician's order of fluid restrictions of 1200 ml (milliliters) in 24 hours with an order date of 12/14/24. A review of the resident's individualized person-centered CP with an effective date of 5/1/24 to present reflected under problems, Dialysis: I am on Dialysis on Tuesday, Thursday, and Saturday. Further review of the CP does not indicate that the residents are noncompliant with fluid restrictions. On 1/30/25 at 9:10 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding the above concern. The CNA stated that he knew the resident was on fluid restriction and would give the resident the allowed fluids. He added that the resident would ask for more water, and he felt bad about it. The CNA revealed that the resident had been on fluid restriction since entering the facility. On 1/30/25 at 10:31 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concern. The DON stated that the resident has a history of non-compliance with the fluid restriction. A review of the facility policy titled Resident Care Plan with the revised date of October 2024 stated under Procedure: The resident care plan will reflect the resident's expressed wishes regarding care and treatment goals. The resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. When such refusal are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. 1. Resident care plan will be developed for all care planning issues including but not limited to: c. Resident's risk factors .d. Resident's needs . NJAC-8:39 11.1 NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications for 3 of 5 residents reviewed for unnecessary medications (Resident #3, #4, and #35). This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:43 AM, the surveyor observed Resident #3 out of bed to the wheelchair inside the activity room, able to answer the surveyor's inquiry. On 1/29/25 at 11:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #3, which revealed the following: A review of the Face Sheet (an admission summary) reflected that Resident #3 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 12/20/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had an intact cognition. A further review of the A/MDS revealed that the resident received antipsychotic and antidepressant medications on a routine basis. A review of the most recent Physician Order Sheet (POS) with the start date of 12/13/24 reflected a physician order of the following: 1. Quetiapine 25 mg (milligram) give one tablet by mouth one time daily, and the order was discontinued on 1/17/24 and increase the dosage to Quetiapine 50 mg give one tablet by mouth one time daily for a mood disorder on 1/17/24 and 2. Sertraline 100 mg is given one tablet by mouth for depression. There was no further documentation to reflect that the resident was being monitored routinely with the use of psychotropic medications after the increase of dosage of Quetiapine 25 mg to 50 mg from December 13, 2024, to January 17, 2024. A review of the January 2025 Medication Administration Record (MAR) revealed that the nurses signed that Resident #3 was administered Quetiapine 50 mg by mouth for mood disorder at 8:00 PM and Sertraline 100 mg by mouth daily for depression at 9:00 PM. The January 2025 MAR did not reflect the target behavior and potential side effects of the psychotropic medication. A review of the recent Psychiatric Progress Note dated 1/21/25 revealed under assessment/plan to continue to monitor mood and behavior for changes. A review of the resident's individualized person-centered care plan (CP) with an effective date of 12/14/24 to present reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring for adverse reactions, and monitoring behavior every shift. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease behaviors and symptoms associated with depression of the resident. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern. The UM/RN revealed that the nurses documented the side effects only if the resident had a side effect but did not provide documentation of the targeted behavior monitoring. 2. On 1/27/25 at 10:01 AM, the surveyor observed Resident #4 sitting in the wheelchair inside the room, able to answer the surveyor's inquiry. On 1/27/25 at 11:29 AM, the surveyor reviewed the hybrid medical record of Resident #4, which revealed the following: A review of the FS reflected that Resident #4 was admitted with diagnoses that included but were not limited to sepsis (body response to infection) and diabetes mellitus (high sugar level). A review of the recent quarterly Minimum Data Set (Q/MDS) dated [DATE] indicated that the facility assessed the residents' cognitive status, with a BIMS score of 13 out of 15, indicating that the resident had intact cognition. A further review of the Q/MDS revealed that the resident received antidepressant medications on a routine basis. A review of the most recent POS with the start date of 7/25/24 reflected a physician's order of amitriptyline 50 mg to give one tablet by mouth daily for depression. A review of the January 2025 MAR revealed that the nurses signed that Resident #4 was administered amitriptyline 50 mg, one tablet by mouth daily for depression at 7:00 PM. The January 2025 MAR did not indicate the target behavior and potential side effects of the psychotropic medication. A review of the resident's individualized person-centered CP with an effective date of 7/18/24 to present reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring behavior every shift, and monitoring for adverse reactions, side effects, and changes in mental status. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease symptoms associated with depression of the resident. 3. On 1/27/25 at 11:00 AM, the surveyor observed Resident #35 sitting in the wheelchair inside the recreation room, unable to answer the surveyor's inquiry. On 1/27/25 at 1:25 PM, the surveyor reviewed the hybrid medical record of Resident #35, which revealed the following: A review of the FS reflected that Resident #35 was admitted with diagnoses that included but were not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the recent Q/MDS dated [DATE] indicated that the facility assessed the residents' cognitive status, with a BIMS score of 5 out of 15, indicating that the resident had severe impairment in cognition. A further review of the Q/MDS revealed that the resident received anti-anxiety and antidepressant medications on a routine basis. A review of the most recent POS reflected a physician's order of the following medications: 1. Risperidone 0.5 mg. by mouth daily with an order date of 2/23/24. 2. Xanax 0.25 mg. by mouth daily with an order date of 4/7/24. 3. Sertraline 75 mg. by mouth daily with an order date of 12/18/24. 4. Mirtazapine 15 mg by mouth daily with an order date of 1/20/25 5. Ativan 0.25 mg by mouth daily as needed with an order date of 1/21/25 The April 2024 MAR revealed that the nurses signed the above medications for Resident #35. There was no further documentation to reflect that the resident was being monitored and evaluated routinely with the use of the above psychotropic medications between the period of February 2024 and January 2025. A review of the resident's individualized person-centered CP with an effective date of 12/11/23 to 8/28/24 reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring behavior every shift, and monitoring for adverse reactions, side effects, and changes in mental status. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease symptoms associated with the resident's behavior. A review of the Behavior/Psychotropic medication changes provided by the DON does not reflect a consistent monitoring of target behavior, potential side effects and evaluate the ongoing benefits of continued use of psychoactive medications. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern. The UM/RN revealed that the nurses documented the side effects only if the resident had a side effect but did not provide further information regarding the targeted behavior monitoring. On 1/29/25 at 12:47 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding the above concern. The DON stated that the nurses documented if there was a side effect noted to the resident with the use of psychotropic medications, and if there was no side effect, there was no documentation. The LNHA and DON did not provide further information. A review of the facility policy with the revised date 5/11/23 titled Behavioral Symptoms, under the Procedure: 11: f. iv Monitoring is necessary as long as the drug is being used to identify side effects and to identify opportunities to reduce the drug dosage or discontinue the use of the drug. NJAC 8:39-29.3(a); 29.8; 33.2(a)

Based on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by failing to provide a resident with respect and dignity during wound care. This deficient practice was identified 1 of 16 residents reviewed (Resident #231). The deficient practice was evidenced by the following: On 1/27/25 at 11:12 AM, the surveyor observed Resident #213 in their room. The resident was observed with a gauze (gauze wrap is a sterile material used to wrap or cover wounds) wrapped around their right elbow. During the interview the resident stated they had a skin tear prior to coming into the facility. Resident #231 was agreeable to allow the surveyor to observe the wound care treatment. A review of Resident #231 medical record revealed that the resident had diagnosis that included but were not limited unspecified fall, anemia (a deficiency of healthy red blood cells in blood), and hypertension (high pressure in the arteries). A review of the admission MDS, (an assessment tool used to facilitate the management of care) with an assessment reference date of 1/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident is cognitively intact. A review of the January 2025 Physician Orders Sheet (POS) revealed an order for wound care. The PO was dated 1/23/25, Vashe 0.033% irrigation solution (1 application) solution irrigation topical. Cleanse right elbow wound with Vashe, pat dry, apply Medihoney, cover with a non-stick gauze pad and wrap with kling daily. On 1/28/25 at 11:51 AM, the surveyor observed the Registered Nurse (RN#1) perform wound care on Resident #231's right elbow. The surveyor then observed RN #1 write a date and her initials with a pen directly on the resident's surgical tape which had already been placed on the residents wound site (right elbow). Surveyor asked RN #1 if writing the date and her initials on the tape while on the resident provided the resident dignity and respect? RN #1 stated, she should have written the date and her initials on a separate piece of tape and then place that on the resident's covered wound site. On 1/29/25 at 9:50 AM, the Director of nursing (DON) provided the surveyor with a facility policy titled, Quality of Life - Dignity with a revised date of 1/24/24. Under the procedure section of the policy it states, 1. Resident shall be always treated with dignity and respect. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity are prohibited. On 1/29/25 at 12:32 PM, the Licensed Nursing Home Administrator (LNHA) and DON met with the survey team to review concerns found during the survey. The DON stated RN #1 did not follow the correct procedure for initialing and dating for a resident's wound and would in-service the staff. No further comments provided. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39-4.1(a)(12)(28), 17.3(c), 17.4(d)

Repeat deficiency Based on observation, interview, and record review of other facility documentation, it was determined that the facility failed secure medications within the medication cart. This deficient practice was observed during wound care observation and was evidenced by the following: On 1/28/25 at 11:51 AM, the surveyor observed Registered Nurse (RN#1) provide wound care on Resident #213. RN#1 was observed gathering medication from the medication cart outside of Residents #213's room. Once RN#1 gathered all medications and supplies from the medication cart, the surveyor observed RN#1 close the drawer to the medication cart and walk away. Surveyor asked RN#1 if they had locked the medication cart. RN#1 went back to the medication cart and stated, I forgot to lock the cart. That was a mistake on my part On 1/29/25 at 9:50 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Storage of medications with a revised date on 5/1/2017. Under the procedure section of the policy it states, 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 1/29/25 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to review concerns found during the survey. The DON stated the medication carts should always be locked whenever the nurse is stepping away from the cart. No further comments provided. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39- 29.4(a) (d)(h), 29.7(a)

Based on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents (Resident #8 and Resident #41) reviewed. The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. On 1/27/25 at 10:51 AM, the facility provided the surveyor with a list of residents who were discharged from the facility within the last 6 months and should have received the SNF ABN form. The surveyor reviewed Resident #8 and Resident #41 who were listed discharged from Medicare Part A coverage stay and were documented that they remained in the facility. 1. Resident #8 was admitted to the facility on [DATE]. The last documented covered day from Medicare Part A service was 1/18/25. A review of the form titled, SNF Beneficiary Notification Review that was filled out by the facility's Director of Social Services (DSS) indicated the SNF ABN was not provided to the resident. There was no additional documentation about the communication of these forms to the resident or the resident's representative. 2. Resident #41 was admitted to the facility on [DATE]. The last documented covered day from Medicare Part A service was 12/24/24. A review of the form titled, SNF Beneficiary Notification Review that was filled out by the facility's DSS indicated the SNF ABN was not provided to the resident. There was no additional documentation about the communication of these forms to the resident or the resident's representative. On 1/30/24 at 1:31 PM, the surveyor interviewed the social worker (SW) who stated to the surveyor the SNF ABN form did not have to be issued when residents remain in the facility after Medicare A's last covered day service. The SW stated she was responsible to send the notices of Medicare non-coverage forms and the have them signed and the ABN forms. She further stated that she should have sent the ABN forms to the residents and or the families. She further stated that she was aware that there were new ABN forms, and she needed to review them. On 1/29/25 at 12:33 PM, the surveyor discussed the above concerns with the facility's Licensed Nursing Home Administrator and the Director of Nursing and Assistant Director of Nursing. There was no additional information provided. NJAC 8:39-4.1(a)(8)

Based on observation, interview and record review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness as evidenced by the following: On 10/30/2023 at 9:59 AM, in the presence of the Food Service Manager (FSM) the surveyor observed the following: 1. In the tray line freezer, room service the surveyor observed a pack of vegetable burgers undated and opened, and six (6) trays of pastries prepared by the baker, the FSM was unable to state when the package was received, opened, or expiration date. 2. In the room service storage, cold prep, [soda brand] refrigerator the surveyor observed shredded mozzarella cheese that was opened and undated. The FSM was unable to state when the package was received, opened, or expiration date. 3. In the freezer walk in the surveyor observed 10 trays with frozen cupcakes and cookies not labeled with a prepared date or a use by date. The FSM was unable to state when the trays were prepared or would expire. On 11/01/23 at 11:20 AM, the FSM provided the surveyor with the Food and Supply Storage Policy #B003, date issued 5/95, revised date 01/23 page 1 and 2 which included: Policies: All food, non -food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for the human consumption. Procedures: -Most, but not all, products contain an expiration date. The words sell by, best by, enjoy-by or use-by should precede date. Foods past the use by, sell by, best-by or enjoy by date should be discarded. - Cover, label and date unused portions and open packages. Complete all sections on an orange label or use the [name]/ Fresh date labeling system. Products are good through the close of business on the date noted on the label. -Refer to the Food Storage Chart in this policy to determine discard dates for food items. Freezer Storage: Food prepared in house, and then stored frozen should be kept no longer than three months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for three months if no expirations date on the package. Once the packaging around the food has been opened, food must be used within three months. At 11/06/23 at 10:23 AM, the surveyor discussed the kitchen concerns with the facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). On 11/08/2023 at 12:00 PM, the DON provided a written statement to the survey team which read . Concern: Kitchen; labeling of food, unsealed food, undated food. Response: We do not have any supporting documents to defend this deficient practice. The kitchen is a third-party entity and cannot be part of our facility survey as they are not employed by the facility. On 11/08/23 at 02:33 PM, the survey team met for an Exit conference with LNHA, Regional Nurse Consultant #1 and #2, and [NAME] President of Clinical. The facility management informed the survey team that there was no additional information. NJAC 8:39-17.2(g)

Based on interviews, record review, and review of the facility provided documents, it was determined that the facility failed to a) identify irregularity for a total of twelve months and b) act upon the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications (Resident #17). This deficient practice was evidenced by the following: On 10/30/23 at 11:51 AM, the surveyor observed Resident #17 in bed asleep. The surveyor reviewed Resident #17's medical records. The resident's Admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had diagnoses that were not limited to essential hypertension (elevated blood pressure), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), presence of cardiac pacemaker (pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heartbeat), unspecified OA (osteoarthritis; a disease that causes inflammation and pain in the joints), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of the resident's significant change Minimum Data Set (scMDS), an assessment tool used to facilitate the management of care with an assessment reference date (ARD) of 9/23/23, Section C Cognitive Patterns revealed a cognitive skills for daily decision making was coded as three (3) which reflected that the resident's cognitive status was severely impaired. The Order Status (OS) active orders as of 6/23/22 showed that the resident had an order of Morphine (a non-synthetic narcotic with a high potential for abuse and is derived from opium) concentrate 100 mg/5 ml (20 mg/ml; milligrams/milliliters) oral sol (0.25 ml=5 mg) oral for pain as needed (PRN) every three (3) hours (hrs) for pain. The OS also included an active order for Tylenol 325 mg tablet (tab), (2 tabs=650 mg) every 8 hrs PRN for mild pain and Tramadol (belongs to a class of drugs known as opioid analgesics) 50 mg one tab every 8 hrs PRN for moderate pain. The above order for PRN Morphine was transcribed to the electronic Medication Administration Record (eMARS) from June 2022 through November 2023. A review of the Consultant Pharmacist-Medication Regimen Review (or MRR) permanent record from 6/15/22 through 10/18/23 [in the paper chart] showed that there were no recommendations identified regarding the order for PRN Morphine for pain. On 11/02/23 at 11:29 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) and LPN #2. The surveyor asked the nurses who were responsible for consultant pharmacist reviews, and LPN #1 stated that it was the nurse. LPN #1 further stated that the nurse notified the physician of the CP's recommendations. On that same date and time, LPN #1 informed the surveyor that for residents with multiple PRN pain medications, the PRN medications should be sequenced to mild, moderate, and severe pain. On 11/02/23 at 01:36 PM, the surveyor asked the Director of Nursing (DON) for a copy of the facility's policy regarding MRR in the presence of another surveyor. On 11/03/23 at 9:57 AM, the surveyor interviewed the Consultant Pharmacist/Owner (CP/O) via phone conference in the presence of the survey team. The CP/O informed the surveyor that he and the other CP were both responsible for residents' monthly MRR. The CP/O stated that the monthly MRR was submitted via email to the DON, Licensed Nursing Home Administrator (LNHA), and other designated people in the facility [usually the Unit Manager]. He further stated that the reports were being submitted within 24 hours. On that same date and time, the CP/O informed the surveyor that part of his responsibility was to check residents with multiple PRN pain medications, to make sure that they were properly sequenced. The surveyor then notified the CP/O of the above findings and concerns regarding the PRN Morphine order that was ordered on 6/23/22 for pain and was not sequenced for mild, moderate, and severe pain. The CP/O acknowledged that it should have been identified as an irregularity for not being sequenced for PRN pain medication. He further stated that he will get back to the surveyor and that he will double check the order himself because the resident was in hospice. On 11/03/23 at 11:17 AM, the survey team met with the LNHA, DON, Regional Nurse Consultant #1 (RNC#1), Clinical Implementation Analyst (CIA), and Executive Director (ED). The surveyor notified the facility management of the above findings and concerns regarding PRN Morphine. On 11/03/23 at 12:11 PM, the CP/O called back in the presence of the survey team. The CP/O informed the surveyor that after checking his notes and records, he found out that on 6/25/23 there was a CP's recommendation to sequence the PRN pain medications, and it looks like that it was not addressed. At that same time, the surveyor asked the CP/O why the CP recommended it on 6/25/23 to sequence the PRN pain medications when the order for PRN Morphine was since 6/23/22. The CP/O responded, We address what we see in our review. Furthermore, the surveyor asked the CP/O why the 6/25/23 recommendation to sequence the PRN pain medications was not included in the medical records that the surveyor reviewed, and the CP/O had no response. Then, the CP/O stated that he would send the 6/25/23 CP MRR to the surveyor to show the CP's recommendation. On 11/03/23 at 12:27 PM, the CP/O sent via email the copy of the Consultant Pharmacist Medication Regimen Review for recommendations created between 6/01/23 and 6/26/23 includes routing for nursing dated 6/25/23 which included Multiple PRN medications are noted for the same or overlapping indications. Please sequence the following medication: Tylenol and Morphine. The 6/25/23 recommendations follow-through and the nurse's signature were both blank, which indicated that the recommendations were not acted upon. On 11/08/23 at 9:51 AM, the surveyor interviewed the DON in the 4th-floor nursing station. The surveyor showed the DON the Consultant Pharmacist-Medication Regimen Review in the resident's chart for the date 6/25/23 14 day PRN-. The surveyor also notified the DON of the provided copy of the CP/O for the date 6/25/23 wherein there was a recommendation for nursing regarding PRN sequencing of medications Tylenol and Morphine. The DON stated that the 14 day PRN did not specify for what medication and that usually it was for psychoactive PRN medications not for PRN pain medications. At that same time, the DON stated that the CP should have documented the recommendations of PRN sequencing of pain medications in the sheet that was reviewed by the surveyor in the resident's medical chart for the nurse to be able to determine what to follow up with the physician. The DON further stated that she will check the records in her office to verify if the facility received the 6/25/23 recommendations of the CP that were provided to the surveyor by the CP/O via email, and will get back to the surveyor. On 11/08/23 at 10:49 AM, the survey team met with the LNHA, DON, RNC#1, CIA, [NAME] President of Clinical Services (VPoCS), RNC#2, and ED [came at 11:15 AM]. The DON stated that it was an expectation that the CP would document in the chart where the sheet of MRR monthly recommendations located the CP's recommendations. The DON acknowledged that the 6/25/23 visit and recommendations of the CP did not include the PRN Morphine sequencing for pain medication. On that same date and time, the surveyor asked the facility management why the provided copy of the facility and the CP/O for 6/25/23 recommendations that were not in the chart of the resident at the time of review were not acted upon. The DON stated, I do not have a good answer. A review of the facility provided Medication Regimen Reviews Policy with a revised date of 8/17/21 that was provided by RNC#2 included that the CP shall review the medication regimen of each resident at least monthly. The Procedure included: 1. The CP will perform an MRR for every resident in the facility. 2. Routine reviews will be done monthly . 7. The CP will document his/her findings and recommendations on the monthly drug/medication record review report . 9. The CP will provide to the DON and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions. 10. Copies of drug/regimen review reports, including physician responses, will be maintained as part of the permanent medical record . To Nursing: 1. The CP will provide a report within seven (7) working days of the review. 2. Nursing will provide a response within two (2) weeks of receipt of report. 3. Nursing will retain a copy of the report pending Nursing documentation review. On 11/08/23 at 02:33 PM, the survey team met for an Exit conference with LNHA, RNC#1 and #2, VPoCS, CIA, and ED. The facility management had no additional information about the concern above. NJAC 8:39- 29.3 (a)(1)

Based on observation, interview, and record review of other facility documentation, it was determined that the facility failed to provide appropriate Pharmaceutical Services and ensure a) a biological was properly labeled with an expiration date, b) removal of a discontinued biological from active inventory for a discharged resident (Resident # 23), c) medications were secured within the medication cart, and d) a narcotic medication for Resident #38 was properly labeled with an expiration date. This deficient practice was observed in two (2) of two (2) refrigerators located in the medication storage room, and one (1) of two (2) medication carts inspected and was evidenced as follows. A review of the manufacturer's specifications for Daptomycin (an antibiotics that can treat infections) under section 2.7 titled, Preparation and Administration of Daptomycin for Injection. In-Use Storage Conditions for Daptomycin for Injection Once Reconstituted in Acceptable Intravenous Diluents Stability studies have shown that the reconstituted solution is stable in the vial for 12 hours at room temperature and up to 48 hours if stored under refrigeration at 2 C to 8 C (36 to 46 F). The diluted solution is stable in the infusion bag for 12 hours at room temperature and 48 hours if stored under refrigeration. The combined storage time (reconstituted solution in vial and diluted solution in infusion bag) should not exceed 12 hours at room temperature or 48 hours under refrigeration. 1. On 11/01/23 at 11:08 AM, in the presence of Registered Nurse #1 (RN #1) the surveyor inspected the Medication Room refrigerator on the third floor. During the inspection, the surveyor observed an intravenous (IV) medication bag of Daptomycin 500 milligram (mg)/50 milliliter (ml), with an affixed label for Resident #23 dated 10/16/23 with a use by date of 10/15/24. On the reverse side of the IV medication bag had another affixed label that revealed a prepared date of 10/17/23 at 4:00 PM and a use by date of 10/24/23 at 4:00 PM. The expiration dates on the affixed labels on the front and back of the bag were different. 2. At that time, RN #1 informed the surveyor that Resident #23 was discharged from the facility. RN #1 stated that the medication should not have been intermingled with the active inventory and should have been returned to the pharmacy for disposal. At that time, the RN explained the process for discontinued medications. She stated that the discontinued medications were separated from the active inventory and kept locked in the medication room. All nurses on all shifts were responsible in ensuring discontinued and expired medications were removed from active inventory. She further stated that the discontinued medication should not be administered to another resident and went against the five (5) rights of medication administration. RN#1 stated that she would inform her supervisor and inform the pharmacy to pick up the IV for return. At 11:27 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) confirmed the discontinued medication for the discharged resident should have been removed from the active inventory. The surveyor reviewed the medical record for Resident #23. The electronic Medication Administration Record (eMAR) for November 2023, included orders for IV Daptomycin 500 mg/50 ml started on 10/14/23, and discontinued on 10/19/23. A review of the transfer/discharge/expiration for Resident #23 revealed the resident was discharged on [DATE] at 12:20 PM. 3. On 11/01/23 at 11:31 AM, the surveyor observed the high side medication cart on the 4th floor parked in front of the nurses' station, located across the elevators. There were two nurses in the station. The Licensed Practical Nurse assigned to the cart was facing the computer located in front of the dining area. At that time, the surveyor greeted the nurses and requested to inspect the high side cart. The surveyor asked the nurse why the medication cart was unlocked, and the Licensed Practical Nurse #1 (LPN#1) assigned to the medication cart stated she did not mean to leave it unlocked. 4. On 11/01/23 at 11:45 AM, the surveyor began the inspection of the refrigerator located in the medication storage room on the 4th floor. At that time, in the presence of LPN#1, the surveyor observed a bag that contained a prefilled Lorazepam (used to treat anxiety) gel 0.5 mg syringe with an affixed labeled for Resident #38, dated 7/06/23, and a use by date of 07/05/24. The prefilled syringe had an affixed label with a date of 7/31/23. At that time, LPN #2 walked into the medication room. LPN #1 and LPN #2 inspected the syringe and could not explain the different dates on the bag against the 7/31/23 date on the syringe. At that time, LPN #2 stated she would call the pharmacy and inquire about the discrepancy between the dates. On 11/1/23 at 01:02 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that he had contacted the pharmacy. The LNHA stated that he had learned from the provider pharmacy that the inscribed date on the affixed label of the prefilled syringe was the expiration date. The pharmacy provider had omitted the description, use by date. The Lorazepam gel 0.5 mg syringe had expired. The surveyor reviewed the Medical Record for Resident #38. A review of the resident's Physician Order sheet for November 2023, included an order for Lorazepam gel 0/5 mg/1 ml, started on 7/17/23. A review of the Individual Patient's Controlled Drug Record reflected two syringes of Lorazepam were recorded as received on 10/03/23, one of which was administered on 10/20/23. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the LNHA, the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the storage and labeling concerns. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the DON, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the RNC #1 stated that they would follow the expiration date on the affixed label on the Daptomycin with the Resident #23's name and not the reverse side. The same label that indicated the expiration was 10/15/24, almost a year from the 10/16/23, prescription order date. At that time, RNC #1 stated that the medication was not expired based on the affixed label with the Resident's name. The expiration date on the Daptomycin provided by the pharmacy was not consistent with the Daptomycin's manufacturer's specification for storage and stability. At that time, the DON confirmed the discontinued medication for the discharge resident should not have been with the active inventory since the resident was discharged at the time of the unit inspection. At that time, the RNC #1 stated the dating on the Lorazepam prefilled syringe was not an error. At that time, the DON stated the pharmacy had informed the facility that the words use by was omitted. The expectation was the use by date would match the affixed label on the bag and the syringe. The provider pharmacy had sent a replenishment of prefilled Lorazepam gel syringes for Resident #38. The facility provided documentation that the expired Lorazepam gel was wasted and was not administered to the resident after surveyor inquiry. A review of the facility provided skilled nursing policies and procedures for storage medications revised 5/1/17 included the following: Policy: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Procedure 3. Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. NJAC 8:39- 29.4(a) (d)(h), 29.7(a)

Based on the interview and review of pertinent documentation, it was determined that the facility failed to ensure that the a) employed designated Infection Preventionist (IP) had at least part time position for one (1) of three (3) IP and b) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for three (3) of three (3) employees reviewed for IP. This deficient practice was evidenced by the following: A review of CMS QSO-19-10-NH, dated 3/11/19, included but was not limited to Background: Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP (infection prevention and control program). Specialized Training for Infection Prevention and Control: In order to receive . a certificate of completion, learners must complete all modules and pass a post-course exam . The Nursing Home Infection Preventionist Training Course is available on CDC's (Centers for Disease Control and Prevention) TRAIN website .Completion of this course will provide specialized training in infection prevention and control. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available. On 10/30/23 at 9:08 AM, the survey team entered the facility and was welcomed by the Assistant Administrator (AA). The AA informed the survey team that there was a COVID-19 positive nurse last Friday (10/27/23), all residents were tested and they were negative. On 10/30/23 at 10:04 AM, the two surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference. Both the LNHA and the DON informed the surveyors that the facility had a designated part-time IP (IP#1) and completed the required training and certificate of an IP. The surveyor asked the LNHA and the DON to provide a copy of the IP's resume, signed job description, and copy of the required training certificate. A review of the designated IP#1 CDC Nursing Home Infection Preventionist Training Course (web-based) required training for IP revealed that it was completed on 6/27/23. A review of the Job Description Acknowledgment for the position of an IP showed that IP#1 did not sign and it was not dated. A review of IP#1's employee file revealed that he was hired on 6/01/23 as per diem IP. On 11/02/23 at 9:46 AM, the surveyor interviewed the DON in the presence of the survey team about the requirement for an IP, and the DON stated that she would get back to the surveyor. On 11/02/23 at 11:50 AM, the surveyor interviewed IP#1 in the presence of another surveyor regarding his job title and qualifications as an IP. IP#1 informed the surveyor that he started in the facility as a part-time IP first week of June 2023. He further stated that his background was a graduate of Public Health. On 11/03/23 at 11:17 AM, the survey team met with the LNHA, DON, Regional Nurse Consultant #1 (RNC#1), Clinical Implementation Analyst (CIA), and Executive Director (ED). The surveyor notified the facility management of the above findings and concern with regard to an IP requirement and that IP#1 was hired as per diem IP on 6/01/23 (according to the payroll authorization form) and assumed the position of an IP prior to completion of the CDC certificate as a requirement for an IP. On 11/03/23 at 01:01 PM, the DON in the presence of the survey team stated that IP#1 was a covering per diem IP because the full-time IP was on leave. The DON further stated that as a DON she also can cover as an IP and the Unit Manager (UM). Then the surveyor asked the DON if she knew that the UM could be the IP while covering for the designated IP#2 who was on leave, and why the facility management did not use the UM as an IP in order to comply with the IP requirement. At that same time, the DON stated that they [facility management] did not know before that it was a requirement to have a 5-year experience to be able to be an IP not until the surveyor's inquiry. The DON further stated that that was why usually the IPs are the nurses because they have the experience. The surveyor asked for a timeline of the facility's designated IP since the last recertification from August 2021 through November 2023, including their resume, signed job description, and copy of education training and certificate. The DON stated that she would get back to the surveyor. On 11/06/23 at 9:28 AM, the LNHA provided a copy of the Infection Preventionist timeline as follows: IP#1=from 6/01/23 through the present (hired as PRN [as needed] to cover IP#2 while out on leave) [this was not previously provided to the surveyor and did not notify the surveyors during the entrance conference that IP#1 was a per diem IP covering for IP#2 not until surveyor's inquiry] IP#2=from 4/18/22 through present IP#3=from 8/2021 through 4/18/22 On 11/08/23 at 10:14 AM, the LNHA provided a copy of IP#2's employee files and revealed that IP#2 was hired on 4/18/22 as a full-time IP of the facility. On 11/08/23 at 10:40 AM, IP#1 provided a copy of IP#2's CDC Nursing Home Infection Preventionist Training Course (web-based) for a total of 19.75 contact hours that was completed on 5/16/22. Further review of the above findings showed that IP#2 assumed the position of a full-time IP on 4/18/22 prior to obtaining a completed training course for an IP on 5/16/22. On 11/08/23 at 10:49 AM, the survey team met with the LNHA, DON, RNC#1 and RNC#2, CIA, [NAME] President of Clinical Services (VPoCS), and ED (joined the meeting at 11:15 AM). The VPoCS acknowledged that the CDC certification was part of the requirement of an IP. The surveyor notified the facility management of the above findings that IP#1 and IP#2 both assumed the position as an IP before completing the CDC web-based education and prior to obtaining the certificate. On that same date and time, the surveyor followed up on IP#3's resume, signed job description, and certificate. On 11/08/23 at 12:59 PM, the DON in the presence of the survey team stated that IP#4 will be the IP as of today until we [facility] figure out with IP#1. The DON provided also a copy of IP#3's signed Job Description Acknowledgment for Infection Preventionist Coordinator dated 5/13/21. On 11/08/23 at 01:50 PM, the DON provided a copy of IP#3's CDC Nursing Home Infection Preventionist Training Course (web-based) that showed that IP#3 completed the 19.3 contact hours on 8/03/21. On 11/08/23 at 01:53 PM, the survey team met with the LNHA, VPoCS, CIA, DON, ED, and RNC#1 and #2. The surveyor notified the facility management of the concern regarding IP#3 assumed the position of an IP as shown in the signed Job Description acknowledgment on 5/13/21 prior to completing the CDC Nursing Home Infection Preventionist Training Course (web-based) on 8/03/21. On that same date and time, the facility management confirmed that IP#3 assumed the position of an IP before completing the requirement of training in CDC after the surveyor showed to the facility management the provided documents of the DON. A review of the facility provided Infection Preventionist Policy that was provided by the DON with a revised date of 11/28/17 did not include the requirements of an IP based upon the IP's education, experience, training, and position according to the CMS, NJDOH, and CDC guidelines. On 11/08/23 at 02:33 PM, the survey team met for an Exit Conference with LNHA, DON, VPoCS, CIA, ED, and RNC#1 and #2. The facility management had no additional information provided and did not refute the findings. NJAC 8:39-19.1(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: The surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Training Hours Transcripts showed the following: CNA #1 had a hire date of 8/09/10. The facility could not provide a Training Hours Transcripts. CNA #1 did not have QAPI training. CNA #2 had a hire date of 8/09/10. According to the Training Hours Transcripts, CNA #2 did not have QAPI training. CNA #3 had a hire date of 10/13/14. According to the Training Hours Transcripts, CNA #3 did not have QAPI training. CNA #4 had a hire date of 9/08/16. According to the Training Hours Transcripts, CNA #4 did not have QAPI training. CNA #5 had a hire date of 10/09/21. According to the Training Hours Transcripts, CNA #5 did not have QAPI training. On 11/02/23 at 01:54 PM, during surveyor interview, the Licensed Nursing Home Administrator (LNHA) stated that CNA #1's last day of work at the facility was in July 2023 and that he did not come back yet because he was asked not to return to work until he finished his mandatory education. The LNHA further stated that CNA #2 was on a medical leave since December 2022. On 11/03/23 at 9:57 AM, the surveyor interviewed the Director of Nursing (DON) regarding education. The DON stated that the facility did not have an educator right now that oversaw the process and that the facility was working on a better process for education. She stated that it was a collaborative process right now and that the Director of Human Resources was overseeing the computer system that contained education and the Infection Preventionist was overseeing nonclinical education. She added that she was also working on some of the education. On 11/03/23 at 12:49 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, Regional Nurse Consultant #1 (RNC #1), Clinical Implementation Analyst (CIA) and Executive Director (ED) the concern that the five CNAs did not have education on QAPI. On 11/08/23 at 11:07 AM, in the presence of the survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON stated that the QAPI education was not completed for the five CNAs. She added that the poster fair that was done did not contain the topic of QAPI. A review of the facility provided policy titled, In Service Training, with a revised date of 6/20/23, included the following: Policy: It is the policy of this community to conduct in-service training programs for all personnel on a regularly scheduled basis. Procedure: 1. In-service training programs are planned and conducted for the development and improvement of skills of all personnel. It may include, but is not limited to: . o. Others that become necessary or appropriate. The list did not include QAPI. A review of the facility provided policy titled, Quality Assessment Performance Improvement Program, with a revised date of 8/23/17, included the following: Procedure: . 20. Education and training will be provided to the QAPI Committee members on the quality process, QAPI improvement principles, data collection and root cause analysis. QAPI Team members will receive training on group facilitation to support and assist in the QAPI and PIP (performance improvement projects) process. The policy did not include all facility staff. N.J.A.C. 8:39-33.1

Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure a medication was administered to the manufacturer's cautionary specifications and in accordance with professional standards of clinical practice. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of four (4) residents during the medication administration observation and was evidence by the following. A review of the manufacturer's specifications for Lopressor (Metoprolol Tartrate) under section 2.1 titled Hypertension. Individualize the dosage of Lopressor tablets. Lopressor tablets should be taken with or immediately following meals. On 11/02/23 at 8:31 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #35. The RN prepared seven medications which included Metoprolol 25 milligram (mg; medication to reduce high blood pressure). At 8:42 AM, the surveyor observed the resident sleeping and the breakfast tray was not in the room. At 8:56 AM, the RN confirmed with the surveyor that she was ready to administer the medications to Resident #35, proceeded into the resident's room and attempted to awaken the resident. The surveyor requested to speak with the RN outside the room. At 9:01 AM, the surveyor and the RN reviewed the resident's bingo card (a multidose card containing individually packaged medications) for Metoprolol tartrate 25 mg. The bingo card had an affixed cautionary label that indicated Take with Meal. At that time, the surveyor and the RN reviewed the electronic Medication Record (eMAR) together. The eMAR included the order for Metoprolol which did not reveal a cautionary to administer the medication with a meal. At that time the RN stated she should not have attempted to administer the medication without the resident having a meal. The RN stated that the medication could be better absorbed with a meal or decrease nausea when taken with a meal. The RN stated that she missed the cautionary on the bingo card. At that time, the RN asked the RN/Charge Nurse (CN) for Resident #35's breakfast tray. At that time, in the presence of the surveyor and the RN, the RN/CN confirmed that Resident #35's breakfast tray was not in the room, the hallway, or the dining room, but would speak with the other staff about it. At 10:22 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager stated the cautionary on the bingo card should have been followed. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the concern regarding the nurse not following the proper administration of Metoprolol by following the cautionary affixed to the resident's bingo card. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON acknowledged the cautionary for the Metoprolol should have been read and followed. The DON informed the survey team that the cautionary would be added to the Medication Administration Record to help the nurses with proper administration of medication. A review of the facility provided policy Medication Administration and General Guideline dated 11/21/22 included the following: Policy; Medications are administered as prescribed in accordance with State Regulations, using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in [drug reference] otherwise authorized personnel should refer to Drug Reference material provided by facility. NJAC 8:39-29.2 (d)

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a) ensure a root cause analysis conclusion was included in a resident's fall investigation/incident report and b) implement and document in the resident's care plan a new intervention after a resident's fall in order to prevent any additional falls for one (1) of two (2) residents reviewed for falls (Resident #35). This deficient practice was evidenced by the following: On 10/31/23 at 11:54 AM, the surveyor observed Resident #35 seated in a wheelchair at the end of the hall looking out the window. The surveyor reviewed Resident #2's medical record. The Admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; hemiplegia (paralysis of one side of the body) following cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain) affecting right dominant side, unsteadiness on feet, difficulty in walking and muscle weakness. Resident #35's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/13/23, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which reflected that the resident's cognition was moderately impaired. Further review indicated the resident had a reentry into the facility from an acute hospital and that the resident had a fall with a major injury. A review of the New Jersey Universal Transfer Form dated 6/30/23 indicated that Resident #35 was transferred to the hospital and the reason for transfer was fell and injured his/her left wrist. A review of the facility provided Full Occurrence Report, an investigation/incident report, dated 6/30/23, revealed under the notes section that Resident #35 was found on the floor and that the resident had fallen. The resident had left wrist pain and was sent to the hospital. Under the Conclusion Statement section was N/A (not applicable). Under the Recommendations section was None Noted. The investigation/incident report did not contain a root cause analysis conclusion or recommendations/interventions to prevent any additional falls. The Fall Risk assessment dated [DATE], indicated Resident #35 was high risk for falls. A review of Resident #35's individualized comprehensive care plan (CP) reflected a problem, with a created date of 12/21/2022, of at risk for falls which included actual falls dated 01/05/23, 02/23/22 and 4/04/23. The 6/30/23 fall was not listed. The interventions listed included additional interventions that were added after each of the falls on 01/05/23, 02/23/22 and 4/04/23. There was no additional intervention added after the 6/30/23 fall or any documented evidence that the interventions already in place were reviewed in order to prevent any additional falls. On 11/02/23 at 10:53 AM, the surveyor interviewed Resident #35's assigned Certified Nursing Assistant who stated that the resident was a fall risk and had a bed that was low to the ground. On 11/02/23 at 11:16 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN) of the third floor unit regarding the process after a resident had a fall. The RN/CN stated that the resident would be assessed, the family and physician would be notified and the resident would be sent to the hospital if warranted. She then stated that the fall would be reported and that a risk watch (incident report) assessment and a fall risk assessment would be done. The RN/CN stated that the unit manager would do an investigation which included a conclusion and that an intervention would be put in place if one was needed. On that same date and time, the surveyor asked the RN/CN if Resident #35 had a fall. The RN/CN stated that the resident fell and broke their wrist on 6/30/23 and that he/she was evaluated at the hospital but was not admitted . The surveyor then asked who would update the CP and if the expectation was to have an added intervention after a fall. The RN/CN stated that the CP was done by the unit manager and that she would expect an intervention. The RN/CP then stated that Resident #35 received physical therapy after the fall to improve transfers, frequently was reminded to ask for help, frequently checked, non slip socks or shoes worn and bed in the lowest position. She added that the resident got confused and tended to transfer self. On 11/02/23 at 11:26 AM, the surveyor interviewed the RN/Unit Manager (RN/UM) of the third floor unit regarding the process for CP and falls. The RN/UM stated that every three (3) months the CP was updated and if there were changes or an incident like fall. She added that if there was a fall then an intervention should be added near the date of fall. The RN/UM stated that at morning meeting the interdisciplinary team discussed the fall and interventions. She stated that the fall would be investigated, concluded and an intervention added. At that same time, the surveyor asked the RN/UM to view Resident #35's CP and to confirm that the 6/30/23 fall was not listed and that an additional intervention was not added. The RN/UM confirmed the CP was not updated and stated that during that time she was working the 3-11 shift and that there was a different UM. She stated that whoever was in charge at that time should have had the fall listed and then added an intervention. The surveyor asked what the importance of adding the fall and an additional intervention was. The RN/UM stated that the importance was so everyone would be alert to prevent the resident from falling again. The RN/UM stated that she knew the resident was very impulsive but that they could try to stop the resident from falling again. Furthermore, the surveyor then showed the RN/UM the investigation/incident report that had no conclusion or recommendations. The RN/UM stated that there should have been a conclusion. On 11/02/23 at 01:14 PM, in the presence of the survey team, the surveyor asked the Director of Nursing (DON) if the investigation/incident report provided was the full and complete investigation. The DON stated that it was the full investigation minus the neuro checks which would be in the computer. The surveyor asked where the conclusion and statements would be. The DON stated that the nurse would write it in the report. On 11/03/23 at 10:28 AM, the surveyor interviewed the DON regarding the process of the CP and falls. The DON stated that when a resident had a fall then the CP should be updated with an intervention that pertained to the fall. She added that hopefully the CP would be updated by the next morning but that sometimes the investigation may take longer. The DON stated that the conclusion should be done within 72 hours. The surveyor then showed the DON Resident #35's CP and investigation/incident report for the 6/30/23 fall. The DON confirmed that there was no conclusion listed on the investigation/incident report and that there was no update to the CP after the 6/30/23 fall. The DON stated that there should have been a conclusion and an added intervention to the CP unless all possible interventions were already in place and if that was the case then that should have been documented. On 11/03/23 at 11:30 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Nurse Consultant #1 (RNC #1), Clinical Implementation Analyst (CIA) and Executive Director (ED) the concern that Resident #35's 6/30/23 fall investigation/incident report did not contain a root cause analysis conclusion and the CP was not updated to include an added intervention to prevent another fall. On 11/08/23 at 11:25 AM, in the presence of the survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON confirmed that the Resident #35's investigation/incident report for the 6/30/23 fall did not have a conclusion and that the CP was not updated. She added that she did not have an explanation for why it had not had a conclusion or why the CP was not updated. The DON confirmed that there should have been a conclusion and the CP should have been updated. A review of the facility provided policy titled, Incident Reporting, with a revised date of 02/01/2021, included the following: Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated .3. Analyze all incidents for risk potential implementing corrective and/or preventative actions as required . Incident Report Investigation Forms: 1. An investigation shall be initiated on all reported incidents. An Incident Investigations Report form shall be completed at the time of the incident. 2. Document in the Comments/Conclusion section if facts relating to the cause of the incident are actually known. Possible causes may be investigated but not documented until substantiated by facts . Quality Monitoring and Management: 1. The Executive Director/Administrator, Director of Nurses/AL Nurse Manager will review all Incident Reports which have occurred in the community/facility, on a monthly basis. 2. A determination will be made as to what corrective and/or preventative measures, if any, will be implemented by the facility staff. 3. Documentation of such determination will be submitted to the Quality Improvement Committee . Risk Watch Reporting Process: . 3. Administrator/DON or designee begins the Review stage a. Reviews Full Report . c. Review for appropriate recommendations, add or modify as needed, and record whether they have been implemented . 4. Unit Manager/Supervisor, DON, or designee generates Daily Safety Review or Occurrence Log in RiskWatch (Analysis menu) for discussion of recent occurrences at daily stand up meeting (Ongoing) a. Communicate relevant information to affected staff b. Update care plans as necessary . 7. Risk Watch Incident Reports along with Medical Charts will be reviewed by the Administrator/DON or designee at the end of each month. a. All data entry will be reviewed i.e. recommendations, interventions, etc. for effectiveness and final outcomes. A review of the facility provided policy titled, Falls Management Program, with a revised date of 12/22/2022, included the following: 11. Post fall a. The interdisciplinary team, at the daily report or Falls Committee, will review the post-fall assessment, incident report, any employee/elder statements, post-fall investigation, post-fall summary, and current interventions to evaluate if they were appropriately implemented, still relevant, and effective. The ECP (elder care plan) will be modified accordingly. All changes to the ECO will be communicated to the direct caregivers . 12. All falls are investigated and trended for possible causative factors utilizing the Risk Watch Analysis and reported to the community Quality Improvement Committee along with appropriate action plans. A review of the facility provided policy titled, Resident care Plan (RCP), with a revised date of 6/29/2023, included the following: Policy: It is the policy .to ensure that the care planning process is systematic, comprehensive, interdisciplinary and timely and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional status. Procedure: . 9. The effectiveness of the RCP must be regularly evaluated based on progress towards goals. The RCP will be modified as necessary based on the evaluation process . 11. The RCP will be updated at the Resident Care Conference and as necessary to address the resident's needs. N.J.A.C. 8:39-27.1 (a)

NJ00168293 Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility staff failed to: a) properly assess bed rails (side rail/enabler) safety to prevent harm to a cognitively impaired resident by not screening the resident properly during admission, ensuring correct installation, usage, and maintenance, b) obtain a physician order, c) educate and obtain consents from the resident/responsible party regarding risk/benefit of using bed rails, and evaluating alternatives before using bed rails prior to installation, d) monitor, inspect, and supervise the usage of bed rails, and e) follow facility policy and procedures. This deficient practice was identified for one (1) of one (1) resident reviewed for bed rails and was evidenced by the following: A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 10/09/23 at 11:48 AM, with an event date of 10/05/23 [unidentified time of event]. The event description included the following: On 10/05/23, the Power of Attorney (POA) spoke with Resident #251 who was told that he/she was hit by a male nurse. The POA did not report to any staff as she did not believe that this had occurred. The POA mentioned to the Director of Nursing (DON) on 10/08/23 regarding Resident #251's statement regarding the young male. The male Certified Nursing Assistant (CNA) on that resident's assignment was immediately removed from the schedule as a precaution but this description fits several staff members. The surveyor reviewed the closed medical records for Resident #251. A review of Resident # 251's admission record reflected the resident was admitted to the facility with a diagnosis that included unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), without behavior/psychosis/mood/anxiety, chronic kidney disease, malignant neoplasm (cancer that can grow or spread) of the prostate, muscle weakness and difficulty walking. According to the admission Minimum Data Set, an assessment tool used to facilitate management of care dated, 9/21/23, Resident #251 was documented as having a Brief Interview for Mental Status score of 99 out of 15, indicating that the resident was unable to complete the interview. The MDS also revealed that Resident #2 required extensive assistance for Activities of Daily Living (ADLs). A review of the Side Rail Screen dated 9/14/23, under the question, Does the facility use side rail? The documented response was No. Under, Comments/Recommendations/Additional Interventions: was blank, signed by Registered Nurse#1 (RN#1). A review of the Side Rail Screen dated 9/20/23, under the question, Does the facility use side rail? The documented response was No. Under, Comments/Recommendations/Additional Interventions: Patient uses enablers while in bed for repositioning, signed by RN #2. The Physician Order Sheet for October 2023 did not reflect an order for bed rails (side rails/enabler). A review of the medical record did not reflect an education and a signed informed consent was obtained regarding the benefits and potential hazards of bed rail usage from the resident/resident representative prior to installation of the bed rails. No additional document was provided. Further review of Resident #251's closed record did not reflect a copy of the maintenance department's inspection of the bed rail. No additional information was provided. The Care Plan reflected interventions dated 10/06/23, included, continue two persons assistance during care, and pad upper side rails with pillows for extra protection. An undated intervention was the use of an enabler for bed repositioning. A review of the facility provided Full Occurrence Report dated 10/08/23 at 12:10 AM, reported by RN #3 documented that Resident #251 had bruises on the left eyebrow that spread to upper and lower eyelids, bruises on the left hip was observed while the resident was being toileted. The resident was unable to explain how it happened. The DON documented on 10/23/23 at 01:07 PM the following: A lengthy conversation with the POA occurred about the resident's skin being frail and easily bruised. In a discussion of the risk versus benefit of side rails [bed rails], the resident used them to position self and the tendency of the resident top pull their body into them that caused bruising. The POA wished to continue the use of side rails and agreed to monitor the resident. The facility did not have padded side rails in stock, and they were ordered. The side rails were padded with pillows in the interim. The resident was observed removing the pillows and any other padding interventions tried. On 10/08/23, the resident sustained more bruising to the hip and eyebrow area from his restless behaviors and attempting to get up unattended. The resident was sent out [to the hospital] and admitted with Urinary Tract Infection. On 11/02/23 at 01:18 PM, during an interview with the surveyor, the DON stated that she had spoken with the POA and discussed the bruising from the side rails and documented the conversation regarding the resident who laid close to the bed rails, the interventions of ordering a Velcro side rail, change the bed to a raised perimeter mattress. The bed frame was rubbing on his hip area and thought the extra cushion would help. On 11/02/23 at 01:20 PM, during an interview with the surveyor, the Registered Nurse/ Unit Manager (RN/UM) stated she somewhat recalled the resident, but some time had passed. She recalled the resident was care planned to have two person assists during care. The two-person assist in the morning would either be two CNAs or a CNA with a Licensed Practical Nurse (LPN) or an RN, and the night shift would be a CNA and an LPN or an RN. The RN/UM further stated that this was our process to prevent abuse in our facility in the case of a resident who had behaviors of hitting staff. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the concern regarding the improper assessment of Resident#251's side rails/enabler prior to installation, the concerns regarding the failure to obtain a physician order, obtain a signed informed consent from the resident or resident's representative prior to installation, proof of inspection from the maintenance department, rehabilitation department as part of the interdisciplinary team, failure to follow facility policy and procedure. At that time, the DON informed the surveyors that the bed rails were coded as enablers which caused the cascade of bed rails screens to not be performed. The DON also stated that the bed rails coded as enablers were discovered in September 2023 and a Quality Assurance and Performance for Improvement (QAPI; a data-driven and proactive approach to quality improvement that included QA and Performance Improvement to ensure services are meeting quality standards and assuring care reached a certain level) was also initiated. The incident for Resident #251 occurred on 10/05/23. On 11/8/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON acknowledged that on 9/15/23 and 9/20/23 an assessment was completed however was documented as an enabler which blocked the remainder of the assessment. At that time, the DON stated that she re-audited the entire building after the surveyor's inquiry for bed rails marked as enablers. On 11/08/23 at 12:43 PM, during an interview with the surveyor, the Physical Therapist (PT)/Rehabilitation Director (RD) stated that she did not receive any referral from nursing to evaluate the resident's ability to use or remove the side rail or what padding should be used. The PT/RD also stated that the resident was cognitively confused and was not capable to unlock or move the bed rail up or down. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON stated that they stood behind their conclusion on the reportable from 10/06/23, that the bruises were related to the use of the side rail. I have witnessed the resident use the side rail, the resident was intermittently cognitively and physically more functional. A review of the facility provided; Side Rail/Enabler Information/Instruction, undated, reflected the following: 1. Complete a Side Rail assessment on admission, quarterly or any time a rail will be used for the first time on a resident. All rails whether it is an enabler, or a side rail follows the same rule and same regulation. 2. Physician Order for the use of side rails/enabler. You must indicate which type is used and which sides . 4. All rails/enabler usage needs consent .If the resident has a BIMS less than 12, you must get consent from family representative. You must explain risk versus benefit of side rail use. This includes risk of injury, risk of entrapment, risk of bruising. A review of the facility policy Side Rails and Bed Safety, revised on 6/2023 included the following: Policy [facility name redacted] shall strive to provide a safe environment for residents while they are in bed. 1. The residence sleeping environment shall be assessed by the interdisciplinary team considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and that environment. 2. To prevent death injuries from the bed and related equipment including the frame, mattress, side rails, headboard footboard and bed accessories the community shall promote the following approaches: a. Inspection by maintenance staff of all bed related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment. d. Ensure that side rails are properly installed using manufacturers instructions and other pertinent safety guidance to ensure proper fit . e. Identify identify additional measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness .) 3. The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee or appropriate action . 4 Maintenance and monitoring of the bed, mattress, and accessories should be ongoing . 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to use . 8. Side Rails may be used if assessment and consultation with the attending physician have determined that they are needed to help manage a medical symptom or condition or help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. NJAC 8:39-27.1(a)