Every finding on record at Plaza Healthcare & Rehabilitation Center

Based on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 6/4/25 at 11:10 AM, the surveyor toured the laundry room along with the Infection Preventionist (IP). Upon entry to the clean laundry area, two laundry aides were emptying a dryer. The laundry room consisted of an area with two front loading washers, both which were running. There was another area with three dryers and room for folding laundry. The surveyor asked the laundry aides, what they needed to do when loading the dirty laundry into the washers. The aide explained that sometimes she finds disposable briefs in the wash when emptying the washer into the dryer. She further stated that if a brief was found, she removed them and disposed of them in the garbage. The surveyor asked if she needed to wear anything to protect her when handling the dirty linens. She repeated her comments about the disposable briefs. The surveyor did not observe any gowns or aprons in the laundry area. On 6/4/25 at 11:20 AM, the surveyor interviewed the Food Service Director/Housekeeping Director (FSD/HD) regarding if any PPE was needed when handling soiled linen. She stated, Not that I know of. The IP was present and stated the staff should wear PPE when handling the soiled linens into the washers. On 6/4/25 at 11:29 AM, the IP showed the surveyor a laundry bag that disintegrates when it hits water. She stated that we use these bags, so they (the laundry staff) aren't touching soiled linens. On 6/4/25 at 11:40 AM, the surveyor interviewed two certified nursing assistants (CNAs) on the 1st floor. The surveyor observed CNA#1 with a clear plastic bag (not biodegradable) and asked what that bag was for. CNA#1 she stated it was for the dirty laundry. The surveyor asked if those laundry bags were also used for isolation. CNA#2 stated they used different bags for isolation, the kind that go right into the washer. On 6/4/25 at 11:50 am, the surveyor requested a policy from the FSD/HD regarding infection control in the laundry room. She stated she was looking for a policy but couldn't find one. She further stated that she googled it, and it does say staff was supposed to wear PPE when handling soiled linen. The surveyor asked what site she googled. She showed the surveyor her phone's screen which was on an AI (artificial intelligence) overview. She also stated that this was her first time doing laundry and housekeeping. On 6/4/25 at 11:55 AM, the surveyor observed two laundry aides in the folding area, folding clean linens with the clean sheets touching their clothing during the folding process. The IP entered the laundry area while the surveyor was there. She stated she was looking for a PPE apron. No apron was observed in the laundry area. On 6/4/25 at 01:08 PM, the Licensed Nursing Home Administrator (LHNA) and the Director of Nursing (DON) were notified of the concerns in the laundry room. A review of the facility provided policy Standard Precaution and Transmission-Based Precaution: Droplet, Universal and Contact Precautions, reviewed January 2025 included: Policy: Standard Precautions are the minimum prevention practices that applies to all resident/patient care, regardless of suspected or confirmed infection status of the resident/patient. Standard Precautions include: Hand Hygiene Use of Personal protected equipment i.e. gloves, mask, eyewear Standard Precautions: Gloves: Staff must use gloves when they anticipate contact with potentially infectious materials, non-intact skin, or potentially contaminated intact skin (i.e. resident incontinent of stool or urine). Gowns: Staff must use gowns to protect skin and prevent soiling or contamination of clothing during care or treatment administration when they anticipate contact with body fluids or excretions. A review of facility provided policy Linen Management, dated June 2025, included: Policy: All linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment for residents, health care workers, and visitors. Standard precautions will be followed when handling soiled linen. Guidelines for Linen Management are as follows: Laundry Staff: 11. Residents on Transmission-based precautions: a. While wearing gloves; remove the bag from soiled linen container, then, place the water dissolvable bag will be opened directly into the washer. b. Generally, soiled linen bag will be opened directly into the washer with gloved hands and apron/gown will place the soiled linen in the washer. NJAC 8:36-19.4 (a) (b) (c)

Based on observation, interview, record review, and facility policy review, the facility failed to have an ongoing monitoring of bed side rails as part of their routine maintenance program for one of one resident (Resident (R)71) of 35 sample residents and 86 of 87 occupied beds reviewed for side rails. Findings include: 1. Review of R71's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/23, located in the MDS tab of the electronic medical report (EMR), revealed R71 had an admitted [DATE]. There was no Brief Interview for Mental Status (BIMS) score conducted and R71 had severely impaired cognition, R71 had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and on the lower extremity (hip, knee, ankle, foot) R71 was dependent with mobility when lying to sitting on the side of the bed. Side rails were not used and R71 had diagnoses of epilepsy and cerebrovascular accident (CVA). Review of R71's side rail assessment provided by the facility, dated 07/07/22, revealed 3. Does the resident has [sic] alternation of safety awareness due to altered cognition? Yes, 5. Does the resident have difficulty moving in bed? Yes, 10. Does resident currently in use of side rails for independent positioning or to assist with positioning? (enabler) Yes. Alternatives included 2. Reminders to use call light for assistance and 3. Restorative care to enhance independence. Recommendations included 1. Side rails are indicated at the present time. a. They will b. promote independence. Side Rail Utilization included 5a. Sides, a. left, b. right, 5b. Rails b. Half. The assessment did not include the risk of entrapment or what condition the side rails were needed for. Review of R71's care plan located in the EMR under the Care Plan tab, dated 07/08/22, revealed R71 has an ADL [activities of daily living] self-care performance deficit r/t [related to] Confusion, Impaired balance, Limited ROM [range of motion] r/t CVA and an intervention included Side Rails: 2/half rails up as per Drs [doctor's] order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of R71's order located in the EMR under the Orders tab, dated 05/27/23, revealed Siderails - Half Side Rails. Review of the 200-hall maintenance log for January 2024, did not include an entry for bed rail maintenance. During an observation on 01/22/24 at 2:50 PM, R71 was in a wheelchair next to her bed. R71's bed was noted to have one silver side rail up that was loose and slightly leaning away from the bed. A hand size gap was present between the mattress and side rail. During an observation on 01/23/24 at 9:38 AM, R71 was in bed with silver side rails in the up position as Nurse Aide (NA)2 used the bed remote to bring R71 up to a seated position. At 9:46 AM, R71 was again observed in bed with the side rails in the up position. The side rail on the right side of the bed was noted to be severely loose and leaning away from the bed. During an interview on 01/23/24 at 1:11 PM, the Maintenance Supervisor (MS) was asked about bed inspections. The MS stated he didn't conduct bed checks. The MS stated the staff would log problems for him to address in a maintenance notebook located at the nurse's station. The MS was asked if he conducted side rail inspections. The MS stated every morning he checked the side rails but didn't document the inspections. The MS then demonstrated what he checked for on an empty bed. The MS stated the only gap he checked was the gap between the top of the side rail and the headboard but didn't check for gaps between the side rail and mattress. The MS was shown R71's side rail on the right side of her bed. The side rail was observed, and the MS confirmed the rail was severely loose, causing it to wobble back and forth. The side rail was noted to have hand size (five inch) gap. The MS stated, it's loose because the nurse aides put them up and down and the bolt gets loose. The MS then tightened the bolt. The MS then stated the silver side rails were the old ones and he would replace R71's side rails with new ones that were black. The MS went on to say he had new side rails that worked better on their beds. 2. Review of a resident roster with occupied beds highlighted with side rails, dated 01/25/24, provided by the facility revealed 86 (101-1, 101-2, 102-2, 103-1, 103-2, 104-1, 104-3, 105-2, 106-2, 107-1, 107-2, 108-1, 108-2, 109-1, 109-2, 110-3, 110-4, 111-2, 119-1, 119-2, 120-1, 121-1, 122-1, 122-2, 123-1, 124-1, 125-1, 126-1, 127-1, 127-2, 128-1, 129-2, 201-1, 202-1, 203-1, 204-1, 204-2, 205-2, 206-1, 206-3, 206-4, 207-1, 208-2, 209-1, 210-2, 211-1, 211-2, 212-1, 212-2, 212-3, 212-4, 213-1, 213-4, 214-1, 214-2, 215-1, 215-2, 216-1, 216-2, 217-1, 217-2, 218-1, 218-2, 219-1, 219-2, 220-1, 221-1, 221-2, 222-1, 222-2, 223-1, 223-2, 224-1, 224-2, 225-1, 225-2, 226-1, 227-1, 228-1, 228-2, 229-1, 230-1, 230-2, 231-1, 231-2, 232-1, and 232-3) of 87 occupied beds had side rails in use. During an interview on 01/24/24 at 1:46 PM, the Administrator was asked for the bed maintenance/manufacture instructions, and he stated they only had the parts catalog. Review of the 2009 on-line manual titled, Owner's Operator and Maintenance Manual - Invacare Continuing Care, Inc. [incorporated] [NAME](R)DLX Series Long Term Care Beds IH820DLX, IH820-3MDLX, SC900DLX https://www.1800wheelchair.com/media/manuals/invacare_dlx_bed_manual.pdf, included on page nine, Entrapment Warning that revealed Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of entrapment. Visit the FDA website at http://www.fda.gov to learn about the risks of entrapment. Review A Guide to Bed Safety, published by the Hospital Bed Safety Workgroup. Refer to the individual instruction sheet included with the bed rails and/or positioning device for additional product and safety information. After any adjustments, repair, or service and before use, make sure all attaching hardware is tightened securely. Assist rails with dimensions different from the original equipment supplied or specified by the bed manufacturer may not be interchangeable and may result in entrapment or other injury. Mattress must fit bed frame, assist rails and/or positioning device snugly to reduce the risk of entrapment. On 01/25/24 at 2:05 PM, the Administrator was asked for a bed maintenance/inspection policy. None was provided. Review of the facility's policy titled, Use of Side Rails, dated 12/23, revealed It is the policy of this facility to ensure the safety and psychosocial well-being of its Residents while avoiding the use of side rails as a physical restraint. However, in review of resident's medical symptoms, the Physician and the Interdisciplinary team will review and determine through assessment the appropriateness of side rails . 10.) Assessment for use of side rails . h.) frequent monitoring by staff. The policy did not address the risk of entrapment. NJAC 8:39- 31.4(c) NJAC 8:39-31.8(c)1

Based on record review, interviews, and facility policy review, the facility failed to inform the New Jersey Department of Health (NJDOH) of one of two abuse allegations reviewed for Resident (R)73 and R41 on 05/20/23 within the mandated two-hour period of 35 sample residents. Findings include: Review of the Investigation Summary provided by the facility, dated 05/23/23, revealed the incident occurred on 05/20/23. The residents were questioned on 05/22/23. R41 had no recollection of the event and stated, I can't fight anybody. How can I hit him? R73 stated he slammed the bathroom door shut, and R41 took offense and began yelling. R73 stated he [R73] opened the door and R41 hit him [R73] in the face. The investigation concluded there was not sufficient evidence to sustain the allegation stating, No visible injury to both residents, and no witness to this incident and therefore unable to determine that there was evidence of any physical altercation. The summary was signed by the then Director of Nursing (DON)2 [no longer employed] and the Administrator on 05/23/23 and faxed to the New Jersey Department of Health (NJDOH) on 05/25/23. During an interview on 01/24/24 at 11:40 AM, the Social Service Director (SSD) stated she began the abuse protocol on Monday, 05/22/24, after she heard about the incident. The SSD stated she could not say if anyone else was called within two hours after the nurse heard the allegation on Saturday the 20th, but she [SSD] began the investigation on the following Monday. During an interview on 01/24/24 at 12:15 PM, Licensed Practical Nurse (LPN)2 stated she called the Director of Nursing (DON)2 immediately after the incident between R41 and R73 had occurred. Review of the Reportable Event Record/Report provided by the facility, dated and faxed to the State on 05/22/23, indicated the alleged abuse occurred at 4:20 PM on 05/20/23. The report indicated the event was not significant and was not called in. The report indicated the Resident-to-Resident Abuse box was checked under the Type of Incident section. During an interview on 01/24/24 at 1:50 PM, the Administrator stated he was not informed of the incident on the Saturday night of the incident. The Administrator stated he did not answer phones or other communications on the Saturday [NAME]. He found out about the incident on the following Monday and began the process. He agreed the DON2 was called the night of the incident, as LPN2 stated in an earlier interview. The Administrator agreed the NJDOH should have been informed within two hours of the accusation of physical contact between residents. Review of the facility's policy titled, Abuse and Neglect, with a revision date of December 2023, revealed It is the policy of this Center that procedures are in place to prevent any incidence of abuse, neglect, mistreatment, or misappropriation of resident's property. If any actual or alleged incidents occur there is a process in place for the reporting and investigation; pursuant to the instruction in Federal and Long-Term Care statutes. The policy further indicated for identifying abuse: a. All personnel will be instructed/educated on the importance of identifying events. Identifying events: i.e., bruising of unknown origin (Please refer to Types of Abuse at the end of this policy.) b. Anyone witnessing abuse and/or hearing an allegation of abuse must report the incident immediately to their immediate supervisor and the nursing supervisor. c. The supervisor will then report to the Administrator, Nursing Director, and Social Service Director. The policy indicated for initial reporting that all cases involving residents over sixty, alleged abuse, neglect, or exploitation will be reported to the Ombudsman Office, and all appropriate authorities will be notified, as directed in Federal and State statutes. NJAC 8:39-9.4(f)

Based on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Residents (R) 46) reviewed for Pre-Admission Screening and Resident Review (PASARR) had a PASARR level one updated upon receipt of a new serious mental health diagnoses not previously identified of 35 sample residents. This failure placed residents at risk for unmet care needs and not receiving appropriate and necessary mental health support/services. Findings include: Review of R46's undated Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses of bipolar disorder and acquired absence of limb. Review of R46's undated Admission Record from the EMR Diagnosis tab revealed a diagnosis of insomnia was added on 03/10/21; bipolar disorder in partial remission, most recent episode mixed was added on 01/23/23; the diagnosis unspecified psychosis was added on 10/30/23; and the diagnosis of schizoaffective disorder depressive type was added on 12/08/23. Review of R46's EMR Miscellaneous tab showed a PASARR level one completed on 01/18/21 that did not identify any serious mental health diagnosis. During an interview on 01/23/24 at 4:01 PM, in response to a request for a PASARR level two screening, the Administrator provided R46's PASARR level one screening, dated 01/18/21. When R46's EMR Diagnosis tab was reviewed, the Administrator stated, Oh, it should have been resubmitted. During an interview on 01/24/24 at 10:59 AM, the Social Services Director (SSD) stated R46's PASARR level one was received from the hospital on admission. When the PASARR level one was reviewed and no serious mental health diagnosis was identified, the (SSD) stated, That should have been corrected. When R46's EMR Diagnosis tab was reviewed and the SSD saw the psychosis and schizoaffective disorder diagnoses, SSD stated, Yes, it should have been updated with the correct diagnosis. Review of the facility's policy titled, PASARR, dated December 2023, showed: The purpose of the Preadmission Assessment and Annual Resident Review Program (PASARR) policy and procedure is to develop guidelines for admission related to those individuals with mental illness and intellectual disabilities to ensure they receive the care and services needed in the most appropriate setting . The policy did not address an incorrect admission screening or the screening resubmission if a serious mental health diagnosis was received after admission. NJAC 8:39-40.3(d)

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan with goals and approaches for three of three residents (Residents (R) 32, R33, and R71) reviewed for side rail use; and one of three residents (R71) reviewed for limited range of motion of 35 sample residents. Findings include: 1. Review of R32's undated Admission Record from the electronic medical record (EMR) under the Profile tab, showed a facility admitted [DATE], readmission on 09/13/23, with medical diagnoses that included bilateral below knee amputation, dementia, macular degeneration, peripheral vascular disease, and anxiety disorder. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/23, located in the MDS tab of the EMR, showed R32 was rarely or never understood and was totally dependent on staff for bed mobility. Review of R32's Care Plan from the EMR Care Plan tab, showed bed rails were not addressed in any area of the plan of care. During an observation on 01/22/24 at 12:17 PM, R32 was in bed, with an air mattress, being assisted during lunch with one full quarter rail up and one in down position where an aide was seated. During an observation on 01/25/24 at 8:08 AM and 9:15 AM, R32 was observed on an air mattress with bilateral full quarter upper rails in the up position. 2. Review of R33's undated Admission Record from the EMR Profile tab showed an admitted [DATE] with medical diagnoses that included cerebrovascular disease, seizures, hemiplegia, and hemiparesis following a subarachnoid hemorrhage, and dysphagia. Review of R33's quarterly MDS with an ARD of 12/28/23, located in the MDS tab of the EMR, showed R33 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicative of being cognitively intact, and only required staff supervision for bed mobility. Review of R33's Care Plan from the EMR Care Plan tab showed the use of bed rails was not addressed in any area of the plan of care. During an observation and interview on 01/22/24 at 12:21 PM, R33 stated he had been in the facility for nine years. It was observed that he had bilateral upper full quarter bed rails. When asked, R33 stated he used them; when asked if anyone had advised him of the risks and benefits of side rails (an example of a risk of putting an arm through the rail and falling out of bed with the arm entrapped), R33 stated he had not been advised of any risks or benefits. During an observation on 01/25/24 at 8:10 AM and 9:15 AM, R33 was asleep in bed with bilateral upper full quarter rails in the up position. During an interview on 01/25/24 at 2:15 PM, the MDS Coordinator (MDSC) stated, The admission nurse starts the care plan and then all the departments do their own part. Then when I do the MDS I check out the care plan to make sure everything is in there. When asked if bed rails would/should be care planned, MDSC responded, They [bed rails] would be in ADLs [activities of daily living] for like bed mobility. MDSC reviewed R32's care plan at 2:22 PM and commented that the rails should be in one of those ADL areas, then confirmed bed rails were not present in R32's care plan. At 2:25 PM, MDSC reviewed R33's care plan and confirmed bed rails were not present. When queried why bed rails should be care planned, MDSC replied, For safety then clarified, from danger of like falling, or to help positioning in bed. 3. a. Review of R71's quarterly MDS with an ARD of 12/12/23, located in the MDS tab of the EMR, revealed R71 had an admitted [DATE]. R71 had no BIMS score, and cognition was severely impaired. R71 had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and on the lower extremity (hip, knee, ankle, foot); was dependent with mobility when lying to sitting on the side of the bed; side rails not used and had diagnoses of epilepsy and cerebrovascular accident (CVA). Review of R71's care plan located in the EMR under the Care Plan tab, dated 07/08/22, revealed R71 has an ADL self-care performance deficit r/t [related to] Confusion, Impaired balance, Limited ROM [range of motion] r/t CVA and an intervention which included Side Rails: 2/half rails up as per Drs [doctor's] order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of R71's side rail assessment provided by the facility, dated 07/07/22, revealed 3. Does the resident has [sic] alternation of safety awareness due to altered cognition? Yes, 5. Does the resident have difficulty moving in bed? Yes, 10. Does resident currently use side rails for independent positioning or to assist with positioning? (enabler) Yes. Alternatives included 2. Reminders to use call light for assistance and 3. Restorative care to enhance independence. Recommendations included 1. Side rails are indicated at the present time. a. They will b. promote independence. Side Rail Utilization included 5a. Sides, a. left, b. right, 5b. Rails b. Half. The assessment did not include the risk of entrapment or what condition the side rails were needed for. Review of R71's order located in the EMR under the Orders tab, dated 05/27/23, revealed Siderails - Half Side Rails. During an observation on 01/23/24 at 9:46 AM, R71 was observed in bed with the side rails in the up position on both sides of the bed. During an observation on 01/24/24 at 9:08 AM, R71 was observed in bed with side rails in the up position on both sides of the bed. During an observation on 01/25/24 at 8:01 AM, R71 was observed in bed with side rails in the up position on both sides of the bed. During an interview on 01/25/24 at 2:15 PM, the MDSC was asked about care plan development. MDS stated the admitting nurse started the care plans and the department heads developed their own care plans specific to their area. The MDSC stated when she reviewed the care plans, she would add interventions if she noticed they were missing. MDSC was asked about the side rail care plans. The MDSC stated the side rails were included only as an intervention and not a full care plan with goals and objectives saying, the side rails are just under ADLs and not as a problem. The MDSC was then asked should the side rails be fully care-planned if an assessment was conducted. The MDSC stated yes, for safety from danger of falling and repositioning. The MDSC was asked if side rails could present a danger should R71's care plan only address the side rails as only an intervention and not a full care plan with a focus area, goals, and interventions. The MDSC stated, yes it should be fully care planned. 3. b. Review of R71's quarterly MDS, with an ARD date of 12/12/23, located in the MDS tab of the EMR, revealed R71 had an admitted [DATE]; had no BIMS score, cognition was severely impaired; had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand);and used a splint or brace assistance. Review of R71's care plan located in the EMR under the Care Plan tab, dated 07/08/22, revealed R71 has potential impairment to skin integrity r/t fragile skin, use of antiplatelets, impaired mobility, splint use, CVA, Incontinence and an intervention included Remove right hand/wrist splint before PM [evening] care or as tolerated. Check skin integrity after splint removal. every evening shift. Review of R71's order located in the EMR under the Orders tab, dated 09/20/23, revealed Apply right hand splint after AM [morning] care and remove before PM care or as tolerated. Check skin integrity before and after application. Review of R71's Medication Administration Review (MAR), dated 01/24, located in the EMR under the Orders tab, revealed 01/01/24 to 01/23/24 for day and evening shifts the right-hand splint was marked as applied. The only day the splint was not marked as applied was on 01/24/24 when the MAR was coded as 9 [Other / See Progress Notes]. Review of R71's progress notes located in the EMR under the Progress Notes tab revealed notes dated 01/24/23 to 01/23/24 did not include a note related to R71's right hand splint. No note dated 01/24/23 was found for the MAR related to the 9 code. During an observation on 01/23/24 at 10:32 AM, R71 was observed in her wheelchair in her room. R71 did not have a splint in place on her right hand. During an observation on 01/23/24 at 1:11 PM and at 1:36 PM, R71 was observed in her wheelchair in her room. R71 did not have a splint in place on her right hand. A splint was observed on the bed next to R71. During an observation on 01/24/24 at 10:32 AM, R71 was observed in her wheelchair in her room. R71 did not have a splint in place on her right hand. During an interview on 01/24/24 at 10:47AM, the Director of Rehabilitation (DOR) was asked about R71's hand splint. The DOR stated R71 was receiving occupational therapy to encourage R71 to wear the splint. The DOR went on to say R71 was noncompliant with it. The DOR stated R71 could take it off. The DOR was asked if R71 refused to wear the splint, should staff document her refusals. The DOR stated, yes, and let therapy know she refuses. The DOR stated the purpose of the splint was to prevent the contracture from getting worse. During an observation and interview on 01/25/24 at 10:30 AM, R71 was observed awake in her wheelchair in her room not wearing a hand splint on the right hand. Nurse Aide (NA)2 was observed in R71's room. At 10:32 AM, NA2 was asked if she cared for R71 and if she got R71 out of bed this morning. NA2 stated, yes. NA2 was then asked why R71 wasn't wearing the splint. NA2 stated because R71 refused it. NA2 went on to say R71 wouldn't let her put it on. NA2 stated when this happens, I report it to the nurse. NA2 stated she was R71's nurse aide on 1/23/24 and 1/24/24 and R71 refused to allow her to put it on. During an interview on 01/25/24 at 10:38 AM, the Director of Nursing (DON)1 was asked about R71's splint who confirmed her refusals. The DON1 was asked if R71's refusal to wear the splint was care planned. The DON1 stated she would have to check. During an interview on 01/25/24 at 10:40 AM, Licensed Practical Nurse (LPN)1 was asked why the January 2024 MAR reflected R71's splint was on when observations of R71 not wearing it and NA2 stated R71 refused to wear it. LPN1 stated because it's on and off all day long. LPN1 stated there was no other way to document it on the MAR. During an interview on 01/25/24 at 2:25 PM, the MDSC was asked about R71's refusal to wear the splint and if R71's refusal should be care planned. The MDSC stated, yes. Review of the facility's policy titled, Comprehensive Care Plans, revised 12/23, revealed Purpose: 1. To provide nursing care to the resident on a 24-hour basis to ensure that resident care and treatment is planned appropriately for the resident's needs. 2. A comprehensive care plan should be defined as person-centered and comprehensive, developed and implemented to meet individual preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. 3. To document the response to the prescribed plan of care to communicate the resident's condition to the health care team. 5. The Comprehensive Care Plan (CCP) will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission from inpatient hospital stay, for any interim problems prior to CCP. Review of the facility's policy titled, Use of Side Rails, dated 12/23, revealed 11.) Care Planning: a.) Interdisciplinary team, once assessment determines appropriateness of side rails will implement interventions supportive of their assessment. b.) Interventions may reflect measures to enhance self-sufficiency or to minimize decline . d.) care Plan goal and interventions will be reflective of any changes in the resident's medical condition. NJAC 8:39-11.2(e) thru (i) NJAC 8:39- 27.1(a),(d) 28154

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that three of three residents (Resident (R) 32, R33, and R71) reviewed for bed rail use of 35 sample residents had attempted alternatives documented, quarterly and annually side rail screen assessments completed according to facility policy, and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use with an informed consent signed prior to the installation of the bed rails. This failure had the potential for the resident, or the RR be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment. Findings include: 1. Review of R32's undated Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] and readmission on 09/13/23, with medical diagnoses that included bilateral below knee amputation, dementia, macular degeneration, peripheral vascular disease, and anxiety disorder. Review of R32's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, located in the MDS tab of the EMR, showed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicative of severe cognitive impairment. During an observation on 01/22/24 at 12:17 PM, R32 was in bed, with an air mattress, being assisted during lunch with one full quarter rail up and one in down position where an aide was seated. During an observation on 01/25/24 at 8:08 AM and 9:15 AM, R32 was observed on an air mattress with bilateral full quarter upper rails in the up position. Review of the Side Rails form for R32 provided by the facility, dated 10/02/19, revealed the following: A. Factors 1. Is the resident ambulatory? No. 2. Is the resident lethargic or comatose? No. 3. Does the resident has [sic] alteration of safety awareness due to altered cognition? Yes. 4. Does the resident has [sic] history of falls? No. 5. Does the resident have difficulty moving in bed? Yes. 6. Does the resident have difficulty sitting on or moving to the side of the bed? Yes. 7. Does the resident have the [sic] difficulty with balance or poor control? Yes. 8. Does resident have difficulty of [sic] getting up / standing from sitting in a chair? Yes. 9. Does resident take any medication that would require safety precautions? No. 10. Does resident currently in use of [sic] side rails for independent positioning or to assist with positioning? (enabler) Yes. 11. Has the resident or family asked / requested to have side rails while on bed [sic]? Yes. B. Alternatives. 1. Toileting Schedule. 2. Reminders to use call light for assistance [this was marked]. 3. Restorative care to enhance independence. C. Recommendations. 1. Side rails are indicated at the present time. a. They will. a. [sic] Provide Safety. b. Promote Independence [this was marked]. c. Carry out request. 2. Side rails not indicated at the present time. 3. Evaluation will continue to determine appropriateness. 4. Notes. Side Rail Utilization. 5a. Sides a. Left b. Right c. Both [marked] d. Neither. 5b. Rails a. Full b. Half [marked]. (Left Right Both). The last part of the form was a place for a signature (signed by a nurse) and a signature date. No other side rail assessments were provided by the facility. Review of R32's care plan tab, Medication Administration Record (MAR)/ Treatment Administration Record (TAR), miscellaneous tab, and evaluation/ assessments in the EMR revealed no documentation related to the use of alternative measures utilized prior to the use of side rails. 2. Review of R33's undated Admission Record from the EMR Profile tab showed an admitted [DATE] with medical diagnoses that included cerebrovascular disease, seizures, hemiplegia, and hemiparesis following a subarachnoid hemorrhage, and dysphagia. Review of R33's quarterly MDS, with an ARD of 12/28/23, located in the MDS tab of the EMR, showed R33 had a BIMS score of 14 out of 15, indicative of being cognitively intact, and required staff supervision for bed mobility. During an observation and interview on 01/22/24 at 12:21 PM, R33 stated he had been in the facility for nine years and it was observed that he had bilateral upper full quarter bed rails. When asked, R33 stated he used them; when asked if anyone had advised him of the risks and benefits of side rails (an example of a risk of putting an arm through the rail and falling out of bed with the arm entrapped), R33 stated he had not been advised of any risks or benefits. During an observation on 01/25/24 at 8:10 AM and 9:15 AM, R33 was asleep in bed with bilateral upper full quarter rails in the up position. Review of the Side Rails form for R33 provided by the facility, dated 08/14/15, revealed the following: A. Factors. 1. Is the resident ambulatory? No. 2. Is the resident lethargic or comatose? No. 3. Does the resident has [sic] alteration of safety awareness due to altered cognition? Yes. 4. Does the resident has [sic] history of falls? No. 5. Does the resident have difficulty moving in bed? Yes. 6. Does the resident have difficulty sitting on or moving to the side of the bed? Yes. 7. Does the resident have the [sic] difficulty with balance or poor control? Yes. 8. Does resident have difficulty of [sic] getting up / standing from sitting in a chair? Yes. 9. Does resident take any medication that would require safety precautions? No. 10. Does resident currently in use of [sic] side rails for independent positioning or to assist with positioning? (enabler) Yes. 11. Has the resident or family asked / requested to have side rails while on bed [sic]? Yes. B. Alternatives. 1. Toileting Schedule. 2. Reminders to use call light for assistance [this was marked]. 3. Restorative care to enhance independence. C. Recommendations. 1. Side rails are indicated at the present time. a. They will. a. [sic] Provide Safety. b. Promote Independence [this was marked]. c. Carry out request. 2. Side rails not indicated at the present time. 3. Evaluation will continue to determine appropriateness. 4. Notes. Side Rail Utilization. 5a. Sides a. Left [this was marked] b. Right [this was marked] c. Both d. Neither. 5b. Rails a. Full b. Half [this was marked] (Left Right Both). The last part of the form was a place for a signature and a signature date. No other side rail assessments were provided by the facility. Review of R33's care plan tab, MAR/ TAR, miscellaneous tab, and evaluation/ assessments in the EMR revealed no documentation related to the use of alternative measures utilized prior to the use of side rails. On 01/24/24 at 2:55 PM, the Administrator and Director of Nursing (DON)1 provided the Side Rails form for R32 and R33 and the DON stated there was no risk/benefit statement or consent. 3. Review of R71's quarterly MDS, with an ARD of 12/12/23, located in the MDS tab of the EMR, revealed R71 had an admitted [DATE]. R71 had no BIMS score, and cognition was severely impaired. R71 had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and on the lower extremity (hip, knee, ankle, foot); was dependent with mobility when lying to sitting on the side of the bed; side rails not used and had diagnoses of epilepsy and cerebrovascular accident (CVA). Review of R71's care plan located in the EMR under the Care Plan tab, dated 07/08/22, revealed R71 has an ADL [activities of daily living] self-care performance deficit r/t [related to] Confusion, Impaired balance, Limited ROM [range of motion] r/t CVA and an intervention included Side Rails: 2/half rails up as per Drs [doctor's] order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of R71's side rail assessment provided by the facility, dated 07/07/22, revealed 3. Does the resident has [sic] alternation of safety awareness due to altered cognition? Yes, 5. Does the resident have difficulty moving in bed? Yes, 10. Does resident currently use side rails for independent positioning or to assist with positioning? (enabler) Yes. Alternatives included 2. Reminders to use call light for assistance and 3. Restorative care to enhance independence. Recommendations included 1. Side rails are indicated at the present time. a. They will b. promote independence. Side Rail Utilization included 5a. Sides, a. left, b. right, 5b. Rails b. Half. The assessment did not include the risk of entrapment or what condition the side rails were being used for. No other side rail assessments were provided by the facility. Review of R71's order located in the EMR under the Orders tab, dated 05/27/23, revealed Siderails - Half Side Rails. Review of R71's EMR and hard chart revealed no informed consent. Review of R71's care plan tab, MAR/TAR, miscellaneous tab, and evaluation/ assessments in the EMR revealed no documentation related to the use of alternative measures utilized prior to the use of side rails. During an observation on 01/22/24 at 2:50 PM, R71 was in a wheelchair next to her bed. R71's bed was noted to have one silver side rail up on the side closest to the door that was loose and slightly leaning away from the bed. A hand size gap was present between the mattress and side rail. During an observation on 01/23/24 at 9:38 AM, R71 was observed in bed with the side rails up on both sides of the bed as Nurse Aide (NA)2 used bed remote to bring R71's head of bed up. At 9:46 AM, R71 was again observed in bed with the side rails in the up position. The side rail on the side of the bed closest to the door was noted to be loose and leaning away from the bed. During an interview on 01/23/24 at 1:25 PM, Licensed Practical Nurse (LPN) 4 was asked why R71 had side rails on her bed. LPN4 stated the side rails were enablers for R71 during care. LPN4 was asked if the side rails were only up during care and LPN4 stated, yes. LPN4 was then asked if it was okay for R71 to have the side rails in the up position while in bed after R71 was provided care and LPN4 stated, yes. During an observation on 01/24/24 at 9:08 AM, R71 was in bed asleep with side rails on both sides of the bed in the up position. During an interview on 01/24/24 at 10:51 AM, the Director of Rehabilitation (DOR) was asked if therapy got involved with side rails. DOR stated, no. The DOR was asked if R71 had the capacity to use side rails and the DOR stated, yes, with assistance. The DOR stated R71's right hand was contracted, and she couldn't use the side rail with her right hand. The DOR went on to say R71 could use her left hand. The DOR was asked if R71 needed assistance when using the side rail and should the side rail remain up after R71 had been assisted. The DOR stated, yes because R71 could move herself some and could reposition herself using the left-side rail with assistance. During an interview on 01/24/24 at 2:10 PM, DON1 was asked why R71 had side rails and was informed consent obtained. The DON1 stated R71 had side rails for repositioning with one hand. The DON was asked if the side rail use was for only one hand, why did R71 have two side rails and could she get trapped on the other side. The DON stated she would have to look at the report. The DON was asked if there were any more recent side rail assessments for R71 than the 07/07/22 she had provided. The DON stated not that she was aware of. The DON was asked why the assessment didn't include entrapment. The DON stated she started in September of 2023, and she had recently recreated a new form for the side rail assessment that included more details including informed consent. During an observation on 01/25/24 at 8:01 AM, R71 was asleep in bed with side rails up on both sides of the bed. During an interview on 01/25/24 at 2:15 PM, the MDS Coordinator (MDSC) was asked about R71's side rails. The MDSC stated R71 could use the side rails with her good hand to reposition herself. The MDSC was asked if there was a risk for entrapment if R71 could only move one side and the MDSC stated, yes. The MDSC stated R71 used the side rails when the NAs reposition her during care. The MDSC was asked should both side rails remain up after care and the MDSC stated, no. Review of the facility's policy titled, Use of Side Rails, effective December 2023, showed: Policy: It is the policy of this facility to ensure the safety and psychosocial well-being of its Residents while avoiding the use of side rails as a physical restraint. However, in review of resident's medical symptoms, the Physician and the Interdisciplinary team will review and determine through assessment the appropriateness of side rails. Procedure: 1.) Upon admission/readmission the resident will have a side rail screen assessment to evaluate the individual need for side rails. 2.) In addition, a side rail screen assessment will also be completed with each quarterly and annual assessment to determine the continued need for side rails. 3.) The side rail screen assessment will also be completed when deemed necessary and appropriate between regular assessments. 4.) Side rails will be used for safety when assessed as appropriate and documented as necessary: a. documented medical diagnosis, i.e., Seizure Disorder, Multiple Sclerosis, Parkinson disease, Hypotensive episodes. b. behavioral symptoms may include repetitive physical movements. c. Psychiatric diagnosis requiring psychoactive medications which may have the potential to cause disturbance in balance or vertigo. d. Severe cognitive loss as associated with the end stages of Dementia where safety awareness is absent. 5.) Staff may utilize side rails while care is provided to enable the resident to assist in their ADL's. 6.) Half side rails or one (1) side rail may be utilized for residents who require/request an assist device in promoting bed mobility or enhance a resident's ability to be more self-sufficient. An example, half rails may assist a resident to enter or to exit their bed independently. 7.) A resident may request a side rail to facilitate their capability of entering or exiting their bed, self-positioning in a safe and independent manner. 8). The Resident and/or Responsible representative will be informed: a. Their medical condition, the potential risks and benefits considered in utilizing a restraint, not using a restraint, and alternatives to restraint use. b. It will be explained to the resident and/or their responsible representative how the restraint would benefit the resident's medical symptoms and assist in attaining or maintaining their present physical well-being, c. Also, the negative outcomes of side rail use may contribute to a decline in muscle condition, incontinence, agitation. d. Once the resident and/or responsible representative has had a discussion with the Interdisciplinary team in regard to the resident's assessment, the determined appropriate use of side rails and their care planning decision the resident and/or the responsible representative will be asked to sign an informed consent .10.) Assessment for use of side rails. a. bed mobility. b. ability to transfer between positions, does the raised side rail enable the resident to transfer. safely or does it pose a potential risk. c. restorative care to enhance and maintain abilities to stand, transfer and walk safely. d. trapeze to enhance resident's mobility while in bed. e. exercise, encouragement of active ROM, or restorative passive ROM. NJAC 8:39-27.1(a) NJAC 8:39-31.8(c)1 36190

Based on interviews, record review, and document review, it was determined that the facility failed to ensure: 1.) the emergency response system was activated to call a code, 2.) 911 was enacted, 3.) the automatic external defibrillator (AED) was utilized for a resident who was found unresponsive (Resident #7) and was a full code status (all resuscitation procedures will be provided when a person stops breathing or heart stops beating). This deficient practice occurred for 1 of 3 residents (Resident #7) reviewed for unexpected deaths and 4.) failed to ensure a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintain the appropriate CPR certification. The facility's system wide failure to appropriately track and maintain appropriate cardiopulmonary resuscitation certifications, and provide the required emergency response, posed a serious and immediate threat to the health, safety, and wellbeing of all residents who resided in the facility. A serious adverse outcome had occurred and was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on [DATE] at 1:50 PM. The IJ situation began on [DATE] at 8:00 AM when Resident #7 was found unresponsive and was identified by the survey team during an on-site survey on [DATE]. The facility submitted an acceptable removal plan on [DATE] at 8:30 AM. The removal plan was verified, as implemented, by the survey team on [DATE] at 9:30 AM. Evidence as follow: On [DATE] at 12:51 PM, the surveyor reviewed the closed medical record for Resident #7, which revealed: A Licensed Practical Nurse (LPN #1) documented a Nurse's Note (NN) on [DATE] at 16:05 (4:05 PM). The NN revealed that during rounds at 7:00 AM, Resident #7 was awake and verbal. Then by 8:00 AM, LPN #1 went to give Resident #7 medications, and the resident was unresponsive, no pulse, body a little cold CPR was done and no response, body was getting cold [SIC]. The RN PP (Director of Nursing) pronounced dead. The Admission record for Resident #7 revealed the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Living Will Declaration signed by Resident #7 on [DATE] revealed there was no life-sustaining procedures that may be withheld or withdrawn indicated if the resident had an illness, disease, or injury, or experienced extreme mental deterioration, such that there was no reasonable expectation of recovering or regaining a meaningful quality of life. The Annual Minimum Data Set (MDS, assessment tool), dated [DATE], revealed under the Prognosis section that the resident was not checked off having a chronic disease that may result in a life expectancy of less than 6 months. The Care Plan for Resident #7 was reviewed. A Problem listed was Advance Directives - Resident had an Advance Directive/Proxy dated [DATE]. The Goal was Resident #7 will continue to be informed and educated of the rights to make Advance Directives/Proxy, change it as needed, and their wishes will be followed and respected, Dated [DATE]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 9:07 AM, the surveyor interviewed LPN #1, the nurse assigned to care for Resident #7 on [DATE]. LPN #1 confirmed she was assigned to Resident #7 on [DATE]. LPN #1 stated the resident was okay, and then in the next twenty minutes, the resident went bad and that the resident was unresponsive. When she went to see Resident #7 prior, she stated that she had spoken with the resident, and Resident #7 said they were going to eat breakfast. The surveyor inquired as to what was she did when the resident was found unresponsive and asked if 911 was activated. LPN #1 stated, we did not call 911, that she went in to give the resident medications, and the resident was already gone. LPN #1 stated she was shocked, she called for help from another nurse (LPN #2), and she stated, I did everything I was supposed to do. LPN #1 stated to refer to her NN; all the information was in her notes. On [DATE] at 9:38 AM, the surveyor interviewed the DON regarding the process that is to be followed if a resident was found unresponsive. The DON stated that if a person was unresponsive, the nurse would check the resident and complete a nursing evaluation. The DON stated that if the resident was a full code, 911 would be called. The DON stated she remembered Resident #7 and that she was called in on the weekend to pronounce (confirm death) Resident #7. The DON stated she was told that Resident #7 had no vital signs, and prior, the resident was alert and oriented, and ambulatory. On [DATE] at 9:50 AM, the surveyor interviewed LPN #2. LPN #2 stated she was told by LPN #1 that Resident #7 had a problem. LPN #2 stated the resident was not on her assignment, and she had been across from Resident #7's room at the nurses' station. LPN #2 stated that LPN #1 called her into the room, and they both started CPR on Resident #7. The surveyor inquired to LPN #2 if she would call 911, and she stated, of course I would call 911. The surveyor asked LPN #2 if either nurse utilized an AED. LPN #2 stated, no, we did not use the AED because no one went and got it. LPN #2 stated she did as much CPR as she could because she was tired and had a shoulder problem. The surveyor inquired to LPN #2 if there was any documentation or a form filled out to record what was happening with Resident #7. LPN #2 stated that no form was filled out and the resident did not have a pulse, but they were still a a little warm. The surveyor inquired again about the AED. LPN #2 stated she went into Resident #7's room, and there was no AED. It was located on the first floor. LPN #2 stated that LPN #1 called her in and that there were only three nurses in the whole building. LPN #2 stated she did not know if LPN #1 had called a code overhead and stated that she and LPN #1 were the only nurses there during the code. On [DATE] at 9:59 AM, the surveyor interviewed a Registered Nurse, Nursing Supervisor (RN#1), at the first-floor nurses station. The surveyor asked RN #1 about the small red machine enclosed in a glass case and attached to the wall. RN #1 stated it is an AED, and it is used when a resident codes or was in distress. She stated we should have one on each floor but that the facility only had one. RN #1 stated that the staff would page code overhead if a resident codes or was in distress. RN #1 stated that all the nurses would go to the code, and the first floor nurse would bring the AED to the code. On [DATE] at 11:00 AM, the LHNA provided the surveyor a copy of the facility's Emergency Procedure-Cardiopulmonary Resuscitation' policy, Revised ,d+[DATE]. The Policy revealed: Policy Statement: Personnel have completed training on initiating cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for sudden [CONDITION(S)]. General Guidelines: 1. Sudden [CONDITION(S)] [SCA] is a loss of heart function due to abnormal heart rhythms (arrhythmias). [CONDITION(S)] occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden [CONDITION(S)]. Typically heart attacks are less sudden than SCA. 3. Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS includes recognizing presentations of SCA. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase the chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material. 3. Provide periodic Mock Codes (simulations of an actual [CONDITION(S)]) for training purposes. 4. Select and identify a CPR Team for each shift in the case of an actual [CONDITION(S)]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort directing other team members during the rescue effort. 5. The CPR Team in this facility shall include at least one nurse, one LPN/Licensed Vocational Nurse (LVN), and two CNAs who have received training and certification in CPR/BLS. 6. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times . Emergency Procedure-Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR. a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events . 6. All rescuers, trained or not, should provide chest compressions to victims of [CONDITION(S)]. Trained rescuers should also provide ventilations with compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. The facility did not call a code, contact 911 or utilize the AED per the facility policy. On [DATE] at 11:27 AM, the surveyor, in the presence of the survey team, interviewed the DON about completing mock codes per the facility policy. The DON stated they have not mock codes recently, and she did not provide any further information related to mock codes. The DON stated the facility educated staff on CPR, and the surveyor requested copies of LPN #1 and LPN #2's CPR certification. On [DATE] at 11:53 AM, the surveyor conducted an additional interview with LPN #2 in the presence of the survey team. The surveyor inquired about the facility process if a resident is found unresponsive. LPN #2 stated when someone is unresponsive, you would start CPR and call 911. The surveyor inquired if LPN #1 had called 911. LPN #2 stated that she didn't know if LPN #1 called 911. LPN #2 stated if they have a code, they would call a code STAT overhead. Furthermore, LPN #2 stated there were only three nurses on staff in the building that day and no Registered Nurse, I didn't hear her call. LPN #2 stated, we do mock fire drills, but not mock codes. LPN #2 stated when a code occurred that, the nurses were supposed to document it in the nurses' notes. LPN #2 stated she had CPR certification and knew how to use it. LPN #2 stated that Resident #7 had no pulse when she went into Resident #7's room, and then LPN #1 exited Resident #7's and LPN #2 began CPR completed a blood pressure and there was no reading, and stated LPN #1 talked to the DON and decided to stop CPR. LPN #2 stated they didn't have enough staff, and there was no supervisor on that weekend. On [DATE] at 12:00 PM, the DON provided the surveyor with a Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR, and AED for LPN #1, and the DON did not provide a CPR certification for LPN #2. The surveyor inquired as to the CPR training at the facility. The DON stated the facility does a CPR class at the facility, American Heart Association (AHA). The DON reviewed the CPR card provided to the surveyor for LPN #2, and the surveyor inquired how the certification met the American Heart Association training standards. The DON did not provide an explanation and stated she didn't have LPN #2's CPR card. On [DATE] at 1:42 PM, the surveyor interviewed the LNHA and DON in the presence of the survey team. The surveyor informed the DON and LHNA regarding the findings; 911 was not activated, a code was not called, and the AED was not utilized for Resident #7 when the resident became unresponsive. The DON confirmed that the staff should have utilized the AED and called 911. The DON further stated that three nurses were working that day, and the process should have been enacted. The surveyor asked the DON regarding the ability of LPNs to assess a resident or are LPNs able to pronounce death. The DON acknowledged the LHNA and stated that LPNs could not pronounce death or assess a resident. On [DATE] at 8:59 AM, the LHNA and DON were interviewed by the surveyor, in the presence of the team, regarding the facility's process of tracking the nursing staff CPR certifications. The DON stated the in-service coordinator should be tracking the CPR certifications, but she was unsure if it was up to date. The DON provided a copy of 7 Employee BLS certifications. The CPR cards provided to the surveyors included 5 AHA Provider Basic Life Support cards, including a copy of LPN #2's card. A second copy of the Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR and AED for LPN #1, and two cards for National CPR Foundation, Provider Card. The survey team requested to see the tracking system at that time. The DON stated the In-service Coordinator/Assistant Director of Nursing (IC/ADON) would provide it. Furthermore, the DON added, there had not been CPR training because of COVID. On [DATE] at 9:31 AM, the IC/ADON provided the surveyor, in the presence of the survey team, a Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log, with 20 names listed and ,d+[DATE] of the names had an X next to it. The surveyor inquired about the list provided by the IC/ADON and how the IC/ADON would know when the CPR certification expired. The IC/ADON stated she did not have expiration dates on it, and she just knew when they expired, and she would put an X next to the staff's name if they had the CPR certification. She stated that was how she tracked it, and she knew if they had the certification by when the facility offered the CPR training. She stated that some staff would forward a card if they had the training elsewhere. There were 12 more employee names on the Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log than copies of CPR cards provided by the facility. On [DATE] at 10:03 AM, the surveyor interviewed the receptionist/staff coordinator (R/SC) in the presence of another surveyor. She stated her responsibilities included putting staffing out, doing the state nursing report, room rosters, and updating admission and discharge charts. She stated she had to schedule a nurse on each shift that was CPR certified. The surveyor inquired how the R/SC would know what nurses were CPR certified. The R/SC stated the IC/ADON had a list of CPR certified staff and stated if the CPR certification was done outside of the building, the staff would bring it in. The surveyor showed the R/SC the undated list of BLS certifications provided by the IC/ADON and inquired to the R/SC if that was the list she utilized. The R/SC stated she utilized a different list with the staff name and the expiration date. The surveyor inquired to the R/SC if a specific type of CPR certification was required. The R/SC stated she was unaware of the type of CPR certification required for nursing staff. She completed a schedule every four weeks and did not look at the CPR certified list every time she completed a schedule; she looked at it every few months. The R/SC provided the surveyors with a list of all Active Employees, Nursing, which included 12 LPNs, 41 Certified Nursing Assistants (CNA), and 8 Registered Nursed (RN). On [DATE] at 10:28 AM, the IC/ADON provided the surveyor with two more CPR cards. Her AHA Provider Basic Life Support CPR card included one AHA Provider Advanced Cardiovascular Life Support Card. There were 10 more names on the Plaza Healthcare and Rehab Center BLS Log than CPR cards provided. The DON was not listed on the list. On [DATE] at 11:11 AM, the surveyor interviewed the DON in the presence of another surveyor. The surveyor asked the DON why she was listed as the 7:00 AM- 3:00 PM (day shift) RN on the day that Resident #7 became unresponsive. She stated she was not in the building that day, and she was on call. The DON stated that the facility did not have a charge nurse on the schedule that day. She stated that they usually would, but she would be on call if they don't have enough staff. Asked why she was not in the building on ,d+[DATE] since she was scheduled from ,d+[DATE], the DON stated that she was on call that day and confirmed that she was on the list as the RN. On [DATE] at 12:01 PM, the R/SC provided the surveyor with a copy of an undated Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log (Log) that she would utilize to make the schedule. The Log revealed 19 nursing staff with an X next to ,d+[DATE] nursing staff. In the column next to the X was an Issue Date, and next to that, Renew By. Five out of the nineteen nursing staff did not have a date listed in the Issue Date and Renew By columns. The surveyor reviewed the Log provided by the DON on [DATE] at 12:00 PM and compared it to the nursing staff schedule for the date Resident #7 required CPR. Both LPN #1 and LPN #2 were on the R/SC's list as having had BLS training. The LPN (only nurse) assigned to the 1st floor on the same date was not listed as having BLS training. On the day Resident #7 coded, five out of thirty-four nursing staff scheduled were listed on the R/SC's list as having had BLS training. On [DATE] at 1:32 PM, the surveyor, in the presence of two other surveyors, conducted a telephone interview with the Medical Director (MD), who was also the attending Physician for Resident #7. The surveyor inquired if she was aware that all of the nursing staff were not CPR certified. She stated she was not aware and assumed that the supervisors knew CPR. The surveyor asked the MD if it was important for nursing staff to have current, appropriate CPR certification. The MD responded, yes, they should, and all nurses should have CPR certification. The MD stated that she was not aware that all staff did not have appropriate or current CPR certification. Review of the Unit Coordinator/Charge Nurse (Registered Nurse/LPN) Job Description indicated that it is the Unit Coordinator/ Charge Nurse responsibility to direct, monitor, and supervise all staff assigned to the unit, to ensure Quality of Care and Quality Life for each resident, to exercise good judgment and to respect confidential matters. The direction of staff will ensure that care and services will be delivered in compliance with all Federal, State, and local requirements and facility policies and procedures. Evaluates emergencies and determine the immediate measures to be implemented according to standards of practice. Communicated all emergencies to the Director of Nursing/ADON and/or designee. Scope of Supervision: Responsible for all nursing staff assigned to the unit and coordinate quality of care and quality of life for every resident residing on the units all shifts. NJAC 8:,d+[DATE].1 (31)iii, 9.6 (g)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility 1.) failed to ensure: that the facility policy for Accident/Incident Reports was followed to determine the causal factor and to update interventions to prevent recurrent falls, for a visually impaired ambulatory resident who was identified as a high fall risk, and sustained multiple falls, including a fall that resulted in a head injury on [DATE], and 2.) failed to ensure; that the emergency crash cart (a set of trays /drawers /shelves on wheels) used for transportation and dispensing of emergency medications and equipment, was secured and not easily accessible to residents and non-licensed staff. The deficient practice occurred for 1 of 2 residents (Resident #57) reviewed for falls and for 1 of 2 crash carts inspected (2nd floor). The deficient practice was evidenced by the following: 1. On [DATE] at 10:41 AM, the Surveyor observed a resident wandering unassisted in the hallway, holding on to different wheelchairs that were in the hallway to move from locations. The surveyor alerted the staff of the resident, Resident #57. A Physical Therapist was in the other hallway assisting another resident. He escorted Resident #57 to the room and stated that Resident #57 was confused and communicated in Spanish only. The surveyor reviewed Resident #57's clinical record on [DATE] which revealed that Resident #57 had a history of falls. Further review of the clinical record, Admission Record, revealed that Resident #57 was admitted to the facility with diagnoses which included, but were not limited to, hypertension, cerebral infarction due to embolism, and [CONDITION(S)] one eye, unspecified eye, fracture and history of falling. The Quarterly Minimum Data Set (MDS - an assessment tool) dated [DATE], revealed Resident #57 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe impaired cognition. A review of the facility provided Fall Scale, dated [DATE], revealed Resident #57 scored a 65 which indicated a high fall risk on the Morse Fall Scale. An interview with the Certified Nursing Assistant (CNA) who cared for Resident #57 on [DATE] at 9:15 AM, revealed that Resident #57 spoke Spanish only, needed assistance with care, and wandered at times. The surveyor reviewed Resident #57 's care plan and noted a fall Care Plan initiated on [DATE]. The goal was for Resident #57 to be free from injury related to falls. A review of the on-going Resident Care Plan revealed a problem area of high risk for falls r/t [related to] vision problems, impaired cognition at times, weakness, h/o [history of] carotid stenosis, hx of falls, [CONDITION(S)] drug use. Goals included will remain free from injury related to fall, date initiated [DATE] and will be free of falls through the review date, target date [DATE]. Interventions included but were not limited to hand-held during ambulation and ensure wearing shoe properly. A review of the Certified Nurse Aide Care Card revealed under Mobility, that Resident #57 required staff assistance of at least one staff member, used a walker, and for handheld assist with ambulation, dated [DATE]. The Resident Care Plan revealed the following: Fall on [DATE], Fall on [DATE], Actual fall on [DATE], Actual fall on [DATE], Actual fall on [DATE] in room, [DATE]- found on the floor in the hallway. (The facility did not identify the causal factor after each fall or implement meaningful interventions to minimize falls. The facility did not indicate/update the care plan how Resident #57 would be supervised to prevent further falls.) On [DATE] at 10:21 AM, the Surveyor, in the presence of another surveyor, interviewed the DON regarding Resident #57's falls and the Care Plan interventions. The DON stated that the care plan should be implemented upon admission, quarterly, and on day 14 of admission to ensure proper care was delivered, identified, and any problems were addressed. The DON stated the care plans should be updated as soon as possible. The DON further stated for a resident identified as a risk for falls, the care plan should be revised after each fall and stated: we don't leave it the same, and after each fall, interventions should be revised. The surveyor asked the DON if falls would be investigated; the DON stated, if it is needed, we investigate. The surveyor asked the DON to clarify her statement regarding interventions needing to be revised after each fall. The DON stated they either revise the intervention or add something new after a fall. They do not leave it the same. On [DATE] at 11:35 AM, the facility provided, Job Description - Staff Nurse, not dated, which included but was not limited to: Care Plan and Assessment Functions: review care plans daily to ensure that appropriate care is being rendered; inform the charge nurse of any changes that need to be made on the care plan; ensure that your nurses' note reflect that the care plan is being followed; review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs; and ensure that your assigned nursing assistants are aware of the resident care plans and that they are being used in administering daily care to the resident. On [DATE] at 9:05 AM, the Surveyor requested all investigations for Resident #57 and a timeline regarding the resident falls with interventions. On [DATE] at 12:56 PM, the DON provided the Surveyor with the following investigations and a Fall Investigation Summary. The Fall time line with interventions implemented after each fall was not provided. The Investigations did not include an investigation for [DATE] and [DATE]. The investigations revealed: -A type-written Fall Investigation Summary dated [DATE]. A Description of Event: A noise was heard in the hallway and found resident sitting on the floor with the rolling walker at his/her side. Right eye was discolored and blood noted between gum and teeth. No other injury noted and resident was able to walk with assistance post fall. Ice pack applied to head. MD gave order to tranfer to the hospital. Medical Data: Resident had Dementia and did not realize his/her limitations and walked with the rolling walker on the unit. Resident has [CONDITION(S)] to left eye. Investigation Summary: The Resident was found in the hallway and he/she lost his/her balance and fell . He/she was tired and wanted to sleep. The Resident was sent to the hospital and admitted with fractured rib related to fall. Plan: Staff to redirect resident to his/her room and offer rest when seen him/her walking in the hallway. -An Un-witnessed Incident report dated [DATE] at 13:31 (1:31 PM), Nursing Description: Resident was found on the floor sitting up right in his/her room next to his/her bed with one shoe on right foot. Immediate Action Taken: No visible injury noted, vital signs take, complained of pain to right femur. Mobility: Ambulatory with assistance. Staff to assist with shoe when seen looking for shoe. Offer toileting after and before meal and bedtime. -An Un-witnessed Incident report dated [DATE] at 11:45 AM, Incident Description: Nursing Description: Resident was seen sitting on the floor in front of the room. Resident was assessed and no apparent injury, complained of pain to lower back. Mobility: Ambulatory with assistance. Immediate Action Taken. Resident to walk in hallway when seen getting up from bed or chair. - An unsigned Investigation for Unknown Injuries, dated [DATE], Nature of Injury: Hematoma on Rt. [right] side forehead. Three nurses and three certified nurse aides have documented hand written statements on the form which revealed that none of the staff witnessed anything. Conclusion: No unusual occurances noted by staff. Resident does not recall anything due to cognitive impairment. Resident ambulatory and has unsteady gait. Refer to therapy. -An Incident report dated [DATE] at 11:46 AM, Incident Description. Nursing Description: During change of shift and making rounds resident was noted with a small hematoma on his/her right side. When resident was asked he/she was noted with a small hematoma on right side of forehead. Resident thought bumped head and was not sure. Denied falling. Injury Type: No injuries observed post incident (The hematoma was not listed). An Investigation Summary dated [DATE] and signed by the Assistant Director of Nursing and Administrator revealed a Description of Event: at [DATE] at 1:00 PM, a Nurse heard a thud in the hallway and noted the resident lost his/her balance. The resident had a bump on the right forehead and complained of right knee pain. Resident had CAT (computer assisted tomography) scan of head and facial bone. Results revealed Subcutaneus anterior frontal soft tissue swelling, no bleeding. Plan: keep in supervised area when possible. Staff will do rounds more frequently when the Resident is in bed. -An Un-witnessed Incident report dated [DATE] at 15:40 PM (3:40 PM), Incident Description: Nursing Description: Resident noted lying in hall way floor. Noted bump on right forehead. Resident Description: Stated while he/she was walking lost his/her balance. Injury Type: No injuries observed post incident (The bump was not listed). There was no witness to the fall. There was no staff statements that would indicate when Resident #57 was last seen/checked. Resident #57 was evaluated at the hospital and diagnosed with subcutaneous anterior frontal soft tissue swelling. On [DATE] at 9:55 AM, the Licensed Nursing Home Administrator (LNHA) provided the, Care Plan - Interdisciplinary Team, policy revised 2008, which included but was not limited to: Our facility's Care Planning / Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning / Interdisciplinary Team which includes but is not limited to the following personnel: h. the Director of Nursing k. others as appropriate or necessary to meet the needs of the resident. On [DATE] 10:30 AM, the Surveyor interviewed the DON, in the presence of another Surveyor. The surveyor inquired as to what is done after a resident falls. The DON stated that after each fall, we should look at the Care Plan and the fall interventions should be revised. The DON stated we don't leave it the same. The DON then stated and confirmed that we either revise the interventions or add something new after a fall that they do not leave the interventions the same. On [DATE] at 12:18 PM, the above concerns were brought to the attention of the LNHA and DON by the Surveyor, in the presence of the survey team. The facility had no additional information to provide which included the missing investigations and a timeline of resident falls including interventions added or revised as stated by the DON. On [DATE] at 11:40 AM, the DON provided a revised care plan and could not provide the rationale for not having a previously updated care plan. Upon further inquiry, the DON stated that all staff should update the care plan. 2. On [DATE] at 12:20 PM, the surveyor observed the crash cart in the hallway on the second-floor unit. The top drawer was ajar, exposing some supplies. The seal to secure the crash cart was broken. Upon further inspection, the surveyor noted that the crash cart contained other supplies that should not be easily accessible. A pair of bandage scissors was observed in the top drawer. The second drawer contained syringes and needles. The 3rd drawer contained intravenous tubing, distilled water solution, 0.45 Normal saline solution, and multiple expired items. That same day at 12:25 PM, the surveyor alerted the Licensed Practical Nurse (LPN) and inquired about the crash cart. The LPN indicated that the 11:00 PM -07:00 AM shift was responsible for checking the crash cart and ensure that the crash cart was secure. The LPN stated that she could not provide any information. On [DATE] at 12:20 PM, the surveyors witnessed a verbal outburst in the common area of the hallway adjacent to the second-floor nursing station. Resident #60 picked up the lunch tray and threw it on the floor because he/she could not understand the roommate who was speaking in Spanish. The resident was very agitated. The social worker and other facility staff witnessed the verbal outburst. That same day at 12:55 PM, the Director of Nursing (DON) arrived on the floor and observed the unlocked crash cart was in the common area. The DON revealed that the cart should not be left open for safety reasons. The DON stated that the crash cart should have been secured and locked at all times. Upon further inquiry, the DON revealed that the 2nd floor housed residents diagnosed with Dementia and residents with behavior issues. The DON stated clearly that the crash cart was to be locked and secured at all times for safety. The facility provided policy titled, Crash Cart Policy with a date of [DATE], indicated that the crash cart inventory and testing would be done by the 11:00 PM-7:00 AM floor nurse daily. When the crash was cart to be found to have a broken red tag, the 11:00 PM-7:00 AM nurse would conduct inventory of the existing contents and would refill the cart. The policy also indicated that expired items would be removed and replaced and that the crash carts must be locked whenever the cart was not in use. When the crash carts were opened to use, staff would keep the carts near them and always under direct supervision. A review of the undated facility policy titled Accident/Incident Reports indicated that all accidents and incidents occurring on the facility's premises must be reported. An incident is any occurrence not consistent with the routine operation of the facility's normal care of the resident, a happening involving visitors, malfunctioning equipment, or observation of a condition that might become a safety hazard. Purpose: To provide a safe and helpful environment for residents, visitors, and employees. 1. Reporting of Accidents/ Incidents: Regardless of how minor an accident or incident may be, it must be reported to the department Supervisor and appropriate documentation completed on the shift that the accident or incident occurred. Employees witnessing an accident or incident involving a resident, employee, or visitor must report such occurrence to his or her immediate supervisor immediately. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance; Any unwitnessed accident/incident must be investigated for potential abuse, neglect, negligent treatment, misappropriation, or exploitation. The supervisor must be informed of all accidents or incidents so that medical attention can be provided if necessary. Documentation and Investigation Action: The charge nurse/ and or the Department Director/ Supervisor must document the incident and conduct an immediate investigation of the incident or accident. The specified Accident/ Incident Form will be used for residents, employees, and visitors. Witnesses, if any, will also be documented in the report. The address and telephone number of the witnesses will be documented. Every attempt will be made to ascertain the cause of the accident/ incident. The Administrator and the Director of Nursing will be aware of such incidents occurring in the facility and will review completed reports. If any accident is of a serious nature, medically or suspected abuse, neglect, negligent treatment, misappropriation, or exploitation, it shall be reported by telephone immediately regardless of time or day. The administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident. The administrator is responsible for coordinating the investigation and assuring that appropriate action is taken. Conducts interviews, collects written statements from all staff or visitors involved in the situation. Completed accident/incident reports and investigation forms must be submitted within 24 hours to the administrator and the Director of Nursing. NJAC 8:,d+[DATE].4(e)(f)(g)(h) 27.1(a) 33.1(d) 11.2(2)(3)i

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the facility visitation process did not restrict visitation as per executive directive from Center for Medicare Services (CMS) QSO-20-39-NH revised 11/12/2021. This deficient practice was identified for 1 of 18 residents (Resident #5) reviewed. The deficient practice was evidenced by the following: On 02/28/22, at 9:45 AM the surveyor toured the second floor of the facility. Resident #5 approached the surveyor and requested information regarding visitation. On 02/28/22 at 10:28 AM, during the entrance conference with the Administrator (LNHA) and the Director of Nursing (DON), the DON stated that visitors must be tested for COVID-19. The LNHA interjected, and stated, that the visitor was not forced to test. On 03/03/22 at 8:08 AM, upon the Survey team entrance to the facility, the Receptionist was interviewed regarding the process for a visitor upon entrance. The Receptionist stated they [visitor] signed in and they have to do a rapid [COVID-19 test]. The Survey team observed boxes of COVID-19 rapid tests located at the reception desk. When inquired as to what happened when a visitor refused to test, the Receptionist stated that no one had ever refused. She stated the Social Worker (SW) had sent out a notice to the families about the rapid test and they signed an informed consent. On 03/03/22 at 12:47 PM, Resident #5 stated that he/she would like to visit with his/her family, but the facility required a COVID test prior to visitation and the family refused to comply. Resident #5 stated that due to his/her Diabetes (a disease where the body doesn't process blood sugar effectively), he/she had [CONDITION(S)] (weakness, pain, and numbness from nerve damage-usually in hands and feet) and could not wash properly. Resident #5 stated that his/her daughter who was a certified nurse aide would come and assist at times with care. Resident #5 stated that due to the restriction imposed by the facility the family member had not been able to visit him/her. The surveyor reviewed Resident #5's medical record which revealed the following: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated dated [DATE] (MDS), an assessment tool used to identify and prioritize care, revealed that Resident #5 was able to make his/her needs known. Resident #5 scored 12 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. On 03/04/22 at 9:56 AM the Surveyor reviewed the facility provided notice sent out by the facility. The notice provided, dated 01/18/22, confirmed that visits were scheduled daily from 10:30 AM -11:30 AM on the first-floor dayroom. On 03/04/22 at 10:05 AM, Resident #5 told the surveyor that the family had not been in to visit since January because of the new requirements for testing. During the last visit, the Administrator told the family that based on directives received from the Department of Health (DOH) visits must be scheduled and family must have a COVID-19 test upon entrance to the facility. Resident #5 stated that the Administrator did not provide the family with the directive and stated that he can impose the rules as he pleased for the facility. On 03/04/22 at 10:15 AM, the Surveyor conducted a telephone interview with the family member (FM) of Resident #5. The FM stated that she was very frustrated about not being able to see her loved one as she would like to. The FM stated that during the last visit, the Director of Nursing (DON) and the Social Worker (SW) told her that she had to have a COVID test done prior to visiting. The FM refused to take a COVID test, and the FM had not been allowed to visit since that time. On 03/04/22 at 11:15 AM, the Surveyor conducted a follow up telephone interview with the FM of Resident #5. The FM stated that she did not get a letter from the facility regarding the visitor restrictions. She stated that she visited last in January and was told that she had to be tested based on DOH directives. She further stated that when she asked for the DOH directive, she was informed that the facility did not have to provide her with any proof. She stated that when she visited in January the facility attempted to administer a COVID-19 test to her without her consent. On 03/04/22 at 11:30 AM, the Surveyor interviewed the SW. The SW stated that families were notified in writing monthly of the facility's visitation. The SW stated that Resident #5's family had not contacted anyone at the facility to request a visit and that the Activity Director (AD) oversaw scheduling visits. On 03/04/22 at 11:35 AM, the Surveyor interviewed the Administrator (LNHA) about the referenced directive. The LNHA stated that the directive was from DOH. He further stated that visitors must have a COVID-19 rapid test to be able to visit with family. When inquired about the current guidelines distributed by Centers for Medicare and Medicaid Service, the LNHA provided the Surveyor, at a later time (12:55 PM), with the Executive Directive No. 21-021 dated 11/24/2021. The Directive which revealed under Visitor Testing section (i) (ii) the following was revealed: Consistent with QSO-20-39-NH, facilities in counties with substantial or high level of community transmission are encouraged to offer testing to visitors. If they do not, facilities should encourage that visitors be tested on their own within 2-3 days before coming to the facility. Non -CMS certified facilities should follow this same recommendation. visitors are not required to be tested or vaccinated as a condition of visitation. On 03/04/22 at 11:45 AM, the Surveyor interviewed the AD. The AD confirmed that visits were by appointment only and visitors must sign the consent. The AD further explained that all visitors were to have their temperature taken, a COVID-19 questionnaire screening, must wear masks, and have a COVID-19 test administered upon entrance. She further stated that visits were handled by the SW and her role was only to schedule the visits. She stated the visits were scheduled daily in an activity room on the first floor for one hour. She stated she was told by the SW that was an administrative decision. On 03/04/2022 at 12:30 PM, the surveyor reviewed the facility provided consent form, dated 06/20/20. The content indicated that the center [referring to the facility] reserves the right to limit the length of any visit, the days on which visits will be permitted, the hours during a day when visits will be permitted, and the number of times during a day or week a resident may be visited. On 03/04/2022 at 12:19 PM the SW provided a letter dated 01/18/2022 that was forwarded to the family and friends. The following were noted: We hope that this letter finds you and yours in good health. We appreciate your understanding and patience as we make every effort to keep our resident safe during this COVID-19 pandemic. While we recommend no visitation at this time, we are pleased to inform you that we will be allowing in-person, in-door visitation in our First Floor Day Room. We need you to note the following guidelines and procedures for the visits- 1. Visits will be scheduled and by appointment only. Please call our recreation department in advance at #908 [-000-0000]; extension [#0000] or by email. 2. Visitation will be scheduled daily between 10:30-and 11:30 AM. 3. During your visit, you should always wear a face covering mask and maintain social distancing and infection control standards. 4. Upon your arrival at the lobby, you will meet with a staff member who will assist with your COVID-19 screen. 5. Please do not visit if you are sick, having elevated temperature, [CONDITION(S)] symptoms or not feeling well. 6. You are asked to notify the facility ASAP if you test positive for COVID-19 or exhibit any symptoms of COVID-19 within 14 days of your visit. On 03/06/22 at 12:45 PM, the Surveyor conducted an interview with the DON. The DON stated that the SW handled visitation in the facility and the AD was responsible to schedule the visits. The DON stated there was no COVID in the facility and they tried to keep all residents safe. On 03/06/22 at 12:55 PM, the Surveyor conducted a subsequent telephone interview with the FM. The FM stated that she had not visited since January. She stated she was notified of the visit's requirement upon the last visit and she was not allowed to return upstairs since she refused the COVID-19 test. She stated she did not receive a letter from the facility regarding the visit requirements from the DOH. On 03/08/22 at 9:13 AM, the surveyor interviewed the SW. The SW stated that all residents were provided with a Resident Bill of Rights and a meeting was held and the Bill of Rights was explained. The SW stated that those who were not in attendance received a copy and a packet was also sent to the family. The SW was asked to elaborate further regarding the visitation process. She stated that she emailed a copy of the letter to all families. The SW stated that any resident that was unable to go downstairs would have to comply with testing. She stated that based on what she knew the family should be allowed to visit. The Surveyor inquired if the families were clear on the rules and requirements about the visitation rules, and the SW stated that the information was sent monthly to the families. On 03/09/22 at 8:03 AM, upon entrance to the facility, the Survey team inquired regarding visitation and the Receptionist stated that visits were by appointment only. On 03/10/22 at 9:50 AM, the Surveyor interviewed the AD regarding visitation time and duration. She stated that visits were scheduled daily from 10:30 AM -11:30 AM downstairs so social distancing could be observed. She stated that the room used for visits also was used as a resident activity room for the first floor. The AD stated they could not infringe more on resident rights due to the utilization of the room for visitation instead of the activities room. According to the Executive Order QSO-20-39-NH revised 1/2021 CMS is providing clarification to recent guidance for visitation (see CMS memorandum QSO-20-39-NH REVISED 11/12/2021). While CMS cannot address every aspect of visitation that may occur, we provide additional details about certain scenarios below. However, the bottom line is visitation must be always permitted with very limited and rare exceptions, in accordance with residents' rights. In short, nursing homes should enable visitation following these three key points: Adhere to the core principles of infection prevention, especially wearing a mask, performing hand hygiene, and practicing physical distancing. Don't have large gatherings where physical distancing cannot be maintained; and Work with your state or local health department when an outbreak occurs. Centers for Medicare and Medicaid Services (CMS) Reference: QSO-20-39-NH revised 11/12/2021 reflected the following information regarding visitation in nursing homes: While CMS guidance has focused on protecting nursing home residents from COVID-19, we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their loved ones. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting. CMS understands that nursing home residents derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends. In light of this, CMS is revising the guidance regarding visitation in nursing homes during the COVID-19 PHE. The information contained in this memorandum supersedes and replaces previously issued guidance and recommendations regarding visitation. Facilities must always allow indoor visitation and for all residents as permitted under the regulations. While previously acceptable during the PHE, facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Although there is no limit on the number of visitors that a resident can have at one time, visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents. Facilities should ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunch time, after business hours, etc.). Also, facilities should avoid large gatherings (e.g., parties, events) where large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained. During indoor visitation, facilities should limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident ' s room or designated visitation area. Facilities may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission. While it is safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility. Visitors should be made aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention. If residents or their representative would like to have a visit during an outbreak investigation, they should wear face coverings or masks during visits, regardless of vaccination status, and visits should ideally occur in the resident ' s room. Facilities may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation. The Admission Packet provided by the facility on 03/01/22 revealed a copy of the Resident's Bill of Rights which revealed: Residents must be informed of all rights as follows: 11. Resident may associate and communicate privately with persons of his or her choice, may join with other residents, individuals within or outside of the facility to work for improvements in resident care . 16. The resident is assured of established daily visiting hours. 19. The resident is allowed privacy for visits with family, friends, clergy, social workers, or for professional or business purposes. NJAC 8:39-4.1(a) 23 NJAC 8:39-4.1(a) 23

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to conduct performance evaluations in a timely manner and to provide documented education for areas of improvement identified on the performance evaluations, for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #5) reviewed. This deficient practice was evidenced by the following: On 03/02/22 at 8:13 AM, the Surveyor requested the CNA performance evaluations and education information from the Registered Nurse (RN) Staff Educator. On 03/02/22 at 10:11 AM, the RN Staff Educator provided the Surveyor with some CNA competencies and nothing else. The RN Staff Educator stated that the in-services she had provided the surveyor are the yearly education for all CNAs. The Surveyor explained there was missing information. The Surveyor explained to the RN Staff Educator that the survey team needed to review the performance evaluations and the educational information for the CNAs. On 03/03/22 at 8:35 AM, the facility had not provided the information on the CNA performance evaluations and education. On 03/03/22 at 1:56 PM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were in the conference room with the survey team. The Surveyor asked again for the CNA performance evaluations and education. On 03/04/22 at 8:07 AM, the Surveyor observed a folder left in the conference room that contained the performance reviews for the five CNAs with areas targeted for improvement but no corresponding education for the improvements was identified. A review of the facility provided, CNA Certification Log, dated 2/28/22, included a hire date for all employed CNAs. The log contained the following hire dates for the 4 CNAs. CNA #1 09/14/2018 CNA #2 08/27/1987 CNA #3 03/05/2001 CNA #5 10/02/2021 A review of the facility provided, Performance Evaluation-Certified Nursing Assistant, revealed the following annual review dates and evaluation keys: CNA #1 had an annual performance review on 10/14/21, on month past the date of hire. CNA #1 was noted to have an objective partially met of conducts periodic resident care and unit checks with appropriate documentation, along with charge nurse. The areas targeted for improvement: educated the importance of documentation. The facility failed to provide the educational information specific to the performance evaluation. CNA #2 had an annual performance review on 10/28/21, two months past the date of hire. CNA #2 was noted to have an objective partially met of conducts periodic resident care and unit checks with appropriate documentation, along with charge nurse and verifies all residents have wrist bands, education, picture and door tags. The areas targeted for improvement: educated the importance of documentation, also to report if missing door tags/name bands. The facility failed to provide the education information specific to the performance evaluation. CNA #3 had an annual performance review on 11/12/21, eight months past the date of hire. CNA #3 was noted to have an objective partially met of verifies all residents have wrist bands, medication, picture and door tags. The areas targeted for improvement: educated to report if resident is missing wrist band, door tags. (The facility failed to provide the education information specific to the performance evaluation). CNA #5 had a 90 Day performance review on 12/6/21, one month short of the 90 Day review date. The facility failed to provide another performance evaluation at the 90-day mark from the date of hire. A review of the facility provided, Policy and Procedure on Nurse Aide training and Performance review, revised 10/21, included but was not limited to the following: Policy - a program shall use a performance record/skills performance checklist which shall include: 1) a record of when the trainee performs the duties and skills and the determination of satisfactory or unsatisfactory performance. Procedure - nurse staff educator will provide the annual in-services as required by DOH [Department of Health]. Performance evaluations will be conducted 90 days after the start of employment and on an annual basis and as needed. On 03/10/22 at 12:18 PM, the above concerns were brought to the attention of the LNHA and the DON. The facility failed to provide any additional information. NJAC 8:39-43.17(b)

Based on observation, interview, and policy review it was determined that the inactions in administration of the facility contributed to the facility failure to ensure: a.) the visitation process did not restrict visitation and complied with executive directive from Center for Medicare Services (CMS) QSO-,d+[DATE]-NH revised [DATE], b.) allegations of abuse were investigated and reported to the State Survey Agency (SSA), c.) the facility followed the facility Policy and Procedure (P&P) for Abuse Identification and Prevention, d.) a system for staff education and monitoring for Basic Life Support/CPR was in place after an adverse resident event occurred, e.) that nurse aides received the minimum required number of in-service hours and annual performance evaluations, f.) the facility developed quantitative and measurable goals for Quality Assessment and Performance Improvement (QAPI) , and g.) Antibiotic Stewardship was being conducted to track and monitor antibiotic use. This deficient practice was evidenced by the following: Reference 678L The Department of Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on [DATE], including the Immediate Jeopardy Template. A revised Immediate Jeopardy Template was provided to the Facility Administrator on [DATE]. The Facility failed to: -ensure staff initiate an emergency response system, failed to call 911 and failed to utilize the facility defibrillator when a resident was found unresponsive. -ensure a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintained the appropriate CPR certification. On [DATE], the Department of Health received an acceptable allegation for the Removal of Immediate Jeopardy and determined that the Immediacy of the Jeopardy could be removed, effective [DATE]. The facility submitted an acceptable removal plan on [DATE] at 8:30 AM. The survey team verified the removal plan onsite on [DATE] at 9:30 AM, which removed the immediacy. The non-compliance for F678 remained as of [DATE], for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Reference: F563, F609, F610, F730, F867, F881) a.) The facility administrator (LNHA) failed to ensure that facility residents were able to have visitation in accordance with the regulatory guidance. On [DATE] at 11:08 AM, the Surveyor interviewed the LNHA about the current facility visitation process. The LNHA stated that visiting hours were based on when the recreation staff was in the facility. The LNHA stated the residents were allowed visitors and that was only by appointments. The LNHA stated that the visitation would occur only in a downstairs area and not allowed in the resident rooms. b.) Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: report to the New Jersey Department of Health (NJDOH) an allegation of resident-to-resident abuse that occurred on [DATE] and b.) develop the facility's Policy on Resident Abuse policy in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. At 12:29 PM, in the presence of the survey team, the Surveyor inquired to the DON if Resident #258's allegation of abuse was reported to the NJDOH. The DON stated that it was not reported. She added that the investigation concluded that the incident was not witnessed and that the incident was fabricated. The Surveyor then inquired to the DON if any allegation of abuse, whether it happened or not, was required to be reported. The DON stated that any allegation of abuse should be reported. On [DATE] at 11:23 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) confirmed that Resident #258's allegation of abuse was not reported to the NJDOH and that the allegation should have been reported. The Surveyor then asked the LNHA when an allegation of abuse should be reported to the NJDOH. The LNHA stated that an allegation of abuse should be reported immediately. c.) Based on interview, record reviews and reviews of pertinent documentation obtained from the facility, it was determined that the facility failed to thoroughly and timely investigate and report an allegation of abuse to the State Agency. This deficient practice was identified for 2 residents, Resident # 60, and Resident #258. It was reported by nursing that on [DATE] in the evening, there was an argument between Resident #60 and the roommate, Resident #60 was moved to room [ROOM NUMBER]. The Social Worker (SW) and DIrector of Nursing (DON)interviewed the residents- Resident #60 reported that he/she was in bed when his roommate came to him/her saying that I stole his/her money and that I have his/her bank account. He/she reports that he/she looked for the money on my but and under my pillow and admitted I hit him/her on the shoulder he/she did not hit me, three nurses came. Resident #60 also stated to the SW that he/she [referring to the roommate] was looking for a driver license . The roommate was interviewed and stated that I really don't know; no one told me anything and denied any wrongdoing. A review of the 24-hour Report dated [DATE] indicated the following the roommate constantly standing by Resident #60's bed stated he/she took his/her money, bank account and car's key. All evening the roommate refused to stay on his/her side of the bed. By 10: 00 PM, Resident # 60 was moved to room [ROOM NUMBER]. The facility did not investigate further to rule out any abuse /misappropriation of funds. There was no late entry made regarding the incident in the clinical record on ,d+[DATE], ,d+[DATE]. An entry was entered on [DATE] at 12:58 PM and indicated that a verbal exchange took place. The surveyor reviewed the electronic progress notes. There was no documentation that the family and the physician were contacted on [DATE] following the incident. On [DATE] at 9:45 AM, during an interview with the DON regarding the incident, the DON stated that she agreed the documentation was lacking. The incident was not entered in the clinical record. The DON submitted a written note and 2 written statements from the nurse and the Certified Nursing Assistant. None of the entries revealed that Resident #60 was involved in a physical altercation. There was no documented evidence that both residents were interviewed and assessed. On [DATE] at 12:15 PM, the surveyor again interviewed the DON regarding the process. She stated that the incident should have been entered in the Progress Notes. She would not elaborate on the time that she was made aware of the incident nor the rationale for the missing documentation in the clinical record. On [DATE] at 11:26 AM during a pre-exit conference with the Administrator and the DON, the DON stated that all allegations of abuse should be investigated and reported immediately. On [DATE] at 11:34 AM, the surveyor reviewed Resident #258's electronic Progress Notes (ePN) which included the following note dated [DATE] at 6 PM: Resident reported to writer that resident across the hall from his/her room hit him/her on the left forehead with a cane when he/she went to the residents' room at 5 pm to approach him/her for taking his/her snacks from the TV room. Left forehead assessed and no redness, no raised area and non-tender to touch. Resident stated he/she does not need writer to do anything, stated that's too much paperwork. Writer reassured resident to check his/her forehead again for any injury. On [DATE] at 11:00 AM, the surveyor asked the DON to provide any incidents that were required to be reported to the Department of Health (DOH) state during the month of February 2022. At 1:41 PM, the DON stated that the facility only had one reportable incident in February. She added that the incident happened yesterday ([DATE]) and that she was faxing it today to the DOH. On [DATE] at 8:27 AM, the surveyor interviewed Resident #258. Resident #258 stated that the unsampled resident was a thief and that the unsampled resident hit him/her with a cane on [DATE]. At 12:29 PM, in presence of survey team, the Surveyor asked the DON if the Incident Interview was the full thorough investigation. The DON stated that this was the incident that was reported to us. She added that at the time of the incident Resident #258 did not report that he/she was hit by the other resident. She stated that the next morning Resident #258 reported to her that he/she was hit by the other resident. The DON then stated when she spoke with Resident #258, the resident told her that he/she spoke to a Nurse after the incident and told the Nurse. The DON added that she called the Nurse and that the Nurse told the DON that she checked Resident #258 and that he/she had no marks. The surveyor asked the DON if the Nurse had made a written statement. The DON stated that the Nurse told her verbally and that she did not write it. The surveyor asked if there was anything else documented regarding the investigation. The DON stated that they did not have anything else written up. The DON stated that the Nurse investigated the incident on [DATE] but that the nurse did not report it to us. The surveyor asked the DON if the investigation done by the Nurse was documented. The DON stated that the investigation done by the Nurse was not documented. The DON stated that the Nurse checked with other residents that were in the area but that she did not document the interviews. The DON confirmed that the Nurse should have taken statements from the residents and documented it. The DON could not provide documentation of a thorough investigation that included statements from residents and staff. On o3o/,d+[DATE] at 10:18 AM, the Licensed Nursing Home Administrator (LNHA) confirmed that a full thorough investigation was not completed at the time of the allegation of abuse, and that on [DATE] the facility added additional documentation to the investigation. e.) Based on interview and review of pertinent facility documentation, it was determined that the facility failed to conduct performance evaluations in a timely manner and to provide documented education for areas of improvement identified on the performance evaluations, for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #5) reviewed. A review of the facility provided, Performance Evaluation-Certified Nursing Assistant, revealed the following annual review dates and evaluation keys: CNA #1 had an annual performance review on [DATE], one month past the date of hire. CNA #1 was noted to have an objective partially met of conducts periodic resident care and unit checks with appropriate documentation, along with charge nurse. The areas targeted for improvement: educated the importance of documentation. The facility failed to provide the educational information specific to the performance evaluation. CNA #2 had an annual performance review on [DATE], two months past the date of hire. CNA #2 was noted to have an objective partially met of conducts periodic resident care and unit checks with appropriate documentation, along with charge nurse and verifies all residents have wrist bands, education, picture and door tags. The areas targeted for improvement: educated the importance of documentation, also to report if missing door tags/name bands. The facility failed to provide the education information specific to the performance evaluation. CNA #3 had an annual performance review on [DATE], eight months past the date of hire. CNA #3 was noted to have an objective partially met of verifies all residents have wrist bands, medication, picture and door tags. The areas targeted for improvement: educated to report if resident is missing wrist band, door tags. The facility failed to provide the education information specific to the need identified in the performance evaluation. CNA #5 had a 90 Day performance review on [DATE], one month short of the 90 Day review date. The facility failed to provide another performance evaluation at the 90-day mark from the date of hire. On [DATE] at 12:18 PM, the above concerns were brought to the attention of the LNHA and the DON. The facility failed to provide any additional information. f.) Based on interview and document review, it was determined that the Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan to; a.) ensure a system for staff training and monitoring for Basic Life Support/CPR was in place after an adverse resident event occurred, and b.) follow the facility process to measure the utilize data acquired for pressure ulcer quality improvement and develop quantitative and measurable goals. On [DATE] at 1:42 PM, the surveyor interviewed the LNHA and DON in the presence of the survey team. The surveyor informed the DON and LHNA regarding the findings; 911 was not activated, a code was not called, and the AED was not utilized for Resident #7 when the resident became unresponsive. The DON confirmed that the staff should have utilized the AED and called 911. The DON further stated that three nurses were working that day, and the process should have been enacted. The surveyor asked the DON regarding the ability of LPNs to assess a resident or are LPNs able to pronounce death. The DON acknowledged the LHNA and stated that LPNs could not pronounce death or assess a resident. On [DATE] at 8:59 AM, the LHNA and DON were interviewed by the surveyor, in the presence of the team, regarding the facility's process of tracking the nursing staff CPR certifications. The DON stated the in-service coordinator should be tracking the CPR certifications, but she was unsure if it was up to date. The DON provided a copy of 7 Employee BLS certifications. The CPR cards provided to the surveyors included 5 AHA Provider Basic Life Support cards, including a copy of LPN #2's card. A second copy of the Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR and AED for LPN #1, and two cards for National CPR Foundation, Provider Card. The survey team requested to see the tracking system at that time. The DON stated the In-service Coordinator/Assistant Director of Nursing (IC/ADON) would provide it. Furthermore, the DON added, there had not been CPR training because of COVID. (Refer 678L) On [DATE] at 9:17 AM, the Surveyor reviewed the facility form titled Pressure Ulcers-Quality Improvement Report 4th quarter 2021 Reports. The report did not have root cause analysis, benchmarks, measurable goals or targets, Step-by-step interventions to correct the problem and achieve established goals; or perform a study act cycle, and a description of how the QAA committee will monitor to ensure changes yield the expected results. On [DATE] at 10:41 AM, in the presence of the survey team, the Surveyor reviewed information concerning QAPI from data acquired for pressure ulcer quality improvement with the LNHA and DON. The LNHA and DON explained the process for QAPI to self-identify problems in the facility, however, could not provide information on how the facility is tracking and trending issues according to the facility policy and procedures. The LNHA stated that they needed to change the QAPI tool to include tracking, trending, and benchmarking and to include root cause analysis. g.) Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to monitor and track resident antibiotic use for 3 of 3 months ([DATE], February 2022, and [DATE]) reviewed for Antibiotic Stewardship. On [DATE] at 10:44 AM, the Registered Nurse Infection Preventionist (RN/IP), in the presence of Surveyor #1 and Surveyor #2, stated the purpose of the facility Antibiotic Stewardship was to track trends in antibiotic use and facility infections. The RN/IP stated the information would be used to determine such things as if the antibiotic needed to be discontinued or if a culture or repeat laboratory test needed to be done. The RN/IP further stated that if a resident were on an antibiotic longer than needed or the wrong antibiotic, it could lead to being resistant to the antibiotic. She stated that the facility also had a monthly meeting for infection control. The RN/IP stated that as of this date, there were no residents on antibiotics in the facility. The RN/IP stated she checked the 24-hour reports daily to see who was on antibiotics and that she would discuss the antibiotic stewardship information with the medical director quarterly. She stated the information was also reviewed with the facility in the Quality Assurance meetings. The RN/IP reviewed the Antibiotic Stewardship logbook, acknowledged antibiotics were not being monitored or tracked since the beginning of 2022, and stated she had no reason to provide why the residents on antibiotics were not being tracked or monitored. The RN/IP stated she had spoken to the physician regarding Resident #206 having [CONDITION(S)] of the abdominal wound and what was being done about it but had not documented that information anywhere. The RN/IP further stated she was not aware that Resident #208 had been ordered an antibiotic on [DATE]. The facility provided form titled. Job-Description-Administrator and dated [DATE] indicated that the Administrator directs the overall operations of the facility's activities, both internal and external, to provide excellent care to patients and residents. The Administrator is to coordinate these activities to ensure compliance with established standards. The policy indicated that the duty of the Administrator is as follows: -Establishes polices pertaining to total patient care, personnel, medical staff, financial status, public relations, maintenance of the building and grounds. Explains such policies to the staff and other concerned parties. Reviews compliance and established policies by personnel and medical staff and periodically reviews policies and makes changes as found necessary. -Prepares job descriptions and policy and procedure manuals for all departments. -Reviews compliance of facility with national, state, and local standards. -Selects competent personnel to supervise activities of major departments. -Meets with Department heads at regular intervals. -Receives advise for major department heads on matters pertaining to department operations and external relationships and reviews and frequently checks competence of the workforce. -Acts as liaison to the governing authority on behalf of the Medical Director, the staff, and the patients. -Interpretation of institution's philosophy and all policies to staff and other concerned parties. NJAC 8:,d+[DATE].2(a)

Based on interview, clinical record review and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to 1.) laboratory results 2.) staff training and certifications for basic life support/cardiopulmonary resuscitation (CPR) and 3.) antibiotic stewardship. This deficient practice was evidenced by the following: 1.) On [DATE] at 12:51 PM, the Surveyor reviewed the closed medical record for Resident #7 which revealed: A Licensed Practical Nurse (LPN #1) documented a Nurses Note (NN) on [DATE] at 16:05 (4:05 PM). The admission record for Resident #7 revealed the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Doctor's Progress note, dated [DATE] was reviewed which revealed K+ 6.2? (Elevated blood potassium level and a Plan Continue Monitor, Repeat CMP (Comprehensive Metabolic Panel) and PTH (Para-[CONDITION(S)]). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A NN dated [DATE], at 15:21 (3:21 PM) revealed a LPN #1 documented CBC and PTH done and results pending. A Final laboratory report, dated [DATE], revealed Tests ordered: CBC (Complete Blood Count) with Auto Differential and PTH Intact with the listed test results. On [DATE] at 11:50 AM, the Surveyor, in the presence of three other surveyors, conducted a telephone interview with Resident #7's Physician (MD), who was also the medical director of the facility. The Surveyor inquired if the MD was aware that the CMP was not ordered. The MD stated she did not keep track of the laboratory tests that she ordered, and the facility would give her the results. She stated that no one had informed her that the CMP was not completed. 2.) On [DATE] at 8:59 AM, the LHNA and DON were interviewed by the Surveyor, in the presence of the team, regarding the facility tracking of the nursing staff CPR certifications. The DON stated the in-service coordinator should be tracking the CPR certifications, but she was not sure if it was up to date. The DON provided a copy of seven Employee BLS certifications. The cards provided included 5 AHA Provider Basic Life Support CPR cards which included a copy of LPN #2's card, a second copy of the Community & Workplace Certification, Basic Life Support, Adult, Child & Infant CPR and AED for LPN #1, and two cards for National CPR Foundation, Provider Card. The survey team requested to see the tracking system at that time, and the DON stated the In-service Coordinator/Assistant Director of Nursing (IC/ADON) would provide it because she tracked the CPR cards, and there had not been a CPR training because of COVID. On [DATE] at 9:31 AM, the IC/ADON provided the Surveyor, in the presence of the survey team, the facility BLS (Basic Life Support) Log, with 20 names listed and ,d+[DATE] of the names had an X next to it. The Surveyor inquired about the list provided by the IC/ADON and how the IC/ADON would know when the CPR certification expired. The IC/ADON stated she did not have expiration dates on it, and she just knew when they expired and would put an X next to the staff's name if they had the CPR certification. She stated that was how she tracked it, and she knew if they had the certification by when the facility offered the CPR training. She stated that some staff would forward a card if they had the training elsewhere (There were 12 more employee names on the Plaza Healthcare and Rehab Center BLS (Basic Life Support) Log, than copies of CPR cards provided by the facility). On [DATE] at 1:32 PM the Surveyor, in the presence of two surveyors, conducted a telephone interview with the Medical Director (MD), who was also the attending physician for Resident #7. The surveyor inquired to the MD if she was aware that all the nursing staff were not CPR certified. She stated she was not aware and assumed that the supervisors knew CPR. The surveyor inquired to the MD if it was important for nursing staff to have current, appropriate CPR certification. The MD responded yes, they should, and that all the nurses should have CPR certification. The MD stated that she was not aware that all of staff did not have appropriate or current CPR certification. 3.) On [DATE] at 11:50 AM, survey team conducted a telephone interview with the Medical Director (MD). The MD stated she was not too involved with infection control because the facility used to have an infectious disease doctor. She further stated she was not aware that antibiotic stewardship was not being tracked for 2022, and that it was definitely important so the facility could be aware and keep track that an antibiotic was given timely. The facility provided the surveyors with a form dated [DATE] and titled, Medical Director Duties. The Medical Director (MD) duties included the following: -The MD shall be a licensed physician and shall be responsible to coordinate medical care in the facility and provide clinical guidance and oversight regarding implementation of resident care polices. -The MD shall collaborate with the facility leadership, staff and other practitioners and consultants to help develop, implement, and evaluate resident care policies and procedures that reflect the current standards of practice. -The MD shall assist the facility in identifying, evaluating, and addressing medical and clinical concerns and issues that affect resident care, medical care, or quality of life. -The MD shall be responsible for integrated delivery of care and services, such as medical nursing, pharmacy, social, rehabilitative, and dietary services which included clinical assessments, analysis of assessment findings, care planning including preventative care, care plan monitoring and modification, infection control including isolation pr special care. -The MD shall be responsible for use and availability of ancillary services such and x-ray and laboratory. - The MD shall be responsible for formulation and facility implementation of advance directives and end of life care. -Shall ensure that systems to ensure that other licensed practitioners who may perform physician-delegated task act within the regulatory requirements and within the scope of practice defined by state law. -Identify facility or practitioner educations and information needs. -The MD shall coordinate and evaluate the medical care within the facility by reviewing and evaluating aspects of physician care and services and helping the facility identify, evaluate, and address health care issues related to the quality of life of the residents. -The MD shall address issues related to the coordination of medical care identified through the facility's quality assessment and assurance committee and quality assurance program, and other activities related to coordination of care. Cross reference: F678 Based on interview, record review and document review, it was determined that the facility failed to ensure: 1.) the emergency response system was activated to call a code, 2.) 911 was enacted, 3.) the automatic external defibrillator (AED) was utilized for a resident who was found unresponsive (Resident #7) and was a full code status (all resuscitation procedures will be provided when a person stops breathing or heart stops beating), and 4.) a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintain the appropriate CPR certification. F770 Based on interview, and closed record review it was determined that the facility failed to order the appropriate physician ordered laboratory test for 1 of 2 closed medical records [MEDICAL RECORD OR PHYSICIAN ORDER] F881 Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to monitor and track resident antibiotic use for 3 of 3 months ([DATE], February 2022, and [DATE]) reviewed for Antibiotic Stewardship. N.J.A.C 8:,d+[DATE].1 (a), (b), (c).

Based on interview and document review, it was determined that the Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan to; a.) ensure a system for staff training and monitoring for Basic Life Support/CPR was in place after an adverse resident event occurred, and b.) follow the facility process to measure the utilize data acquired for pressure ulcer quality improvement and develop quantitative and measurable goals. This deficient practice was evidenced by the following: a.) (Refer to 678 L) b.) On [DATE] at 9:08 AM, the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the facility process for QAPI. The LNHA stated that the facility QAPI meeting is held quarterly, and attendance included the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the LNHA, Medical Director (MD), department heads, and vendors such as lab, x-ray, pharmacy consultants etc. He stated that concerns were brought to the QAPI committee's attention by conducting environmental rounds, department audits, food committee meetings, Resident Council, staff meetings and clinical morning meetings. He further added that through daily morning meetings the team discussed concerns and if those concerns were being addressed. He stated that we know how problems were improving though meetings, audits, and environmental rounds and then he stated that now we will be developing QAPI through all the issues the state had found during inspection. On [DATE] at 9:17 AM, the Surveyor reviewed the facility provided form titled Pressure Ulcers-Quality Improvement Report 4th quarter 2021 Reports. The report did not have root cause analysis, benchmarks, measurable goals or targets, Step-by-step interventions to correct the problem and achieve established goals; or perform a study act cycle, and a description of how the QAA committee will monitor to ensure changes yield the expected results. On [DATE] at 9:28 AM, the Surveyor interviewed the DON who stated that she attended the quarterly QAPI with the LNHA and departments heads including the MD. She stated that to identify problems, that the facility had clinical morning meetings and that the nurses would bring issues to the DON. She also stated that the facility did random monitoring of problems. She stated that once the facility identified a problem that the facility would investigate and put a plan in place to identify, monitor and correct the problem. She also stated that the facility did tracking and trending to assure corrective action was happening. On [DATE] at 9:38 AM, the Surveyor interviewed the Registered Nurse Supervisor (RNS) who stated that if she saw any concerns, she would report them in clinical morning meeting to make sure concerns got addressed and from there the QAPI committee wound develop a plan to assure that the issue got resolved. I am new here but I'm sure the facility is doing QAPI and addressing concerns. On [DATE] at 10:41 AM, in the presence of the survey team, the Surveyor reviewed information concerning QAPI from data acquired for pressure ulcer quality improvement with the LNHA and DON. The LNHA and DON explained the process for QAPI to self-identify problems in the facility, however, could not provide information on how the facility is tracking and trending issues according to the facility policy and procedures. The LNHA stated that they needed to change the QAPI tool to include tracking, trending, and benchmarking and to include root cause analysis. The facility provided form titled, Quality Assurance and Performance Improvement Plan dated [DATE], indicated that the facility was committed to enhancing the quality of life by nurturing individuality and independence and that the purpose of QAPI was to take a proactive approach to continually improve the way they cared for residents, caregivers and other partners as to provide an exceptional environment were people are valued, care for and attain or maintain physical, mental and psychosocial well-being. According to the facility QAPI plan, QAPI focuses on systems, sets goals for performance and measures progress toward those goals. The plan indicated that the facility would aim for safety and quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents by ensuring that their data collection tools, and monitoring systems were in place and were consistent for proactive analysis. The plan further indicated that the facility would utilize the best available evidence (such as data from the MDS and CASPER reports, national benchmarks, published best practices and clinical guidelines, etc ) to define and measure goals. The plan indicated that the facility would be using performance indicators to monitor a wide range of care processes and outcomes and would review findings against benchmarks or goals that the facility had established for performance. It would also include tracking, investigation and monitoring adverse events every time they occur, and action plans would be implemented through the plan, do study act cycle or improvement to prevent recurrences. NJAC 8:,d+[DATE].2(a), 33.1(a), 33.2(b), 33.2(c)(13), 33.2(d) & 33.3

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to monitor and track resident antibiotic use for 3 of 3 months (January 2022, February 2022, and March 2022) reviewed for Antibiotic Stewardship. This deficient practice was evidenced by the following: The survey team entered the facility on 02/28/22. The facility was asked to provide information for review which included the Antibiotic Stewardship tracking. The survey team was provided daily with an Antibiotic Stewardship log book dated 2021. On 02/28/22 at 10:15 AM, Surveyor #2 observed Resident #206 lying in bed and a yellow container of Personal Protective Equipment (PPE) hanging on the door. A review of the Admission Record revealed Resident #206 had been admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS - an assessment tool), dated 2/28/22, revealed a Brief Interview for Mental Status (BIMS) of 05/15 which indicated the resident was severely cognitively impaired; and an active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/28/22 at 9:41 AM, Surveyor #2 observed Resident #208 lying awake in bed. Resident #208 did not speak English but motioned for the surveyor to come into the room. Resident #208 pulled up the sheet and pointed at his/her feet. Surveyor #2 observed Resident #208's both feet were swollen and reddish in color. A review of the Admission Record revealed Resident #208 had been admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission MDS, dated [DATE], revealed a BIMS of 07/15 which indicated the resident was severely cognitively impaired. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/08/22 at 10:44 AM, the Registered Nurse Infection Preventionist (RN/IP), in the presence of two surveyors, stated the purpose of the facility Antibiotic Stewardship was to track trends in antibiotic use and facility infections. The RN/IP stated the information would be used to determine such things as if the antibiotic needed to be discontinued or if a culture or repeat laboratory test needed to be done. The RN/IP further stated that if a resident was on an antibiotic longer than needed or the wrong antibiotic, it could lead to being resistant to the antibiotic. She stated that the facility also had a monthly meeting for infection control. The RN/IP stated that as of this date, there were no residents on antibiotics in the facility. The RN/IP stated stated she checked the 24 hour reports daily to see who was on antibiotics and that she would discuss the antibiotic stewardship information with the medical director quarterly. She stated the information was also reviewed with the facility in the Quality Assurance meetings. The RN/IP reviewed the Antibiotic Stewardship log book, acknowledged antibiotics were not being monitored or tracked since the beginning of 2022, and stated she had no reason to provide why the residents on antibiotics were not being tracked or monitored. The RN/IP stated she had spoken to the physician regarding Resident #206 having [CONDITION(S)] of the abdominal wound and what was being done about it, but had not documented that information anywhere. The RN/IP further stated she was not aware that Resident #208 had been ordered an antibiotic on 2/11/22. On 03/09/22 at 9:06 AM, the MDS RN stated if an antibiotic were started on a resident, it would be discussed during morning meeting with the team. She stated it was important for the antibiotics to be monitored for effectiveness and side effects. On 03/10/22 at 11:50 AM, the Medical Director stated she was not too involved with Infection Control because the facility used to have an Infectious Disease doctor. She further stated she was not aware that the facility's Antibiotic Stewardship was not being tracked for 2022 and that it was definitely important so the facility could be aware and keep track that antibiotics were given timely. A review of the facility provided, Infection Surveillance Form, revised 11/19, included but was not limited to: if 'criteria' was met or not met or hosp [hospital]/community; the date the infection was first noted or date or admission is less than 14 days; evidence of infection present at time of admission or re-admission; Diagnostic Workup; sections to include a type of infection and examples of symptoms and/or test results; antibiotic ordered, started and for how long; scheduled diagnostic follow up; and follow-up/comments. A review of the facility provided, Monthly Infection Control Rate form, dated 8/19, revealed categories of tracking as infections, infections on each floor, if the criteria had been met, total number of nosocomial infections, current infection on admission, criteria not met antibiotics ordered, and antibiotic percentage rate utilization. A review of the facility provided, Comprehensive Antibiogram Toolkit: Phase 4 Sample Antibiotic Use Tracking Sheet, dated 5/14, included areas of tracking as onset date, signs and symptoms, site of infection, culture site, infection type, treatment start date, antibiotic name, broad or narrow spectrum, and [CONDITION(S)]/pneumonia: adherent to antibiogram. A review of the facility provided Infection Prevention and Control manual included the following policies: Criteria for Determining Infections, policy and process, reviewed 3/21, included but was not limited to: Policy- the following of a criteria (Infection Constitutional Criteria in Residents of Long-Term Care Facilities) to be used for establishing the presence of an infection may also prove useful in identifying community-acquired infections. Process- before a decision for the presence of infection is made, non-infectious causes of signs and symptoms should be considered. Infection Control Reporting, reviewed 3/21, included but was not limited to: Policy- to provide documentation on individual infections for surveillance activities. Process- all infections will be reported to the Infection Preventionist as soon as possible, the Infection Control Reporting form is to be completed, admitted and onset of disease date are important information, utilize one form for each infection regardless of how long the infection lasts. Monthly Infection Control Report, reviewed 3/21, included but was not limited to: Policy- to collect, analyze and investigate infection data to reduce infection rates at this center. Process- all infections will be documented utilizing the form monthly, calculate the nosocomial rate, enter the total number of infections in the appropriate column, and enter the total number of hospitalization s due to the infection and all individuals receiving antibiotics. Resident line listing, reviewed 3/21, included but was not limited to: Process- record all reported infections from the first day of the month to the last day, at the end of the month count the new nosocomial infection rate, the total becomes the numerator for calculation of rates, follow all infections in this manner until resolved, and analyze this data for potential outbreaks. On 03/10/22 at 1:00 PM, the concerns were discussed with the facility administrative staff. The facility had no additional information to provide. NJAC 8:39-19.4(d)(g)

Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to consistently perform interventions designed by an Occupational Therapist to promote range of motion and positioning for 2 of 2 residents (Resident #159 and #259) who were reviewed for positioning and mobility. The deficient practice was evidenced by the following: On 02/28/22 at 10:16 AM during tour, the Surveyor interviewed Resident #159 who was sitting up in bed. Resident #159 stated that he/she wanted to be able to walk, however he/she did not receive rehabilitation and wanted to know why. He/she stated that he/she got of bed to chair daily and did not walk. The surveyor reviewed Resident # 159's medical record which revealed the following: The Admission Record (AR) indicated that Resident #159 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) an assessment tool dated 01/06/22, indicated that Resident #159 was cognitively intact and required complete care of two staff members for transfers and bed mobility. The MDS also indicated that the resident was non-ambulatory and required complete care with activities of daily living (ADLs) and was free from pressure ulcers and skin impairments. There was documentation on the MDS that indicated that the resident had limitations with range of motion on one side of the upper body and both sides of the lower body. On 03/01/22 at 10:30 AM, the Surveyor interviewed the Director of Rehabilitation Physical Therapist (DORPT) who stated that Resident #159 had been in the facility for a few years and had been non-ambulatory. The DORPT revealed that the resident was on a restorative nursing program (RNP) and that the Director of Nursing (DON) was responsible for oversight of the RNP. The DORPT stated that Resident #159 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He added that he was not aware that the resident ever refused RNP. On 03/01/22 at 11:11 AM, the Surveyor interviewed the Restorative Certified Nursing Assistant (RCNA#1) who stated that she performed range of motion (ROM) on Resident #159's upper and lower body two times a week and bed mobility (turning and moving in bed) two times a week. The CNA showed the Surveyor the restorative book and provided the surveyor with Resident #159's restorative referral from the rehabilitation department. The restorative referral contained instructions on what type of restorative Resident #159 should receive to be able to maintain the resident's current level of functional mobility. The RCNA stated that there were times when restorative nursing could not be performed because the restorative CNAs had to take a patient assignment or when they had to take residents out for appointments. She then added that any assigned Certified Nursing Assistant (CNA) could also perform the restorative nursing for the residents when the restorative CNA was not available. The surveyor and the RCNA reviewed the form located in the restorative nursing book which was titled, Restorative Nursing Program Attendance Grid (RNPAG) the RCNA stated that there should be RCNA signatures slotted on the days that restorative nursing was provided to Resident #159. The RCNA did not have a response as to why there were no signatures on the RNPAG from 02/13/22 until 02/28/22 indicating that Resident #159 received restorative nursing for ROM of upper and lower body and bed mobility. The RCNA stated that the resident did not have a history of refusal of RNP. On 03/01/22 at 11:27 AM, the Surveyor interviewed the Registered Nurse (RN) who was providing care to Resident #159 who stated that she also did not know why the RNPAG was not signed by the RCNA from 02/13/22 until 02/28/22 that Resident #159 received RNP for ROM upper and lower body and bed mobility. She also indicated that if there were no signatures on the RNPAG then you would not know if the task was performed. Signatures from staff would indicate that a task was performed. The Surveyor reviewed the Occupational Therapy Discharge Summary (OTDS) dated 8/10/17, which indicated that discharge recommendations and RNP were to facilitate patient maintaining current level of performance and to prevent decline, development of the instruction in the following RNPs had been completed with the interdisciplinary team (IDT): ROM (active and passive) and bed mobility. The Surveyor reviewed the restorative referral dated 8/11/17, which contained instructions that Resident # 159 would participate in RNP 6 days a week for range of motion (ROM) 3 sets of 10 or as tolerated for bilateral (b/l) upper and lower extremities and will participate in bed mobility to maintain current level of function to prevent pressure points. The Surveyor reviewed Resident #159's Care Plan (CP) dated 08/30/19 and revised on 01/27/20 which revealed the following information: Resident #159 had limited physical mobility related to (r/t) [CONDITION(S)] and was prescribed ROM/bed mobility exercises and was at risk for contractures. The bedside CNA Kardex Report (KR) dated 03/09/22, which indicated that Resident #159 was on a nursing rehab/restorative: active ROM program and bed mobility. On 03/01/22 at 12:17 PM, the Surveyor interviewed Resident #159 who stated that he/she did not always receive restorative ROM exercises and was not happy about it. The resident also added that he/she did not think that he/she had a decline in functional level and stated that his/her skin was intact. On 03/01/22 at 12:35 PM, the Surveyor interviewed the Director and Nursing (DON) who stated that she oversaw the Restorative Nursing Program. The DON reviewed the RNPAG with the surveyor from 02/13/22 until 02/28/22 and stated that there should have been RCNA signatures slotted on those dates from 02/13/22 until 02/28/22 to indicate that the resident received ROM to upper and lower body, as well as bed mobility. The DON confirmed that if there were no signatures, then you could not say for certain if the resident received the restorative nursing that was recommended by rehabilitation. The Surveyor reviewed the skin assessments for February for 02/01/22, 02/08/22, 02/15/22, and 02/22/22 and there were no new skin impairments documented. The Surveyor interviewed the DORPT who stated that he evaluated Resident # 159 on 3/2/22 and indicated that the resident did not have any new contractures or change in ROM. The DORPT provided the surveyor with a physical therapy evaluation (PTE) dated 03/02/22 which indicated that the resident required skilled PT services to increase lower extremity strength and improve dynamic balance, increase functional activity tolerance, facilitate motor control, and enhance rehabilitation potential and develop and struct in restorative nursing program in or to enhance the resident's quality of life by improving ability to increase performance skills and functional task. 2. On 02/28/22 at 10:48 AM, the surveyor observed Resident #259 lying in bed and was wearing heel booties on. Resident #259 stated that he/she wanted to get physical therapy. The surveyor reviewed Resident #259's medical record which revealed the following: A review of Resident #259's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #259's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/20/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident #259 was cognitively intact. Further review indicated that Resident #259 required complete care of 2 staff members for transfers and bed mobility. The MDS also indicated that the resident was non-ambulatory and required complete care with activities of daily living (ADLs) and was free from pressure ulcers and skin impairments. There was documentation on the MDS that indicated that the resident had limitations with range of motion on both sides of the upper body and both sides of the lower body. A review of the Occupational Therapy Discharge Summary signed and dated by the Occupational Therapist on 8/24/21, included the following: RNP: To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): ROM (range of motion) (Active-Assisted/Passive) bed mobility and splint or brace care. On 3/1/22 at 12:05 PM, the Surveyor reviewed Resident #259's Restorative Nursing Program Attendance Grid for February 2022 which included the following: Under the procedures of PROM OR A/AA ROM (passive or active range of motion) and Ambulation/Bed Mob.(mobility), there was the number 15 documented on 2/2, 2/4, 2/8, 2/9, 2/10, 2/11, 2/12 and 2/13 which indicated Resident #259 received 15 minutes of the procedures on those days. There was a X documented on 2/1, 2/3, 2/5, 2/6 and 2/7 which indicated Resident #259 did not receive the procedures on those days. The remaining days of February (2/14 to 2/28) were blank. A review of the Restorative Nursing instruction Form did not include a frequency of how many times a week it was to be performed. At 12:08 PM, the Surveyor interviewed the RCNA#1 who stated that she or RCNA #2 worked with Resident #259 but that they sometimes would be pulled from their RNP functions to performed CNA functions. She added that they document the ROM exercises that they perform with a resident in a book but that it was hard to keep the book updated. On 02/04/22 at 11:08, the Surveyor interviewed RCNA #2 who stated that he worked three days a week and that RCNA #1 worked the opposite three days in the week and that they performed RNP for the entire building (two floors). He added that in the past there was an aid for each floor. RCNA #2 stated that the RNP included ROM, splints, braces and ambulation. He added that each resident in the RNP is supposed to participate a minimum of six days and that he cannot get to each resident in the RNP every day. RCNA #2 stated that he had a personal notebook that he documented in to keep track of who received or did not receive RNP for each day and that at the end of the month would document it in the facility's Restorative Nursing Program Attendance Grid. The surveyor then asked RCNA#2 if Resident #259 received RNP every day. RCNA#2 stated that sometimes he was unable to get to Resident #259 because he would get pulled when someone called out, or if they needed him to escort a resident to a physician's appointment. He added that he felt bad when he could not get to the residents. The surveyor then asked RNCA#2 if he made anyone aware that the residents did not always receive RNP. He stated that he informed the Director of Nursing (DON) that it was not feasible to get to everyone daily. RNCA#2 provided the Surveyor a document that had a list of the residents that were on RNP for splints, braces and/or ROM. Resident #259 was listed for knee brace and PROM (passive). The document also included the following: Everyday Monday-Sunday. On 03/04/22 at 11:38 AM, the Surveyor asked the DON if she was aware that the Restorative Nursing Program Attendance Grid was not filled out from 02/14/22 to 02/28/22 and that the staff stated they fill it out at the end of the month. The DON stated that the staff should be signing the Attendance Grid on the same day and that it should not wait until the end of the month. At 2:31 PM, the surveyor interviewed the DORPT who stated that residents on RNP are scheduled to have it 5-6 or 6-7 days a week. He added that the Attendance Grid should be filled out daily. On 03/10/22 at 9:55 AM, the Surveyor asked the DON if she checked that the staff documented RNP. The DON stated that she did not check daily but that she tried to check weekly. The surveyor then asked the DON if RNCA #1 and RNCA#2 were only assigned to perform RNP. The DON stated that they get pulled sometimes. She added that the goal was RNP was to be done daily and documented. The facility policy with a revised date 03/01/22 and titled, Rehabilitative Nursing Care indicated that rehabilitative nursing care is provided for each resident admitted . The policy also indicated that rehabilitative nursing care did not require a qualified professional therapist to render. The facility's rehabilitative nursing care program was designed to assist each resident to achieve and maintain an optimal level of self-care and independence and to assure that there is no decline in physical function. Rehabilitative nursing care is performed daily for those who require such services and included but was not limited to: -Maintaining good body alignment and proper positioning. -Encouraging and assisting bedfast residents to change position at least every two hours day and night to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities. -Assisting residents with their routine ROM exercises. NJAC 8:39-27.1 (a)

Based on interview and record review it was determined that the facility failed to: a.) administer medications in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) follow-up on recommendations from the hemodialysis center for 1 of 2 residents who received [CONDITION(S)] treatments (Resident #3). The deficient practice was evidenced by the following: On 03/01/22 at 10:08 AM, the Surveyor conducted an interview with Resident #3 in the resident's room. The resident stated that he/she attended [CONDITION(S)] on Monday, Wednesday and Friday at 1:45 PM. Resident #3 stated he/she had been going to the [CONDITION(S)] center on Monday, Wednesday and Friday a few months ago. Resident #3 stated that prior to that, he/she used to go to [CONDITION(S)] on Tuesday, Thursday and Saturday. The Surveyor reviewed the medical record for Resident #3 and the following was revealed: A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pharmacist Note dated 02/24/22 at 10:13 AM, located in the progress notes, revealed Follow med [medication] times with [CONDITION(S)]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order for [MEDICATION(S)] 25 MG TAB 1 tablet by mouth twice daily three times weekly on Saturday, Tuesday, Thursday, hold for SBP less than 110 or HR less than 60 at 8 AM (handwritten) and 9 PM (handwritten). The Care Plan Revealed a Problem: Resident #3 needs [CONDITION(S)] (hemodialysis) due to End Stage [CONDITION(S)] (Tue-Thu-Sat.), Revised on 09/28/21. The Goal was Resident #3 will have no signs and symptoms of complications from [CONDITION(S)] through the review date, revised on 10/15/21 with a Target date of 03/15/22. Interventions/Tasks included: Encourage resident to go for the scheduled [CONDITION(S)] appointments. Resident receives [CONDITION(S)] (Tuesday-Thursday-Saturday), Date Initiated, 09/16/21 and Revised, 10/26/21. The surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #7. The [CONDITION(S)] book contained the Renal [CONDITION(S)] Progress/Communication Notes for Resident #3, which included the dates that Resident #3 attended [CONDITION(S)] and [CONDITION(S)] Center Nurse Communication back to the facility. The Documents revealed: 01/31/22 Resident #3 attended [CONDITION(S)]. Treatment Problem: Yes circled, If yes, explain: Low B/P [blood pressure], (see note below). There was a note on the document that revealed note: To SNF [Facility]-RN Please do not (underlined) give [blood pressure] medications prior to [Hemodialysis] treatment. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 02/02/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was administered at 5:00 PM. 02/04/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered at 8 AM and 5 PM. 02/07/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered at 8 AM and 5 PM. 02/09/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered at 8 AM and 5 PM. 02/11/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered at 5 PM. 02/14/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. 02/16/22 Resident #3 attended [CONDITION(S)]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. 02/18/22 Resident #3 attended [CONDITION(S)]. The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. 02/23/22 Resident #3 attended [CONDITION(S)]. The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. 02/25/22 Resident #3 attended [CONDITION(S)]. The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. 02/28/22 The Resident #3 attended [CONDITION(S)]. The [MEDICATION(S)] was signed off as administered on 8 AM and 5 PM. On 03/01/22 at 10:32 AM, the Surveyor interviewed the Licensed Practical Nurse who was assigned to Resident #3 (LPN). The LPN stated that Resident #3 went to [CONDITION(S)] on Monday, Wednesday and Friday. The LPN showed the surveyor the MAR for Resident #7, and stated that when she initialed the MAR, it indicated that the medication was administered. On 03/02/22 at 9:07 AM, the Surveyor conducted a telephone interview with a Registered Nurse (RN) at the [CONDITION(S)] center. The RN stated she was familiar with Resident #7's care. The RN stated she remembered the [CONDITION(S)] treatment that Resident #3 had on 01/21/22 and referred to the note on the [CONDITION(S)] communication form. The RN stated that Resident #3's blood pressure was low and the note was documented to the nursing facility. The RN stated when the resident's blood pressure was low the [CONDITION(S)] facility treatment would not pull off enough fluid from the resident and stated Resident #3's blood pressure was not always low. On 03/02/22 at 9:51 AM, the Surveyor conducted a telephone interview with the Consultant Pharmacist (CP) regarding note he wrote re: [CONDITION(S)] times. The CP stated the [MEDICATION(S)] should be given at [CONDITION(S)]. On 03/03/22 at 9:17 AM, the Surveyor interviewed the Director of Nursing (DON) regarding when the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON, in the presence of the Surveyor, reviewed the note written on the [CONDITION(S)] communication form regarding holding BP medications 01/31/22 and the MD order for the [MEDICATION(S)] with the DON. The DON stated the MD order was from the nephrologist (kidney doctor). The DON stated that whoever was the nurse at the time, whoever received the note from the [CONDITION(S)] center and when they changed the days should have picked up the change that needed to be done. The surveyor inquired to the DON regarding if a nurse should have picked up the need to change the order and communication from [CONDITION(S)]. The DON stated absolutely it should have been picked up. She stated she was not aware that this was a concern. The DON stated that the resident should not have received the blood pressure medications on the [CONDITION(S)] days. The DON stated the nurses should have communicated with the physician regarding the [CONDITION(S)] center recommendation, she reiterated that it should have been communicated with the doctor. On 03/03/22 at 9:33 AM, the surveyor, the DON, in the presence of the surveyor checked the electronic medical record (EMR) and reviewed the nursing and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . At 9:35 AM, the DON reviewed the physical medical record for Resident #3 and looked for physician documentation regarding the medication hold. The DON stated stated it is not here absolutely not and the DON stated it was common sense. Inquired to the DON, and reviewed the [CONDITION(S)] monitoring form, and inquired as to what the purpose of the [CONDITION(S)] monitoring form was. The DON stated the purpose was to ensure the resident received medications before and after hemodialysis as ordered and establish communication with the [CONDITION(S)] center. On 03/09/22 at 8:57 AM, the surveyor interviewed Minimum Data Set Coordinator/ Registered Nurse (MDS) regarding the care plan process. The MDS stated she completed the initial care plan and that any changes made regarding medications, resident status, or if anything is reported, the care plan would be updated and reviewed the care plan after the morning meeting. The MDS stated the purpose of the care plan was for the residents plan of care and how we would manage them individually. The MDS stated it was the total plan of care for the residents including medications and restorative would be on the care plan. The Surveyor inquired as to if a resident was on [CONDITION(S)] would that be on the care plan. The MDS stated yes and she would expect to see the day and time that the resident attended [CONDITION(S)]. The MDS stated yes that usually the nurses, social worker, rehabilitation, or the dietitian would update the care plan if there was a change. On 03/09/22 at 10:36 AM, the Surveyor, interviewed the DON about what the purpose of the resident care plan was. The DON stated to ensure the patient gets the proper care The DON stated, problems, goals and interventions should be changed immediately, if there was a change. The facility form untitled with a revised date of 11/2021 indicated that residents would receive appropriate care and monitoring pre and post hemodialysis and to facilitate good communication between the facility and hemodialysis center. The policy indicated that the purpose of this policy was the following: -To assist the resident/patient in maintaining homeostasis pre and post hemodialysis. -To establish guidelines for communication with the [CONDITION(S)] center was to ensure continuity of care to resident requiring [CONDITION(S)]. -To ensure resident received medications before and after hemodialysis as ordered. -Ensure ongoing communication with [CONDITION(S)] and staff. NJAC 8:39-27.1(a)

Based on observation, interview and review of other pertinent facility documentation, it was determined that the facility failed to: 1.) ensure that expired medications and supplies were removed from two medication rooms and two unit emergency carts, and 2.) ensure the temperatures were monitored daily for 1 of 2 unit (1st floor) medication refrigerators. This deficient practice was identified for 2 of 2 units and was evidenced by the following: 1) On 03/01/22 at 9:01 AM, Surveyor #1 inspected the medication storage room on the 2nd floor. The surveyor observed that there were plastic bins in the medication storage room filled with supplies. Upon further inspection of the plastic bins, the surveyor observed that the bins had multiple individual bags of resident personal medications from multiple un-sampled residents who either discharged to home or who were deceased and were mixed in with with intravenous (IV) tubing supplies and dressings. The surveyor found the following: 1.) .9% sodium chloride (NaCl) IV 100 cc bag expired [DATE]. 2.) .9% NaCl 100 cc IV bag expired 01/12/2021. 3.) discharged residents' personal bottles of medication of [MEDICATION(S)] (diurectic medication) expired 07/18/203, 2 bottles of [MEDICATION(S)] (stool softener) expired 07/08/2020 and 06/2020, 3 vials of IM injectable [MEDICATION(S)] (antipsychotic) expired 06/08/2020, Tums (antiacid) expired 09/13/2019, [MEDICATION(S)] (neuropathic pain) expired 07/26/2020, Loratadine (antihistamine) expired 07/2020, [MEDICATION(S)] (Platelet Aggregation Inhibitors) expired 06/2020, [MEDICATION(S)] (blood pressure) expired 06/25/2020. On 03/01/22 at 9:13 AM, while Surveyor #1 was in the process of inspecting the medication storage room on the 2nd floor, the Director of Nursing (DON) was standing at the nurse's station and observed the Surveyor inspect the plastic bins that were full of IV supplies, individual bags of medications and dressing supplies. The Surveyor interviewed the DON at this time who stated that there should not be personal bottles of resident medications stored in the medication storage room. The DON looked at the names labeled on the medication bottles and revealed that those medications were from residents that were either discharge or expired. She then stated that when a resident was admitted to the facility and brought their own medications from home, that the medication should be sent back home with the families. She also indicated that if a resident was sent home, then the medication from the pharmacy would be sent back as this was the policy of the facility. She stated that the nurses should be checking the medication room and returning expired or deceased residents' medication to the pharmacy. The DON stated that the Pharmacy Consult (PC) would come in monthly to check the medication room to assure that there were no expired medications and that medications were labeled correctly. She stated that the PC was in on 01/24/22 and checked the medication room. She was not notified of any discrepancies. The DON confirmed that there should not be expired medications or expired IV supplies mixed with supplies that were still in use. On 03/01/22 at 9:33 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) who stated that when a resident expired or discharged out of the facility that medications should be returned to the pharmacy. She also stated that when residents or resident families brought in personal medications from home, that the resident's family was asked to take the medication back home and that the medication would be ordered from the facility pharmacy. She stated that there should not be resident personal bags of medications stored in the medication storage room. She also stated that the PC inspected the medication room monthly and should have taken resident personal medication, expired medications, and expired supplies out of the medication storage room. She also stated that the supervisors were responsible for making sure that the medication room was clean and that expired medications or resident personal medications were not stored in the medication storage room. On 03/01/22 at 9:38 AM, Surveyor #1 interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she was relatively new to the facility and was still learning the facility policy and procedures. She added that from her experience working as a nurse in long term care, that resident personal medications should not be stored in the medication storage room and should be returned to the family to take home. She also stated that expired medications should not be kept in the medication storage room and should be returned to the pharmacy and that expired IV supplies should not be kept in with supplies that were in use. On 02/28/22 at 12:26 PM, Surveyor #2 and Surveyor #3 noted a red crash (emergency) cart in the resident hallway with the top drawer open. Upon further observation revealed that the crash cart was not locked. The surveyor noted that that top drawer had a pair of bandage scissors, second drawer had syringes with needles ready to use such as 17 intramuscular syringes (IM), 1 100 count box of lancets, 24 count 25-gauge needles and 2 count of 22 syringe gauge needles. The 3rd drawer of the crash cart had 11 counts of IV tubing expired 4/2020, 1 sterile H20 (water) irrigation bottle expired 12/13/20 and normal saline .45% solution with an expiration date of 11/20/20. On 02/28/22 at 12:34 PM, Surveyor #1, Surveyor #2 and Surveyor #3 interviewed the LPN that was in the hallway and inquired about the crash cart. The nurse stated that the 11:00 PM to 07:00 AM shift was responsible to check the crash cart and ensure that the crash cart was locked. The LPN stated that anything could happen regarding the crash cart being left open. The LPN could not provide further information, she told the surveyor to see the supervisor for further information. 2.) On 02/28/22 at 12:36 PM, Surveyor #4 and Surveyor #5 noted a red crash cart behind the 1st floor nurse's station desk. The RN Supervisor was behind the nurse's desk and reviewed the crash cart with the surveyors. The surveyors noted the top drawer had 14 individually wrapped alcohol pads all with an expiration date of 2/16, and a sealed needle pack that was visibly soiled; the second drawer had 3 IV start kits which expired 8/13/21, 1 IV administration set which expired 11/9/21; and the fifth drawer had 20 border gauze pads which had expired 12/17. The surveyors also reviewed the 1st floor, Crash Cart Inventory and Testing logs. The first log was dated January 2022 and revealed that the inventory and testing will be done by 11-7 nurse. The log was blank on 1/1, 1/2, 1/6, 1/7, 1/8, 1/9, 1/18, 1/22, 1/25, 1/26, 1/27, 1/28, 1/30, and 1/31/22 = 14 of 31 days. The Defib [defibrillator] tested was blank 26 of 31 days. The second log was dated February 2022 and revealed that the inventory and testing will be done by 11-7 nurse. The log was blank on 2/6, 2/7, 2/15, 2/21, 2/27, and 2/28 = 6 of 28 days. The Defib tested was blank 19 of 28 days. At that time, the RN Supervisor stated there should be no expired supplies in the crash cart with supplies in use and that the inventory and testing log should be signed every day. On 02/28/22 at 12:40 PM, the surveyors interviewed the DON who stated that the crash cart should have been secured and locked as residents could get to the cart and use supplies. The DON added that the crash cart should not be accessible. She also stated that the crash cart should be checked daily and that the staff was supposed to check the crash cart for expired items and then should lock the cart after daily inspection. The surveyors reviewed the form that was attached to the top of the crash cart labeled Crash Cart Inventory and Testing (CCIT). The DON stated that this form should be signed daily by the 11:00 PM to 7:00 PM nurse to verify that they checked the crash cart for expired items and that the nurse should lock the crash cart after they inspect the cart. The DON had no explanation as to why the CCIT was not signed by the 11:00 PM to 7:00 PM nurse on the following dates 02/11/222, 02/12/222, 02/18/222, 02/26/222, 02/27/222 and 02/28/222. 3) On 03/01/22 at 8:25 AM, Surveyor #4, in the presence of the RN/IP, reviewed the first floor medication storage room. Surveyor #4 observed that the medication refrigerator was locked, contained medications and vaccinations, and the temperature log was missing signatures. Surveyor #4 and the RN/IP reviewed the following logs: November 2021 revealed no temperatures documented on 11/12, 11/13, 11/14, 11/20, 11/28, and 11/29/21 = 6 of 30 days. December 2021 revealed no temperatures documented on 12/10, 12/11, 12/12, 12/13, 12/24, 12/25, 12/26, and 12/27/21= 8 of 31 days. January 2022 revealed no temperatures documented on 1/1, 1/8, 1/9, 1/10, 1/22, 1/24, 1/29, and 1/30/22= 8 of 31 days. February 2022 revealed no temperatures documented on 2/5, 2/6, 2/7, 2/15, 2/19, 2/21, and 2/26/22= 7 of 28 days. At that time, the RN/IP stated that the 11 PM - 7 AM nurse was responsible to document the temperatures of the medication refrigerator. She further stated it was important to ensure the integrity of the medications. On 03/02/22 at 8:58 AM, Surveyor #1 conducted a telephone interview with Registered Nurse (RN) who worked the 11:00 PM to 7:00 AM shift on the 2nd floor 02/07/2022. The RN revealed that she was the only nurse with 62 residents. She stated that it was her responsibility to check the crash (emergency) cart on the 2nd floor. She stated that when she arrived for her shift, The 3:00 PM-11:00 PM shift had moved the crash cart from its usual location near resident room [ROOM NUMBER] to the left hallway by the window and left it opened. I have no idea why, so I left it that way. She revealed that the green lock tab was off the crash cart when she came in to start her shift on 2/27/22 at 11:00 PM-7:00 AM shift. The RN suddenly ended the interview by phone and stated that she needed to call the surveyor back. The RN did not return the surveyor's call. On 03/02/22 at 9:50 AM, Surveyor #1 conducted a telephone interview with the Pharmacy Consultant (PC) for the facility who stated that he had been working in the facility for a good number of years. He stated that his responsibility was to perform monthly resident chart review, periodic employee medication pass observation, inspect stock medications and medication cart for expiration dates and proper labeling and storage, and to inspect the refrigerator temps. He stated that if the medications were expired, they could spoil and not be effective or lose efficacy. He stated that that refrigerator temps needed to be in range 36-46 so that efficacy could remain intact. We check the emergency medication kits, not the actual crash cart. He added that he came to facility a couple weeks ago and report was provided to the DON. He stated, In general in was pretty good. I may not see everything because I look at stock medications. It is very tight and cluttered in the medication rooms. He also added that he did not investigate the plastic bins that were in the medication rooms so he could not speak on what was in those plastic bins. The facility provided policy titled, Medication Storage Policy with a revised date of April 2007, indicated that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. The policy also indicated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals and that all such drugs shall be returned to the dispensing pharmacy or destroyed. The facility provided policy titled, Discarding and Destroying Medications with a revised date of April 2007, indicated that medications that cannot be returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and/or medications left by the residents upon discharge) shall be destroyed. The facility provided policy titled, Crash Cart Policy with a date of 09/05/21 indicated that the crash cart inventory and testing will be done by the 11:00 PM-7:00 AM floor nurse daily. When the crash cart to be found with a red tag, the 11:00 PM-7:00 AM nurse will conduct inventory of the existing contents and will refill the cart. The policy also indicated that expired items would be removed and replaced. The policy indicated that the crash carts at the facility must be locked whenever the cart was not in use and when the crash carts were opened to use, the staff would keep the carts right near them and always supervised the carts. The facility provided policy, Policy for checking temperature for Refrigerator, dated 4/21, revealed Policy: to maintain medicine quality, both floor refrigerator temperature needs to be checked daily. Procedure: 11-7 shift assigned floor nurse will be checking the temperature daily to ensure refrigerator temp [temperature] is within normal range 36 to 46 degree. After checking the temp, needs to log in temp log and sign in and date it. Any abnormal temperature needs to be reported to maintenance department immediately. NJAC 8:39-29.4(e)(f)(g)(h)

Based on interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the mandatory 12 hours of in-service education. This deficient practice was identified for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #4) reviewed. This deficient practice was evidenced by the following: A review of the facility provided, CNA Certification Log, dated 02/28/22, included a list of the employed CNAs and their hire dates. The log revealed the following hire dates: CNA #1 09/14/2018 CNA #2 08/27/1987 CNA #3 03/05/2001 CNA #4 09/01/2008 On 03/01/22 at 1:39 PM, the Registered Nurse (RN) Staff Educator provided the requested CNA in-services. The RN Staff Educator stated that the in-services she had provided were the yearly education for all the CNAs. The in-services provided did not include the in-service length of time or who presented the in-services. The in-services were as follows: 1/13/21: Infection control, handwashing, standard & transmission base precautions, isolation, PPE [personal protective equipment]. 2/10/21: pain management, HIPAA, Infection control-donning and doffing. 03/4/21: fire/electrical emergency preparedness, accident prevention, PPE, handwashing 05/3/21: infection control - PPE, donning / doffing 06/7/21: infection control - blood borne pathogens, drug resistance, disease, handwashing 7/19/21: donning/doffing, handwashing 7/12/21: resident's rights, cognitive impairment, meaningful activities, PPE, handwashing 08/9/21: falls, dysphagia, elopement, PPE, handwashing 9/15/21: body mechanics, employee safety, infection control 10/4/21: Abuse, neglect, infection control 11/8/21: infection control - [CONDITION(S)], standard precaution 12/20/21: handwashing, PPE, standard precaution, transmission base precaution, isolation precaution On 03/02/22 at 10:11 AM, the RN Staff Educator and the Director of Nursing (DON) were present with the surveyor. The surveyor explained to the RN Staff Educator and the DON that we need to review the yearly educational information for the CNAs, date of hire to date of hire. The DON acknowledged she understood what was needed. On 03/03/22 at 8:35 AM, the facility provided no additional information. On 03/04/22 at 12:09 PM, the RN Staff Educator stated she had not been tracking the mandatory education and in-services for the CNAs, and did not track annually from the date of hire. The RN Staff Educator further stated she did not have the instructors names, or the amount of time of the education, or in-service education material provided for the documented sign in sheets. A review of the facility provided, Job Description-Certified Nursing Assistant', not dated, included but was not limited to attends conferences and in-services, including the 12 hours required for re-certification. A review of the facility provided, Policy and Procedure on Nurse Aide training and Performance review, revised 10/21, included but was not limited to the following: Procedure - Nurse staff educator will provide the annual in-services as required by DOH [Department of Health]. On 03/10/22 at 12:18 PM, the above concern was brought to the attention of the Licensed Nursing Home Administrator and the Director of Nursing. The facility had no additional information to provide. NJAC 8:39-43.17

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 1 of 18 residents reviewed (Resident #259) and was evidenced by the following: On 02/28/22 at 10:48 AM, the Surveyor observed Resident #259 lying in bed with heel booties on. The surveyor observed a flat tap call bell draped over the resident's bed side rail and was within the resident's reach. On 03/01/22 at 8:36 AM, the Surveyor observed Resident #259 lying in bed and was wearing heel booties. The Surveyor interviewed Resident #259 at that time who stated that he/she was not good because he/she could not reach the remote control for the bed. The surveyor observed that Resident #259's bed remote that was hanging off of the bed and it was touching the floor. The surveyor then asked Resident #259 where his/her call bell was so he/she could call the nurse for help. Resident #259 then shrugged his/her shoulders. The Surveyor then observed Resident #259's flat tap call bell which was draped over the cord at the area where the call bell was attached to the wall. The call bell was not within Resident #259's reach. At 8:44 AM, in presence of another Surveyor, the Surveyor interviewed Resident #259's Certified Nursing Aid (CNA). The Surveyor asked the CNA how a resident would call for help if needed. The CNA stated that the resident would press the call bell. The surveyor then asked the CNA if she had made rounds on the residents that morning. The CNA stated that she made rounds and checked Resident #259 this morning but that she had not performed morning care yet. The Surveyor then asked the CNA what the reason was that the call bell was hanging on the wall and was not within Resident #259's reach. The CNA stated that she moved the call bell out of reach because the call bell kept going off. She then stated that she should not have moved the call bell out of reach. At 8:55 AM, in the presence of another Surveyor, the Surveyor asked the Licensed Practical Nurse (LPN) to observe the location of Resident #259's call bell. The LPN confirmed that the call bell was draped over the cord on the wall and not within Resident #259's reach. The LPN then stated that sometimes when staff change the resident, they move the call bell and forget to move it back. The surveyor then told the LPN what the CNA told the surveyors. The LPN then placed the call bell within Resident #259's reach. She then stated that the call bell should always be with the resident. A review of Resident #259's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/20/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident #259 was cognitively intact. On 03/02/22 at 12:09 PM, the surveyor interviewed the Director of Rehabilitation Physical Therapist (DORPT) regarding Resident #259's call bell. The DORPT stated that Resident #259 had a special tap bell because the resident could not use his/her hands properly. He then stated that the staff should place the call bell on the bed next to the resident on the resident's stronger side. He added that the call bell should not be placed on the siderail of the bed. On 03/10/22 at 9:55 AM, the Surveyor informed the Director of Nursing (DON) about the location of Resident #259's call bell. The DON stated that sometimes the staff forget to place the call bell back after care. The surveyor then shared the interview the Surveyor conducted with the CNA. On 03/11/22 at 11:04 AM, the DON stated that the CNA had documented a statement that she had left the room of Resident #259 for a minute to get something. The surveyor then asked the DON if a call bell was not working properly what should the staff do. The DON stated that the staff should report it to the Maintenance Department and provide the resident with another device to call for help. A review of the facility provided Job Description for Certified Nursing Assistant (CNA) included the following: 11. Enforces safety measures and protects residents from injury by: .placing the call bell within reach of the resident . A review of the facility provided policy titled Answering Call Bells with a reviewed date of 10/2021, which included the following: Policy: Call bells must be answered promptly and properly. Objective: 1. To promptly meet needs of the resident . Procedure: . 7. Check to see that call bell is within reach before you leave . 11. Call bells to be answered immediately and promptly. 12. Call bell must be within reach of all residents. 13. Call bell must be accessible to the unaffected side of a paralyzed resident. N.J.A.C. 8:39-31.8(c)(9)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) report to the New Jersey Department of Health (NJDOH) an allegation of resident to resident abuse, and b.) develop the facility's Policy on Resident Abuse policy in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for 1 of 2 investigations of reportable incidents reviewed (Resident #258) and was evidenced by the following: On 02/28/22 at 11:34 AM, the Surveyor reviewed Resident #258's electronic Progress Notes (ePN) which included the following note dated 02/08/22 at 6 PM: Resident reported to writer that resident across the hall from his/her room hit him/her on the left forehead with a cane when he/she went to the residents' room at 5pm to approach him for taking his snacks from the TV room. On 03/01/22 at 11:00 AM, the Surveyor requested the Director of Nursing (DON) provide the Surveyor with any incidents that were required to be reported to the state agency for the month of February. At 1:41 PM, the DON stated that the facility only had one incident that was required to be reported to the state agency for the month of February. The DON stated that the incident occurred yesterday (02/28/22) and that they would be faxing it to the agency today. On 03/02/22 at 10:05 AM, the Surveyor requested that the DON provide any incidents or investigations that occurred in the last 3 months for Resident # 258. At 12:15 PM, the Director of Social Services provided the Surveyor with a one-page document titled, Incident Interview dated 02/09/22 which included a summary of the incident that occurred between Resident #258 and an unsampled resident. At 12:29 PM, in the presence of the survey team, the Surveyor inquired to the DON if Resident #258's allegation of abuse was reported to the NJDOH. The DON stated that it was not reported. She added that the investigation concluded that the incident was not witnessed and that the incident was fabricated. The surveyor then inquired to the DON if any allegation of abuse, whether it happened or not, was required to be reported. The DON stated that any allegation of abuse should be reported. On 03/11/22 at 11:23 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) confirmed that Resident #258's allegation of abuse was not reported to the NJDOH and that the allegation should have been reported. The surveyor then asked the LNHA when an allegation of abuse should be reported to the NJDOH. The LNHA stated that an allegation of abuse should be reported immediately. The facility did not provide any documented evidence that Resident #258's allegation of abuse was reported to the DOH. A review of the undated facility provided policy titled Policy on Resident Abuse included the following: It is the policy of this facility to protect all residents from physical or mental abuse; involuntary seclusion, neglect or misappropriation of personal property and to investigate and report all alleged or suspected incidents of resident abuse to the appropriate regulatory agencies . An employee witnessing any form of abuse is required to promptly report the incident to the charge nurse. Any staff member failing to report these incidents will be subject to disciplinary action which may include immediate discharge. The administrator will report the incident to the department of health and the Ombudsman's office within 72 hours. The investigation and its outcome will be reported to the above agencies . VII. Reporting All violations and alleged or suspected incidents of any form of abuse/neglect will be reported to appropriate state agencies within 72 hours . A review of the facility provided policy titled, Accident/Incident Reports with a revised date of 10/2021, included the following: Policy All accidents and incidents occurring on the facility's premises must be reported. An incident is any occurrence not consistent with the routine operation of the Facility, normal care of the resident, a happening involving visitors, malfunctioning equipment, or observation of a condition which might become a safety hazard . All DOH reportable events will be reported to the appropriate jurisdiction. N.J.A.C. 8:39-5.1(a)

Based on observation, interview and record review it was determined that the facility failed to maintain hazardous chemicals in a locked and secure manner at all times, resulting in the potential for serious harm, injury, or death to 6 of 52 cognitively impaired residents that resided on the second floor. Resident #'s 15, 16, 19 and 3 other residents that were cognitively impaired and independently ambulatory. This deficient practice was observed on 11/19/13 at 8:26 a.m. when a surveyor observed an ajar door of a "Janitor's Closet" which stored hazardous chemicals on the second floor of the facility where 6 confused and independently ambulatory residents resided. On 11/19/13 at 8:26 a.m. the surveyor observed a "Janitor's Closet" door that was ajar. The closet was located on the second floor common corridor opposite room 225. The door was observed to have a paper towel stuffed into the hole which prevented the door from latching securely to the door frame. The surveyor was able to gain entrance into the room by simply pulling the door open. The surveyor observed the following stored in the room: One gallon of bleach located on the floor and labeled as "Corrosive, may cause severe skin and eye irritation or chemical burns to broken skin, causes eye damage." One gallon of Santac Violet on an open shelf approximately three feet from the floor and labeled "Hazardous to humans and domestic animals. Corrosive-causes irreversible eye damage. Harmful if swallowed or absorbed through the skin." One gallon of Santac Green on the same open shelf and labeled "Do not get in eyes, skin or clothing. If on skin-immediately flush skin with plenty of water-if in eyes-flush with large quantities of water. Seek medical attention immediately." A spray bottle identified as "Santac Gold" on the same open shelf and labeled "Do not get in eyes. If ingested do not induce vomiting. Drink large quantities of water. Seek medical attention immediately." One gallon of "Spray Buff Floor Finish Maintainer and Restorer" which contained a white liquid on the same shelf and labeled "May be harmful if swallowed, avoid eye contact. A spray bottle which was unlabeled and contained the same white liquid as above (confirmed by an 11/19/13, 10:00 a.m. interview with Housekeeper #2). At the time of the above observation, the surveyor observed Resident #15 self propel in the area of the unlocked Janitor's Closet. Also at that time, the surveyor observed that there was no housekeeping staff in the area of the Janitor's Closet until approximately 8:35 a.m. Also between 8:26 a.m. and 8:35 a.m. the surveyor observed other facility staff intermittently walking by the Janitor's Closet through the corridor. There were periods of time during this timeframe that no staff were observed to be within eyesight of the Janitor's Closet. On 11/19/13 at 9:00 a.m. the surveyor interviewed Nurse #1 who stated that Resident #15 was cognitively impaired as well as Resident #'s 16 and 19. She also stated that in addition to Resident #15, Residents #16, #19, three others were able to move about the entire second floor (where they reside) either self ambulatory or in a wheelchair in the vicinity of the Janitor's Closet. On 11/19/13, surveyors on the survey team identified by review of the Minimum Data Set (MDS) that the six above residents were cognitively impaired. On 11/19/13 at 12:08 p.m. the surveyor interviewed Certified Nurse's Assistant (CNA#1) who stated that Resident #15 was capable of opening and closing doors independently as she has observed the resident doing this. On 11/19/13 at approximately 8:36 a.m. the surveyor observed Housekeeper (Housekeeper #1) appear at the Janitor's Closet. The surveyor then interviewed Housekeeper #1 who acknowledged that the paper towel was stuffed into the hole which prevented the door from latching securely to the door frame. Then at approximately 8:41 a.m. Housekeeper #2 appeared at the Janitor's Closet. Both Housekeeper #'s 1 and 2 stated that they did not put the paper towel in the hole and each did not know how it got there. Housekeeper #1 removed the paper towel from the hole and then was able to close the door appropriately as it latched to the frame and could not be opened without a key to unlock the door. Each stated that only Housekeeping staff, Maintenance staff and Porter staff had access to the Janitor's Closet with keys that unlocked the door. Also at 10:12 a.m. the surveyor interviewed other Housekeepers, Porters and Maintenance staff present and all stated they did not have any knowledge how the paper towel got stuffed in the hole. On 11/19/13 at 10:00 a.m. the surveyor interviewed the Facility Administrator who agreed that the above issue was very serious as residents including cognitively impaired residents had access to the dangerous chemicals stored in this Janitor's Closet. He then confirmed what the Housekeepers stated that only Housekeeping staff, Maintenance staff and Porter staff had access to the Janitor's Closet with keys that unlocked the door. On 11/20/13 at 1:24 p.m. the surveyor reviewed the facility policy titled "Chemical Storage Policy and Procedure" which was in effect at the time the surveyor observed the door to the Janitor's Closet ajar. The policy indicated that all hazardous chemicals shall be stored in the housekeeping supply closet and in the housekeeping carts. The closet and carts must be locked at all times. All hazardous chemicals shall be labeled and be secured at all times. At that time the Facility Administrator stated that the facility did not follow this policy. The surveyor notified the facility Administrator on 11/19/13 at 11:00 a.m. of the immediate jeopardy due to accessible hazardous chemicals. A formal plan of correction was accepted at 11:45 a.m. The immediate plan of correction included the following: 1. Closet doors were immediately locked on each floor that stored chemicals. 2. Staff were in-serviced on securing hazardous chemicals and storage. 3. A log was created to document that hazardous areas are checked daily to ensure doors are locked. 4. Housekeeping Director and nursing supervisors will conduct daily audits to ensure that all closets and carts are locked when unattended. 5. All audit findings will be reported to the Administrator weekly for a month and then quarterly to the CQI committee. The survey team was able to verify that the plan of correction was put in place through staff interview and observation. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to develop or follow a comprehensive care plan for a) pain management that included measurable, appropriate interventions to provide effective pain relief and b) an indwelling catheter. This deficient practice was identified for 1 of 19 residents, Resident #5, reviewed for care plans. The lack of effective pain management interventions resulted in resident #5 experiencing unnecessary, unrelieved pain. See F 309 a) On 8/22/11 at 1:21 p.m. the surveyor reviewed the pain care plan for Resident #5. The care plan for pain included: Assess pain on a scale of 1 - 10 and instruct resident in alternate pain management. According to the resident's Annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE], the resident had short and long term memory impairment and was severely impaired in decision making skills. Due to the cognitive impairment Resident #5 would be unable to understand and utilize the 1 to 10 pain scale. The surveyor observed the resident moaning, crying, and grimacing during a treatment by the facility nurse on 8/22/11 at 10:51 a.m. The nurse and the UM did not ask the resident what her pain level was on a 1 - 10 scale. The resident did not verbally respond when spoken to by the facility nurse and the Unit Manager (UM). Resident #5's care plan for pain also indicated that the resident was to be "pre-medicated before TX (treatments) i.e. PT/OT, dressing changes, bathing as needed." There was no indication in the resident's record that she was assessed before bathing or physical therapy. On 8/23/11 at 9:25 a.m. the facility nurse told the surveyor that the resident was not assessed for pain or pre-medicated before therapy. b) Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] indicated that the resident had short and long term memory impairment and was severely impaired in decision making skills. A review of Resident #5's care plan for indwelling catheter use included: "Assess urine output, observe color, odor, cloudiness, sediment" and "monitor for complaints of pain or discomfort from catheter." A review of the resident's medical record did not indicate that the resident's urine was assessed or that the resident was monitored for pain or discomfort from the catheter. The resident's care plan for indwelling catheter use also included: "Keep drainage bag off floor at all times." The surveyor observed the resident who was in bed with the indwelling catheter on the floor on 8/22/11 at 8:30 a.m., 8/22/11 at 9:14 a.m., and 8/22/11 at 10:30 a.m. On 8/22/11 at 10:30 a.m. the Unit Manager agreed that the indwelling catheter was on the floor. NJAC 8:39-11.1(2)

Based on observation, interview, and record review, it was determined that the facility failed to provide effective pain management interventions in order to relieve or decrease pain for 1 of 11 residents, Resident #5, which resulted in the resident experiencing unnecessary pain. The facility failed to address signs and symptoms of pain that the resident displayed during treatments, and provide pain management as ordered prior to treatments and physical therapy. This deficient practice was evidenced by the following: Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] indicated that the resident had short and long term memory impairment and severely impaired decision making skills and required the total assistance of staff for all Activities of Daily Living. On 8/22/11 at 10:30 a.m. the surveyor observed a wound treatment being administered by the facility nurse to Resident #5's stage IV sacral wound. The Unit Manager (UM) was present to assist the nurse. When the nurse repositioned the resident on the resident's side, the surveyor observed the resident to be moaning and crying. The nurse and the UM continued with the wound treatment. The nurse then removed the resident's old dressing from the wound and the resident continued to moan and cry. The UM told the resident that they were almost finished and the nurse continued with the treatment. However, the resident continued to moan and cry. At 10:51 a.m. the surveyor intervened and requested that the nurse stop the treatment. The surveyor then asked the nurse what was the protocol when a resident moans and cries. The UM and the nurse said they were unsure. The nurse then said that she had given the resident Tylenol at 10:15 a.m., and would give the resident another dose of Tylenol again in 4 hours, and attempt the treatment again. The nurse said that she was going to check on the resident in 1/2 hour and if the resident was not observed to be in pain she would do the treatment over. On 8/22/11 at 11:05 a.m. the surveyor spoke with the DON in reference to the resident's signs of pain during the wound treatment. The DON said she was going to in-service the nurse and the UM on pain management. On 8/22/11 at 11:10 a.m. the surveyor reviewed Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]., 2 tabs (650) mg. (milligrams) via [DEVICE] to be administered 30 minutes prior to wound care for pain management. The time scheduled by the nurse on the MAR indicated [REDACTED]. On 8/22/11 the nurse signed that she administered the Tylenol at 8 a.m., which was not 30 minutes prior to wound treatment as previously stated by the nurse. On 8/22/11 at 11:15 a.m. a review of the physician's orders [REDACTED]. A Quarterly MDS dated [DATE] and an Annual MDS dated [DATE] indicated that the resident had short and long term memory impairment and severely impaired decision making skills. The MAR indicated Monitor for pain every shift on a scale of 1 - 10." Due to the resident's severe cognitive impairment this was an inappropriate assessment tool to evaluate Resident #5's pain. The resident was unable to understand and respond to the question of what level of pain she was experiencing. There was no indication in the resident's medical record that she had been assessed for pain using an indicator that was appropriate for the resident's cognitive status. The surveyor reviewed the physician's orders [REDACTED]. and to discontinue the Tylenol order 30 minutes prior to wound care. In addition a new order at 12 p.m., was written to give [MEDICATION NAME] 37.5mg./325mg before wound care. On 8/22/11 at 12:38 p.m., the nurse stated that she was going to perform the wound treatment. The nurse stated that the resident had been given a one time dose of Tylenol at 11:30 a.m. When the nurse and UM repositioned the resident the resident started to cry. The nurse then stopped the treatment. On 8/22/11 at 2:35 p.m. the surveyor interviewed the Physical Therapist (PT). The PT said that the resident had exhibited signs of pain during therapy, especially when doing stretching exercises. The PT said that the resident grimaces, cries, and moans at times. When this happens, the PT said that she stops the exercises and continues when the resident looks more comfortable. If the resident continues to exhibit signs of pain, the PT takes the resident back to her unit. The surveyor asked the PT if she tells nursing about the resident's pain. The PT said that she writes it in her notes but does not always remember to do so. On 8/23/11 at 9:25 a.m. the facility nurse said that the resident is not assessed for pain or pre-medicated before therapy. A review of the resident's care plan for pain indicated that the resident was to be pre-medicated as needed before therapy. There was no indication in the resident's record that she was assessed for pain before therapy. On 8/23/11 at 10:20 a.m. Resident #5's regular Certified Nursing Assistant (CNA) said that the resident grimaces and cries at times when being moved by the CNA during care and when being transferred to and from the Geri chair. The CNA also said that she tells the nurse when she thinks that the resident is in pain. The resident's pain care plan indicated that the resident was to be "pre-medicated before TX (treatments) i.e. PT/OT, dressing changes, bathing as needed." There was no indication in the resident's record that she was assessed before bathing. NJAC 8:39-27.1(a)