Every finding on record at Our Ladys Center for Rehabilitation & Healthcare

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 06/01/2026 from 9:46 AM until 10:27 AM the surveyor, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. In the walk-in refrigerator there was ham wrapped in plastic wrap that was not labeled with an open or use by date. The FDS said that the ham should be labeled and removed the ham from the refrigerator. 2. Also, in the walk-in refrigerator 4 boxes of juices and a crate filled with milk cartons were on the floor. The FDS said they should not be stored on the floor. 3. In the walk-in freezer there was an open bag of diced chicken that was not labeled with an open or used by date. The FDS said the chicken should be labeled and removed from the freezer. During an interview on 06/04/2026 at 1:52 PM with the surveyor, the Licensed Nursing Home Administrator (LNHA) said that all food in the refrigerator and freezer should be labeled, and no food or drinks should be on the floor for sanitation purposes. A review of a facility provided policy titled Food Storage revealed, Food shall be stored in a manner that complies with safe food handling practices, and All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). N.J.A.C. 18:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a safe, clean, and homelike environment for 2 of 2 stairwells observed in the resident courtyard reviewed under the Environmental Task. The deficient practice was evidenced by the following:On 06/01/2026 at 11:28 AM during initial tour, the surveyor observed the resident courtyard. At that time the surveyor observed two stairwells on both sides of the resident courtyard. At that time, the surveyor observed garbage at the base of both stairwells that included foam containers, foam cups and paper plates.On 06/04/2026 at 12:40PM upon return to the resident courtyard, the surveyor observed garbage that included foam, containers, foam cups and paper plates at the base of both stairwells. At that time, when asked if there should be garbage in the resident courtyard stairwells the Maintenance Director (MD) stated he will find someone to clean the garbage now.On 06/04/2026 at 1:43 PM during an interview the Licensed Nursing Home Administrator (LNHA) answered yes when asked if outdoor resident areas and their surroundings should be kept clean and free from garbage. The LNHA further answered that it was necessary to do so to maintain a sanitary and homelike environment. A review of the facility provided policy titled Homelike Environment revised 06/2024 revealed under Policy Statement that Residents are provided with a safe, clean, comfortable and homelike environment. N.J.A.C. S 8:39-31.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include resident directed self-tracheostomy care. This deficient practice was identified for 1 of 35 residents reviewed for resident-centered care plans (Resident #7), and was evidenced by the following: On 06/01/2026 at 9:54 AM resident #7 was observed in their room exiting the bathroom. At that time the surveyor observed Resident #7's tracheostomy (surgical opening in the neck for artificial airway). Resident #7 communicated to the surveyor through written words that he/she performed their own tracheostomy care including suctioning. A review of Resident #7's Minimum Data Set (MDS; an assessment tool) revealed that Resident #7 had a Brief Interview of Mental Status (BIMS) of 15, indicating that Resident #7 is cognitively intact. A review of Resident #7's Electronic Medical Record (EMR) revealed Resident #7 was admitted with diagnosis of but not limited to; chronic respiratory failure (prolonged difficulty in breathing), and unspecified tracheostomy.A review of Resident #7's EMR under physician's orders revealed orders that included Tracheostomy suction as needed for secretions with an order date of 09/06/2025. A review of Resident #7's resident-centered care plan did not reveal a focus or intervention that included resident #7 performed self-suction. On 06/02/2026 at 12:07 PM, during an interview with the surveyor, when asked who performs Resident#7's tracheostomy suctioning, Licensed Practical Nurse #1 answered that both nursing staff and the resident perform suctioning. LPN #1 answered yes when the surveyor asked if the resident should be care planned to self-suction. On 06/04/2026 at 1:43 PM, during an interview with the surveyor, the Director of Nursing (DON), stated that Resident #7 should be care planned to self-suction. The DON further answered it was necessary to do so that staff know that the resident performs their own suctioning, and staff can ensure Resident #7 was suctioning correctly. A review of the facility provided policy titled Resident Plan of Care with a revision date 06/2024 under Policy Interpretation and Implementation revealed The interdisciplinary team, resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. NJAC 8:39-11.2

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice by failing to ensure physician orders were followed for 1 of 4 residents (Resident #137) reviewed for respiratory care. This deficient practice was evidenced by:On 06/01/2026 at 10:41 AM during the initial tour, the surveyor observed Resident # 137 sitting on the side of the bed. Resident # 137's nasal cannula (a tube delivering oxygen into the nose) was not on the resident and was draped over the nightstand. On 06/02/2026 at 12:15 PM, the surveyor observed Resident # 137 in their room sitting in a wheelchair. Resident # 137's nasal cannula was in a bag, and the oxygen concentrator was turned off. The oxygen concentrator was behind the resident. A review of Resident # 137's admission Record located in the EMR revealed that Resident # 137 was admitted to the facility with diagnoses that included but were not limited to encounter for acute pulmonary insufficiency following a surgery ( the inability of the respiratory system to maintain adequate gas exchange following surgery), and heart failure (when the heart muscle doesn't pump blood as well as it should). A Review of Resident # 137's physicians orders located in the EMR revealed a physician's order for Oxygen 4 liters(L) per minute via nasal cannula continuously. May titrate 2L-4L as needed. The order was started on 05/06/2026. During an interview on 06/03/2026 at 12:36 PM with the surveyor, the Registered Nurse unit manager (RNUM) said that Resident #137 had been on continuous oxygen since admission. The RNUM then said there are orders to adjust the rate of oxygen, however the oxygen should have been on the resident as the order states it is continuous. On 06/04/2026 at 1:52 PM during an interview with the surveyor, the Director of Nursing (DON) said it is important to follow the physician's orders with oxygen to ensure the resident does not have shortness of breath and is receiving enough oxygen. A review of the facility-provided policy titled, Administering Medications revealed, Medications shall be administered as prescribed N.J.A.C. 8:39-29.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 4 residents, errors were observed for 3 of 4 residents (Resident #64, Resident #175 and Resident #198). There were 29 opportunities for error with 15 errors observed resulting in an error rate of 51% as evidenced by the following: During the medication pass observation on 06/02/2026 from 9:37 AM until 9:51 AM, the surveyor observed the following: At 9:37 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare seven medications for Resident #179, including the following: Metformin HCL 500 mg (milligram) oral tablet, give one tablet by mouth two times a day, which included a pharmacy cautionary to take with food. LPN #1 did not provide food to the resident during administration. At 9:51 AM, the surveyor and LPN #1 reviewed the Metformin unit dosed medication card. LPN #1 confirmed the instructions included take with food and stated she should have offered food but had believed the resident had eaten breakfast and that was enough. When asked what time breakfast was delivered to the unit she stated 8:00 AM and acknowledged that it was over one and a half hours before the Metformin was administered. The surveyor did not observe any food delivery trucks on the unit and there was no food observed on the residents' overbed table. During the medication pass observation on 06/02/2026 from 10:01 AM until approximately 10:40 AM, the surveyor observed Licensed Practical Nurse #2 (LPN #2) prepare eleven medications for Resident #198. They were as follows: Amlodipine besylate 10 mg tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:30 AM.Aspirin 81 mg oral tablet delayed release, give one tablet one time a day; scheduled for 9:00 AM and administered at 10:30 AM.Biktarvy 50-200-25 mg oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:31 AM. Farxiga 5 mg oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:33 AM.Lactobacillus capsule, give one capsule by mouth one time a day; scheduled for 9:00 AM and administered at 10:33 AM.Losartan potassium oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:35 AM. Magnesium Gluconate 500mg oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM, and administered at 10:35 AM.Metformin HCL 500 mg oral tablet, give one tablet by mouth two times a day; scheduled at 9:00 AM and 6:00 PM, and administered at 10:28 AM.Multivitamin oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:36 AM. 10. Oxybutynin chloride ER (extended release) 5 mg oral tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 10:37 AM. 11. Tylenol 325 mg oral tablet. Give two tablets by mouth every 6 hours as needed for mild pain 1-4. This medication was on an as needed basis and did not have a scheduled time for administration. At 10:22 AM, the surveyor interviewed LPN #2 who acknowledged Resident # 198's medications were administered late, they were scheduled for 9:00 AM, but the resident was attending therapy at that time, and he could not administer medications when a resident was in therapy. The surveyor reviewed Resident # 198's Medication Admin Audit Report with a scheduled date range of 06/02/2026- 06/03/2026 to confirm the above referenced administration times. During the medication pass observation on 06/03/2026 from 9:37 AM until approximately 9:55 AM, the surveyor observed Licensed Practical Nurse #3 (LPN #3) prepare six medications for Resident #64. They were as follows: 1. Midodrine 5 mg oral tablet, give one tablet by mouth every 12 hours, hold for SBP (systolic blood pressure) greater than 130. Medication was held. 2. Eliquis 5 mg oral tablet, give one tablet by mouth two times a day; scheduled 8:00 AM and 5:00 PM and administered at 9:54 AM. 3. Bactrim DS 800-160 mg oral tablet, give one tablet by mouth two times a day; scheduled 8:00 AM and 5:00 PM and administered at 9:54 AM. 4. Venlafaxine HCl ER (extended release) 150 mg oral tablet, give one tablet by mouth one time a day; scheduled for 8:00 AM and administered at 9:54 AM. 5. Metoprolol Succinate ER (extended release) 50 mg oral tablet, give one tablet by mouth one time a day; scheduled for 8:00 AM and administered at 9:54 AM. 6. Magnesium Oxide 400mg oral tablet, give one tablet by mouth two times a day; scheduled for 8:00 AM and 5:00 PM and given at 9:54 AM. The surveyor reviewed Resident # 64's Medication Administration Audit Report with a scheduled date range of 06/02/2026- 06/03/2026 to confirm the above referenced administration times. At 9:54 AM, the surveyor interviewed LPN #3 who stated Resident #64's medications were late and should have been given at 8:00 AM. LPN #3 further stated medications could be administered up to one hour before and one hour after the scheduled time. On 06/04/2026 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed the medications were given late, an acceptable timeframe for administration was one hour before and one hour after the scheduled medication administration time. She further acknowledged medications with pharmacy cautionaries, like take with food should be followed as directed. A review of the facility's Administering Medications policy with a revised date of 3/2023 did not reference following pharmacy cautionaries or the allowance of one hour before and one hour after scheduled administration time for a medication to be administered. A review of the facility's Physician Orders policy with a revised date of 7/2023 included Policy- was to ensure medication/treatment orders were implemented accurately, timely, and in accordance with the State of New Jersey and Federal Government regulations. The policy did not address following pharmacy cautionaries or the allowance of one hour before and one hour after scheduled administration time for medication to be administered. NJAC 8:39-29.2(d)

NJ Complaint: 2605819 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant medication errors. The deficient practice was evidenced by the following: NJ Complaint: 2605819 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant medication errors. The deficient practice was evidenced by the following: A review of Resident #193s admission Minimum Data Set (MDS) (an assessment tool) dated 07/16/2025, revealed that Resident #193 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. The MDS also reflected that this resident had a diagnosis which included diabetes mellitus (a chronic condition where the body cannot regulate blood sugar) and received insulin medication (a medication used to treat diabetes)A review of Resident #193's physician's orders revealed the following insulin orders which included but were not limited to: 07/10/2025 Insulin Glargine Subcutaneous Solution Pen-injector 100/unit/milliliter (ML); inject 10 units subcutaneously in the morning for Diabetes Mellitus, ordered to be administered at 9:00 AM, 07/11/2025 Insulin Lispro Injection solution 100 unit/ml; inject as per sliding scale, scheduled to be administered at 7:00 AM, 11:30 AM, 4:30 PM, and 9:00 PM, 08/06/2025 Novolog injection solution 100 unit/ml; Inject as per sliding scale to be administered at 7:00 AM, 11:30 AM, 4:30 PM, and 9:00 PM. A review of Resident #193's Medication Administration Audit Report for July and August 2025 revealed the following insulin medications were administered outside of the required time frame as follows: Insulin Glargine Subcutaneous Solution Pen-injector 100/unit/ml; inject 10 unit subcutaneously in the morning for Diabetes Mellitus, ordered to be administered at 9:00 AM: 07/11/2025 administered at 10:15 AM Insulin Lispro Injection solution 100 unit/ml; inject as per sliding scale, scheduled to be administered at 7:00 AM: 07/25/2025 administered at 09:06 AM07/28/2025 administered at 06:10 AM08/12/2025 administered at 06:09 AM Insulin Lispro Injection solution 100 unit/ml; inject as per sliding scale, scheduled to be administered at 11:30 AM:07/15/2025 administered at 1:46 PM07/18/2025 administered at 4:07 PM7/20/2025 administered at 10:37 AM 08/01/2025 administered at 1:33 PM08/02/2025 administered at 12:25 PM08/08/2025 administered at 10:47 AM08/09/2025 administered at 2:15 PMInsulin Lispro Injection solution 100 unit/ml; inject as per sliding scale, scheduled to be administered at 4:30 PM:07/16/2025 administered at 5:35 PM07/18/2025 administered at 5:19 PM07/19/2025 administered at 5:20 PM07/22/2025 administered at 7:28 PM07/23/2025 administered at 6:38 PM07/28/2025 administered at 5:44 PM08/01/2025 administered at 5:23 PM08/02/2025 administered at 7:53 PM08/07/2025 administered at 6:31 PM Insulin Lispro Injection solution 100 unit/ml; inject as per sliding scale, scheduled to be administered at 9:00 PM:07/16/2025 administered at 10:12 PM07/22/2025 administered on 07/23/2025 at 12:19 AM07/23/2025 administered at 10:00 PM07/24/2025 administered at 10:12 PM 07/26/2025 administered at 11:14 PM07/28/2025 administered at 11:00 PM Novolog injection solution 100 unit/ml; Inject as per sliding scale to be administered at 9:00 PM:08/07/2025 administered on 08/08/2025 at 2:26 PM08/10/2025 administered at 10:42 PM Novolog injection solution 100 unit/ml; inject as per sliding scale to be administered at 4:30 PM:08/08/2025 administered at 5:18 PM08/09/2025 administered at 5:52 PM08/10/2025 administered at 6:19 PM On 06/04/2026 1:39 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that sliding scale insulin should be administered one half an hour before or one half an hour after the scheduled medication administration time. The DON stated that routine insulin can be administered an hour before or an hour after the administration time. A review of the facility policies titled, Administering Medications with a revision date of 3/2023 and Administration of Insulin with a revised date of 10/2022 did not address the timing of the insulin administration. N.J.A.C.: 8.39-29.2 (d)

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to use appropriate infection control practices specifically by a) failing to use personal protective equipment and entered resident room with wound treatment cart, for 1 of 2 residents reviewed under Pressure Ulcer/Injury (Resident #13) and c) respiratory equipment for 1 of 4 residents reviewed for respiratory care. (Resident #177). The deficient practice was evidenced by the following: On 06/01/2026 at 11:16 AM surveyor #1 observed signage that indicated Resident #13 was on Enhanced Barrier Precautions (EBP). The signage indicated that high-contact resident care activities required staff to wear a gown and gloves, high-contact. The signage indicated high-contact care activities included wound care. At that time Resident #13 informed surveyor #1 that he/she had wounds to both their heels due to positioning while in bed. On 06/03/2026 at 10:48 AM, with permission from Resident #13, surveyor #1 observed his/her wound care provided by Licensed Practical Nurse (LPN) #1. At that time, Surveyor #1 observed Licensed Practical Nurse (LPN) #1 entering Resident #13's room with the wound treatment cart. At that time, while in Resident #13's room LPN #1 sanitized the surface of the wound treatment cart, applied a clean pad to its surface and began to gather supplies from the cart. LPN #1 donned gloves with no gown and removed Resident #13's soiled dressings. After removing Resident #13's soiled dressing, LPN #1 performed hand hygiene then donned a gown and clean gloves. At the time wound care concluded surveyor #1 asked LPN #1 if she should have donned a gown prior to removing resident #13's soiled dressings. LPN #1 answered yes. A review of Resident #13's Electronic Medical Record (EMR) revealed Resident #13 had diagnosis that included but were not limited to; Acute Osteomyelitis (an infection of the bone) of the left ankle and foot, open wound to right foot and open wound to left foot. A review of Resident #13's EMR revealed a physician order for Collagenase Ointment (an enzyme ointment that selectively breaks down dead or damaged tissue in wounds, promoting the growth of healthy skin) 250 unit/g with directions to apply to bilateral heel topically every evening shift for wound care cleanse with normal saline, pat dry, apply collagenase then cover with pad and kerlix ordered on 06/01/2026. A review of Resident #13's resident-centered care plan revealed a focus of Enhanced Barrier Precautions related to wound, initiated on 05/29/2026. Further review of Resident #13's resident-centered care plan revealed a focus of, infection related to acute bilateral calcaneal osteomyelitis, initiated on 05/30/2026 with interventions that included; implement appropriate isolation precautions as ordered, initiated on 05/31/2026. On 06/04/2026 at 12:25 PM during an interview with surveyor #1 the Infection Preventionist (IP) when asked if staff should bring the wound treatment cart into the residents room answered no. The IP further stated that the wound treatment cart should remain outside the door. The IP answered no they should use the bedside table when asked if staff should utilize the top of the wound treatment cart as the clean surface during wound care. When asked when if staff should don a gown prior to removing soiled wound dressings during wound care, the IP answered yes, it should be donned before any high-contact care is provided. A review of the facility provided policy titled. Enhanced Barrier Precautions effective 09/2024 under General overview revealed, Enhanced Barrier Precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of Multidrug Resistant Organisms (MDRO). Further review revealed, EBP may be used when contact precautions do not otherwise apply to residents with any of the following: Wounds or indwelling medical devices, regardless of the MDRO colonization status. Further review of the policy revealed examples of high-contact resident care activities requiring gown and gloves for EBP include but are not limited to; Wound care; any skin opening requiring a dressing. The facility was unable to provide a policy regarding use of wound treatment carts. 8:39-19.4 (a) On 6/1/2026 at 10:49 AM, the surveyor entered Resident #177's room and observed the resident in bed receiving oxygen via nasal cannula. The tubing for the oxygen was hanging off the bed down into the trash can next to the bed and ultimately resting directly on the resident's floor. At 10:53 AM, Resident #177's Licensed Practical Nurse (LPN) walked into Resident # 177's room. The surveyor interviewed the LPN who stated the oxygen tubing should not be hanging off the bed into the trash and onto the floor because this could cause contamination or infection. A review of Resident # 177's admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to, acute respiratory failure, atelectasis (the partial or complete collapse of a lung or its air sacs) and dementia. A review of Resident # 177's physician's orders revealed orders 2 liters (L) via NC (nasal cannula) PRN (as needed), may titrate 2 L to 4 L for SOB (shortness of breath) every shift related to acute respiratory failure with hypoxia (a life-threatening emergency where the lungs cannot adequately oxygenate the blood); initiated 9/23/2025. A review of the facility's Enhanced Barrier Precautions policy with an effective date of 9/24 did not address the positioning of oxygen tubing for infection control purposes. A review of the facility's Oxygen Administration- Resident policy dated revised 12/2024 did not address the positioning of oxygen tubing for infection control purposes. A review of the facility Respiratory Equipment policy dated effective 3/22 did not address the positioning of oxygen tubing for infection control purposes. NJAC 8:39-19.4(k)(n)

Complaint # 179819 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep all areas clean, in good repair and, a bed rail in place. The deficient practice was identified for 3 of 4 residents reviewed under the Environmental Task and 4 out 4 nourishment rooms. The deficient practice was evidenced by the following: On 12/16/2024 at 10:01 AM during the initial tour of the facility, the surveyor # 1 observed Resident # 11's bathroom. At that time, surveyor # 1 observed a toilet paper dispenser mounted to the wall that was crooked and appeared loose. There were also stains located on the floor near the resident's window. Lastly, surveyor # 1 observed stains on the wall outside the bathroom door. On the same date at 10:09 AM during the initial tour of the facility, surveyor # 1 observed Resident # 319's room. At that time, surveyor # 1 observed the bed rail on the left side disconnected from the bed frame and left on the floor along with the bed remote control. On 12/17/2024 at 11:17 AM during observation of the smoking area grounds, surveyor # 1 observed over a dozen discarded, used cigarettes on the ground in the grass areas and sidewalks. During the same observation, surveyor # 1 observed an outdoor bench that was cracked. On 12/18/2024 at 9:37 AM, the surveyor visited Resident # 20, surveyor # 1 observed a discarded medication cup, liquid, and a straw on the floor. The resident was unsure of what the liquid was. On the same date at 11:14 AM while visiting Resident # 11 in their room, surveyor # 1 observed one, loose, unidentified tablet under the bed and an opened package of incontinence briefs left on the bed side table. At that time, Resident # 11 confirmed that he/she has visitors from time to time and he/she does not want the incontinence briefs left out. He/She stated, They should be put away. A review of the facility policy titled, Cleaning of Resident Rooms with an effective date of 3/20 revealed under, General Guidelines that Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A review of the facility policy titled, Smoking revealed that, 11. The designated area will be closed for a short duration for regular cleaning. S 8:39-31.4 (a) 49712 On 12/16/2024 at 10:08 AM during initial tour surveyor # 2 observed pillowcases tucked in the window of the bathroom on unit B room [ROOM NUMBER]. Also observed on unit B in room [ROOM NUMBER] A-side, surveyor # 2 observed the wall next to the bed with scratches and peeling paint. On 12/19/2024 at 09:54 AM during a tour of the Unit C and D nourishment room surveyor # 2 observed the following: 1. Under the sink there was a water bottle with a blue substance not labeled and a sponge open to air. 2. The ice machine was observed with white stains on the front and the tray was filled with water and rust was noted on the rack in the tray. 3. A stack of 3 paper cups were observed facing up and open to air. During an interview on 12/19/2024 at 09:57 AM with surveyor # 2, Registered Nurse/Unit manger #1 (RN/UM) said that the cups should be facing down to keep germs out. The RN/UM #1 also said that the blue substance was his/her own personal dish soap and that it should not have been in there. She removed the bottle and sponge. On 12/19/2024 at 10:02 AM during a tour of the Unit G and H nourishment room surveyor # 2 observed the following: 1. The kitchen cabinet if poor condition with a missing drawer, missing knob on one of the drawers and the cabinet doors missing knobs and attached paperclips used as a way to open the cabinet doors. 2. Peeling and chipped paint at the bottom of the cabinet. During an interview on 12/19/2024 at 10:08 AM with surveyor # 2, the RN #2 said the cabinet had been like that for about a month and that she thinks a new one was ordered. On 12/19/2024 at 10:10 AM during a tour of Unit and B nourishment room surveyor # 2 observed the following: 1. Cabinet doors under the counter with missing knobs and attached paper clips in their place. 2. A tied plastic bag with a mop head in it left in one of the cabinets. 3. An open bag with what appeared to be clothes in it left on a chair. During an interview on 12/19/2024 at 10:12 AM with surveyor # 2 the RN/UM #3 said she didn't know the mop got into the cabinet and removed it. She also said that the bag of clothes was a staff members jacket. On 12/19/2024 at 10:22 AM during a tour of the Unit E and F nourishment room surveyor # 2 observed the following: 1. The upper cabinets were open and empty with visible dirt and a dead bug in them. 2. The bottom cabinets were all nailed shut. 3. A layer of dust noted on the counter tops. 4. Six tied plastic bags of clothes on the counters that were identified as staff belongings. 5. Missing paint around the soap dispenser where it had been moved. 6. A layer of dirt and debri behind the sink. During an interview on 12/20/2024 at 10:22 AM with surveyor # 2, the Director of House Keeping (DHK) said they start with room cleanings after breakfast, they empty all the trash, multiple microfibers are used per room. One for the bathroom and one for the rest of the room. They sweep the floors then mop their way out. He said they clean the nourishment rooms daily. They wipe the counters, empty trash and clean the floor. The unit hallway floors, and the nourishment rooms get a deep cleaning monthly, nursing staff empty the cabinets and drawers then house keeping goes in and wipes them out. The DHK said that the bottle of dish soap should not have been left under the counter, and that counters and floors should be clean. During an interview on 12/20/2024 at 10:30 AM with the surveyor, the Maintenance Director (MD) said that maintenance does rounds on rooms and hallways daily. They prioritize what is most important for the residents and handle those issues as soon as possible. The MD agreed that the counters and lower cabinets in the nourishment needed replacing and said they have started the process by ordering a new one for one of the units. The MD was unsure of the time frame when they would all be replaced. During and interview on 12/20/2024 at 12:58 PM with surveyor # 2, the Licensed Nursing Home Administrator (LNHA) said there should be appropriate ways of opening the drawers and doors to the cabinets in the nourishment, they are working on replacing them. The LHNA also said that staff does have lockers and that is where their belongings should be kept. Lastly the LHNA said they were aware the cabinets in the panty need replacing and they are working on it. A review of a facility provided Policy dated 03/20 and titled Homelike Environment revealed under Policy Statement that, Residents are provided with a safe, clean, comfortable and homelike environment . S 8:39-31.2 (e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications and biologicals were stored and labeled properly in medication carts. The deficient practice was identified for 4 of 5 medication carts reviewed under the Medication Storage and Labeling Task. The deficient practice was evidenced by the following: On 12/16/2024 at 12:47 PM, the surveyor inspected the D-Hall medication cart. At that time, the surveyor observed two, loose tablets in the second drawer of the medication cart. Secondly, the surveyor observed one, multi-use vial of Insulin Lispro (fast-acting medication used to treat blood sugar levels) and one, multi-use vial of Lantus (long-acting medication used to treat blood sugar levels) undated. Lastly, the surveyor observed loose vials of Heparin (medication used to thin the blood) placed in a plastic basket with the insulins. At that time, during an interview with the surveyor, Licensed Practical Nurse (LPN) # 1 said they [insulins] should be dated. She also removed the Heparin vials and placed them in the 3rd drawer box of Heparin. On 12/17/2024 at 11:01 AM, the surveyor inspected the B-Hall medication cart. At that time, the surveyor observed five, loose tablets in the second drawer of the medication cart. At that time, LPN # 2 placed the loose tablets in the drug-buster (bottled solution used to disintegrate medications). On the same date at 11:07 AM, the surveyor inspected the A-Hall medication cart. At that time, the surveyor observed seven, loose tablets in the second drawer of the medication cart. At that time, during an interview with the surveyor, LPN # 3 replied, I'm not sure. It happens on night shift. when the surveyor asked how often are carts cleaned. On the same date at 1:25 PM, the surveyor inspected the G-Hall low medication cart. At that time, the surveyor observed one, loose tablet in the second drawer of the medication cart. At that time, the nurse placed the tablet in the drug buster. A review of the facility policy titled, Treatment & Medication Cleaning dated 03/2020 revealed under, Procedure that, 3. Treatment and Medication carts are cleaned routinely. A review of the facility policy titled, Medication Storage dated 03/2020 revealed under Policy Interpretation and Implementation that, 1. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. and that, 7. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. A review of the facility policy titled, Administration of Insulin dated 03/2020 revealed under Steps in the Procedure (Insulin Injections via Syringe) that, 4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after openings). N.J.A.C. S 8:39-29.4 (a)(b)2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide reasonable accommodation of a resident, specifically by having the resident's call device on the floor while the resident was in bed. The deficient practice was identified for 1 of 4 residents (Resident # 320) reviewed under the Environmental Task. A review of Resident # 320's Admission Record located in the Electronic Medical Record revealed a diagnoses of but not limited to, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region (Infection of the bone). On 12/16/2024 at 10:15 AM, the surveyor observed Resident # 320 in bed. At that time, their call device was on the floor, outside of reach of Resident # 320. On 12/20/2024 at 9:40 AM, the surveyor observed Resident # 320 in bed. At that time, their call device was on the floor, outside of reach of Resident # 320. On 12/23/2024 at 9:15 AM during an interview with the surveyor, the Licensed Nursing Home Administrator said the facility provided education regarding call devices to the Certified Nurse Aide that was assigned to Resident # 320. A review of the facility-provided policy titled, Call Bell System with an effective date of 03/2020 revealed that, Facility utilizes a call bell system to allow residents to call for staff assistance. N.J.A.C. 8:39- 31.8 (c)(9)

Based on observation, interview, and record review, it was determined that the facility A.) failed to maintain medication records that were complete with staff signatures according to professional standards of clinical practice. This was identified for 1 of 32 residents reviewed (Resident #23) and it was determined that the facility B.) failed to follow the physician orders with regard to medications (meds) with parameters for 1 of 34 residents (Residents #51) reviewed. This deficient practice was identified by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A.) On 12/16/2024 at 11:37 AM, surveyor # 1 observed Resident #23 in the bed on a pressure relieving mattress. Resident #23 was a resident in the facility and had diagnosis that included dementia and arthritis. A quarterly Minimum Data Set (qMDS) an assessment tool used to facilitate management of care, with an Assessment Reference Date (ARD) of 10/29/2024, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #23 scored 00 out of 15, which indicated that the resident's cognition was severely impaired. On 12/19/2024 at 12:04 PM, the surveyor reviewed the December 2024 Treatment Administration Record (TAR) for Resident #23. When treatments were ordered by the physician, the order was placed on the TAR. When administered by the nurses, the nurse would sign their initials on the TAR indicating that they had completed the treatment. Surveyor # 1 observed the treatment for Medihoney (a topical cream) ordered on 9/19/2024 to be applied to the sacral wound daily. Surveyor # 1 observed blank areas, that is no nurse's initials which would indicate the completion of the treatment on 12/2/2024, 12/13/2024, 12/14/2024, and 12/16/2024 for the day shift. When interviewed on 12/19/2024 at 12:04 PM, the Licensed Practical Nurse stated that when the TAR is signed it means the treatment was completed. He stated there should not be blanks on the TAR. When interviewed on 12/19/2024 at 12:04 PM, the Registered Nurse Manager (RNM) stated there should not be blanks in the TAR. She stated the treatments should be completed then signed out. When interviewed on 12/19/2024 at 12:46 PM, the Director of Nursing stated there should not be blanks on the TAR. She stated if there are blanks, the nurse forgot to sign the TAR, or the nurses didn't complete the treatment. The surveyor reviewed the facility's Administering Medications policy with a revised date of 3/2020 which included the individual administering medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. 48423 B.) On 12/18/24 at 10:58 AM, surveyor # 2 did not see Resident #51 in their room. Resident's roommate informed the surveyor that the resident went out for hemodialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy). The surveyor reviewed Resident #51's hybrid (electronic and paper) medical records that revealed the following: The Admission Record reflected that Resident # 51 was admitted to the facility with diagnoses that included hypertension (high blood pressure), End Stage Renal [kidney] disease, Schizophrenia, anxiety disorder, insomnia and Anemia. A quarterly Minimum Data Set (qMDS) an assessment tool used to facilitate management of care, with an Assessment Reference Date (ARD) of 12/1/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #51 scored 00 out of 15, which indicated that the resident's cognition was severely impaired. A review of the Order Summary Report (OSR) reflected that Resident #51 had an active physician order (PO) dated 12/9/24 for a med: Midodrine HCL (hydrocholoride) Oral Tab 5 mg- Give 1 tablet by mouth before meals for hypotension hold for SBP [systolic BP] greater than 135. The corresponding PO was transcribed into the October 2024 through December 2024 electronic Medication Administration Record (eMAR). Further review of the October - December 2024 eMARs for Resident #51 revealed that nurses signed and reflected a checkmark which means that the med was administered when the med should have been held for a SBP that was greater than 135 according to the PO, for the following dates and times: Date Time SBP 10/31 4 PM 136/88 12/6 11 AM 142/93 12/6 4 PM 142/93 12/7 11 AM 138/76 During an interview with surveyor # 2 on 12/19/24 at 10:38 AM, the Licensed Practical Nurse (LPN #1) stated that the Midodrine was given to increase blood pressure when its low. The LPN further stated that if the SBP was greater than 135 then she would hold the med as per the holding parameters [directions in the PO] otherwise it would raise the BP higher. During an interview with surveyor # 2 on 12/19/24 at 1:34 PM, the LPN #2 stated the check marks on the eMAR means the medication was administered. LPN #2 stated Midodrine would be given when the BP was low. The LPN #2 further stated she would hold the medication if SBP was greater than 135 as the BP was at a decent range. Surveyor # 2 reviewed the December eMAR with LPN #2, LPN #2 confirmed it was her signatures for 2 entries where Midodrine was administered and should have been held. The LPN #2 stated it might be incorrect documentation and I know I did not give it. The LPN #2 checked progress notes for supporting documentation. The LPN #2 was not able to provide any additional information or explanation to the surveyor. During an interview with surveyor # 2 on 12/20/24 at 10:07 AM, the Director of Nursing (DON) stated Midodrine was given for hypotension (low blood pressure), and it would be held for BP >135 as per the PO and if given it would raise the BP more. The surveyor notified the DON of the above-mentioned concerns. A review of the facility policy titled Administering Medications policy revised 3/20 included under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementations-3.) Medications must be administered in accordance with the orders, including any required time frame. NJAC 8:39-11.2(b), 27.1 (a), 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to a resident who was unable to carry out activities of daily living (ADLs). This deficient practice occurred for 1 of 3 residents (Resident #122) reviewed for nail care and was evidenced by the following: On 12/17/24 at 12:38 PM, the surveyor observed Resident #122 sitting on the edge of their bed. The surveyor observed resident's both arms were shaking, and their nails were long, squared (Square shape) with sharp edges. On 12/18/24 at 11:47 AM, the surveyor observed Resident #122 sitting in their bed. Resident #122's nails were long, squared with sharp edges. Resident #122 stated I don't remember when my nails were cut last, and further stated, I am going to ask my family to bring me a nail cutter. On 12/18/24 at 11:54 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated his responsibilities included feeding, bathing, and providing ADL care, such as grooming, shaving the resident, and cleaning their nails during morning care. The CNA further stated if he saw a resident with long nails, he would ask the resident if they want their nails trimmed. The CNA stated it was important to trim nails to avoid bacteria and prevent infections because residents use their hands to eat finger food. The CNA stated he was familiar with Resident #122 and the resident had never refused care. The CNA observed Resident #122's nails in the presence of the surveyor, the CNA acknowledged that the resident's nails were long, and he never provided nail care to Resident #122. The CNA further stated that he should have trimmed resident's nails because resident was not able to cut his/her own nails due to shakiness in their arms. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included type II diabetes mellitus, anxiety disorder, muscle weakness, and lack of coordination. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/29/24, reflected the Resident #122 had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated resident was cognitively intact. Section GG documented that Resident #122 required supervision or touching assistance with personal hygiene. A review of the individualized comprehensive care plan (ICCP) included a focus area for an ADL care deficit related to decreased mobility, muscle wasting and atrophy [decrease in size or wasting away of a body part or tissue]. Interventions included assist with daily hygiene, grooming . as needed. Further review of the ICCP did not include a focused area for refusal of ADLs. On 12/19/24 at 10:20 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated if she saw a resident with long nails, she will ask them if they want their nails trimmed. The LPN stated the nail care was important for infection control and to keep up with good hygiene. The LPN stated Resident #122's behavior was calm and cooperative and did not refuse any care. The LPN stated Resident #122 was confused and was asked on Friday and the resident did not want their nails cut. The LPN further acknowledged that the resident was not able to trim their own nails because he/she was too shaky. On 12/20/24 at 10:07 AM, during an interview with the surveyor, the Director of Nursing (DON) stated if a resident had long nails, it was important to cut their nails short for hygiene. The DON further stated if a resident refuses nail care, then the staff should ask them again at a later time. A review of the facility policy titled Resident Nail Care policy dated 3/23 included: The Purpose of this procedure is to provide guidelines for the provision of care to a resident's nails. Under section Policy Explanation and Compliance Guidelines:1.) Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. A review of the facility policy titled Activities of Daily Living policy revised 3/2022 included under Policy Statement: The facility will ensure that ADLs are provided in accordance with accepted standards of practice . Under section Policy Interpretation:1.) The facility nursing staff will provide the resident who is unable to carry out ADLs on their own necessary services to maintain good nutrition, grooming, and personal and oral hygiene. NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview and record review, it was determined that the facility failed to ensure medication administration times were sequenced to accommodate a resident's hemodialysis (HD) schedule in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents reviewed on hemodialysis (Resident #43), and was evidenced by the following: On 12/18/2024 at 09:17 AM, the surveyor observed Resident #43 in their room. Resident #43 stated that the facility gets him/her to dialysis on time. The surveyor reviewed the medical record for Resident #43. The medical reflected Resident # 43 had a primary diagnosis of but not limited to anemia and end stage renal disease. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/1/2024 which reflected that the resident had moderate cognitive impairment and that the resident received hemodialysis (a procedure that uses special equipment to clean the blood). The care plan reflected an intervention to confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed. A review of the order Summary Report with active orders as of 11/25/24 reflected physician orders for the following: 1. Resident receives dialysis on Tuesday, Thursday, and Saturday, 11am. 2. Clonidine HCl Oral Tablet 0.3 MG Give 1 tablet by mouth three times a day for hypertension. (high blood pressure) 3. Isosorb Dinitrate-hydralazine Oral Tablet 20-37.5 MG Give 2 tablets by mouth three times a day for hypertension. A review of the dialysis communication sheets from 11/26/24 through until 12/19/2024 resident did not receive clonidine or isosorb dinitrate-hydralazine while at dialysis. A review of the electronic Medication Administration Record (eMAR) for November and December 2024, indicated that clonidine and isosorb dinitrate-hydralazine were not given to the resident on 11/26/2024, 11/30/2024, 12/5/2024,12/12/2024, 12/14/2024, 12/17/2024, and 12/19/24 at 1:00 PM because the resident was off the unit in dialysis: On 12/20/2024 at 09:36 AM, the surveyor interviewed the Licensed Practical Nurse who was familiar to Resident # 43. She stated Resident #43 attends dialysis on Tuesdays, Thursdays, and Saturdays he/she leaves the facility around 9:30 AM and returns around 3:30 PM. The LPN and surveyor reviewed the December 2024 MAR together. She stated that Resident #43 is not receiving clonidine and isosorb dinitrate-hydralazine while at dialysis. She stated the resident should be receiving the medication and will call the physician to clarify the orders. On 12/20/2024 at 09:45 AM, the surveyor interviewed the Nurse Manager. She stated Resident #43 should be receiving the medications as ordered. She stated she will speak with the doctor to clarify and change the medication times to coincide with dialysis. The surveyor reviewed the facility provided policy titled Hemodialysis, with a revised date of 06/2024 which reflected that resident medications will be administered as ordered. Medication times may be altered based on dialysis times. NJAC 8:39-11.2(d), 27.1(a)(b)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents A.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, B.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 34 residents (Resident #51, #52, #119, and #122) reviewed for physician visits. This deficient practice was evidenced by the following: 1.) A review of Resident #51's hybrid (electronic and paper) medical records (MR) from May 2024 - December 2024 revealed the following: The Admission Record reflected that the resident was admitted to the facility with diagnoses that included but weren't limited to hypertension (high blood pressure), End Stage Renal [kidney] disease, Schizophrenia, anxiety disorder, insomnia, and Anemia. A review of the quarterly Minimum Data Set (qMDS) an assessment tool dated 12/1/24, revealed the Resident #51 had a Brief Interview Mental Status (BIMS) of 00 out of 15, which indicated that the resident's cognition was severely impaired. A review of the Electronic Medical Record (EMR) revealed the Nurse Practitioner (NP) visit progress notes (PN) dated 7/18/24, 7/25/24, 8/1/24, 8/8/24, 8/15/24, 8/22/24, 8/26/24, 9/13/24, 9/16/24, 9/19/24, 9/27/24 (Note Text - History and Physical [H&P]), 10/4/24, 10/31/24,11/18/24. A further review of the PN did not reveal any PN from the attending physician from May 2024 through December 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP for May 2024 and June 2024 or that the physician and NP were consistently alternating monthly visits. On 12/19/24 at 1:52 PM, during an interview with the surveyor, the Registered Nurse (RN) stated that physicians made rounds everyday and documented in the EMR. For a new admission, the staff would call the doctor. The RN further stated the expectation would be that the doctor would be in to see the resident for an H&P within 24-hours as per facility policy and write physician visit PN once a month. The RN reviewed Resident #51's EMR in the presence of the surveyor and confirmed that there were no PN from the attending physician from May-Dec. The RN further stated Resident #51's attending physician did not come to the facility anymore. 2.) On 12/17/24 at 11:43 AM, the surveyor observed Resident #52 lying in their bed. The resident was watching television. A review of Resident #52's hybrid MR from May 2024 - December 2024 revealed the following: The AR reflected that the resident was admitted to the facility with diagnoses that included hypertension (high blood pressure), anxiety disorder, weakness, and difficulty in walking. A review of the qMDS dated [DATE], revealed the Resident #52 had a BIMS of 7 out of 15, which indicated that the resident's cognition was severely impaired. A review of the EMR revealed an attending physician PN dated 5/23/24, 5/29/24 and 11/26/24. Further review of the EMR revealed the Physician Assistant (PA)/ NP PN also documented visits for the resident on 5/13/24, 5/31/24, 7/8/24, 8/23/24. A review of the EMR did not reveal a PN from the attending physician or the attending NP for June 2024, September 2024, and October 2024 or that the physician and NP were consistently alternating monthly visits. 3.) On 12/17/24 at 11:21 AM, the surveyor observed a non-verbal Resident #119 sitting in their bed. Resident had a tracheostomy [a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck.] and was able to use communication board to communicate with the surveyor. A review of Resident #119's hybrid MR from May 2024 - December 2024 revealed the following: The AR reflected that the resident was admitted to the facility with diagnoses that included hypertension (high blood pressure), anxiety disorder, muscle weakness, malignant neoplasm (cancerous tumor) of tongue and mouth. A review of the qMDS dated [DATE], revealed the Resident #119 had a BIMS of 15 out of 15, which indicated that the resident was cognitively intact. A review of the EMR revealed the NP visit PN dated 5/31/24, 8/23/24, and 12/11/24. A further review of the PN did not reveal any PN from the attending physician from May 2024 through December 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP for June 2024, July 2024, September 2024, October 2024, and November 2024 or that the physician and NP were consistently alternating monthly visits. 4.) On 12/17/24 at 12:38 PM, the surveyor observed the Resident #122 sitting on the edge of their bed. Resident was calm and cooperative. A review of Resident #122's hybrid MR from June 2024 - December 2024 revealed the following: A review of the AR reflected the resident was admitted to the facility with diagnoses which included type II diabetes mellitus, anxiety disorder, muscle weakness, and lack of coordination. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/29/24, reflected the Resident #122 had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated resident was cognitively intact. A review of the EMR revealed the NP visit PN dated 7/18/24, 7/25/24, 8/1/24, 8/8/24, 8/15/24, 8/22/24, 8/29/24, 9/6/24, 10/7/24, 10/26/24, 11/25/24. A further review of the PN did not reveal any PN from the attending physician from June 2024 through December 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP for June 2024 or that the physician and NP were consistently alternating monthly visits. On 12/20/24 at 10:26 AM, during an interview with the surveyor, the Director of Nursing (DON) stated attending physician would see their residents and write PN within 24-48 hours of admission other than if the resident was admitted on Friday, then attending physician would see the resident by Monday. The DON further stated that the attending physician would make rounds every month for first 90 days after that every 60 days and as needed. The surveyor notified the DON of the above-mentioned concerns. At 1:57 PM, the LNHA provided an additional handwritten PN for Resident # 51 titled as Doctor's Progress Note dated 7/15/24 indicated as ID (infectious disease)/IM (internal medicine). A review of the facility policy titled Physician Services dated 3/20 included under Policy Interpretation and Implementation section: Physician orders and progress notes shall be maintained in accordance with current OBRA regulations. All attending physician or physician groups will document physician orders, progress notes, and physician history or physicals in the facility health record Physician visits, frequency of visits, are provided in accordance with current OBRA regulations and facility policy. NJAC 8:39-23.2 (b), 23.2 (d)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically, by staff not wearing a personal-protective gown while entering a room under Contact Precautions. The deficient practice observed for 1 of 2 residents (Resident # 320) reviewed for Transmission-Based Precautions under the Infection Control task. The deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html A review of Resident # 320 Admission Record located in the Electronic Medical Record (EMR) revealed a diagnoses of but not limited to, Methicillin Resistant Staphylococcus Aureus Infection as of the cause of diseases classified elsewhere (multi-drug resistant organism). On 12/16/2024 at 12:56 PM, the surveyor observed Registered Nurse (RN) # 1 in Resident # 320's room. Resident # 320 was in his/her bed. RN # 1 was wearing gloves but no gown. Outside of the room, the surveyor observed a sign that revealed, Contact Precautions Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Outside of the doorway, the surveyor observed a plastic bin containing masks, gloves, and gowns. At that time, during an interview with the surveyor, RN # 1 said she wasn't doing direct care except shutting off a pump alarm. On 12/17/2024 at 12:11 PM during an interview with the surveyor, the Infection Preventionist confirmed Resident # 320 was on Contact Precautions. When the surveyor asked if a gown is required to be worn upon entering the room, the Infection Preventionist replied that may be the expectation but we go by the policy. On 12/23/2024 at 10:32 during an interview with the surveyor, the Director of Nursing (DON) said they gave the nurse education on entering rooms under Contact Precaution and that she will have to wear a mask, gown, and gloves. The DON concluded that they are going to give all staff re-education. A review of the facility policy titled, Transmission Based Precautions revised 4/2024 revealed, In addition to Standard Precautions, implement contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident - care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. Secondly, the policy revealed, p. Wear a gown whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment. N.J.A.C. S 8:39-19.4 (a)

FACILITY F812 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/14/2023 at 9:20 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the walk-in refrigerator a previously opened box contained shelled eggs. The box was open, and the eggs were exposed. The box was sitting on the floor of the walk-in refrigerator. 2.- In addition, a bulk bottle of Ranch dressing and a bottle of bulk BBQ sauce were previously opened. The bottles did not have an open or use by date. A pan contained Jello and was covered with clear plastic wrap. The pan of Jello was undated, and the plastic wrap did not completely cover the Jello, exposing it to the air. 3. On a middle shelf of the walk-in refrigerator a white plastic bin contained what appeared to be oranges. The oranges were in the process or were turned brown and several of the oranges had a fuzzy white mold-like substance on the exterior of the orange. 4. In the walk-in freezer, a previously opened box of Tyson Chicken filet had no dates. The box was opened and the bag inside the box that contained the chicken filets was opened and the chicken filets were exposed. 5. In the reach-in refrigerator, a previously opened bottle of lemon juice had no open or use by date. On the same shelf a clear plastic take-out style container appeared to contain a salad. The container had no dates. 6. In the food prep area a cleaned and sanitized meat slicer and stand-up mixer were not in use. The meat slicer and stand-up mixer were not covered and were exposed. 7. In the dry storage area a bulk container contained a previously opened bulk bag of rice. The bulk container did not have the clear plastic cover in place and the bag of rice was opened and exposed to the air. In addition, the bag of was observed to contain a clear plastic 4-ounce portion control cup and a plastic dessert dish in the rice used to access the rice for food production of resident meals. On 11/16/2023 from 11:24 AM to 11:42 AM the surveyor accompanied by the Licensed Practical Nurse (LPN # 5) observed the following on the G/H unit pantry: 1. In the pantry refrigerator (2) containers of Nepro (a liquid supplement designed for patients with renal disease) that were brought to the facility by a resident family had a manufacturer's use by date 10CT2022. A plastic take out style container with a clear plastic lid contained an unidentified food. The container had no name and no dates. In addition, a plastic take out container of tortellini in [NAME] sauce had no dates. An unopened container of Low Fat Cottage Cheese had a BEST IF USED BY date of 09/22/23. LPN #5 agreed that the unit nursing staff is responsible for monitoring the dates of food products in the pantry and that all food products should have a date and name on them, per facility policy. On 11/16/2023 from 11:47 to 11:56 AM the surveyor, accompanied by the Registered Nurse/Unit Manager (RN/UM#3) observed the following on the C/D Unit Pantry: 1. Inside the freezer there was an accumulation of ice build-up and unidentified yellow/orange food stains on the ice build-up. RN/UM #3: on interview agreed that the freezer required defrosting and sanitizing, and that maintenance would be responsible for that task. On 11/21/202 from 10:55 to 11:45 AM the surveyors, accompanied by FSD, observed the following in the kitchen: 1. In the dry storage room on the can good mobile storage rack the surveyor identified that a can of Cheddar Cheese Sauce and a can of Sauerkraut had significant dents on the seam. On interview the FSD stated, I missed those. 2. In the middle of the dry storage room a wheeled (7) compartment dishware storage cart, used to store cleaned and sanitized dishware used for resident meals, The cart contained (2) racks of dessert plates and (1) rack of monkey dishes (a small bowel with a flat bottom). The plates and dishes were stored uncovered, not in the inverted position, and were exposed to contamination. 3. In the walk-in refrigerator on a top rack, a half pan contained what appeared to be grape jelly. The 1/2 pan was covered with plastic wrap. The pan had no dates. 4. In the walk-in freezer on an upper rack two (2) clear plastic containers with lids contained pesto, according to the FSD. The containers had no dates. 5. In the reach-in refrigerator on an upper shelf (2) 4-ounce portion control cups with lids were labeled applesauce and had a use by date of 11/15. On a shelf below a previously opened package of orange cheese slices were wrapped in plastic wrap. The cheese had no dates. 6. Prior to taking food temperatures before the lunch meal tray line the facility cook performed hand hygiene. Lunch Tray Line: [NAME]/Cook: Hand hygiene performed. The surveyor watched the cook turn on the faucet, wet their hands, apply soap, and perform hand washing for approximately 25 seconds. The cook then rinsed their hands under running water. After rinsing his hands, the cook turned off the faucet with a bare hand after completing hand washing. The cook then secured a hand towel from the dispenser and proceeded to dry their hands. The cook then threw the hand towel into the waste receptacle. On interview the FSD agreed that the cook should not turn off the faucet with their bare hand after completing hand washing. 7. During preparation for the lunch meal tray line a kitchen staff was observed in the tray line area prior to the serving of the lunch meal. The staff had a lengthy beard. The staff had no beard guard, and the beard was exposed. The surveyor reviewed the facility policy titled Dating and Labeling Policy and Procedure, undated. The policy revealed the following under the PROCESS heading: 1. All food items must be labeled with either a manufacturer label or handwritten label. 2. All food products, upon receiving, must be dated with receiving date. 3. All prepared (individually wrapped) items will be dated with compliance of the 3-day rule and labeled with a use on or by date. Examples: Applesauce, Pudding, Sandwiches, Salads. **Note the day the item is prepped counts as the 1st day of usage.** 5. All bulk pre-packaged prepared items, i.e., mayonnaise, salad dressing, pickles, barbeque sauce, uncooked pastas, opened cake/brownie mixes, beef, or chicken base. bread crumb, bulk cheeses, sour creams, etc. will be marked with an opened date and discarded date of 30 days. Example: Open 5/10/22, Use by 6/10/22. 9. Any item which is found not properly dated and labeled shall be discarded. 10. All open boxes in the freezer of items that have not been cooked yet get an open date and a use by or use on date of 30 days. The surveyor reviewed the facility policy titled Hair Nets and Beard Guards, undated. The following was revealed under the heading Beard Restraints: All facial hair that is longer than a 1/4 inch must be restrained through the use of a beard net. The surveyor reviewed the facility policy titled Dented Cans, undated. The following was revealed under the heading Procedure: Place all dented cans in a clearly marked, specifically designated area away from other product so that the food service director can safely discard product and get a refund for said cans. The surveyor reviewed the facility policy titled Foods Brought by Family/Visitors, undated. The following was revealed under the heading Policy Interpretation and Implementation: 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. 7. The nursing staff is responsible for discarding perishable foods on or before the Use by date. 8. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.) The surveyor reviewed the facility provided competency titled Hand Washing. The following was revealed under the Procedure section: 1. Turn on faucet and run water until a desired temperature is achieved. Hot water is unnecessarily rough on the hands. 2. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) outside the stream of water. 3. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. 4. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. 5. Discard towels into trash. 6. When possible, utilize lotions throughout the day to protect the integrity of the skin. N.J.A.C. 18:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment. This was identified for 3 of 4 units and was evidenced by the following: During the initial tour of B hall on 11/14/2023 at 10:58 AM the surveyor observed the following; -privacy curtain between the beds in room B 09 had dark stains on it. -The floor at foot of A bed had a dark orange/brown stain. -The floor was observed to have brown pieces of debris scattered on it. -There was no foot board on A bed. On 11/15/23 at 9:23 AM, the surveyor observed the radiator cover between rooms [ROOM NUMBERS] on B hall in disrepair, with chipped paint. Multiple doorways into resident rooms on B hall observed with chipped paint. During a tour of A hall on 11/17/2023 at 9:19 AM, the surveyor observed the following: -A Hall door jams where they meet floor were observed to have dark areas for rooms 3, 4, 5, 6, 7, 8, 9, 10 11, 12, and 14. -The privacy curtain in room [ROOM NUMBER] was observed to have dark stains. On 11/17/2023 at 9:24 AM, the surveyor observed A hall soiled linen room threshold to be stained and appears dirty. On 11/17/2023 at 9:28 AM, the surveyor observed on B hall, the threshold on the shower room and tub room [ROOM NUMBER] to be black with underlying white color. On 11/17/2023 at 9:35 AM, the surveyor observed the radiator B hall with dust, debris in top cover between rooms [ROOM NUMBERS]. On 11/17/2023 at 9:45 AM, the surveyor observed that on B unit all rooms had debris and dark stains where the door casing meets the floor. The lower walls were observed with dark marks, and stains. On 11/17/2023 at 09:48 AM in the hallway between A/B and C/D units by Rainbow room, the floor was observed with dark stains where the floor meets the baseboards with dark debris and stains on the baseboard itself. The radiator cover behind the smoke door at the end of B hall was observed with dust in top cover. On 11/17/2023 at 9:56 AM, the surveyor observed dark marks on the floor by the doctor's office door, under the chart rack on G/H hall. On 11/20/2023 at 9:24 AM, the surveyor observed the baseboards where they meet the floor on G hall to have dark stains throughout the length of the hallway along with dust. On 11/20/2023 at 9:26 AM, the surveyor observed a large trash can at the nurse's station for G/H hall that had dark spots on the lower end facing the hallway. On 11/20/2023 at 9:27 AM, the surveyor observed that on H hall the baseboards where they meet the floor have dirt and dark marks throughout the length of the hall. The surveyor observed that all the corners of door jams where they meet the floor were observed with dark marks on G and H hall. During an interview with the surveyor on 11/17/2023 at 1:20 PM, the Director of Environmental Services (DEVS) said the process for cleaning rooms is a daily schedule and most housekeepers work 7-3. We work around trays being delivered. We clean all surfaces, fixtures, includes counter, windowsill, soap dispenser, toilet, sink, floor. We do a dry sweep the we use micro fiber wiping pads. We use 2 to a room [ROOM NUMBER] for the bathroom, 1 for living space. After used we put pads in dirty linen bag as they are washable. Also, empty trash and rebag. When asked how often resident rooms are cleaned, the DEVS replied they are cleaned daily. The surveyor questioned if there are any type of deep cleaning done in resident rooms and the DEVS said a schedule is posted and we deep clean the room that coincides with the date of the month (example room [ROOM NUMBER] on all units done on the 12th day of the month). This includes all high dusting, light fixtures, over the bed table and legs, walls are cleaned, corners behind doors windows are done with windowsills. The DEVS went on to say the privacy curtains are washed weekly from all the rooms. All rooms are done monthly. The housekeepers are responsible for the deep cleaning. The porters are responsible for the curtains. Beds, railing and mattresses are also cleaned. The DEVS said he was responsible to make sure resident rooms are deep cleaned. The DEVS went on to say that throughout the day, I am constantly on the floor, and I always do spot inspections and check carts, rooms etc. The surveyor asked what the process is for cleaning the hallways and floors in the hallways. The DEVS said My porters are responsible for cleaning hallways. They dry sweep 1 uses traditional mop with water and auto scrubber that mops and scraps the floor. They are done daily. The DEVS went on to say At the same time baseboards and corners are done. The porters are responsible for walls, handrails, fixtures, and radiators. Porter is responsible for top grill of the radiator to clean. We spray with solution and wipe them down and brush for dust that gets caught in between. During an interview with the surveyor on 11/20/2023 at 11:17 AM, the Director of Maintenance (DOM) was asked what the process is for identifying areas of the facility that need repair, paint or replacement. The DOM said usually we take a walk around and check rooms to see if anything needs to be painted or repaired. I jot it down. We have an electronic system and if the aides find if anything needs to be fixed they put it in the system. The DOM went on to say I have 1 guy that does the painting, and the other guy will assist if needed. Most of time I have 3 guys beside myself, and I may take care of it or one of the other guys would take care of it. The DOM confirmed Yes, I would assign them. The surveyor asked if there are any type of environmental rounds performed and if so who is included in this. The DOM replied, I do this once or twice a month, resident rooms, hallways, office, activity rooms, kitchen area dining rooms therapy. The DOM confirmed Yes, it is just me. A review of a facility policy titled Routine Cleaning and Disinfection with a date reviewed/revised 02/2023 revealed under the Policy section It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Under the Policy Explanation and Compliance Guidelines section 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at time of discharge. 13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. 14. Privacy curtains in resident rooms will be changed when visibly dirty by laundering or cleaning with an EPA (Environmental Protection Agency) registered disinfectant per the curtain and disinfectant manufacturer's instructions. NJAC 31.4(a)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests by failing to remove insect traps filled with carcasses from a resident's room and failing to remove dead insect carcasses from a resident dining area. The deficient practice was observed for 1 of 8 residents (resident # 71) and 1 of 2 Dining Areas under the Environmental Task. The deficient practiced was evidenced by the following: On 11/14/2023 at 10:37 AM during the initial tour, the surveyor met Resident # 71 in his/her room. At that time, the resident said he/she that insects were observed in the room on multiple occasions. At that time, the surveyor observed two insect traps underneath the baseboard heater. The traps mechanism for action was a sticky substance that prevents the insects from moving out of the trap. The traps were filled with insect carcasses. The majority of the insects in the trap appeared to be but not limited to cockroaches. On 11/15/2023 at 8:15 AM, the surveyor observed what appeared to be a live cockroach climbing the wall in the G/H Dining/Lounge room where the surveyors were stationed for the survey. On 11/15/2023 at 12:48 PM, the surveyor again observed the insect traps in Resident # 71's room in the same location as the day before. The traps contained numerous insect carcasses. On 11/16/23 09:40 AM, during an interview with the surveyor, Registered Nures/Unit Manager (RN/UM #1) said if we see any bugs or pests, we notify maintenance and the pest company comes. She further said that when the pest company does spray, all residents are taken off the unit and they spray. She concluded by saying we stay off the unit for two to three hours that it is more frequent than every two to three months. On 11/17/2023 at 12:31 PM while in the dining room referred to as the Rainbow Room, the surveyor observed numerous carcasses of flying insects on top of the baseboard heater. The insects were observed at the same time that residents were eating lunch in the room. On 11/20/2023 at 11:19 AM during an interview with the surveyor, the Maintenance Director said the facility is treated for pests once a week. He explained that the facility uses a communication log book where staff can write where they observed insect activity. The Maintenance Director further explained that either the pest control company, housekeeping, or himself remove the insect traps from resident rooms. On 11/21/2023 at 09:05 AM during an interview with the surveyor, Resident # 71 stated that, They need to remove these traps. At that time, the surveyor again observed the insect traps in the room under the baseboard heater. On the same date at 01:17 PM during an interview with the surveyor, the Licensed Nursing Home Administrator stated, Once they notice, the Housekeeper should be checking that [insect traps] and taking that away. She further revealed that the Housekeeper for each unit is responsible for removal of insect traps. The surveyor reviewed the facility-provided Pest Control invoices. The invoice dated for 10/17/2023 revealed that the H Unit was treated for cockroaches. The invoice further revealed that insect activity was mainly around the heaters. A review of the facility policy titled, Pest Control with an effective date of 6/2019 revealed under Policy Interpretation and Implementation that, 5. Maintenance services assist, when appropriate and necessary, in providing pest control services. N.J.A.C. S 8:39-31.5

Based on observation, interview, and record review, it was determined that the facility failed to implement a comprehensive, person-centered care plan to prevent fall and fall related injury for 1 of 34 residents reviewed (Resident #52). This deficient practice was evidenced by: On 11/14/2023 at 10:50 AM during initial tour, the surveyor observed Resident #52 resting in bed. There was no floor mat on the floor. On 11/17/2023 at 08:10 AM, the surveyor observed Resident #52 resting in bed and watching TV. The floor mat was not on the floor. During that time, the surveyor observed Resident #52's room and did not see the floor mat. The surveyor also observed a bed alarm pad placed underneath Resident #52, with gray cord extending on the floor and not connected to the powering device (a box with batteries which makes the alarm work). On 11/20/2023 at 08:38 AM, the surveyor observed Resident #52 sleeping in bed. The floor mat was not on the floor by Resident #52's bed. A review of Admission Record found in the Electronic Medical Record (EMR) indicated that Resident #52's diagnosis included, but were not limited to, muscle weakness, muscle wasting and atrophy (thinning of muscles), abnormal posture, unsteadiness on feet, spinal stenosis (spinal narrowing), osteoarthritis, history of bone fractures, chronic pain, and dementia. A review of a quarterly Minimum Data Set (MDS; an assessment tool) dated 07/08/2023 revealed that Resident #52's Brief Interview for Mental Status (BIMS; a tool use to screen cognitive condition) was 03 (severe cognitive impairment). A review of Resident #52's Care Plan (CP) located in the EMR revealed CP for falls dated 02/01/2020 with Focus: Actual fall r/t [related to] multiple fx [fractures], osteoporosis, lack of coordination. Furthermore, the CP indicated interventions for bed alarm initiated on 06/14/2023 and floor mat to side of bed initiated on 12/29/2021 to prevent injury. A review of Progress Notes found in the EMR and facility provided Incident Report revealed that Resident #52 had unwitnessed fall without injury on 06/14/2023. A review of Fall Risk Assessment 1.0 Revised found in the EMR and dated 12/26/2022 revealed that the resident was at high risk for falls. On 11/17/2023 at 12:12 PM during interview with the surveyor, Certified Nurse Assistant (CNA#1) replied, I usually help [resident's name] get washed and dressed. [Resident's name] needs lots of support with transfers when asked about Resident #52' care needs. On 11/17/2023 at 12:17 PM during interview with the surveyor, Unit Manager/Licensed Practical Nurse (UM/LPN #1) stated, Yes! [Resident's name] had one fall in June. We put bed alarm on her/his bed to prevent her/him from getting out and falling when asked about Resident #52's risk for falls or history of falls. At that time and in the presence of UM/LPN #1, the surveyor showed the bed alarm pad which was not connected to the powering device. The UM/LPN #1 lifted the mattress, checked around the room, but could not locate the powering device. At that time, UM/LPN #1 confirmed that the powering device was not present, and the cord extending from the bed alarm pad should have been connected to the powering device in order to work. The UM/LPN #1 stated, Yes, absolutely! The alarm should have the box [powering device]. It won't work without it. On 11/20/2023 at 08:35 AM during interview with the surveyor, UM/LPN #1 replied, Yes when asked if documented care plan interventions should be followed in practice. During the same interview, UM/LPN #1 also said, Yes when asked by the surveyor if Resident #52's interventions outlined in the care plan (floor mat and bed alarm) should be implemented when the resident is in bed. On 11/20/2023 at 01:05 PM during interview with the surveyor, the Director of Nursing (DON) stated, If we put care plan, we should be putting interventions as well, and we follow it. We put it in TAR [treatment administration record] and POC [point of care; documentation system] if it is needed for the aides when asked about expectations for care planning. During the same interview, the DON said, Yes when asked if care planned intervention such as bed alarm and floor mat should be followed in practice. Furthermore, the DON stated, Bed alarm, because when they [residents] try to get out of bed, we respond to the alarm. Floor matt is needed to prevent injury from fall when asked by the surveyor why it was important to have a floor mat at the bedside and a functioning bed alarm. The DON also stated, If it's defective, it is not going to work. We aren't going to hear it when asked by the surveyor why it was important to ensure that bed alarm is not defective or malfunctioning. A review of policy titled Fall Prevention/Management and revised on 2/2021 revealed under section Approaches to Managing Falls and Fall Risk that Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. N.J.A.C. 8:39-11.2(f); 27-1(a)

Complaint # NJ163585 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide the needed care and services in accordance to professional standards of practice that met the resident's physical needs by not obtaining laboratory diagnostics, specifically a blood test as ordered by the physician for the next day. The deficient practice was discovered for 1 of 3 residents (Resident # 355) investigated for Change of Condition. The deficient practice was evident by the following: A review of Resident # 355's Electronic Medical Record (EMR) revealed that he/she had diagnoses of but not limited to a fracture of unspecified part of right clavicle, subsequent encounter for fracture with routine healing, paroxysmal atrial fibrillation (irregular heart rhythm), and chronic obstructive pulmonary disease (lung disease). A review of Resident # 355's Physician Orders revealed an order to Send to ER [emergency room ] re: critical lab result 3/24/2023 and that the resident is a Full Code (provide life sustaining measures). A review of Resident # 355's EMR revealed a Routine Nursing Progress Note dated 3/22/2023 that revealed, PACE MD called to order CBC [complete blood count test] lab for next morning then follow up on the result. The EMR did not reveal any orders for a CBC blood test for 3/23/2023 and showed no laboratory results under Results in the EMR at all for 3/23/2023 as the previous progress note revealed the physician ordered a CBC for that morning. A follow-up review of Resident # 355's EMR revealed that the next CBC blood test was obtained on 3/24/2023 at 06:30 AM. The result revealed that Resident # 355's white blood cell count was abnormally high at 30.1. The reference range for white blood cell counts according to the laboratory results was 3.5 through 11.0. Once the physician was notified of the abnormally high white blood cell count, and order was given to send the resident to the emergency room . The previous CBC blood test obtained from Resident # 355 on 3/22/2023 resulted in a white blood cell count of 8.2. On 11/17/2023 at 12:08 PM during an interview with the surveyor, the Unit Manager/Registered Nurse (UM/RN) # 2 replied, Yes. when the surveyor asked if a physician orders labs for the following morning, do they get added as an order. On the same date at 12:45 PM during an interview with the surveyor, the UM/RN # 3 replied, Yes, definitely. when asked by the surveyor if a resident has a change of condition and the physician orders labs for the next morning, does an order for that need to be added to the EMR. On 11/21/2023 at 1:17 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) replied, That would be reasonable. when the surveyor asked is it reasonable to believe that if the labs were completed on March 23rd, the elevated white blood cells may have been discovered earlier. On 11/22/2023 at 10:21 AM during an interview with the surveyor, the Director of Nursing (DON) replied, She [RN/LPN # 3] forgot to put the physician's order for March 23rd to the [EMR]. A review of the facility-provided policies titled, Physician Orders and Venipuncture for Lab Draws did not contain pertinent information about laboratory orders. N.J.A.C. S 8:39-11.2 (b)

C#: NJ 1, NJ 5 Based on observations, interviews, medical record review, and review of other pertinent facility documents on [DATE] & [DATE], it was determined that the facility failed to (a) prepare a mechanical soft diet at the correct texture and consistency, (b) obtain a Physician's Order and notify the Physician of a change in diet and (c) follow the residents plan of care for a resident who had a history of Dysphagia. The facility also failed to follow its policies titled Care Plans, Therapeutic and Mechanically Altered Diets, the 2018 DHCC (Dietetics in Health Care Communities) Manual of NJ (New Jersey), Textured Modified Diets, Resident Nutrition Services, Change in Resident Condition and Physician Orders. This deficient practice was identified for 1 of 4 residents (Resident #2), who was served regular steak fries by the Temporary Nursing Assistant (TNA) on [DATE], which resulted in Resident #2 having a choking episode that resulted in emergency hospitalization , and was evidenced by the following: The review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted on [DATE] with diagnoses which included but were not limited to Dysphasia (difficulty in swallowing), Oropharyngeal Phase, Other Unspecified Disorders of the Brain, Unspecified Heart Failure, Unspecified Cerebral Infarction, Cerebral Ischemia and Acute Respiratory Failure with [CONDITION(S)]. Review of a Minimum Data Set (MDS), an assessment tool dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], indicating that the resident was moderately cognitively impaired. The MDS also showed that the resident had to be fed by staff during meals. A review of Resident #2's Care Plan (CP) initiated on [DATE] showed Under Focus: (Resident #2) is at risk for malnutrition as evidenced by therapeutic/mechanically altered diet, decreased intake, skin breakdown, BMI > (more than) 30, chronic diseases: DM (Diabetes Mellitus, [CONDITION(S)] (Cerebral Vascular Accident). Under Goal: Resident #2 will maintain nutritional status as evidenced by no s/sx (signs/symptoms) of malnutrition . Under Interventions included: Provide and serve diet as ordered-CCD/NAS (carbohydrate-controlled diet/ no added salt)puree, honey-thick liquids . A review of an Order Summary Report (OSR) dated [DATE]-[DATE] for Resident #2 revealed a Physician's order (PO's) for a CCD/NAS diet Pureed texture, Honey consistency with an order and start date of [DATE]. A review of the Speech Therapy Treatment Encounter Note(s) for Resident #2 written by the Speech Therapist at 11:49 a.m., with a Date of Service of [DATE], revealed it is recommended for the resident to consume mechanical soft textures and NTL (nectar thick liquids) at this time with 1:1 for small bites/sips, cyclic ingestion, and double swallow as needed. This therapist educated the patient (Resident #2) and licensed nursing staff on diet level upgrades and safe swallowing strategies. Understanding noted. However, there was no documented evidence that the Physician also was provided this information about the diet change for Resident #2. A review of the Diet Requisition Form (DRF) undated revealed a diet change request for Resident #2 to CCD, Mech (Mechanical) Soft, Nectar Thickened Liquids, and D/C (discontinue) Puree texture and Honey Thickened Liquids. The DRF also noted Supplements/Special Requests/Comments: Mechanical Soft/Nectar thick liquids, 1:1 for all meals and PO (by mouth) intake, small bites/sips, and cyclic ingestion. However, further review of the OSR did not reveal a PO's for the change in diet upgrade to Mechanical Soft/Nectar thick liquids on [DATE] for Resident #2. A review of the Resident #2's Progress Notes (PNs) from [DATE] through [DATE] revealed the following: On [DATE] at 9:48 p.m. and [DATE] at 2:11 p.m., reflected that the honey-thick liquid diet for Resident #2 was continued as ordered by the Physician. However, the facility staff could not verify if Resident #2 received a puree or mechanical soft diet from [DATE] through [DATE]. On [DATE] at 6:59 p.m., the PN written by the Registered Nurse revealed the CNA (Certified Nursing Assistant) alerted this Nurse that the patient (resident) was choking as he/she was being fed dinner. According to the PN, Resident #2 was in distress, and a code was immediately called in the building, and staff came to assist. The PN also showed that 911 was called ., the [MEDICATION(S)] was started, the resident's mouth was swept clear immediately upon entering the room . and suctioning was initiated. A team of staff-initiated CPR while paramedics were on their way. The AED (automatic external defibrillator) was applied and used .The Police arrived shortly after. The patient was taken to the hospital via stretcher by the paramedics. A review of Meal Tracker Notes for Resident #2 received on [DATE] at 1:03 p.m. from the current Food Service Director (FSD) revealed on [DATE] (a) diet slip was sent to change the resident's diet to be prepared as a mechanical soft, and Nectar thick liquids. A review of the Facility's Spring/Summer 2022 Diet Guide Sheet given to the surveyor by the FSD revealed Under Monday (Day 2) Dinner for Steak Fries, Under Mech (Mechanical) Soft diet 4 Oz (ounces) of Mashed Potatoes was to be prepared for the mechanical soft diet, and for the Puree diet 4 Oz of mashed potatoes should be prepared. During an interview on [DATE] at 2:50 p.m., the Speech Therapist stated she was familiar with Resident #2. She said the resident was awake and alert, but his/her voice was not audible. When the surveyor asked her to describe the difference between a Pureed Diet and a Mechanical Soft Diet, she stated that a pureed texture appears as baby food with a smooth consistency with no chunks. A mechanical soft (diet) is softer foods, ground meat texture, and no dry foods. The Speech Therapist explained Mechanical Soft Diet was moist, with nothing crunchy or hard or difficult to chew. During an interview on [DATE] at 2:56 p.m., the TNA who fed Resident #2 on [DATE] stated I opened up the (meal) tray. Resident #2 had regular French (Steak) fries, water, juice, and a hot dog roll on his/her tray. Resident #2 couldn't speak, but he/she shook his/her head, indicating yes when I asked if he/she wanted the fries. The TNA stated that before I fed (Resident #2), I raised the head of the bed; I don't remember to what degree. The resident was already sitting up on Oxygen. She stated she learned to feed residents during CNA training. The TNA proceeded to say: that the French (Steak) fries were sized slightly smaller than my index finger, so I cut them up into three to four pieces. I gave the resident the first piece of French (Steak) fry and a sip of water, and then I gave him/her a second piece. Then, Resident #2 sounded like he/she was choking, so I called for the Nurse. After I gave the resident the second piece of the fry, he/she seemed to want to throw up, so I called the Nurse from the door; I was with the resident the whole time. When the surveyor asked her what food was on the meal slip, she stated everything on her meal slip was on the tray. During an interview on [DATE] at 9:00 a.m., the Unit Manager/Registered Nurse (UM/RN) stated I was the ,d+[DATE] p.m. Supervisor on [DATE]. The UM/RN said the diet change comes from the Speech Therapist for upgrading or downgrading the diet; the Speech Therapist and the Dietician work together, tell the Nurse, and then the new dietary slip is faxed to the kitchen. The UM further explained that the Nurse assigned to the resident that day gets the Physician's Order for the diet change, notifies the family, and all of the documentation should be in the progress notes (PNs) when it happens. The Unit Manager (UM) further stated that Resident #2's care plan should have been updated with the diet change. When the surveyor asked him, who does the update, he replied, I do. The Nurse assigned to the resident tells me, and I update the care plan; once it is brought to my knowledge, I have to do it. During an interview on [DATE] at 9:44 a.m., the Director of Nursing (DON) stated the process of a diet change is the Speech Therapist evaluates the resident, informs the Nurse before and after her evaluation of the diet change, gives or faxes DRF to the kitchen director, and the kitchen director updates it; then the Nurse or the manager notifies the Physician and the family; the Nurse should document in the PNs. The DON also stated a diet change is a change in condition for a resident, so the Nurse or the UM should notify the Physician. When the surveyor asked the DON what is considered a mechanical soft diet, the DON replied mechanical soft diet is soft and chopped. The DON explained the food is not cut unless there is an order for chopped. Mechanical soft is a soft texture. In the same interview, when the surveyor showed the DON the unsigned DRF written by the Speech Therapist for Resident #2, she stated the Nurse assigned to the resident or the Unit Manager would sign the DRF. During a second interview at 2:35 p.m., the DON said Resident #2's care plan was not updated. I told the Unit Manager he didn't do it. The Care plan should have been updated within 24 hours. She continued to say all residents have a care plan in reference to the diet. The purpose of the CP is to know how we take care of patients. During an interview on [DATE] at 10:25 a.m., the FSD stated that I get a diet slip for any diet change. A diet requisition form (DRF) is faxed to me from whoever changed the diet, the Nurse, Dietician, or speech therapist. They call to make sure I got the change, then I go into the meal tracker system and reprint the tickets immediately. When the surveyor asked him if steak fries would be part of a mechanical soft diet, the FSD replied that a regular steak fry should not be served on a mechanically soft diet. We automatically would serve mashed potatoes or an applicable starch. During a telephone interview on [DATE] at 3:39 p.m., when the surveyor asked the Physician if he was notified of Resident #2's diet change on [DATE], he replied, Mostly, if I get notified, there'd be an order. The Registered Nurse & the Dietician assigned to Resident #2 on [DATE] were unavailable for interviews at the time of the survey. During an interview on [DATE] at 12:50 p.m. with the Cook, she stated a mechanical soft diet is foods that are soft and go through a food processor. She continued to say something (the food) that was chopped by hand was not mechanical soft. She stated the resident would get mashed potatoes, not whole steak fries. A review of a facility policy titled Care Plans with a revised date of ,d+[DATE] Under Policy: Resident's individual care, needs, problems and goals will be addressed, in measurable form and in a timely manner by an interdisciplinary team in compliance with federal and state regulations. Under Guidelines: .4. Care plans are updated as needed based on any occurrences and changes that are relevant to the resident's care. Care plans will include measurable objectives with interventions based on the resident's care needs. 5. Care plans are reviewed and updated quarterly and annually and as needed for each resident by the interdisciplinary team. A review of an updated facility's policy titled Therapeutic and Mechanically Altered Diets indicated the following: Under Policy,: In order to assure residents are provided with foods that are appropriate in nutrient content and texture based on their individual needs and medical conditions. These diets will be prepared and served in accordance with the adopted diet manual and congruent with the menu extensions. Under Procedure: .4. Diets are prepared according to the guidelines set forth in the approved diet manual. A review of a facility's 2018 DHCC (Dietetics in Health Care Communities) Manual of NJ (New Jersey) Textured Modified Diets included a list of varied diet textures served in the facility. Review of the Puree-Consistency included but was not limited to: Under Purpose: To safely provide adequate nutrition and to facilitate eating for individuals with impaired chewing and/or swallowing ability. Under Indications for Use: revealed This diet is commonly prescribed for individuals with dental problems, dry mouth, oral or [CONDITION(S)] surgery, mouth sore, cancer or tumor of the mouth, head or neck and head injury. Under Description: indicated the pureed food are eaten and swallowed with minimal chewing and minimal jaw movement. Foods are pureed, homogenous, and smooth; and have pudding-like consistency. Under Menu Planning Guidelines: revealed Meat, fish, vegetables, starches, soups and fruit must be pureed. Gravy, sauce, broth, or extra butter/margarine may be served to moisten the food . Bread .may be pureed or slurried . Further review of the 2018 DHCC Manual of NJ Under Textured Modified Diets the Mechanical Soft Consistency revealed Under Purpose: To safely provide adequate nutrition and to facilitate eating for individuals with impaired chewing and/or swallowing ability. Under Indications for Use: This diet is commonly prescribed for individuals with dental problems, dry mouth, oral or [CONDITION(S)] surgery, mouth sore, cancer or tumor of the mouth, head or neck and head injury . Individuals who are at risk for choking and aspiration may need this consistency for dysphagia management. Under Description: The Mechanical Soft foods are easy to chew and soft in texture. Meats are ground. Fruits and vegetables are fork mashable. A review of an updated facility's policy titled Resident Nutrition Services indicated the following: Under Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Under Policy Interpretation and Implementation: 1. The multidisciplinary staff, including nursing staff, the Attending Physician and the Dieticition will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment. Review of a facility's policy titled Change in Resident Condition dated ,d+[DATE] indicated the following: Under Policy Statement: Our facility shall notify the resident, his or her Attending Physician, an authorized representative of change in the resident's medical condition and/or status. Under Policy Interpretation and Implementation: 1. The Nurse will notify the resident's Physician when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition that impacts their current plan of care; . e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the Physician of changes in the resident's condition. 4. The Nurse will record in the resident's medical record information relative to changes in the resident's condition or status. A review of a facility's policy titled Physician Order dated ,d+[DATE] indicated the following: Under Purpose: To ensure that physician orders are complete and accurate. Under Policy: . All ancillary orders are complete and accurate. N.J.A.C. 8:39 17.4 (a)(2)

COMPLAINT # NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to consistently implement identified safety interventions for 1 of 3 sampled residents (Resident #1) who had multiple falls. Resident #1 fell six times in a 22 day period, including two times during the night shift of 4/8/2012 and required hospital treatment for [REDACTED]. This deficient practice is evidenced by the following: Interviews with staff and/or residents, review of the medical record and other facility documentation occurred on 5/22/2012 unless otherwise noted. 1. According to the Admission Record, Resident #1 was admitted to the facility in August, 2006. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 4/23/2012 showed Resident #1 was cognitively impaired with short and long term memory impairment and needed assistance with activities of daily living. A Physician order [REDACTED]. A Care Plan (CP) initiated on 4/3/2012 showed the resident had falls on the following dates; 4/2, 4/3, 4/4, 2 falls on 4/8 and 4/24/2012. Interventions were identified to prevent falls on 4/3/2012. On 4/4/21 a bedside mat on the floor, bed to chair alarm and bed pad alarm which were to be monitored for placement and working order every shift were initiated. The CP showed no intervention(s) to prevent Resident #1 from removing her alarms until 4/10/2012 when the following was added; check bedside table for alarm and call bell (CB) as she removes them and "tucks them into the drawer", check every 2 hours for placement and working order of CB and alarm. Review of Nurses Notes (NN), Incident Reports (IR) and corresponding Fall Investigation showed the following; On 4/2/2012 at 6:10PM, Resident #1 was found on the floor next to her bed and chair, having slid from a chair attempting to ambulate. She was assessed with [REDACTED]. A tab alarm was recommended by the nurse completing the IR but after review the next day the Unit Manager Nurse (UM) documented on the Fall Investigation form that the "tab alarm not feasible for this resident at this time". During an interview with the surveyor at 1:20PM, the Assistant Director of Nursing (ADON) stated she had determined that that "tab alarm" would not work as she had a history in the past of removing them. On 4/3/2012 at 8:55AM and 4/4/2012 at 6:30AM she fell attempting to ambulate from bed/chair and was assessed with [REDACTED]. There was no indication on the Fall Investigation that the resident had an alarm in place at the time of the fall. The Fall Investigations indicated a pad alarm (sensor) was added on 4/4/2012 and a physical therapy evaluation had been recommended after the 4/3/2012 fall. The CP did not indicate any interventions to decrease/prevent the removal of the alarm until 4/10/2012. Review of a Facility Reportable Event Record/Report (AAS-45) faxed to the Department of Health and Senior Services (DHSS) on 5/14/2012 showed Resident #1 had 2 falls on 4/8/2012. The first fall was at 4:15AM with no injury. She again fell at 5:30AM and was found on the floor near the sink and noted with bleeding from the back of her head. She had a history of [REDACTED]. She had multiple falls earlier in the week and had been treated for [REDACTED]. The AAS-45 noted "This particular fall was not preventable as this resident was very non compliant in understanding she needed to ask to (for) assistance when getting up to toilet and or ambulation. She was also known to turn off her bed alarm or remove them and hide them.....this fall was unavoidable". The IR revealed that on 4/8/2012 at 4:15AM, Resident #1 was found face down on her room floor and was assessed with [REDACTED]. The Fall Investigation completed by the 11PM-7AM Registered Nurse (RN) showed the resident was alert and confused, did not use the CB for assistance and was in a low bed. However, it did not indicate in the "did the resident have" check off section if the mat was on the floor or bed alarm in place. The Corrective measures showed; "activate bed and chair alarm at all times and assist to bathroom (BR) (every) 2 hours".?@A second fall occurred on 4/8/2012 at 5:30AM. The IR noted that Resident #1 got up, used her walker and was found on the floor. She was assessed with [REDACTED]. The Fall Investigation did not indicate if a mat was on the floor or if the bed alarm was in place and functioning but showed the resident was confused, disoriented and did not call for assistance. Corrective measures included; constant monitoring, close supervision and assistance to the BR every 2 hours. There was no further documentation in the NN or statements from staff to verify if an alarm was in place and/or sounding. An April/2012 Treatment Administration Record (TAR) showed an order, initiated 4/4/2012 for "bed to chair alarm for safety, check every shift for working order and placement". On 4/8/2012, the 11PM-7AM shift nurse signed and circled her initials which indicated the bed alarm had not been applied. On the back of the TAR, a corresponding note from the nurse documented "No bed alarm in place". There were no statements from the assigned Certified Nurses Aide (CNA) or the nurse who signed the TAR as to why there was no bed alarm in place. During interviews with the surveyor at 1:00PM and 2:00PM, the Assistant Director of Nursing (ADON) confirmed that if the nurse's initials are circled on the TAR, it indicated that the order was not carried out. When asked by the surveyor to clarify if she was aware, after review of the IR and Fall Investigation, that the nurse had documented in the TAR that the alarm had not been applied, the ADON stated she was not aware until the surveyor pointed it out on the day of survey. Additionally, she stated she reviewed the IR and Fall Investigations for 4/8/2012 but did not sign the Fall Investigation sheet as she only signs when she has a comment and she did not notice the alarm was not mentioned/checked and thought interventions had been in place. She clarified that according to the facility policy a "fall assessment" is to be completed noting that in place of it, the facility uses the Fall Investigation sheet. She added that she had been working with the staff recently to make sure all the interventions listed on the IR/Fall Investigation are completed. She confirmed she did not have any further documentation or statements from staff regarding the above falls to clarify if alarms were in use. During a telephone interview with the surveyor on 5/29/2012 at 1:12PM, one of 2 CNAs assigned to Resident #1 on 4/8/2012 during the 11-7 shift, stated she was unable to remember if an alarm was in place at the time of the falls. The other assigned CNA and Nurse were unable to be interviewed by the surveyor. Review of the hospital records, dated 4/8/2012, showed Resident #1 was treated after sustaining 2 falls at the facility on 4/8/2012. She was assessed with [REDACTED]. Further review of NNs and IR showed that on 4/24/2012 at 2:20PM, Resident #1 was found on her right side on the floor in her room and was assessed with [REDACTED]. The corrective measures noted that a disciplinary action was given to the assigned CNA for not making sure the alarm was turned on after therapy. During an interview with the Surveyor at 2:30PM, the CNA stated that she turned off the alarm so the resident could receive Physical Therapy. She was unaware that the Physical Therapist had not turned the alarm back on after the therapy session. She checked the resident and thought the alarm had been on. The CNA stated she received counseling regarding alarms after the incident. During an interview with the surveyor at 1:50PM, the ADON stated alarms are to be on and functioning at all times and the nurses and CNAs are responsible to check them. Resident #1 was observed by the surveyor on tour at 10:15AM in bed with a CB and bed alarm in place and functioning. Review of an undated facility "Fall Prevention Policy" included but was not limited to; the resident should be evaluated to determine what new constitutional or environmental factors may have precipitated the fall. Precipitation factors should be corrected when possible. Review of a facility policy dated 4/15/2004 titled "Fall Assessment Follow-up Procedure" included but what was not limited to; a follow-up fall assessment sheet (Fall Investigation) must also be completed. All appropriate responses must be checked off on the sheet. All corrective action is immediately taken. The supervisor reviews the assessment sheet for completeness, ensures that ask corrective action has been taken, signs and dates the Fall Assessment Sheet.?@ NJAC 8:39-27.1(a)?@?@?@?@?@?@?@?@?@?@?@?@?@?@?@?@?@?@?@

Based on observation, interview, medical record review and review of documentation provided by the facility, it was determined that the facility failed to ensure that all residents received adequate supervision to prevent accidents. This deficient practice resulted in a resident sustaining multiple facial fractures that required a hospitalization . In addition, the facility failed to conduct a thorough investigation into the causative factors that may have contributed to the accident and the resulting fractures. This deficient practice occurred to 1 of 7 residents (Resident #4) reviewed for falls and was evidenced by the following: According to the medical record, Resident #4, who was alert but confused had [DIAGNOSES REDACTED]. During the initial tour of the facility's "B" unit, on 9/13/11 at 10 a.m., the unit manager told the surveyor that Resident #4 "had a recent fall and had some facial fractures." At that time, the surveyor observed the resident lying in a low bed with a bed alarm in place, and, a mat on the floor next to his bed. The surveyor also observed faint ecchymotic areas which covered the left side of the resident's face from his/her eyebrow to the cheek. The unit manager also stated that no one had seen the resident fall and that s/he was "found crawling on the floor inside (Resident #4's) room." This incident had occurred after being returned to the facility on [DATE] after a mandatory evacuation. The unit manager stated that when interviewed, by the staff, at the time of the incident, the resident had stated, "I fell " but was unable to give any details. According to an interdisciplinary note, dated 8/28/11 at 23:43 (11:43 p.m.), a facility nurse documented "Resident was mandatory evacuated on Friday 8/26/11 and back to facility in no distress on Sunday 8/28/11." There was no documentation indicating the time that the resident returned to the facility on [DATE]. A further review of the medical record revealed an interdisciplinary note, dated 8/28/11 at 23:44 (11:44 p.m.), indicating that "resident seen crawling on the floor inside (his/her) room with blood on (Resident #4's) face. Noted bruise and swelling to the L (left) eye and the L side of cheek." The resident was subsequently sent to the hospital and admitted with multiple facial fractures. According to the facility's "Policy on Resident Incidents/Accidents", that was provided to the surveyors, by the facility, on 9/20/11, "When the cause of the incident/accident is not known, an investigation must be conducted and a written report must be completed...by employees of all 3 shifts who are directly involved with the resident's care prior to the Incident and Accident." A review of the investigation material that was provided by the facility on 9/20/11 at 10:20 a.m., revealed that a Registered Nurse (RN) assessed the resident the night of the fall and documented the findings on an incident report. Aside from the RN's assessment on the incident report, there was only 1 statement, documented by the Certified Nurse Aide (CNA), who wrote that, "while doing my rounds at 5:15 p.m. I saw the resident crawling at the floor with blood on left side of (his/her) face." On the "Fall Investigation Conclusion", that was attached to the "Incident Report" and dated 9/15/11 (untimed), 18 days after Resident #4 fell and sustained multiple facial fractures, the DON documented that she contacted the RN who had completed the Incident Report for this resident's accident that occurred on 8/28/11. According to this documentation, the RN told the DON that "she thinks but cannot conclusively confirm" that the alarm was on the resident "at this point in time." According to a "Fall Investigation Statement" dated 9/16/11, 19 days after the evening that the resident was found crawling on the floor and bleeding, the CNA, who had written the only statement on 8/28/11, indicated that "he does not recall hearing an alarm sound and does know whether or not the alarm was in place" at the time of this incident. The surveyor on 9/20/11 at 2:30 p.m., interviewed the Administrator (LNHA), in the presence of the Assistant Administrators and the Director of Nurses (DON). The Administrator stated that the surveyor had been provided the complete investigation, except for the "Reportable Event Record/Report", with regards to Resident #4 fall on 8/28/11 and his/her subsequent facial fractures. The DON stated, during this interview, that the resident had "came back from the evacuation site and fell in (his/her) room." The DON added, that she didn't know exactly how or why and stated, "(Resident #4) was found crawling in (his/her) room." When asked, by the surveyor, if the resident was in the bed or in the chair prior to being found on the floor, the DON stated, "I can't tell you which. There is no documentation. The resident can't communicate on that level." When asked, by the surveyor, which staff member put Resident #4 in his/her room upon return from the evacuation site, the DON stated, "We don't know. Could we have found out what happened with more investigation? Possibly." A subsequent review of the resident's medical record that was conducted by the surveyor on 9/21/11 at 8:20 a.m., revealed a telephone verbal order, dated 4/15/11 at "9" (no a.m. or p.m.) for a "self release belt at all times when on wheel chair." Another telephone verbal order, dated 6/8/11 (untimed), was obtained for an "alarm to wheelchair while out of bed." When reviewed, at 9/21/11 at 8:20 a.m., the current plan of care, that had been developed for Resident #4, did not include either the self release belt or the wheelchair alarm. When interviewed, by the surveyor, on 9/21/11 at 8:30 a.m., the unit manager stated that she had just added the self release belt to the resident's care plan. A subsequent review of the care plan revealed that the unit manager had not added the wheelchair alarm as an intervention to the resident's plan of care. The surveyor, on 9/21/11 at 10:20 a.m., again interviewed the LNHA, in the presence of the Assistant LNHAs and the DON, who stated a hospital report on Resident #4 was found by the facility staff "yesterday" and that a section of the hospital report indicated that Resident #4's pacemaker "failed." The LNHA stated that the resident's pacemaker failure "may be a reason for (his/her) fall." The LNHA also provided the surveyor with a copy of a time log from Tricare Medical Transport. According to this time log, Resident #4 was returned to the facility, from the evacuation site, at 15:27 (3:27 p.m.) on 8/28/11. One of the Assistant LNHA stated, "I spoke to the aide who took the resident back to (his/her) room that day and she told me that everything was in place when (s/he) was put in (his/her) room." When asked, by the surveyor, if this aide had been interviewed or had written a statement after the incident happened, an Assistant LNHA shook her head and said, "I don't know. I spoke with her just today." On 9/22/11 at 9:15 a.m., 25 days after the incident, the facility faxed "supplementary documentation", to the surveyor, regarding Resident #4's incident and subsequent facial fractures. According to "supplementary documentation", a CNA, who had not provided a statement at the time when the incident occurred on 8/28/11, wrote that he had "met" Resident #4 at the nurses station on the "A/B" unit of the facility but did not document a time. This CNA wrote that the resident, who was "assigned" to this CNA, "wanted to go to bed." The CNA wrote that he put Resident #4 in bed "about 4 pm" and that when the CNA left the room, the resident was lying with his/her eyes closed and the bed in the lowest position. The CNA documented that he put the "clip type alarm on (Resident #4), on the back of (Resident #4's) shirt." This CNA wrote that Resident #4 was "on the floor in (Resident #4's) room", the next time that the CNA observed this resident. N.J.A.C.8:39-27.1(a)