Every finding on record at Preferred Care at Cumberland

Based on interviews and review of facility documentation on 6/10/26 and 6/15/26, it was determined that the facility failed to maintain a resident's medical information confidential in accordance with standards. This deficient practice was identified for 1 of 7 residents reviewed (Resident #7), and was evidenced by the following:a.) A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: acute osteomyelitis, type II diabetes, and memory deficit following cerebral infarction. A review of facility documented grievance records revealed a grievance dated 5/13/26 for Resident #1, which was completed by the Licensed Nursing Home Administrator (LNHA) following a phone notification by third party provider. The grievance revealed that another resident's AR was sent with Resident #1's medical information. b.) A review of the AR revealed that Resident #7 was the resident whose medical and personal information was sent with Resident #1 to a third party facility appointment. Further review revealed that Resident #7 was admitted to the facility with diagnoses that included but were not limited to: metabolic encephalopathy, type II diabetes, and atrial fibrillation (irregular heart rhythm). A review of facility documented grievance records revealed a grievance dated 5/13/26 for Resident #7, completed by the LNHA after receiving a phone call from a third party provider. The grievance revealed that Resident #7's AR was sent with Resident #1's medical information to an appointment. A joint interview was conducted on 6/10/26 at 5:15 PM with the Director of Nursing (DON), the Regional DON (RDON) and the LNHA. The LNHA stated that he received a call from Resident #1's provider who informed him that Resident #7's AR was mixed in with Resident #1's paperwork. LNHA stated that he completed a grievance form and investigated the incident. He further stated that the facility determined that a new Unit Clerk who was being trained by the Medical Record staff, had erroneously mixed up Resident #7's document with those of Resident #1. During a follow-up interview on 6/15/26 at 3:38 PM, the LNHA acknowledged that an error occurred and that the wrong paperwork was sent with Resident #1 to a third party facility. He stated that the facility took residents' privacy seriously and that all staff were re-educated on the importance of keeping residents medical record confidential. A review of the facility's Health Insurance Portability and Accountability Act (HIPPA) policy, revised on 6/1/26, revealed that the facility would maintain residents' confidentiality and that they would safeguard all written documentation. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 128 of 132 residents who received dietary services. Findings include:Review of the facility's policy titled, Cleaning and Storage of Pots/Pans in Dietary, dated 02/28/25 revealed, Policy: To ensure pots and pans are cleaned, sanitized, and stored in a sanitary manner that prevents contamination and complies with state and federal regulations. Procedure: 1. Cleaning and Drying: Cookware should be properly cleaned and dried after use using available methods approved for kitchen sanitation. Staff should ensure items are appropriately dry before putting them away.3. Stacking and Nesting: Staff should use good judgment when stacking or nesting cookware to avoid taping moisture or introducing contaminants. During an observation and interview on 08/04/25 at 9:55 AM, the Dietary Manager (DM) confirmed six pans, 12 inches by 12 inches by 6 inches deep, three pans 8 inches by 12 inches by 6 inches deep that had been cleaned and stacked for use and were still wet when they were stacked. The pans were found to have been stacked wet and not allowed to properly air dry prior to being stacked. Interview with the DM at this time, stated, they should be dry before being put away, they weren't dry before they were stacked. Being put away wet increases the risk of contamination. NJAC 8:39-17.2(g)NJAC 8:39-19.7

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that one (Resident (R) 13) out of four residents reviewed for Minimum Data Set (MDS) assessments was transmitted in a timely manner, out of a sample of 32 residents. This had the potential for the resident's progress not to be monitored and potential for decline. Findings include:Review of the RAI manual version 1.191 dated 10/24 revealed . Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS.RAI OBRA-required assessment summary for admission.MDS completion date (Z0500B) no later than 14th calendar day of the resident's admission (admission date + 13 calendar days) .Transmission date no later than care plan completion date + 14 calendar days. Along with, Discharge Assessment.MDS completion date (Item Z0500B) no later than discharge date + 14 calendar days.Transmission date no later than MDS completion date +14 days.Review of R13's Face Sheet provided by the facility revealed R13 was re-admitted to the facility on [DATE]. Review of the resident's Census Data located in the electronic medical record (EMR) under the Census tab revealed R13 discharged to the hospital on [DATE]. The EMR also revealed a discharge return not anticipated Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/08/25 was started, however the status did not indicate that it had been completed or accepted. During an interview on 08/07/25 at 1:58 PM with the Regional Nursing Director (RND) she confirmed that the MDS team submitted the assessment late on 08/07/25 (five months after the MDS was started). When asked why the assessment was not submitted timely, she stated that it was overlooked. NJAC 8:39-11.2

Based on record review, interview, and policy review, the facility failed to ensure the baseline care plan included sufficient information to provide person-centered care for one of three sampled residents (Resident (R) 161) reviewed for new admission in a total sample of 32 residents. This failure had the potential for the resident to have unmet care needs.Findings include: Review of the facility policy titled, Baseline Care Plan created 01/2025 revealed, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards. The baseline care plan will .include the minimum healthcare information to properly care for the resident .but not limited to .Physician Orders. Review of R161's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed that R161 was admitted to the facility on [DATE] with diagnoses that included pneumonia, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), dependence on oxygen, and chronic bronchitis. Review of the Physician Orders dated 03/12/25 located in the EMR under the Orders tab revealed, apply BiPAP (Bilevel Positive Airway Pressure machine to improve breathing during sleep) machine at the following settings at bedtime for sleep apnea and remove in the morning per schedule. Review of the Baseline Care Plan dated 03/12/25 located in the EMR under the Care Plan tab failed to reveal that R161's conditions of pneumonia, obstructive sleep apnea, chronic obstructive pulmonary disease, dependence on oxygen, chronic bronchitis, and use of BiPAP were included in the baseline plan of care. Review of the five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/25 identified a Brief Interview for Mental Status (BIMs) score of 15 out of 15 that indicated R161 was cognitively intact, had shortness of breath when lying flat, required continuous oxygen, and utilized a non-invasive mechanical ventilator- BiPAP. During an interview on 08/07/25 at 1:09 PM, the Regional Nursing Director (RND) reviewed R161's Baseline Care Plan and confirmed the resident's respiratory conditions of COPD, OSA, pneumonia, dependence on oxygen, and order for BiPAP were not included in R161's Baseline Care Plan. NJAC 8:39-11.2

Based on record review, activity calendar review, interview, and observation the facility failed to ensure activities were provided in accordance with the resident's preferences for one of two sampled residents (Residents (R) 98) reviewed for activities in a total sample of 32 residents. This failure had the potential for the resident to have a diminished quality of life.Findings include: Review of R98's Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed R98 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) and dementia. Review of R98's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/25 identified a Brief Interview for Mental Status (BIMs) score of three out of 15 that indicated severe cognitive impairment, total dependence for wheelchair mobility, and the interview for daily and activity preferences should be conducted. The interview for daily activity preferences revealed that the resident indicated it was somewhat important while at the facility to listen to music, keep up with the news, do things with groups of people, go outside, and get fresh air in good weather, and participate in religious activities. Review of the Care Plan dated 03/17/25 and revised on 06/15/25 located in the EMR under the Care Plan tab revealed, [Resident name] enjoys listening to all kinds of music, sitting outside when weather permits, watching tv and movies. [Resident name] will take part in the sensory program. Interventions included to transport to activities of interest, provide supplies/materials for leisure activities as needed/requested and encourage participation in group activities. Review of the July 2025 and August 2025 activity calendars revealed programs included move and music, music performances, coffee socials, religious programs, karaoke, and group activities. Review of R98's July 2025 Record of One-on-One Activities documentation provided by the Interim Activity Director (AD) revealed one on one activities were provided once a day on 07/01/25, 07/03/25, 07/06/25, 07/10/25, 07/14/25, 07/18/25, 07/23/25, 07/27/25, and 0730/25. The activities provided included snack, chat, mail, card, and reading a book. Review of R98's August 2025 Record of One-on-One Activities documentation provided by the Interim AD revealed one on one activities were provided once a day on 08/01/25, 08/02/25, and 08/05/25. The activities provided included mail, snack, and chat. During an observation on 08/04/25 at 10:00 AM revealed R98 was in bed sleeping and the TV was on and tuned to a talk show. At 2:01 PM R98 was in bed, and the TV was on and tuned to a soap opera drama. At 2:10 PM a music program was taking place in the main dining room/activity room. R98 was not in attendance. At 3:00 PM R98 was in a Broda chair in the hallway alcove area near the nurse's station. The area did not have any form of stimulation, and no activities were being provided. During an observation on 08/05/25 at 10:30 AM revealed R98 was in a Broda chair in the hallway alcove area near the nurse's station. The area did not have any form of stimulation, and no activities were being provided. During an observation on 08/06/25 10:27 AM revealed a music program was taking place in the main dining room/activity room and R98 did not attend. During an interview on 08/07/25 at 9:10 AM, the AD stated recreation staff would bring residents to programs and if they did not go to programs they would provide one on one visits. The AD stated music programs take place at least every Monday and Wednesday and sometimes more often when performers come in. The AD reviewed the R98's activity attendance documentation and stated the resident had not attended any scheduled programs including the music programs in July and August 2025. The AD was unsure of R98's specific activity preferences and stated one to one visits were being provided. The AD confirmed the one on one activities being provided were not based on the resident's activity preferences. NJAC 8:39-7.3

Based on record review, Functional Maintenance Program documentation review, and interview, the facility failed to ensure recommendations for passive range of motion (ROM) were implemented for one sampled resident (Residents (R) 98) reviewed for limitation in ROM in a total sample of 32 residents. This failure had the potential for the resident to experience a decline in ROM.Findings include: Review of R98's Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed R98 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) and hemiplegia (paralysis or weakness on one side of the body) affecting the left side. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/25 identified R98 had a Brief Interview for Mental Status (BIMs) score of three out of 15 that indicated severe cognitive impairment and limitation in range of motion in the upper and lower extremity on one side. Review of the Occupational Therapy Discharge summary dated [DATE] in the EMR under the Therapy tab revealed, .Discharge Recommendations and Status .Functional Maintenance Program Established/ Trained = Range of Motion Program .Range of Motion Program Established/Trained: PROM [passive range of motion] on Left UE [upper extremity] and LE [lower extremity]. Review of the Functional Maintenance Program (FMP) document dated 04/30/25 located in the Assistant Director of Nursing (ADON) office in a FMP notebook revealed, .Reason why resident recommended to Functional Maintenance Program -maintain gains achieved in therapy .goals for restorative program: maximize available ROM [range of motion] on left UE/LE .approaches/recommendations for implementation of goals: PROM on left UE/LE as tolerated .Modify goal: Gentle ROM as tolerated during AM/PM care. Review of the Care Plan dated 03/28/25 and 06/29/25 located in the EMR under the Care Plan tab revealed the resident had a cerebral vascular accident (stroke) with left sided weaknesswith interventions that included to monitor/document/report to physician as needed for neurological deficits, level of consciousness, visual function changes, aphasia, dizziness, weakness, restlessness, monitor/document the residents abilities for activities of daily living and assist resident as needed, encourage resident to do what he/she is capable of doing for self, and monitor for contractures. The care plan did not identify that PROM was an intervention being implemented for limitation in range of motion of the left upper and lower extremities. Review of the May, June, July, and August 2025 certified nurse aide (CNA) documentation (Kardex) with the Assistant Director of Nursing (ADON) on 08/07/25 at 1:00 PM did not reveal that PROM was being provided to R98. During an interview on 08/06/25 at 1:00 PM, the Rehab Director (RD) stated Occupational Therapy (OT) in the OT discharge made a recommendation for the resident to receive ROM to the left upper and lower extremities through the FMP (facility restorative rehab program). The RD stated referrals for FMP are made to nursing. During an interview on 08/06/25 at 2:30 PM, the RD confirmed the resident did not receive services by the facility FMP per the OT recommendation. During an interview on 08/07/25 at 10:00 AM, the ADON stated she was the Registered Nurse (RN) that oversaw the FMP in the facility. The ADON stated the FMP committee includes the ADON, Therapy Director, Rehab CNAs, and Unit Managers. The ADON stated at the April (2025) monthly FMP committee meeting, the committee discussed the OT recommendation for the resident to be picked up by the FMP to receive PROM. The ADON stated the FMP committee decided not to pick the resident up for services, but to refer the resident to the unit CNAs for gentle ROM of the upper and lower extremities during morning and evening care. The ADON stated the Unit Manager is responsible to include the intervention in the resident care plan and the CNA Kardex. The ADON reviewed the resident's care plan and CNA Kardex and was unable to find PROM was included as an intervention. The ADON stated the unit the resident resides, had changes in unit managers over the past three months and it must have been missed. NJAC 8:39-27.1(a)

Complaint #: NJ175824 Based on interviews, medical record review, and review of other pertinent facility documents on 08/19/2024, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and follow the Certified Nursing Aide (CNA) job description and follow its policy titled Documentation in Medical Record for 1 of 3 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to Other Forms of Acute Ischemic Heart Disease, and Pressure Ulcer of Sacral Region Stage 2. The Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 08/31/2023 revealed that Resident #2 had diagnoses that included but were not limited to Non-Alzheimer's Dementia. The MDS revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated severe cognitive impairment. Resident #2's Cognitive Skills for Daily Decision Making were found to be severely impaired. The MDS also indicated that Resident #2 required extensive assistance and weight bearing support with bed mobility. Review of Resident #2's Care Plan (CP) revealed a Focus, initiated on 08/25/2023, that Resident #2 had actual skin impairment related to physical immobility. Review of Resident #2's Documentation Survey Report v2 (DSR) for August, September, and October 2023 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Turning & Repositioning for a total of 11 days: On 08/26/2023 through 8/28/2023, 09/01/2023, 09/15/2023, 09/19/2023, 09/24/2023, 09/28/2023, 10/04/2023, 10/10/2023, and 10/11/2023. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation for Turning & Repositioning for a total of 17 days: On 08/26/2023 through 08/29/2023, 09/01/2023, 09/04/2023 through 09/06/2023, 09/17/2023, 09/23/2023, 09/24/2023, 09/27/2023, 10/01/2023, 10/04/2023, 10/05/2023, 10/09/2023, and 10/10/2023. On the 11:00 P.M. to 7:00 A.M. shift, there was no documentation for Turning & Repositioning for a total of 23 days: On 08/24/2023 through 08/30/2023, 09/02/2023 through 09/04/2023, 09/08/2023, 09/11/2023 through 09/13/2023, 09/17/2023, 09/18/2023, 09/21/2023, 09/22/2023, 09/26/2023, 10/02/2023, 10/03/2023, 10/06/2023, and 10/10/2023. Review of Resident #2's Progress Notes revealed no documentation that Resident #2 was turned and repositioned during the aforementioned shifts. Review of Resident #2's Progress notes revealed no documentation that Resident #2 refused turning and positioning during the aforementioned shifts. During an interview at 2:25 P.M. on 08/19/2024, a CNA stated that CNAs were responsible for turning and repositioning and for documenting what care was done in the electronic system. The CNA further stated that changes of position were provided every two hours unless a resident refused position change. The CNA stated that if residents refused turning, she would check back with them in 30 minutes. The CNA confirmed the presence of blanks on the DSR and stated that blank spaces may be due to staff forgetting to document, or not having time to document the care that was provided. The CNA confirmed that the expectation was that there should have been no blank spaces in DSR documentation. In an interview at 2:30 P.M. on 8/19/2024, the Assistant Director of Nursing (ADON) reported that turning and positioning was done by CNAs according to the turning and positioning schedule located on the units. The ADON reported that Nurses and Unit Managers were responsible for ensuring that turning and positioning was done and documented. The ADON stated that it was her expectation that there were no blanks in documentation. ADON confirmed the presence of blanks in Resident #2's DSR for August, September, and October 2023. The ADON stated that blank spaces in the DSR can indicate that the care was not performed, or that care may have been provided but not documented. Review of the facility's job description document for the position Certified Nurse Aide revealed that the following Duties/Responsibilities were described as essential functions of the job: turn bedridden residents every two (2) hours or sooner as indicated, and records all entries on flow sheets or Point of Care/Care Tracker in an informative and descriptive manner. Review of the facility policy titled, Documentation in Medical Record with a last revised date of September 2023 indicated that Documentation shall be completed in a timely manner. This policy further stated that documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or responses to care. NJAC 8:39-35.2(f)

NJ # 156264 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a clean environment in the second and third floor shower room. The deficient practice was identified on 2 of 3 shower rooms (Second & third floor) under the Environmental Task. The deficient practice was evidenced by the following: On 02/16/2024 at 11:14 AM, the surveyor entered and observed the shower room located on the second floor. At that time, the surveyor observed uncapped, opened bottles of shampoo and aftershave, discoloration on the shower floor, and white shower tiles with stains orange in appearance. The shower room also contained personal clothing draped on a shower chair, and a pair of black shoes left on the ground. Further, the surveyor observed a black, vegetative substance on the shower walls. Lastly, the surveyor observed clothing hangars, tags, and papers left on top of a plastic shower gurney. On the same date at 11:30 AM, the surveyor entered and observed the shower room on the third floor. At that time, the surveyor observed linen draped over a shower chair. Secondly, the surveyor observed a whirlpool tub. Within the tub, there was a clear, plastic bag containing soiled linen, brown-stained towels and a stained hospital gown. On 02/21/2024 at 11:04 AM during an interview with the surveyor, the Director of Housekeeping (DHK) replied that shower rooms are cleaned every day when the surveyor asked how often the rooms are cleaned. The DHK also confirmed that there should not be anything in the whirlpool tubs. On 02/22/2024 at 1:07 PM during an interview with the surveyor, the Director of Nursing said that the nursing staff place linen in the shower room and the housekeeping staff removes it. During the same interview, the Licensed Nursing Home Administrator (LNHA) replied, No when the surveyor asked if soiled linens should be stored in the whirlpool tub. On 02/23/2024 at 10:31 AM during an interview with the surveyor, the LNHA stated that the facility initiated an in-service for the staff on handling and placing soiled linens. A review of the facility policy titled, Routine Cleaning and Disinfection implemented on 8/2023, revealed under subsection, Policy Explanation and Compliance Guidelines that, 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas . NJAC S 8:39-31.4 (a)

NJ # 154489 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer, specifically by leaving the Treatment Administration Record blank on specific dates and times. The deficient practice was identified for 1 of 4 residents (Resident # 222) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 222's Significant Change Minimum Data Set (MDS; an assessment tool) dated 01/02/2023 and the Quarterly MDS dated [DATE] revealed that he/she had one stage four ulcer (severe tissue damage). A review of Resident # 222's Admission Record revealed a diagnosis of but not limited to, Pressure Ulcer of Sacral Region, Stage 2. A review of Resident # 222's Care Plan revealed a focus, Impaired skin integrity at risks for further skin breakdown r/t [related to] incontinence, impaired mobility, and poor appetite. sacral wound - 5/24/22 The Care Plan revealed interventions including but not limited to, treatment sacral wound and fungal dermatitis rash on bilateral butt/sacrum per orders - report any worsening or delayed healing PRN [as needed]. and, tx [treatment] to sacral wound per orders and report status changes and or s/s [signs and symptoms] infection . A review of the Treatment Administration Record (TAR) for April of 2022 revealed the following physician orders and blanks on the TAR: Medihoney Wound/Burn Dressing Gel (Wound Dressings). Apply to right lat [lateral] buttocks topically every day shift for wound care apply with optifoam dressing. The order was started on 03/26/2022. The TAR revealed blanks on 04/09/2022 and 04/10/2022 for the day and evening shifts. Cleanse sacral and buttocks intact skin with NSS [Normal Saline Solution] pat dry. Apply Nystatin/Zinc 1:1 mix every shift and PRN [as needed] incontinence every shift for MASD [Moisture Associated Skin Damage]. The order was started on 04/11/2022. The TAR revealed blanks on 04/16/2022 for the night shift, 04/19/2022 for the evening shift, and 04/25/2022 or the night shift. A review of the TAR for May of 2022 revealed the following physician orders and blanks on the TAR: Skin prep to B/L [bilateral] heels every day and evening shift. The order was started on 08/20/2021. The TAR revealed blanks on 05/08/2022 for the day and evening shifts. Cleanse sacral and buttocks intact skin with NSS [normal saline solution] pat dry. Apply Nystatin/Zinc 1:1 mix every shift and PRN [as needed] incontinence every shift for MASD [Moisture-Associated Skin Damage]. The order was started 04/11/2022. The TAR revealed blanks on the day and evening shifts on 05/08/2022. Prevalon boots to bilateral feed while in bed. Every shift for risk for skin breakdown. The order was started on 03/17/2022. The TAR revealed blanks on 05/08/2022 for the day and evening shift. The TAR revealed blanks on 05/23/2022 for the day and night shift and blanks on 05/27/2022 for the day shift. Nystatin-Triamcinolone Cream 100,000-0.1 Unit/gram-%. Apply to sacral redness topically every shift for ppx mix with silvadene and zinc. The order was started on 05/05/2022. The TAR revealed blanks on 05/23/2022 for the day and night shift and 05/27/2022 for the day shift. Silvadene Cream 1% (Silver Sulfadiazine). Apply to sacral redness topically every shift for ppx mix with nystatin and triamcinolone and zinc. The order was started on 05/05/2022. The TAR revealed blanks on 05/23/2022 for the day and night shift and 05/27/2022 for the day shift. On 02/21/2024 at 10:37 AM during an interview with the surveyor, Licensed Practical Nurse # 3 replied, No, we have codes to use. If it is a hold or refusal, there is a number that corresponds to that. A review of the Progress Notes located in Resident # 222's electronic Medical Record did not reveal any notes of resident refusals of care for the above specified dates and time. On 02/22/2024 at 11:22 AM during an interview with the surveyor, the Director of Nursing (DON) replied, The nurse should be documenting in the progress notes. when the surveyor asked what is the procedure for documentation if a resident refuses care. Further, the DON replied, No, because there is a code that they [nurses] use. when the surveyor asked if the TAR should be left blank. When the surveyor asked if blank spaces on the TAR and no notes reflecting why it may be left blank, would you consider the treatment, order, or intervention as administered. The DON replied, Absolutely not. A review of the facility policy titled, Medication Administration last reviewed 1/2024 revealed under section, Policy Explanation and Compliance Guidelines that, 19. If a resident refuses medication, document refusal on MAR [Medication Administration Record] or TAR and/or in resident medical record . S N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review and other facility documentation, it was determined the facility failed to ensure there was a Physician's Orders (PO) for 1 of 1 residents (Resident # 471) reviewed for Respiratory Care. This deficient practice was evidenced by the following: On 2/14/24 at 11:48 AM during initial tour the surveyor observed Resident # 471 in bed with a nasal cannula (tubing that delivers oxygen to a person) applied to his/her nose with oxygen being administered at two liters per minutes. At that time, Resident # 471 said that he/she always wears oxygen. A review of Resident # 471's Admission Record revealed he/she was admitted to the facility with diagnoses including but not limited to, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, and Chronic Pulmonary Edema. A review of Resident # 471 Order summary report dated 2/08/2024 did not show any orders for oxygen. A review of Resident # 471 Care Plan initiated on 01/11/2024 and revised on 02/20/2024 revealed a focus for oxygen therapy r/t [related to] Ineffective gas exchange, h/o [history of] Covid, chronic respiratory failure, COPD [Chronic Obstructive Pulmonary Disease]. During an interview on 2/21/23 at 11:25 AM with Licensed Practical Nurse (LPN) # 1, when asked what the policy is for putting orders on admission, LPN # 1 replied, We get the discharge packet from the hospital; we assess the resident then call the doctor with the assessment and orders to see what they want to continue. When asked if any medication should be given before orders are entered, LPN # 1 replied, No. The surveyor then asked, What about oxygen? LPN # 1 replied If they are in distress we have standard orders, and if they come in from the hospital, we don't take it off until we get the orders entered. When asked, why is it important to have orders entered? LPN # 1replied, So the nurses know what to give and when last given, and to ensure their care is continued. During an interview on 2/21/24 at 12:08 PM, the Director of Nursing (DON) said that they have order sets that are entered for all residents and that they take the orders that the hospital gives them and review the orders with the doctor to clarify what orders to keep. When asked if medication should be given without orders, the DON stated No. The surveyor then asked, What about oxygen? The DON replied, If they are coming in the facility with oxygen on we wouldn't take it off of them, but we would still get orders, the orders would be entered that same day. When asked why is that important the DON replied, Because we would never administer a medication without a doctor's orders. A review of a facility policy titled Oxygen with a revised date of 9/12/23, revealed under the Procedure section, 1. Check MD Order. And 9. Document initiation of oxygen in the resident medical record, including time, flow, indication and method: cannula or mask, in TAR (Treatment Administration Record and or in progress notes). Document use and resident reaction to Oxygen. N.J.A.C. S 8:39-27.1(a)

NJ #154489 Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed through 04/24/2022 through 05/07/2022. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 04/24/2022 through 04/30/2022 and 05/01/2022 through 05/07/2022 revealed the facility had no RN coverage for all shifts on 04/30/2022 and 05/01/2022. A review of the facility provided document titled, Time Card Report with a date range of 04/30/2022 through 05/03/2022 did not reveal any hours covered by an RN for 04/30/2022 and 05/01/2022. On 02/23/2024 at 10:30 AM, during an interview with the surveyor, the Licensed Nursing Home Administrator replied, So far, I haven't found anything for those two days' when the surveyor asked if the facility had an RN on duty for 04/30/2022 and 05/01/2022. A review of the facility policy titled, Registered Nurse Staffing reviewed 8/2023 revealed under section, Policy Explanation and Compliance Guidelines: that, 1. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. NJAC 8:39-25.2(h)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow appropriate standards of practice for, a. the storage of medications at proper temperatures and b. accountability of a narcotic count sheet. This deficient practice was observed in 1 of 2 medication rooms and 1 of 3 medication carts inspected for storage and labeling and was evidenced by the following: a. On 2/16/24 at 12:16 PM, the surveyor observed the first-floor medication room for storage and labeling in the presence of Licensed Practical Nurse #2(LPN#2). Upon opening the refrigerator, the surveyor observed that the thermometer reflected a temperature of 60 degrees Fahrenheit (60F.) The surveyor also observed a clear liquid which appeared to be melted ice on the lowest shelf in the refrigerator. LPN#2 verified the temperature of the refrigerator was 60F and that she believes that the clear liquid is most likely melted ice. LPN#2 stated that she believes the 11 to 7 shift is responsible for checking the temperature of the refrigerator. The surveyor observed the following medications in the first-floor medication refrigerator: 1.A box with one injection of Copaxone Medication (used to treat Multiple Sclerosis). The label reflected to store at 36F to 46F. LPN#2 stated, The fridge temperature is too high. 2.One bottle of unopened insulin glargine (used to treat diabetes). The label reflected to refrigerate until opened. 3. Two bottles of unopened Humalog (used to treat diabetes). The label reflected refrigerate until opened. 4. One bottle of unopened lispro (used to treat diabetes). The label reflected to refrigerate until opened. 5. One Injection of Prevnar (a vaccine). The label reflected to refrigerate. LPN #2 stated that the medications that were stored in the refrigerator will not be administered to the residents. The UM#1 verified that the 11 to 7 shift is responsible for checking the refrigerator temperature. She furthered that she would remove the medications from the refrigerator right now. The Maintenance Director verified that the refrigerator feels warm. He stated, The ground fault tripped. It has never happened before. On 02/16/24 12:57 PM the Director of Nursing stated the refrigerator temperature should be between 37 -41 degrees 60 degrees was not proper. On 2/16/23 at 2:19 PM, the surveyor reviewed the facility provided policy titled Medication Refrigerator Temperature Checks which was created on 9/18/23. The policy reflected that the temperature range must be from 36-46 degrees. b. On 2/16/23 at 12:16 PM, the surveyor, in the presence of Licensed Practical Nurse #2 (LPN #2), reviewed the narcotic count sheets for the first-floor AB side medication cart. The surveyor observed the following: Resident #54's narcotic count sheet for Tramadol 50mg (a pain medication) reflected that there were 112 pills. The blister packs of the Tramadol reflected that there were 111 pills. LPN#2 stated she gave a Tramadol at 12:00 PM however she forgot to sign the narcotic count sheet for Resident #54. LPN #2 was able to show that the medication was given and signed in the residents' electronic medication administration record (MAR). On 2/16/24 at 12:57 PM, the Director of Nursing stated the nurse should have signed in book when she took the Tramadol out of the drawer. On 2/21/24 at 11:30 AM, the surveyor reviewed the facility policy titled Controlled Substances which was reviewed on 3/8/23. The policy reflected that controlled substances are reconciled upon . administration . NJAC: 8:39-29.4

Complaint # NJ00158190 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure palatable temperature of food and beverage for 1 of 1 lunch meal served on 1 of 3 units (First Floor). This deficient practice was evidenced by the following: On 02/20/24 at 10:34 AM, the surveyor conducted a meeting with Resident Council which included five residents (Residents #23, #32, #54, #59, and #69). All five residents informed the surveyor that the breakfast meal was always served cold and warm food was cold and cold food was hot on all three nursing units. On 02/21/24 at 11:30 AM, the surveyor observed the Supervising Cook (SC) as she obtained food temperatures from the steam table. The surveyor observed that the SC did not document the food temperatures that she obtained. The SC stated, I should have recorded the temperatures. On 02/21/24 at 11:45 AM, The Food Service Director (FSD) calibrated (to check the setting) his thermometer in the presence of the surveyor to 31.8 degrees Fahrenheit (F) and stated that 32 F was the desired calibration. The food truck left the kitchen at that time, and went to the first floor nursing station. On 02/21/24 at 11:47 AM, the food truck arrived on the first floor nursing unit where the nursing staff awaited meal delivery. On 02/21/24 at 11:54 AM, the last resident meal tray was passed. On 02/21/23 at 11:55 AM, the FSD obtained food temperatures from a regular tray using a calibrated thermometer which included: cranberry juice 54 F, milk 49 F, and mixed fruit 56 F. The FSD stated that the cold food and beverages should be served below 41 F. On 02/21/24 at 11:59 AM, the FSD obtained food temperatures from a pureed (a way to change the texture of solid food so that it was smooth with no lumps) tray using a calibrated thermometer which included: milk 42 F, apple juice 55 F, and pureed mixed fruit 56 F. The FSD stated the temperatures of the cold items were a little off from 41 F. On 2/22/24 at 12:40 PM, the surveyor returned to the kitchen and obtained a copy of the Service Line Checklist dated 02/21/24. The lunch meal temperatures were recorded on the form and indicated that milk was 34 F, and cold beverage/juice was 33 F, and fruit was 34 F. The SC was not available for interview at that time. On 02/23/24 at 10:32 AM, the Licensed Nursing Home Administrator (LNHA) presented the surveyor with a copy of the Service Line Checklist dated 02/21/24 and stated that food temperatures were obtained and milk was recorded at 33 F. LNHA further stated that temperature preference was subjective. The surveyor informed the LNHA that during the tray line observation on 02/21/24 at 11:30 AM, the surveyor did not observe the SC obtain cold food or beverage temperatures or document the hot food temperatures that were obtained prior to the lunch meal delivery to the first floor nursing unit. Review of a facility policy titled, Food Temperatures (Reviewed 08/2023) revealed the following: .The cook is responsible to see all food is at the proper temperature. Temperatures of all food items will be recorded prior to meal service. .The following range of temperatures is recommended for food at point of tray assembly: .Chilled Foods and Beverages (45 F or Below). According to USDA (United States Department of Agriculture) Food Safety and Inspection Service, .Cold foods should be held at 40 F or colder . Reference: https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/steps-keep-food-safe NJAC 8:39-17.4(a)(2)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to implement appropriate use of personal protective equipment, specifically by staff not wearing a gown while inside a resident room under transmission-based precautions. The deficient practice was identified for 1 of 6 residents (Resident # 470) reviewed under the Infection Control facility task. The deficient practice was evidenced by the following: On 02/15/2024 at 12:00 PM on the second floor, the surveyor observed a Certified Nurses Aide (CNA) # 1 enter a resident (Resident # 470) room with a sign on the door that revealed, USE STANDARD PRECAUTIONS PLUS + ENTERIC CONTACT ISOLATION Prior to Entering the Room. The sign revealed a illustration of a gown along with gloves. CNA # 1 entered the room with a tray of food. Outside of the resident's room was a plastic bin containing disposable, blue gowns, gloves, and a container of bleach surface wipes. CNA # 1 did not wear a gown or gloves while inside the room. At that time from the hallway, the surveyor observed CNA # 1 and Resident # 470 inside the room. While inside the room, CNA # 1 was observed placing the tray of food on the bed side table, assisting with setting up the meal, adjusting the bed side table, and retrieving a pair of eyeglasses from the floor. CNA # 1 did not wear a gown or gloves during this time. Approximately five minutes later, CNA # 1 left the room and used alcohol-based hand rub during hand hygiene. On the same date at approximately 12:05 PM, during an interview with the surveyor, CNA # 1 replied, I should have worn a gown in there. when the surveyor asked if she should have worn anything specific. On 02/16/2024 at 12:07 PM, during an interview with the surveyor, the Infection Preventionist confirmed Resident # 470 was on transmission-based precautions due to a diagnosis of Clostridium Difficile (highly contagious bacterial infection of the colon). The Infection Preventionist said that staff is expected to wear a gown, gloves, and a mask upon entering Resident # 470's room. Lastly, the Infection Preventionist clarified that alcohol-based hand rub can be used upon entrance of a room but not when exiting a room. She said, They [staff] have to use soap and water. A review of Resident # 470's Admission Record revealed a primary diagnosis of but not limited to, Enterocolitis Due to Clostridium Difficile, Not Specified As Recurrent. A review of Resident # 470's Electronic Medical Record (EMR) revealed a Care Plan focus, [Resident # 470] is being treated with ABT [antibiotic] for community acquired c-difficile. The Focus was initiated on 02/13/2024. The Care Plan also revealed an Intervention, Contact isolation precautions initiated 02/13/2024. A review of Resident # 470's Order Summary Report revealed a physician's order initiated on 02/13/2024 to, Maintain contact isolation precautions due to c-difficile; check isolation cart every shift to ensure supplies and signage are in place . On 02/20/2024 at 11:22 AM during an interview with the surveyor, the Director of Nursing (DON) stated, Any rooms that are under precautions, the staff should be using the proper PPE [personal protective equipment; including by not limited to gowns, gloves, masks] . The DON replied, Yes when the surveyor asked if the staff member should be wearing a gown in the room if the sign on the door dictates that. A review of the facility policy titled, Transmission Precautions - Contact last revised on 1/2024 revealed under section Procedure, part 3. Gowns: to, Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Wear a gown if the resident is incontinent, has diarrhea . Further, the policy revealed under section, General Information, that, Contact precautions for enteric infectious diseases, such as clostridium difficile or norovirus includes washing hands with soap and water and performing daily cleaning of the resident's room and high touch surfaces using a C. difficile sporicidal agent (EPA List K agent), such as bleach. A review of the facility policy titled, Management of Clostridioides Difficile (C-Difficile) Infection last revised 1/2024 revealed under section, Policy Explanation and Compliance Guidelines: number 4, a. All staff are to wear gloves and a gown upon entry into the resident's room when providing care for the resident when anticipating substantial contact between your clothing and the resident, environmental surfaces, or items in the room. S 8:39-19.4 (a)

Based on observation and interview it was determined that the facility failed to ensure that corridors were equipped with firmly secured handrails on each side. The deficient practice was identified on 1 corridor (Second Floor) and evidenced by the following: On 02/14/2024 at approximately 09:28 AM, a request was made to the Director of Maintenance (DOM) to provide a copy of the facility lay-out which identifies the various rooms, common areas and smoke compartments in the facility. A review of the facility lay-out identified the facility is a three-story (3) building with 91 Resident sleeping rooms and common areas where Residents and Visitors could go. Starting at approximately 10:10 AM on 02/14/2024 and continued on 02/15/2024 in the presence of the facility Director of Maintenance (DOM) an inspection of the building was conducted. Along the two (2) day tour the surveyor observed the following location that the facility failed to provide handrails in the corridor. On 2/14/24 at approximately 10:30 AM the surveyor observed a resident in the salon getting their hair done. On 02/15/2024 at approximately 12:22 PM, the surveyor observed on the second floor, an approximately 79-foot-long section of corridor leading from the Residents Main Dining room to the Residents Salon that had no handrails on both sides of the corridor. At this time the surveyor asked the DOM, Do Residents come down this corridor. The DOM replied, Yes. On 02/23/2024 at 10:31 AM during an interview with the surveyor, the Licensed Nursing Home Administrator stated, It's not a corridor that is commonly frequented by residents. Our understanding that handrails are not required in this specific corridor. We initiated staff in-servicing asking that staff always accompany residents to the beauty salon and we are installing handrails. N.J.A.C S 8:39-31.2(e)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster container area free of garbage and debris. This deficient practice was evidenced by the following: On 11/04/2021 at 10:26 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's designated trash disposal area. The surveyor observed two trash compactor units (closed units) on a cement slab. On the ground surrounding the trash compactor unit, the surveyor observed the area littered with used gloves, crates, clear plastic bags, Styrofoam and plastic cups, cooked food, leaves, sticks, plastic utensils and other unidentifiable debris. When interviewed, the FSD stated that housekeeping was responsible for cleaning the trash area. The FSD also added that if food was dropped around the dumpster area, then dietary would be responsible for cleaning the area. During an interview with the surveyor on 11/09/2021 at 11:22 AM, the Director of Environmental Services (DES) stated that environmental services was responsible for cleaning outside around the trash compactor, and that dietary was supposed to assist environmental services with the cleaning. The DES stated that environmental services and dietary would clean any debris or food debris daily around the dumpster area. The DES added that there was no specific time of day or schedule of when the cleaning was supposed to be completed. A review of the facility's Dining Services: Disposal of Garbage and Refuse undated policy, indicated that all garbage and refuse will be collected and disposed in a safe and efficient manner. The policy further reflected that the dining services director coordinates with the director of housekeeping to ensure the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. NJAC 8:39-19.3(c)

Based on observation, interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 1 residents (Resident #104) reviewed for hospice and was evidenced by the following: During the initial tour of the 3rd floor on 11/04/21 at 10:11 AM, Resident #104 was observed lying in bed, awake, alert and wearing oxygen via nasal cannula. According to the Admission Record, Resident #104 was admitted with diagnoses, that included but were not limited to, Pneumonia due to [CONDITION(S)]- Associated Coronavirus, COVID-19, and Mild-Protein Malnutrition. Review of the Order Summary Report (OSR), for Active Orders as of 06/21/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 06/20/21 through 06/30/21 progress notes reflected that Resident #104 received hospice services on 06/21/21, 06/26/21 and 06/28/21. Review of the Resident 104's Significant Change MDS, dated [DATE], revealed under Section O: Special Treatment, Procedures, Programs that the resident was not receiving hospice care while a resident. Review of the OSR, for Active Orders as of 10/01/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the 10/02/21 through 10/27/21 progress notes reflected that Resident #104 received hospice services on 10/06/21 and 10/11/21. Review of the Resident #104's Quarterly MDS, dated [DATE], revealed under Section O: Special Treatment, Procedures, Programs that the resident was not receiving hospice care while a resident. Review of the resident's Care Plan (CP), initiated 07/08/21 and last reviewed 10/8/21, included that the resident was under hospice care. During an interview with the surveyor on 11/08/21 at 11:23 AM, the MDS Coordinator stated that a Significant Change MDS would be completed within 14 days when a resident was placed on hospice care or removed from hospice care. The MDS Coordinator stated that the 07/07/21 Significant Change MDS and the 10/07/21 Quarterly MDS for Resident #104 should have been coded in Section O that the resident was receiving hospice care. The MDS Coordinator stated It was my mistake, and I will need to submit a correction. I would call this a data entry error. During an interview with the surveyor on 11/09/21 at 1:04 PM , the Director of Nursing stated that if a resident was receiving hospice care, then the resident's MDS should be coded for hospice. Review of the facility's Minimum Data Set Policy and Procedure policy, issued 01/17, revealed that the MDS Coordinator will be responsible . to keep assessment data current at all times. The policy further suggested that referenced areas to support MDS completion included the current plan of care, MD notes/orders and nursing notes . NJAC 8:39-11.1

Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to a.) implement appropriate infection control practices related to the use of Personal Protective Equipment (PPE) in a manner to prevent the transmission of COVID-19 in accordance with the Center for Disease Control and Prevention (CDC) and New Jersey Department of Health (NJDOH) guidelines. This deficient practice was identified for 2 of 2 staff members, who provided care to residents on the unit designated for Persons Under Investigation for Covid-19 (PUI), during the Covid-19 survey conducted on 1/25/21. The facility's failure to don isolation gowns during direct resident care and to doff soiled isolation gowns between residents during direct care encounters on a PUI unit exposed residents to Covid-19 infection and posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for Covid-19). The immediate jeopardy began on 1/20/21 and confirmed on 1/21/2021 with further investigation that two CNAs were observed by the survey team moving from room to room during lunch delivery on a PUI unit without changing PPE. The CNA, during this time, also provided contact care to Resident #5 and without doffing her PPE, moved on to Resident#4 to provided contact care. Resident #5 tested positive for Covid-19 on 1/18/21 and was reported to the facility on [DATE]. Staff, upon surveyor inquiry, stated they were unaware of the appropriate PPE procedure. The facility was notified of the immediate jeopardy situation on 1/21/21 at 3:17 PM. On 1/22/21 the facility submitted an acceptable removal to the New Jersey Department of health (NJDOH). On 1/25/21 during an onsite removal plan verification survey, the facility was found to have corrected the immediate jeopardy. The deficient practice was evidenced by the following: Part A. 1. On 1/20/21 at 10:30 AM, the surveyors conducted an entrance conference with the facility's Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Infection Control Preventionist (IP). The IP informed the surveyors that there were 25 in-house Covid-19 positive residents in the facility and nine staff members who were out on quarantine because they tested positive for Covid-19. The IP further stated that 19 of the 25 Covid-19 positive residents results were acquired at the facility. Both the DON and the IP stated that the entire facility was considered PUI and was on Transmission Based Precautions (TBP) because all units has had exposure to either Covid-19 positive staff or residents. The DON stated that the facility had three resident floors which included First, Second and Third floor. The DON stated that the facility had a designated Covid-19 positive area on C-wing of the Third floor. The IP and the DON added that the facility had two cohort groups: one cohort was the Covid-19 positive area on the Third floor (C-Wing) and the second cohort was the PUI which included all other residents' units on the First, Second and the Third floors. The DON stated that the new admission and re-admissions were on the Second-floor unit and were included as part of the PUI cohort and that all PUIs were on TBP including the use of full PPE. The DON stated that their testing schedule for staff was twice a week, and weekly for residents and that if a resident tested positive for Covid-19, the resident would be moved to the Covid-19 Unit on the third floor C-Wing. When interviewed about PPE requirements for the two cohorts, the DON and the IP stated that for the Covid-19 positive Unit, staff were supposed to don isolation gowns, N95 masks, face shields or goggles when entering the unit and to wear gloves in addition to above PPE when going into a resident's room. For the PUI unit, the DON and the IP stated that staff were supposed to don N95 masks, face shields or goggles and to don isolation gown and gloves when entering a resident's room. The IP reiterated that staff were supposed to don full PPE when entering residents rooms throughout the facility to help prevent the potential for the spread of Covid-19. On 1/20/21 from 12:05 PM to 1:10 PM, the surveyor observed lunch meal distribution to residents on the Second floor unit. The surveyor observed a certified Nursing Assistant (CNA #2) who wore a re-useable gown, surgical mask, and eye shield, distribute lunch from one resident room to another while wearing the same gown, surgical mask, and face shield. At 12:50 PM, the surveyor observed CNA#2 take a lunch tray to Resident #5's room and placed the tray on the resident's bedside table and left the room. With the same gown/PPE, CNA #2 went to the food cart in the hallway and removed another lunch tray and delivered it to Resident #4's room. At that time, the surveyor interviewed her regarding facility protocol for gown use on the PUI unit. CNA#2 stated that the facility protocol was to wear the same isolation gown from room to room during meal service and that they only changed gowns between residents during resident's care such as bathing or incontinent care. At 12:55 PM, the surveyor observed CNA #1 who wore disposable isolation gown, KN95 mask and eye shield, as she entered Resident #5's room and started to set up the resident's lunch tray. CNA#1 moved the resident's bedside table closer to the resident, leaned over the resident and assisted the resident to sit up in bed. The surveyor noted that the whole front part of CNA#1's gown touched Resident #5's bedding and bed rail. After repositioning Resident #5, CNA #1 placed her right arm on Resident #5's pillow, leaned close to the resident and spoke into the resident's right ear as she tried to wake the resident and to encourage him/her to eat. After she woke up Resident #5, CNA#1 handed the resident a utensil and the resident started to eat. CNA#1 did not offer hand hygiene to Resident #5. After CNA#1 performed her own hand hygiene using ABHR, she left Resident #5's room and proceeded to Resident #4's room across the hall while still wearing the same gown that she wore while providing contact care to Resident #5. While in Resident #4's room, CNA #1 leaned over Resident #4 in order to reposition the resident in bed for lunch. The surveyor noted CNA#1's gown touched the resident, the resident's bedding and bed rail. At that time, the surveyor noted that CNA #2 was also at Resident #4's bedside wearing a surgical mask and an eye shield without an isolation gown and no KN95 mask. The surveyor observed as CNA#2 leaned over Resident #4 with her uniform touching Resident #4's bedding and bed rail while she assisted CNA #1 to reposition the Resident #4 in bed for lunch. After both CNAs finished caring for Resident #4, the surveyor interviewed CNA #2 at 1:05 PM. She stated that she had just removed her gown and did not get a chance to put on another gown before going to assist CNA #1 to reposition Resident #4. When questioned about her use of surgical mask instead of N95 mask, CNA#2 stated that she had an N95 mask in her locker but she preferred the surgical mask because N95 mask was too tight around her head and that the Infection Preventionist was aware that she wore the surgical mask. Before CNA#1 could go into another resident's room, the surveyor called her for an interview at 1:10 PM. The surveyor questioned CNA#1 regarding the use of the same gown to care for different residents on the PUI unit. CNA#1 stated that she did not provide care for Resident #5 and that she only set the residents up for lunch. When the surveyor pointed out about her leaning over Resident #5, touching the resident and the resident's environment with her isolation gown, and using the same gown to provide contact care to Resident #4, CNA#1 acknowledged that her practice could spread Covid-19 virus to other residents when she wore the same isolation gown from one resident to another on the PUI unit. CNA#1 stated, I understand what you mean now. She added that they were not taught to change gowns between residents during meal service and that she did not know she was supposed to. CNA#1 stated that they were told to change gowns during care such as incontinent care but not during meal service. During a follow-up interview with CNA#2 on 1/21/21 at 11:45 AM, CNA #2 stated that she knew she was supposed to don an isolation gown to enter a resident's room on the PUI unit and on a Covid-19 unit, but she was in a hurry and forgot. On 1/21/21 at 11:30 AM, the surveyor interviewed the Second floor Licensed Practical Nurse Unit Manager (LPN/UM #1). She stated that changing gowns was dependent on the type of contact staff had with residents and that staff did not need to change gowns if they were delivering meals and pulling residents up in bed on the PUI unit; and that staff only needed to change gowns if they had extensive contact with a resident. On 1/21/21 at 11:40 AM, the DON informed the surveyors that Resident #5's Covid-19 test came back last night and that the test revealed that Resident #5 was positive for Covid-19. The resident was then moved to the COVID-19 unit. On 1/20/21 at 1:55 PM, the DON informed the surveyors that she was a Certified Infection Control Practitioner (IP) and that she assisted the facility IP with infection control functions. She stated that she did not think that staff needed to change gowns between residents during meal pass even on the PUI units. The DON stated that staff only needed to change gowns if they were providing morning care or incontinent care. She further stated that mealtime will go on forever if staff had to change gowns between residents. She added that changing gowns during meal service was a catch 22, it is impossible and not feasible to keep changing gowns, I encouraged staff to do the best they can do. The DON did not address the fact that both CNA#1 and CNA#2 had provided contact care to two residents (Residents #4 and #5) with Resident #5 known positive Covid-19 results, without wearing the appropriate PPE. During an interview with the IP on 01/21/21 at 1:56 PM, she stated that staff did not have to change gowns when passing meal trays and that staff only changed gowns after they performed patient care. The IP explained that she considered patient care to include activities such as dressing a resident, bathing, and incontinent care. The IP reiterated that changing gowns after each resident when passing meal trays would not be feasible because the residents' meal trays would get cold. The surveyor questioned the IP again about CNA #1's wearing of the same gown and providing contact care for different residents. IP stated that staff were educated to don the reusable gown to pass meal trays and could wear the same gown as long as they did not provide care. The IP further stated that she thought donning a clean reusable gown was enough and that staff did not think that having a direct contact with the resident's environment presented a likely scenario to spread the Covid-19 virus. The IP agreed that it was possible to transmit infectious agents on the CNA's gown onto another resident if gowns were not changed. During another interview with the DON and the LNHA On 1/21/21 at 3:17 PM, both the LNHA and the DON stated that they were aware that Resident #4 was admitted on [DATE] with a Covid-19 positive diagnosis. Review of the CDC guidance dated June 25, 2020 and titled; Preparing For COVID-19 in Nursing Homes Infection Control for Nursing Homes indicated that universal use of all recommended PPE for care of all residents on the affected unit was recommended when even a single case among residents or healthcare professional (HCP) was newly identified in the facility. Review of the CDC guidance dated December 14, 2020 and titled; Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, indicated that recommended PPE when caring for a patient with suspected or confirmed COVID-19 included: a respirator or facemask (if a respirator is not available), eye protection, gloves, and gowns. The New Jersey Department of Health (NJDOH) guidance dated October 22, 2020 and titled, Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities indicated that full Transmission-Based Precautions and all recommended COVID-19 PPE should be used for all residents who are suspected of having COVID-19 and for residents who are on a unit, regardless of presence of symptoms, when transmission is suspected or identified. Part B F 880 continues at a lower scope and severity level of F, as follows: On 1/21/21, it was determined that F 880 deficiency continued at an F level, for failure to a.) ensure that staff used proper Personal Protective Equipment (PPE) consistently when caring for residents who were identified as Persons Under Investigation (PUI) for sign/symptoms of COVID-19 b.) follow appropriate infection control protocols related to doffing of isolation gown prior to exiting the COVID unit in accordance with facility protocols and c.) provide hand hygiene to residents before their meals. This deficient practice was identified for 11 of 14 staff members observed for infection control practices on 3 of 3 nursing floors as was evidenced by the following: 1. On 1/20/21 from 12:05 PM to 1:10 PM, the surveyor observed lunch meal distribution to residents on the Second floor unit. The surveyor observed LPN/UM #1 as she took a lunch tray from food cart in the hallway and delivered the tray to the room of Resident #2 and Resident #3 wearing a gown, gloves and surgical mask with cloth mask over the surgical mask. LPN/UM #1 then set up Resident #2's lunch. She did not provide hand hygiene for Resident #2. When interviewed on 1/20/21 at 12:10 PM, regarding the use of surgical mask with a cloth mask, instead of the required N95 mask, she stated that she could not breath with N95. mask. When asked if she informed the IP that she had trouble wearing an N95 mask, she stated that she did not. LPN/UM#1 did not provide explanation for why she did not provide hand hygiene for Resident #2. 2. On 1/21/21 at 12:30 PM, while the surveyor was speaking with LPN/UM#1, the surveyor observed a unit LPN (LPN #1) who was assisting Resident #3 with his/her lunch in the room. LPN #1 did not provide hand hygiene for Resident #3 and was wearing surgical mask instead of N95 mask. When interviewed, she stated that she could not breath with the N95 mask and indicated that the IP was aware that she wore surgical mask. She did not provide information as to why no hand hygiene was provided to Resident #3. 3. On 1/20/21 at 12:15 PM, the surveyor observed a staff member who identified herself as Rehabilitation staff (Rehab Staff), as she provided rehab treatment at the bedside for Resident #3. When she finished, she left the resident's room and met the surveyor in the hallway across from Resident#3's room. The surveyor noted that the Rehab staff wore a surgical mask and then a K-N95 mask over the surgical mask. (which was a reverse way to don the masks). When questioned about wearing the K-N95 mask incorrectly, she stated that she wore surgical mask under the K-N95 because she had sensitive skin. She indicated that the IP was not aware that she wore the mask incorrectly. 4. At 12:40 PM, the surveyor observed CNA #2 going in and out of residents' room and distributing lunch meals to residents in their rooms on the Second floor. She wore a surgical mask with a cloth mask over the surgical. When interviewed regarding her use of surgical mask instead of N95 mask, she stated that she had N95 mask in her locker but she preferred the surgical mask because N95 mask was too tight around her head and that the IP was aware she wore surgical mask. 5. At 12:55 PM, the surveyor observed CNA #1 in the room of Resident #5 setting up the resident's lunch. After setting up the meal tray, CNA #1 did not provide hand hygiene for the Resident #5. CNA#1 then proceeded to the room of Resident #4 and set the resident up for lunch without offering hand hygiene to the resident. When interviewed, CNA #1 stated that dietary did not usually provide hand sanitizers on meal trays and acknowledged that she did not provide hand hygiene for Resident #5 or Resident #4. CNA#1 could not explain how the facility provided hand hygiene for residents prior to their meal. On 01/21/21 at 10:15 AM, the DON stated that the Activities Director (AD) completed hand hygiene for the residents on the second floor PUI unit for the lunch meal service on 01/20/20. The DON further stated that the AD completed hand hygiene before the meal trucks arrived at the unit. On 1/21/21 at 10:33 AM, the surveyors interviewed the AD who stated that she usually provided hand hygiene to the residents on the second floor PUI unit. The AD stated that she was conducting Facetime appointments with residents and their families during the lunch meal service on 01/20/21 and did not provide hand hygiene for the residents. When asked if it was her official function to provide hand hygiene for residents before meal, the AD stated that she used to provide hand hygiene in the dining room prior to Covid-19 and that she continued to do so for Second floor residents. She added that no one told her to perform hand hygiene for residents and that it was just something she did for residents in the past. She added that she was not sure that staff on the Second floor knew she provided hand hygiene for residents whenever she was available. The surveyor noted that none of the staff members who were observed by the surveyor on 1/20/21 indicated that they knew that AD provided hand hygiene to residents until after surveyor inquiry. During a follow-up interview with LPN/UM#1 on 1/25/21 at 10:15 AM, she stated that the AD provided hand hygiene to residents on the Second floor on 1/20/21. She did not know that the AD had already informed the surveyors that she did not provide hand hygiene to residents on 1/20/21 because she was conducting Facetime activity with residents/family. Review of hand hygiene policy dated March 2020, indicated that staff were supposed to perform hand hygiene before handling meals and before/after assisting residents with meals. The policy did not address providing hand hygiene for residents before serving their meals 6. On 01/20/2021 at 11:50 AM, the surveyor observed the lunch meal service on the First floor PUI unit. The surveyor observed a staff member by the food truck in the hallway, directing the lunch meal distribution to residents. When interviewed, the staff member identified herself as a Quality Assurance staff (QA) and stated that she did not normally work on the units. The surveyor observed that she wore PPE which consisted of a black surgical mask, hair cover and face shield. The surveyor observed that the QA was not wearing an N95 or KN95 mask while on the PUI unit. The QA stated that the required PPE for the unit consisted of a face shield or goggles and a face mask. The surveyor asked if there was a specific mask that needed to be worn while on the PUI unit. The QA stated that most staff members wore N95 masks. The QA added that staff with complications, history of COVID-19, and those who could not breathe in the N95 mask were allowed to wear a surgical mask instead of the N95 mask while on the PUI unit. 7. On 01/20/21 at 12:01 PM, the surveyor observed the First floor unit LPN/UM #2 and a Unit LPN (LPN #2) as they assisted with lunch meal service. The surveyor observed that both LPN/UM #2 and LPN#2 wore PPE which consisted of an N95 mask. The surveyor observed that both LPN/UM#2 and LPN#2 did not wear a face shield or goggles while on the PUI unit. When interviewed, LPN/UM #2 stated that full PPE was required when assisting the residents in their rooms. LPN/UM #2 further stated that full PPE consisted of K-N95 or N95 mask, face shield/goggles, or prescription eyeglasses, and gown. LPN/UM #2 further stated that staff were required to wear an N95 or K-N95 when on PUI unit. According to current CDC guidance, prescription eyeglasses is not listed as an appropriate eye protection to wear in place of goggles or face shield and the facility did not provide evidence that showed such a guidance from the CDC. 8. On 1/20/21 at 12:22 PM, the surveyor observed a staff member assisting Resident #6 with lunch meal tray at the resident's bedside on the First floor. The surveyor observed that the staff wore PPE which consisted of a face shield, gown, gloves, surgical mask, and a cloth mask over the surgical mask. The surveyor observed that the staff member was not wearing an N95 or K-N95 mask while on the PUI unit. When interviewed, the staff member identified herself as an agency Certified Nursing Assistant (CNA #3). CNA #3 stated that she had an N95 mask, but it was too tight and that the surgical mask was more comfortable for her. She stated that she was allowed to wear the surgical mask instead of an N95 mask while on the PUI unit. At that time, the surveyor called LPN/UM #2 for an interview. LPN/UM #2 confirmed that CNA #3's PPE consisted of face shield, gown, gloves, surgical mask, and a cloth mask. LPN/UM #2 stated that staff could wear a surgical mask with a cloth mask covering if the N95 mask did not fit them. 9. On 01/20/2021 at 12:28 PM, the surveyor observed a staff member standing near First floor's nursing unit desk. The surveyor observed that the staff member wore PPE which consisted of a surgical mask and face shield. The surveyor observed that the staff member was not wearing an N95 or K-N95 mask. When interviewed, the staff member identified himself as a housekeeper (HK) and stated that he was routinely assigned on the First-floor unit. HK stated that the required PPE when cleaning residents' room consisted of a surgical mask, gown, and gloves. The surveyor asked if a N95 or KN95 was required when cleaning residents' rooms on the PUI unit. HK stated that a N95 or KN95 was not required and that a surgical mask was good enough when cleaning PUI rooms. During a follow up interview with the DON on 1/20/21 at 1:54 PM, the DON stated that she was aware that some staff members wore surgical masks instead of N95 or K-N95 masks while on the PUI units. The DON stated that staff who could not tolerate or breathe in the N95/K-N95 masks were allowed to wear a surgical mask. The DON stated that the Centers for Disease Control and Prevention (CDC) recommendations, allowed them to don surgical masks or any type of face covering while on PUI units and that some face covering was better than nothing. The DON further stated that it was the facility's policy and protocol to wear an N95 mask on the PUI units, but she did not want staff who could not tolerate the N95 or K-N95 masks to wear them, and risk having some problems. During an interview with the LNHA and DON on 1/21/20 at 3:17 PM, the DON stated that she informed the Local Health Department (LHD) that there were staff at the facility who could not wear N95 masks. The DON further stated the LHD did not provide any additional guidance and that the facility staff were doing their best. The DON added that she knew her staff and that they would not say that they could not wear the N95 mask unless they really could not. The LNHA stated that they encouraged staff members as much as possible to wear the N95 mask. The LNHA added that staff who could handle the N95 mask, wore the N95 mask and those who could not handle the N95 mask, wore some face covering. The facility did not provide documented evidence regarding their communication with the LHD. The DON provided the surveyor with a CDC document dated 12/18/2020 and titled: considerations for wearing masks. The surveyor reviewed the document which appeared to be addressed to general community use of masks and not HCP in healthcare settings. 10. The surveyor conducted a tour of the Third floor PUI unit on 01/20/2021 at 12:58 PM. Third floor had a designated area which was used for Covid-19 positive residents, (on C-Wing) and separated from the rest of the unit by a door. The surveyor observed LPN/UM (LPN/UM#3) on the Third floor unit sitting at the nursing station. When interviewed, she pointed to door which was near the nurses' station and stated that the door led to the designated Covid-19 positive unit-(C-Wing). The surveyor observed a sign posted on the door which indicated that the door led to a Covid-19 positive area. As the surveyor interviewed LPN/UM #3, the surveyor observed a staff member wearing an isolation gown as she exited the same door that led to the COVID-19 area (C-Wing) walk onto the Third floor hallway on PUI area. At that time, the surveyor questioned LPN/UM #3, and asked if it was appropriate for staff members to exit the COVID-19 area while wearing their isolation gown. LPN/UM #3 identified the staff member as a Certified Nurse Assistant (CNA #4) and stated that CNA#4 should not have exited COVID-19 area with her isolation gown. LPN/UM #3 further stated that staff were supposed to doff their gowns and place them in the bins before exiting the COVID-19 area. At time, LPN/UM #3 stopped CNA #4 and asked her to remove the gown. CNA#4 responded that she had just donned the gown and that the gown was clean. CNA#4 also stated that she had not entered a resident's room with the gown and that she came out of Covid-19 unit to obtain the residents' lunch truck. Later on, during an interview on 1/20/21 at 1:54 PM, the DON stated that the gown that CNA #4 was wearing while on COVID-19 positive area was clean and that CNA#4 came out of designated Covid-19 unit, in order to obtain the lunch cart that was delivered for them on the PUI side. 11. As the surveyor continued the interview with LPN/UM #3, the surveyor observed a second staff member as she exited the same door that led to (C-wing) COVID-19 area. With her isolation gown on, she walked near the nurses' station on the PUI side of the Third floor. The surveyor noted that the staff member wore two isolation gowns and was holding a laptop computer in her hands. The surveyor observed that the staff member stopped, glanced over at the nursing station, and turned around and walked back to the COVID-19 positive area. LPN/UM #3 identified the staff member as an LPN (LPN#3) and stated that LPN #3 did not normally work on the COVID-19 area. LPN/UM #3 further stated that LPN #3 should not have exited COVID-19 area with a gown on. During an interview with LPN #3 on 1/20/21 at 3:04 PM, she stated that she normally wore two gowns while on the COVID-19 area. She explained that she used one gown as a lab coat and changed the second gown as needed. LPN #3 further stated that she came out of the COVID-19 unit with two gowns to get an extra gown from the linen cart on the PUI unit. She did not explain why she did not obtain a gown from the linen cart on the Covid-19 area. She stated that she at no time had resident contact or their person or their rooms. Review of the CDC guidance dated December 14, 2020 and titled; Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, indicated that Health Care Professionals (HCP) caring for patients with suspected or confirmed COVID-19 infection should not wear more than one isolation gown at a time. During an interview with the IP and the DON on 1/20/21 at 1:08 PM, the IP stated she expected staff to remove their gowns prior to exiting the COVID area because the gown could have been contaminated. In the presence of the LNHA and the DON, the surveyor reviewed another document provided by the LNHA dated 11/17/2020 and titled: Recommendations for Long-term care Facilities during Covid-19 pandemic. The document which reflected the following: for suspect or confirmed Covid-19 cases, standard and TBP including use of gowns, gloves, eye protection and N95 respirator or higher or facemask if N95 is not available. The document further indicated that N95 respirators were preferred unless there was shortage. The LNHA informed the surveyor that they had no shortage of PPE or N95 masks. The document further indicated that employers must demonstrate and document good faith efforts to comply with Occupational Safety and Health Administration (OSHA) standards, as outlined in the Respiratory Protection Guidance. During an interview on 1/20/21 at 1:54 PM, the surveyor inquired about protocols or specific education the facility developed regarding staff wearing of surgical masks on PUI units. The DON stated that there was no formal policy or protocol and no specific training other than the general in-service provided to all staff. The DON provided a face mask policy dated May 2020 which reflected to consider alternatives and adaptations if wearing masks was not feasible. There were no uniform adaptations made by the facility for further protocol in response to the many staff members that complained of having issues with the N95 mask. Review of facility's Infection Prevention and Control Measure policy statement dated November 2020, and revised January 2021 indicated that staff should wear all recommended PPE, N95 and respirator if available and that staff in residents' room should don N95 mask or higher if available. Review of the facility's Outbreak Response Plan dated September 2020 indicated that the facility would implement TBP in accordance with CDC guidance. NJAC 8:39-19.4 (a)(b)(c)(d)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation safely and consistently to prevent the potential for foodborne illness. This deficient practice was evidenced by the following: On 11/19/19 from 8:32 AM to 9:10 AM, the surveyor accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room on an upper rack of a multi-tiered rack, a can of pickled white cabbage was observed dented on the upper/top seam. The surveyor interviewed the FSD, who stated, that should have been placed in the dented can area. The FSD removed the can to the designated dented can area. 2. In the walk-in freezer on the dessert shelf, a frozen pie was removed from its original container and had no date. The surveyor interviewed the FSD, who stated, that should have been dated with the received date when it was removed from its original box. The FSD removed the pie and threw it into the trash. 3. On a middle shelf in the walk-in freezer, a hotel pan contained two individual plastic bags of frozen sausage with no dates. The FSD stated, This came in last week. I in-serviced my cook last week. They are not dated. The FSD removed the two bags of sausage and threw them into the trash. 4. In the cook's area, a can of marinara sauce was observed on top of the cook's table/food production area with other food ingredients. The can was noted to have two dents on the top seam of the can on opposite sides. The FSD stated, we're not gonna use that, it's dented on the seam. My cook knows better. The FSD removed the can to the dented can rack in the dry storage room. 5. On a top shelf in the reach-in refrigerator, two plated salads for resident meals were covered with plastic wrap and dated 11/15/19 and use by 11/18/19. The FSD stated, Is today the nineteenth? That's my bad. I should have thrown them away this morning. The FSD threw the salads into the trash. The surveyor reviewed the facility policy titled, Food Storage-Dented Cans, updated and reviewed-May (YEAR). The policy noted the following under the Policy interpretation and Implementation section: All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. No indented, rusty, damaged cans will be used. Any dented cans found after delivery will be stored in a designated area, labeled for dented cans. The cans will be returned to the vendor at the next delivery. The surveyor reviewed the facility policy titled, Dating And Labeling Policy, no review date. The policy noted the following under the Procedure: Inspect all deliveries carefully, check for damage, and label with the received date. Use a black marker or date gun with legible writing to date and label products. Refer to storage times for the refrigerator and freezer as well as storage for dry goods. Discard all foods that expire immediately. Note: All products should be stored in their original container. NJAC 8:39-17.2(g)

Based on observation and interview on 11/20/19, in the presence of facility management, it was determined that the facility failed to maintain a sanitary environment for residents, staff, and the public. This deficient practice was evidenced by the following: During a tour of the facility, at 10:45 AM, the surveyor along with the facility's Director of Maintenance (DM), Director of Housekeeping (DHK), and Administrator (LNHA) observed that there were 25-30 black rubber caps littering the floor of the 2nd floor Oxygen Storage room and 15-20 black rubber caps littering the floor of the 1st floor Oxygen Storage room. In an interview, at the time, the DM stated that the rubber caps were from the full Oxygen tanks that are removed prior to use by the nursing staff. The LNHA acknowledged the deficient practice. NJAC 8:39-31.2(e)

C# NJ Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to implement their identified safety intervention for 2 people assistance with lift transfers for 1 of 4 sampled residents (Resident #1). On [DATE], Resident #1 who was careplanned as needing 2 assistance with lift transfers, was transferred with 1 person assistance from her bed to her wheelchair. Resident #1 was lowered down to the floor due to her behavior, was noted with right knee swelling, and had to be transferred to the emergency room (ER) due to Acute Right Distal Femur Fracture. She was admitted to the hospital on the same day, required Open Reduction Internal Fixation (ORIF) surgery, and returned to the facility on [DATE] with a right knee immobilizer, pain management, and was placed on comfort measures only (CMO). This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on ,[DATE] and [DATE] revealed the following: 1. According to her record of admission sheet (RAS), Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident was cognitively impaired with poor decision making skills, and required total assistance with two persons for transfer. She was assessed as totally dependent with staff for her activities of daily living, and had no recent falls. A resident care plan for resident #1 dated [DATE] with a revision date of [DATE], identified the resident as at ..."risk for injury" with..."Hx of rejection of care."...The goal was to .."remain injury free." Interventions included to ..."use proper techniques with lift and 2 person assist"..., and keep arms inside of lift straps. The resident care plan did not indicate what kind of lift was indicated for Resident #1. An undated nurse aide's information sheet (NAIS) for Resident #1, used by the Nurse's aides as their guide on how to take care of their residents reflected that Resident #1 required 2 assist with transfers with a Vanderlift. The Vanderlift is used by the facility for Residents with a higher level of care but it can't accommodate residents sitting in a chair. This lift can also be used for residents 450 pounds and above. A Vera Lift is used by the facility to lift residents from a standing or sitting position. The Vera Lift can be used for residents up to 350 pounds. A reportable event record/report (AAS-45) dated [DATE] faxed by the facility to the Department of Health and Senior Services (DHSS), documented that on [DATE] at 10:20 AM, Resident #1 was on the mechanical lift to be toileted by staff when she lifted her legs in the air, and ..."staff lowered the mechanical lift so that resident would not fall and resident then crossed her legs underneath her as the lift was lowered."....It was further documented that the resident is combative with care, and has a history of rejecting care, and being easily annoyed, and that her behavior had been careplanned prior to the incident. An incident report dated [DATE] at 10:20am, documented that the writer was called to room by staff "resident was sitting upright on floor, legs crossed, knees flexed, leaning back against side of bed facing window. CNA @ her side..." It was further documented that the resident's right leg was swollen, X-ray was obtained, and was sent to the ER after the x-ray results was received. An employee statement of incident (ESI) dated [DATE] obtained from the Certified Nursing Assistant (CNA) who transferred the resident with the lift by herself on the day of the incident, reflected that ..."While doing am care on ................. I went to place her on toilet with the Vera. When I put her on the Vera she had lift both legs in the air so I lowered the Vera down so she wouldn't fall off when I lowered her she crossed her legs underneath her." A review of the interdisciplinary progress notes (IPN) dated [DATE] at 10:40am, corroborated the documentation on the incident report. It was further documented that the family requested for an Xray be conducted in the facility instead of sending her to the hospital. X-ray was done of her right knee with positive result for acute distal femur fracture, and she was sent to the hospital on the same day. On [DATE], it was further documented that Resident #1 was readmitted as comfort measures only (CMO) and for Hospice care consultation after she had undergone ORIF surgery at the hospital. The resident remained on CMO until she expired on [DATE] in the facility. A hospital discharge summary dated [DATE], reflected that Resident #1 was admitted to the facility on [DATE] after sustaining a femur fracture at the nursing facility. The patient had slipped and fallen on her knee, and underwent an ORIF. The resident was to remain non-weight bearing to the right lower extremity, and was placed on CMO. Discharge medications included Roxanol 5 mg every 3 hours as necessary (PRN) for pain or oxygen hunger. In addition, Ativan 0.5 ml every 4 hours PRN was ordered for agitation. During an interview by the surveyor on [DATE] at 11:30am with the CNA who transferred the resident on [DATE] when the incident occurred, revealed that she has been in the facility since the resident was admitted there. She verified transferring the resident by herself with a Vera lift, and stated that only one person was needed with transfers since the resident could hold on to the handles. The CNA denied knowing that Resident #1 required two assistance with transfers, and thought that two assistance was only for Vanderlift use. Further interview with the CNA about the incident corroborated her written statement about what occurred, and revealed that the resident was lowered sitting.."indian style." A medication nurse and charge nurse came to assist with putting the resident back to bed. During an interview by the surveyor on [DATE] at 11:40am with the medication nurse (LPN) who has worked in the facility for two years, and first responded to the CNA during the incident, revealed that she did not see what happened. She was by the doorway of Resident #1 preparing medications for his roommate when she was called by the CNA for help. She found the resident sitting on her bottom..."indian style," with her lift straps still on. According to the LPN, the resident looked uncomfortable with swelling on her right knee. The LPN denied knowing how the resident should be transferred from her care plan, but stated that the resident was always transferred via lift with one person assistance. During an interview by the surveyor on [DATE] at 11:12am with the RN coordinator regarding Resident #1, revealed that she was total care and required a Vera lift with two person assistance with transfers. She further stated that with any kind of mechanical lift, two assistance is required. When asked by the surveyor if she had any concerns with the way the resident was transferred by her CNA when the incident occurred, the RN coordinator stated that it was the Director of Nursing (DON) who conducted the investigation. When the RN coordinator was questioned by the surveyor regarding what 2 person assist meant when it is written on their resident care plan, she revealed that there should be two persons near or close enough to guide the resident during transfer. During an interview by the surveyor on [DATE] at 2:20pm with the DON about any concerns with the [DATE] incident for Resident #1 when she investigated, the DON stated that she had no concerns on how the resident was transferred. She further stated that she concluded it to be an accident. When questioned by the surveyor about the intervention on the resident's ,[DATE] care plan about needing 2 assistance with lift transfers, and what it meant. The DON, revealed that it meant ..."need to use two people." The DON denied seeing the intervention for 2 assistance with transfers on the resident's care plan during her investigation, and would have had concerns if she did. A post survey interview by the surveyor on [DATE] at 11:35am with the facility's therapy director (PT) about Resident #1, revealed that the resident last had therapy on ,[DATE]. They recommended restorative therapy which the resident received until ,[DATE]. According to the PT, the resident was combative with refusals to participate with both therapies. When questioned by the surveyor about what lift the resident required and how much assistance she required. The PT stated that on ,[DATE], he received a referral from the RN coordinator to evaluate the resident for a Vera lift from a Vanderlift. He could recall seeing the resident, and he recommended the Vera lift with two assistance for transfers. According to the PT, the resident could bear weight and could hold on to the handles, but required two person assistance with transfers due to her agitation. The PT further stated that he could not find any documentation, but could recall speaking with the RN coordinator about the Vera lift and two person assistance with Resident #1 for safety after he received the referral from nursing on ,[DATE]. NJAC 8:,[DATE].1 (a) .

Based on observation, interview and record review, it was determined that the facility failed to consistently implement interventions in order to protect the residents from falls/injuries. This was identified for Residents #6, #7, #8 and #9, 4 of 11 residents reviewed for falls/injuries. As a result, 1 resident, Resident #6 had a fall which required a hospital evaluation/sutures. This resident continued to sustain multiple falls placing this resident at risk for further injury. In addition, the facility failed to maintain an environment that was free of accident hazards. This deficient practice was identified on 3 of 3 nursing units and, was evidenced by the following: 1. During a tour of the facility on [DATE], the Unit Manager (UM) told the surveyor that Resident #6 had impaired vision, was known to put him/herself on the floor while having a tantrum, was impulsive and had fall deterrent alarms. In addition, a lap buddy restraint was used as needed. On [DATE] at 9 a.m., Resident #6 was observed asleep in a low bed with a bed alarm. The surveyor observed a fall alarm also on the resident's wheelchair. Later at 10:45 a.m., the resident was observed in the activity room in a wheelchair with the chair alarm on. The resident was holding a cup of coffee. No lap buddy was observed. On [DATE] at 9:24 a.m., Resident #6 was observed lying on the bed with his/her eyes closed. The bed alarm was in place. No lap buddy was observed in the resident's room. At this time, the surveyor interviewed the resident's assigned Certified Nursing Assistant (CNA). The CNA said that the resident ambulated with a walker and/or that the resident stood behind the wheelchair and pushed it. The CNA added, that it was not safe to do this without assistance from the staff. The CNA said the resident used to have a table top restraint on the wheelchair but that Resident #6 used to throw it and so, they stopped using it. The CNA said Resident #6 was very confused and could be very pleasant or woud yell out. According to the medical record, Resident #6 had a [DIAGNOSES REDACTED]. Between [DATE] and [DATE], the resident had utilized a lap buddy restraint. It was discontinued on [DATE] with no other orders for a physical restraint. On [DATE], it was re-ordered following a fall on that date, after which, the resident was sent to the hospital for a laceration of the head. According to the plan of care, Resident #6 had utilized a bed and chair alarm since at least [DATE]. There were no nurses notes from [DATE] to [DATE] regarding the use of restraints for Resident #6. It was not clear why a lap buddy had been ordered or why it had been discontinued, and, why no other fall deterrent devices had been ordered. According to the [DATE] nurses note at 1 p.m., several staff members heard a "bang." Resident #6 was found on the bathroom floor with a laceration, 2 cm by 1 cm by 0.1 cm, to his/her right forehead which was bleeding. The resident was sent to the hospital for 5 sutures. There was no information in the nurses note about the resident's fall deterrent alarms that should have been in place. The incident investigation documented that the resident had been lying in bed before the fall, however, failed to provide information about whether or not, the bed alarm was sounding and/or functioning. There were no interviews with the staff who heard the resident fall, or, who were assigned to the resident at the time of the fall. Then the lap buddy was ordered. According to nurses notes on [DATE], just after midnight, Resident #6 threw the lap buddy off his/her wheelchair. In response to this incident, a clear table top was applied with a pommel cushion to the wheelchair. There was a physician's order at this time to use the clear table top for 24 hours only. On [DATE] a nurses note at 12:45 p.m., documented that Resident #6 was aggressive and agitated when staff attempted to place the table top on the wheelchair. At 12:55 p.m., the table top was successfully placed on the resident's wheelchair. On [DATE], just after midnight, a nurses note stated that Resident #6 had a bruise on his/her right knee which the resident stated was sore. The incident investigation was dated [DATE] and did not include any interviews with staff. Further nurses notes on [DATE] at 12:30 a.m., documented that staff had placed the resident in a wheelchair with a tray for safety. However, the resident no longer had an order for [REDACTED]. Additionally, the lap buddy order should have been in place. The nurses note further documented that the resident was banging on the wheelchair, screaming and threw food on the floor. At 3:30 a.m., a nurses note stated that Resident #6 could remove the clear table top tray and could bang it up and down. The note further stated that the staff had to protect the resident from hitting him/herself with the tray. A physician's order was obtained at 6 a.m. on [DATE] to discontinue the lap buddy and to use the clear table top when out of bed. However, the staff had not been utilizing the lap buddy when the 24 hour table top order had expired, and, had used the table top without a physician's order. In addition, the nursing staff had documented that Resident #6 could remove the hard acrylic table top and bang it on anything, including him/herself. There was no written evidence of the rationale for this type of restraint. There was no accompanying nurses note at 6 a.m. on [DATE]. According to a nurses note on [DATE] at 1 p.m., Resident #6 was observed pounding on his/her table top, screaming and was agitated. A nurses note on [DATE] at 1 p.m. documented that the resident had removed the table top twice. At 4:30 p.m., the nurses note stated the resident was grabbing the table top and slamming it against the wheelchair repeatedly saying, "I hate this"; the table top continued. According to a nurses note on [DATE] at 8 p.m., Resident #6 was found sitting on the floor mat next to the bed. The note documented that the resident was assisted to the wheelchair with the table top in place. The incident investigation stated the resident had been in bed prior to the fall, and, that there was a bed alarm on the bed. On the form, the area to check if the alarm sounded was blank. There were no statements from the resident's assigned staff or any other information about the bed alarm. According to a nurses note written on the 11 p.m. to 7 a.m., either on [DATE] or [DATE] (handwriting unclear), Resident #6 sustained skin tears to the back of both of his/her arms. The nurses note documented that this injury occurred after the resident had removed and thrown off the table top, and, that Resident #6 slid out of the wheelchair several times. The incident investigation dated [DATE], contradicted the statement in the above nurses note, which stated the resident scraped his/her arms on the table top while sliding out of the chair. The interventions written by the nurse were to remove the resident from the wheelchair and place him/her in a geri recliner with a pommel cushion. There was no physician's order for this intervention. A separate nurses note dated [DATE] at 2 p.m., documented that the resident was ambulating in the wheelchair with the table top for safety. According to a nurses note on [DATE] at approximately 9 p.m., Resident #6 was placed in his/her wheelchair with the table top on. The note stated that the resident slid out of the wheelchair, and, when staff attempted to reposition the resident, he/she started hitting the staff. Further documentation revealed that by 11 p.m., the resident was again throwing the clear table top up over his/her head and trying to hit the staff. Resident #6 was also sliding him/herself to the end of the wheelchair and threatening to slide to the floor. The resident was then placed in a wheelchair with a seatbelt and became calmer. A physician's order was obtained at 11 p.m. on [DATE] to utilize the seatbelt for 24 hours as needed due to the resident's behaviors of throwing the table top. According to a nurses note on [DATE] at 1 p.m., Resident #6 was found lying on the floor mat next to the bed with his/her legs propped up on the wheelchair. The wheelchair still had the table top attached to it; however, the resident should still have been utilizing the seatbelt as the 24 hour order was still in effect. The incident investigation documented that the resident had been sitting in the wheelchair with the table top prior to the fall. Additionally, the investigation stated the chair alarm was "not applicable" and was therefore, not in place. There were no statements from the staff assigned to care for the resident at this time. There were no new interventions recommended. Between [DATE] and [DATE], multiple references were made to the resident's use of the table top restraint. After [DATE] no mention was made of the table top. According to nurses notes on [DATE] (untimed), Resident #6 was found sitting on the floor in front of her wheelchair. There was no mention of the table top or chair alarm. The incident investigation stated the fall occurred at 11:30 a.m. and checked both "yes" and "not applicable" for the resident's bed alarm, and, "yes" for the resident's chair alarm but made no mention as to either one sounding. There was no information about what the resident had been doing prior to the fall and/or if Resident #6 had been in bed or in the wheelchair. There was no mention of the table top and the restraint section was listed as not applicable; the table top restraint order was still active. In addition, there were no statements from the staff assigned to the resident at the time of the fall. There continued to be no mention of the resident's table top restraint in the nurses notes. According to a nurses note on [DATE] at 8:05 p.m., Resident #6 was found lying on his/her back in the room by a CNA who heard a thump and an alarm sounding. The nurse found the resident unresponsive and called the Registered Nurse to the room. By that time, the resident was responsive again and told the nurse the he/she hit his/her head. No visible injury was observed. The resident went to the hospital as 911 had been called when the resident was found unresponsive. The resident did not sustain any injuries. The incident investigation stated the resident had been in the wheelchair prior to the fall. The investigation stated the resident's wheelchair alarm was on and sounding at the time of the fall. The area for restraints was left blank. As part of the incident investigation, the facility copied the resident's plan of care which clearly stated the resident should have had a clear table top in place at the time of the fall. There was a statement from the staff member who found the resident but it was unclear whether this CNA was assigned to Resident #6 at that time or not. There were no other statements obtained. The surveyor did not observe any restraining devices on the resident during the survey. An interview with the resident's assigned CNA on [DATE], indicated that Resident #6 did not use a restraint anymore. The resident's plan of care and current physician's orders included a table top restraint. On [DATE] at 10:30 a.m., the surveyor questioned the UM about these discrepancies. The UM said the resident no longer used a restraint and that it should have been discontinued. The UM could not tell the surveyor when the restraint was to have been discontinued. Therefore, there were multiple issues with this resident and pattern of falls and injuries: a. The resident had active physician's orders and a care plan for a device that was not used and the resident fell twice; b. The resident had a 24 hour order for a seatbelt which was not used and the resident fell ; c. The resident had orders for chair and bed fall deterrent alarms, there was no evidence they were used for 4 of the resident's falls; d. In addition, it was unclear why the table top restraint was even ordered for a resident who was known to remove it, attempted to hit others with it and had sustained injuries him/herself while removing and wielding it. Refer to F225 2. During the initial tour of the nursing unit on [DATE], the UM told the surveyor that Resident #8 used a lap buddy restraint. On [DATE] at 10:42 a.m., Resident #8 was observed in the hallway in a wheelchair with a lap buddy on. Anti-tippers were observed on the front and back of the wheelchair. On [DATE] at 10:53 a.m., the surveyor interviewed the assigned CNA for Resident #8. The CNA stated, that the resident was total care, could stand and ambulate with assistance and would become tired late in the day. Furthermore, it was at this time, that she would give Resident #8 the opportunity to nap. The CNA said the resident tended to lean forward in his/her wheelchair and sit toward the middle of the wheelchair seat. According to the medical record, Resident #8 had been ambulating around the facility ad lib until a fall on [DATE] which resulted in a head injury. an order for [REDACTED]. The resident had a [DIAGNOSES REDACTED]. According to a nurses note on [DATE] at 5:30 p.m., Resident #8 was found on the floor in the hallway after an employee heard a loud thud. The resident's wheelchair had fallen over with the lap buddy still in place. The resident was sent to the hospital and returned with a [DIAGNOSES REDACTED]. According to the plan of care, anti tipping devices were added to the resident's wheelchair on [DATE]. According to a nurses note on [DATE] (untimed), Resident #8 was found with a bruise to the left lower leg. The incident investigation listed 2 bruises--the left lower leg and the right upper thigh. There were no statements from staff assigned to the resident prior to the CNA who discovered the bruise. However, there were no documented interventions and/or prevention of thigh bruising as the resident wore a soft padded lap buddy at all times in the wheelchair. According to a nurses note on [DATE] at 3 p.m., Resident #8 was being pushed into the sun porch for dinner and the resident leaned forward. The note stated the resident was lowered to the floor onto his/her knees. There were 2 bruises noted to the resident's right knee. There was no incident investigation. However, the resident was supposed to have anti-tippers on the wheelchair so it was unknown how this fall/lowering could have occurred. There were no new interventions put into place. According to a nurses note on [DATE] (untimed), Resident #8 was being pushed into the sun porch for lunch when the resident leaned forward and landed on his/her knees. There was also no investigation into this incident and no information about the anti-tippers. Refer to F225 3. During the initial tour of the facility on [DATE], the UM told the surveyor that Resident #9 wandered in her wheelchair with a lap buddy restraint and was confused. On [DATE] at 11:55 a.m., Resident #9 was observed in the dining room eating lunch. The resident's lap buddy was removed, the resident was up to the table and was making no attempts to wander. The resident was easily distracted, however, had a very short attention span. Later at 12:42 p.m., Resident #9 was observed wandering the halls of the nursing unit, and, was going into and out of resident rooms; the resident moved very quickly in the wheelchair. On [DATE] at 11:35 a.m., Resident #9 was observed in the dining room awaiting lunch. The resident's lap buddy was on, the resident was up to the table and made no attempts to wander. Later at 12:17 p.m. Resident #9 was observed wandering the halls quickly in the wheelchair. The resident was able to go under the room door barriers as they were observed too high. The surveyor also observed that Resident #9 had entered another resident's room by the nurse's station. The resident of that room, was heard yelling for someone to get him/her out. On [DATE] at 11:35 a.m., Resident #9 was observed in the dining room wearing short sleeves. The resident's arms were covered in bruises and dark discolorations. There was a clear bandage observed on the left lower forearm. On [DATE] at 12:50 p.m., the surveyor was exiting the elevator to enter the First floor (which was actually below the main/lobby level of the facility). The facility had 2 elevators that exited to a vestibule area. There was a doorway to the left that exited to an area with vending machines, tables with chairs and separate chairs by the windows. Walking through the vestibule area, after turning right and through double doors, this direction led to the central services area. Turning left and walking down a long corridor and making another left, led to the nurse's station. Upon exiting the elevator, the surveyor observed Resident #9 in the elevator vestibule area. The resident attempted to stand several times, hit his/her legs on the lap buddy and sat back down. The resident was in constant motion. Additionally, there were no staff members with the resident. The surveyor followed the resident into the central services vestibule area. This was an open area with 2 sets of doors. The first set of doors led to a dietary storage area that had a padlock on the door but the lock was open. The second set of doors was to a supply storage area. This door was open with a cart in the middle of the doorway blocking entry. To the right, the vestibule area contained what looked like a nightstand with multiple bottles of enteral feeding on top of it. Inside the drawers were wheelchair wheels, oxygen gauges, wheelchair brake arms and wires. Next to the nightstand were privacy screens. On the floor to the left when you entered this vestibule, were large metal structures from 2 resident lift devices, a box of wire on the floor, siderails from resident beds, a dustmop, a lap buddy restraint and a short table with a telephone on it. The surveyor continued to follow and observe Resident #9. Upon entering this vestibule area, the resident wandered over to the area to the left. The resident attempted to open the dietary storage doors but could not manipulate the padlock to open. Then the resident moved to the area where all the equipment was stored on the floor. Note that the resident could not be seen from the elevator area or hallway. Resident #9 continually touched the wall, the box of wire and anything else he/she could reach. At 12:56 p.m., a staff member exited the supply storage area, removed the cart that was blocking entry, locked the supply room door and left the area. The resident had inadvertently placed the right side/wheels of the wheelchair along side of a long piece of metal lying on the floor that belonged to the resident lift device. Resident #9 moved back and forth but could not release the wheelchair from this metal piece until the surveyor intervened and was able to instruct him/her. At 12:58 p.m., the resident finally freed him/herself, left the area and immediately returned. The resident left this room at 1 p.m. At 1:02 p.m., the resident was in the elevator vestibule area (just outside the central services vestibule) when an employee exited the elevator. The employee said nothing. The resident then wandered back toward the nursing unit to the vending machine area. According to the medical record, Resident #9 had a [DIAGNOSES REDACTED]. The plan of care included avoiding congested areas and/or redirecting from cluttered areas. On [DATE] at 10:56 a.m., the surveyor interviewed the assigned CNA for Resident #9. The CNA said the resident was jittery and constantly in motion, even during the provision of care. The CNA said the resident required constant redirection. Additionally, the CNA said the resident could ambulate a long distance with staff assistance and was non-compliant with wearing long sleeves, geri-sleeves and geri-gloves. At this time, the resident was observed wearing long sleeves that had been pushed up by the resident to the elbow. The CNA said the resident would not keep her sleeves down and would continually push them up after the CNA pulled them back down. According to nurses notes on [DATE] (untimed), Resident #9 was observed with a skin tear to the left forearm. The incident investigation stated that Resident #9 was found in the hallway with this skin tear. The investigation also indicated that the resident's protective sleeves were being laundered. There was no information if the resident was wearing long sleeves or not. According to a nurses note on [DATE] at 1:40 p.m., the resident was found with a skin tear to the left elbow. The note stated the resident usually wore long sleeve clothes or geri gloves but the gloves were in the laundry, and, that central supply would be contacted for more gloves. The incident investigation stated the resident had poor safety awareness and propelled throughout the unit. There was no information about whether the resident was wearing long sleeves. There was another incident report completed on [DATE] at 4:30 p.m. However, there was no nurses note about this incident. The report stated that Resident #9 was found with multiple skin tears/flat hematomas to the left thumb, arm and hand. The report stated the resident kept running into objects and opening these areas. The investigative follow-up stated that new geri gloves would be provided. According to a nurses note on [DATE] at 2:55 p.m., Resident #9 had a skin tear to the left elbow which documented that the resident had scraped it on the wall. The incident investigation provided no information about the resident's sleeve length or other interventions. According to a nurses note on [DATE] at 2:45 p.m., Resident #9 had a skin tear to the left upper arm. The incident investigation indicated that Resident #9 was in and out of the hallway and rooms, however, the incident was not witnessed. There was no information about sleeves, gloves or anything else. According to a nurses note on [DATE] at 5:15 a.m., Resident #9 was found on the floor after the Licensed Practical Nurse (LPN) heard a yell and a thump. The resident was found in front of the wheelchair with his/her back resting against the seat of the wheelchair. This nurses note was written by the Registered Nurse (RN) who was called to the room. The note stated that the RN found the resident back in bed. Therefore, the resident was initially assessed by the LPN and was returned to bed before he/she could be assessed by the RN. The LPN statement verified that she had performed the initial assessment and returned the resident to bed before notifying the supervisor. The LPN statement did not include any information about an injury. The RN, however, did find a large abrasion on the resident's back. The incident investigation was completed by the RN which stated the resident had been in bed prior to the fall. The report checked both "no" and "not applicable" for a bed alarm. The investigative follow up area stated the resident's fall alarm had been discontinued the previous Friday and would now be re-instated. However, there were no nurses notes about discontinuation of fall deterrent alarms. The plan of care still included a bed alarm at the time of this fall. Additionally, there were no statements from the resident's CNA who was caring for Resident #9 at the time of this fall. According to a nurses note on [DATE] (untimed), Resident #9 was found with a skin tear to the right arm. The incident investigation was timed for 7 p.m. and gave no information about the location of the skin tear and what sleeves and/or other interventions were in place. According to a nurses note on [DATE] at 3 a.m., Resident #9 was found with a skin tear to the left forearm. The incident investigation was dated [DATE] at 6:30 p.m., and, documented that the resident was wheeling around in the wheelchair. There was no mention of interventions in place. According to a nurses note on [DATE] (untimed), Resident #9 was found with a bleeding toe which the writer surmised was caused by getting it caught on something. The incident investigation stated the resident had been in his/her wheelchair at the time, and may have caught the toenail on the bed railing or bedside table. There was no mention of the resident's footwear at the time, though it was assumed that Resident #9 was not wearing any. The resident's plan of care stated that he/she should be wearing non-skid footwear. According to a nurses note on [DATE] (untimed on the 3 p.m. to 11 p.m. shift), Resident #9 was observed with an open area to the right thumb. The note documented that the resident had been wheeling up and down the hallway, and, had a dose of an anti-anxiety medication on the previous shift. The incident investigation, timed for 4 p.m., stated the resident had protective sleeves on his/her arms. There was no mention of the resident's protective geri gloves. According to a nurses note on [DATE] (untimed on the 3 p.m. to 11 p.m. shift), Resident #9 was found with a skin tear to the left elbow. The note stated the resident was wearing the protective sleeves. The incident investigation gave no new interventions and/or explanation as to how the resident obtained a skin tear if the sleeves were properly placed. According to a nurses note on [DATE] at 5 p.m., Resident #9 was found in the tub room . The resident had geri-gloves on and sustained skin tears to the left hand at the base of the thumb, and, the right thumb-lower knuckle. The incident investigation included a statement from the CNA who found the resident in the shower room who stated blood was dripping from the resident's hands. The investigative follow-up portion of the form stated the resident wore geri gloves but continued to attempt to squeeze into small spaces. No new interventions were recommended. According to a nurses note on [DATE] (untimed), Resident #9 was found with active bleeding from the back of the right hand. The note stated the resident's geri gloves were on and the resident continued to self-propel throughout the hallways and needed close supervision. The incident investigation was also not timed and gave no information about new interventions or the CNA assigned to the resident at the time of the injury. According to a nurses note on [DATE] (untimed), Resident #9 was found with a bruise on his/her left shin by a CNA during first rounds. It was described as dark purple with firm swelling. The incident investigation timed at 7 p.m., failed to describe the appearance of the bruise and did not contain information and/or interviews from the staff who cared for the resident on the previous shift to attempt to ascertain the cause. According to a nurses note on [DATE] at 7:30 p.m., Resident #9 was found with a skin tear to the right forearm. The incident investigation documented that the resident wore geri gloves but did not state if they were actually in place at the time of the incident. Additionally, there was no mention of the resident's sleeve length. According to a nurses note on [DATE] at 6 p.m., Resident #9 was found with a skin tear to the left hand middle finger. The nurse's note stated the resident was wheeling back and forth in the hallway, anxious and had been medicated earlier with an anti-anxiety agent. The incident investigation stated the resident was going in and out of resident rooms. There was no mention of the resident's interventions that should have been in place, and, no new interventions were recommended. There was no information from the CNA assigned to the resident at the time. According to a nurses note on [DATE] at 4 p.m., Resident #9 was found with a bleeding left thumb after observing the resident going in and out of other resident's rooms. The incident investigation made no mention of the resident's interventions that should have been in place, and, no new interventions were recommended. There was no information from the CNA assigned to the resident at the time. According to a nurse note on [DATE] at 8:30 a.m., Resident #9 was found with a left upper forehead bruise which had been observed by the CNA during morning care. The incident investigation stated that the resident had been going in and out of rooms on [DATE] at 4 p.m. and may have bumped his/her head. There was no evidence that any staff caring for the resident prior to the finding of this bruise had been interviewed. The writer assumed that the bruise may have resulted from the previous incident. According to a nurses note on [DATE] (untimed), Resident #9 bumped into another resident's chair. Resident #9 informed staff that the other resident grabbed him/her by the arm. The resident's right upper arm was slightly red per the nurses note. There was no incident investigation into this matter. According to a nurses note on [DATE] at 9 p.m., the CNA of Resident #9 reported a skin tear to the top of the right hand. The incident investigation stated the resident had old bruising to the top of this hand as well. There was no information about where this old bruise had come from. There was an incident investigation for [DATE] at 2:30 p.m., which described a skin tear to the right upper hand. The nurse stated the resident had very fragile skin. No further investigation was conducted and there was no nurses note for this incident. According to an untimed nurses note on [DATE], Resident #9 was found with a bruised area to the left leg. The incident investigation was timed 12:30 p.m. which documented that the resident would go around the unit alone. The intervention listed, was to have staff be more aware of the resident's whereabouts at all times. There were no staff interviews. According to an another untimed nurses note on [DATE], Resident #9 was found with a cut on the right hand middle finger knuckle. The note stated the resident was trying to go out of the door from the sun porch to the outside. The incident investigation was timed 3:30 p.m; there was no mention of or anything documented regarding the resident's geri gloves. According to a nurses note on [DATE] at 5 p.m., Resident #9 was found with a skin tear to the left bicep. The incident investigation stated the resident had a history of [REDACTED]. There was no information about the resident's sleeve length or any statements from the assigned CNA staff. According to a nurses note on [DATE] at 8 p.m., Resident #9 was found with a reddened swollen area to the left shin. The incident investigation stated the resident propelled him/herself in the wheelchair. No statements were obtained and no new interventions were recommended. According to a nurses note on [DATE] at 7 p.m., Resident #9 was found with an open scab on the left forearm. The incident investigation provided no additional information. There was no mention of the resident's sleeve length. According to an untimed nurses note on [DATE], Resident #9 was found with a skin tear to the right elbow. The incident investigation provided no additional information. There was no mention of the resident's sleeve length. Surveyor review of an incident investigation dated [DATE] at 3 p.m., documented that the resident was found with a skin tear to the left wrist. The nurse wrote that the use of geri gloves would be encouraged, however, the nurse's note did not state if they were in place at the time of the discovery of the injury. Additionally, there was no evidence of an accompanying nurses note. According to a nurses note dated [DATE] at 8 p.m., Resident #9 was hit by another resident. There was no evidence provided or found that an incident investigation was completed. It was also unclear whether this incident was witnessed and/or if the resident sustained [REDACTED]. According to an untimed nurses note on [DATE], Resident #9 was found with a skin tear on the left hand with purpura/ bruising up and down the arms. There was no incident investigation provided or evident in the medical records. According to an untimed nurses note on [DATE], Resident #9 was foun