Every finding on record at Rose Mountain Care Center

Based on observation, interview, and record review, it was determined that the facility failed to provide qualified interpreter services for a resident identified as having a language barrier. The deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for language and communication.The deficient practice was evidenced by the following:On 5/13/2026 at 9:32 AM during initial tour, the surveyor observed Resident #5 laying in his/her bed speaking a foreign language later identified as Spanish. The surveyor introduced self to the resident who responded in Spanish. A review of Resident #5's quarterly Minimum Data Set (MDS; an assessment tool) dated 04/30/2026 revealed under section B that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating Resident #5 had moderately impaired cognition. The MDS further revealed under section A, that Resident #5's preferred language was Spanish and that an interpreter was needed to communicate. A review of Resident #5's personalized care plan revealed a focus of potential for difficulty communicating related to language barrier initiated on 04/28/2023, with an intervention to utilize interpreter for native language as needed. On 05/14/2026 at 9:20 AM during an interview Licensed Practical Nurse (LPN) #1 stated that they used Spanish speaking staff to communicate with Resident #5. LPN #1 further stated that the Spanish speaking staff utilized are housekeeping staff and when they were not available, they would contact Resident #5's family member. On 05/14/2026 at 9:30 AM, the surveyor was approached by LPN #1 who showed the surveyor a Visually Speaking board, (a two-sided document that utilized pictures for communication purposes). At that time, LPN #1 stated that if staff was unable to find a staff member or reach the residents family member that they could use the Visually Speaking board. LPN #1 further stated that they have not had to use the board because there has always been a housekeeper around to translate. The surveyor did not observe the Visually Speaking board in Resident # 5's room during any observation. On 05/18/2026 at 1:25 PM during an interview with the surveyor, LPN #2 stated that they utilized Spanish speaking employees to translate for Resident #5. LPN #2 further stated that these employees were not employed as translators but as housekeepers and confirmed that they used housekeeping staff to translate for Resident #5. On 05/19/2026 at 10:31 AM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that the facility had translators available on the day and evening shifts. The LNHA responded No, when asked if any of the translators were Spanish language translators. The LNHA further stated that the facility used Spanish speaking staff that included housekeeping staff to communicate with Resident #5. When asked by the surveyor if the housekeeping staff should be translating confidential medical information about the resident, the LNHA replied that housekeeping staff does not have the right to the resident's information. A review of the facility provided policy titled Language Barrier/Limited English Proficiency (LEP) Policy revised on 02/01/2026 revealed that the facility will, provide qualified interpreter services when necessary. The policy further revealed that the facility will, Utilize telephone interpreter services, video remote interpretation (VRI), qualified bilingual staff, or approved interpreter services as available. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 1 of 3 forms provided. The evidence was as follows:On 5/19/2026 at approximately 10:00 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed one of the three provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The following forms were reviewed:Order form number:260545518-voided260545519- Part 5 was not completed to include number received and date received.260545520- awaiting pharmacy delivery. On 5/19/2026 at 10:51 AM, the surveyor and the Director of Nursing (DON) reviewed the provided DEA 222 forms in the presence of the survey team. The DON acknowledged she should have completed Part 5 as instructed on the reverse of the DEA 222 form as required. A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item . A review of the facility Documentation and Inventory of Controlled Substances policy with a revised date of February 2023 included Controlled drugs are inventoried and documented under proper conditions with regard to security and state/federal regulations. NJAC 8:39-29.7(c)

Based on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficient practice was identified for 1 of 6 residents (Resident # 89) reviewed under the Infection Control task. The deficient practice was evidenced by the following: On 05/13/2026 at 10:20 AM while in the hallway outside of Resident # 89's room. Outside of the room was a sign that revealed, Stop: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting . At that time, the surveyor observed a Certified Nurses Aide (CNA) in the room providing care to Resident # 89 who was in bed adjacent to the window. Specifically, the CNA had on clear, disposable gloves on while manipulating the bed linens and removing the trash bag from the room. The CNA was not wearing a protective gown. On 05/13/2026 at 10:21 AM during an interview with the surveyor, the CNA said she does have to wear a gown in the room but stated she was working on the door side of the room. At that time, the surveyor observed the side of the room closest to the door. There was no resident present in that portion of the room, the bed was made and appeared undisturbed. At no time was the CNA working on the door-side of the room during the surveyor's observation. At that time, the CNA left the presence of the surveyor holding a clear plastic bag of trash. A review of Resident # 89's Electronic Medical Record revealed that he/she had a physician's order for Enhanced Barrier Precautions (Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) related to a surgical incision. The order was started on 04/30/2026 A review of Resident # 89's Care Plan revealed that the resident is at increased risk for infection and has a surgical wound requiring enhanced barrier precautions to prevent the spread of infection. A review of the facility provided policy titled, Enhanced Barrier Precautions (EBP) Policy revealed that staff shall wear gloves and an isolation gown during high-contact resident care activities including, but not limited to: Bathing or showering, Dressing, Transferring or repositioning, Toileting assistance, Incontinence care or brief changes, Changing linens or bed making, Wound care, Device care, Providing hygiene care, Assisting with mobility when extensive physical contact is anticipated. The policy revealed under, PPE [Personal Protection Equipment] that Staff shall don gloves and an isolation gown prior to high contact care activities. N.J.A.C. 8:39-19.4(a) Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically with respiratory equipment for 1 of 1 residents reviewed for respiratory care. (Resident #8). The deficient practice was evidenced by the following: On 5/18/2026 at 12:41 PM, the surveyor observed Resident #8 being transported via wheelchair into their room by a Certified Nursing Assistant (CNA). The resident was not wearing a nasal canula and did not have oxygen in use. The CNA stated she needed help to transport the client and the oxygen concentrator together, that there was no one to help her at the moment, so she was going to go back to the dayroom to get the concentrator after she settled the resident into bed. At that time the resident's licensed Practical Nurse (LPN) came into the room to check the resident's vitals and overheard the CNA state she was unable to transport the resident and the oxygen concentrator together and offered to retrieve the concentrator from the dayroom while the CNA helped Resident #8 into bed. The surveyor followed the LPN into the day room and observed Resident #8's tubing and nasal cannula attached to concentrator laying across the tablecloth on the dining room table. The LPN and surveyor returned to the room. The LPN took the nasal cannula and tubing and placed it into a plastic bag and proceeded to donn surgical gloves without performing hand hygiene, she then removed the tubing from the plastic bag and was attempting to place the nasal cannula into Resident #8's nostrils when the surveyor stopped the LPN. When the surveyor asked the LPN if that was the same tubing that had been laying exposed on the dining room table the LPN responded that it was. When the surveyor asked when tubing should be replaced and who could replace the tubing, she stated the tubing was changed by nurses every night shift or if it was dirty. The LPN then stated she should probably replace the tubing because it could be contaminated. At that time the surveyor interviewed the CNA who stated there was usually a plastic bag attached to the concentrator where she would place the tubing when not in use, but there was no bag today. The CNA acknowledged she should have discarded the tubing and asked the nurse for new tubing. On 5/19/26 at 10:40 AM, the surveyor interviewed the Director of Nursing (DON) who stated oxygen tubing was changed weekly or if the tubing became contaminated. The DON confirmed Resident #8's oxygen tubing should have been replaced after it had made contact with the dining room table and had potentially become contaminated. A review of Resident # 8's admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to, acute respiratory failure with hypoxia (a life-threatening emergency where the lungs cannot adequately oxygenate the blood) and bronchiectasis (a chronic lung condition where the airways become permanently damaged, widened, and scarred) and adult failure to thrive. A review of Resident # 8's physician's orders revealed orders for O2 (oxygen) 4L (liters) via NC (nasal cannula) continuously every shift Dx: (diagnosis) SOB (shortness of breath); initiated 1/13/2026. A review of the facility's undated Oxygen and Respiratory Equipment Storage policy included Purpose to ensure oxygen tanks, respiratory equipment, and related supplies are stored, handled, maintained, and used safely in accordance with CMS regulations, New Jersey Department of Health requirements, OSHA standards, fire safety regulations, infection prevention guidelines, and manufacturer recommendations. Ensure oxygen tubing and respiratory equipment are maintained in clean and safe condition.Store respiratory medications, nebulizer supplies, and oxygen-related equipment in clean designated areas. NJAC 8:39-19.4(k)(n)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide appropriate and sufficient services based upon current standards of practice to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 2 residents (Resident # 7) investigated for Urinary Catheter.The deficient practice was evidenced by the following:On 05/14/2026 at 9:35 AM, Resident #7 was observed seated in a wheelchair in the Dining Room reading a magazine. At that time Resident #7 stated that he/she had a urinary catheter (tube inserted into the bladder to drain urine) but no longer has one. On 05/18/2026 at 12:37 PM during an interview, the Unit Manager (UM) stated that Resident #7 does have a urinary catheter.A review of the quarterly Minimum Data Set (MDS; An assessment tool) dated 04/16/2026 revealed under section, C that Resident #7 has a Brief Interview for Mental Status (BIMS; a brief assessment to determine cognitive status) of 11, indicating the resident had moderately impaired cognition. Further review of Resident #7's MDS, revealed under section, H that Resident # 7 had an indwelling catheter.A review of the Electronic Medical Record (EMR) under Diagnoses revealed that Resident #7 was diagnosed with but not limited to infection and inflammation reaction due to indwelling urinary catheter.A review of the EMR revealed an active physician's order to monitor urine output every shift with a start date of 09/19/2025.A review of Resident #7's personalized Care Plan revealed a focus of, catheter 16F with 30cc balloon related to obstructive uropathy initiated on 09/03/2025. The focus further revealed a goal to remain patent through next review.A review of Resident # 7's Treatment Administration record for May 2026 revealed blank sections of documentation to monitor output every shift on the following date and shift:05/15/2026: evening shift blank.A review of Resident # 7's Treatment Administration record for April 2026 revealed blank sections of documentation to monitor output every shift on the following dates and shifts:04/05/2026: evening shift blank04/29/2026: night shift blankA review of Resident # 7's Treatment Administration record for March, 2026 revealed blank sections of documentation to monitor output every shift on the following dates and shifts:03/04/2026: night shift blank03/17/2026: night shift blank03/22/2026: day shift blank03/24/2026: night shift blankA review of Resident # 7's Treatment Administration record for February, 2026 revealed blank sections of documentation to monitor output every shift on the following dates and shifts:02/07/2026: night shift blank02/08/2026: night shift blank02/14/2026: night shift blankA review of Resident # 7's Treatment Administration record for January, 2026 revealed blank sections of documentation to monitor output every shift on the following dates and shifts:01/03/2026: night shift blank01/04/2026: night shift blank01/06/2026: night shift blank01/15/2026: night shift blank01/23/2026 evening and night shift blank01/30/2026: night shift blankOn 05/19/2026 at 10:31 AM during an interview with the surveyor, the Director of Nursing (DON) stated that the TAR documentation to monitor output, should not have blank documentation. The DON further stated that this was important so that staff could ensure that the catheter is draining properly. A review of the facility provided undated policy titled Indwelling Urinary Catheter Policy revealed that staff will monitor catheter patency, output and resident tolerance. N.J.A.C. S 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) carry out activities per a resident's care plan for 1 of 5 residents reviewed (Resident #25), and b.) conduct on-going activity assessments to determine resident's interests, hobbies, and cultural preferences to acquire a meaningful life for 5 of 5 residents (Resident #3, #21, #25, #83, #84) reviewed for activities. This deficient practice was evidenced by the following: 1. On 12/3/2024 at 9:58 AM, the surveyor observed Resident #25 lying in bed. Resident #25's family member was present and stated that the resident was supposed to be getting a daily newspaper in their preferred language. On 12/5/2024 at 8:27 AM, the surveyor observed Resident #25 lying in bed and no newspaper was available. On 12/5/2024 at 9:35 AM, the surveyor observed Resident #25 lying in bed and no newspaper available. On 12/5/2024 at 9:49 AM, the Activities Director (AD) was interviewed. The AD stated that she had been AD for only a few weeks. The AD stated that when a resident was admitted , the activities department would conduct an assessment. She stated the assessment would go into the electronic medical record (EMR) to track residents participation in activities. The AD stated she was familiar with Resident #25 and that the resident was supposed to get a newspaper daily, but she was not sure who was supposed to provide the newspaper. The AD stated that there should be an activities assessment done quarterly for all residents. On 12/5/2024 at 9:50 AM, the Minimum Data Set (MDS) Coordinator approached the surveyor and the AD. The MDS coordinator stated that the newspaper had been a discussion in morning meeting very far back but not sure of the date and that the surveyor should ask the admissions staff about the newspaper. On 12/5/2024 at 9:57 AM, the Admissions staff who stated she was not sure why the resident did not get a newspaper and that she would investigate. A review of the Admission Record (AR) revealed Resident #25 had been admitted with diagnoses which included but were not limited to; Parkinson's disease (a neurodegenerative disease of the central nervous system). A review of the resident-centered on-going care plan included but was not limited to; resident prefers to stay in room . goal: will respond positively to 1:1 visits by staff or volunteers accepting 5 visits per week and interventions including encourage volunteer visits, invite, and encourage to social programs of interest, visit 1:1 five times a week for increased social interaction. A review of the most recent facility provided, Activity Participation Review was dated 06/30/2022, and included but was not limited to; B. Attendance and Participation Summary . relaxing in room reading the newspaper and conversation with staff. On 12/05/2024 at 10:12 AM, the AD stated that she had no idea who went to Resident #25's room for 1:1 visits and was not aware of any documentation of Resident #25's participation in activities. On 12/05/2024 at 11:13 AM, the in presence of the survey team, the AD and the Social Worker (SW) were interviewed. The AD stated an activities staff member who worked at a different facility was helping with the facility's activities program. The SW stated there was no documentation that the residents had participated in any activities that were identified as their individual interests. The SW further stated the previous AD left the facility in the summer. 2. On 12/05/2024 at 1:38 PM, the surveyor requested the activity assessments and participation documentation for Resident #3, #21, #25, #83, and #84. On 12/05/2024 at 2:50 PM, the Assistant Director of Nursing (ADON) informed the survey team that there was no updated activity assessments for the residents. A review of the EMR's revealed the following: Resident #3, admitted in 2013, and the last documented activity assessment was dated 2022, and there were no activity participation logs to confirm that resident participated in activities. Resident #21, admitted in 2022, and there were no activity assessments or documentation to confirm activity participation. Resident #25, admitted 2018, and the last activity assessment completed was dated 2022, and there was no documentation to confirm activity participation. Resident #83, admitted 2024. On 12/05/2024, the surveyor was told there was no activity assessment completed and documented. On 12/11/2024 at 1:54 PM, the facility provided a handwritten form of three pages that had not been entered into the EMR. Page one had the resident's name and was filled out, pages 2 and 3 had no resident name, admitted , room number, or date of birth and page 3 was blank. Resident #84, admitted 2024, and there were no activity assessments completed and no documentation to confirm activity participation. The facility was unable to provide any documentation to confirm resident's participation activities for the residents who resided in the facility. The surveyor requested a policy for activities and received the facility provided job description for Recreation Director. The description included but was not limited to; summary: establish, coordinate, and direct a comprehensive recreation program . develops a program to relate to the physical, psychological, social, intellectual, cultural, and spiritual needs of each resident. Establish, coordinates, and documents all assessments, review plans and progress notes pertaining to activities. Facilitate activity and recreation pursuits of residents. Part I: Standards: 1. Coordinate, monitor, and document all assessments timely and appropriately. 3. Review progress notes . for tardiness and accuracy of treatment outcomes. 4. Design and implement a comprehensive therapeutic program of activities accommodating resident needs, abilities, and interests. 5. Adheres to objectives, standards of practice, policies and procedures . for the therapeutic recreation department and ensures personal are being supervised. Part II: 13. Evaluates and recommends appropriate activities programs for the residents. On 12/12/2024 at 12:44 PM, the above concerns were discussed with the facility administration. The facility had no additional information to offer. NJAC 8:39-4.1 (a)(24); 7.1(a); 7.2; 7.3(a)(1-7)(g); 8.1

38079 Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility activities program was directed by a qualified therapeutic recreation specialist or activity professional. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: On 12/03/2024 at 9:58 AM, Surveyor #1 observed a family member in resident #25's room. The family member stated they were upset because Resident #25 was supposed to be getting a daily newspaper in their language, but no newspapers were being delivered. On 12/04/24 at 9:19 AM, Surveyor #2 observed a staff assisting residents at mealtime in the main dining room. The staff identified herself as the Staffing Coordinator/ Lead Certified Nursing Aide (SC/LCNA). On 12/05/2024 at 9:49 AM, Surveyor #1 observed activities taking place in the main dining area. Surveyor #1 interviewed a staff member who introduced herself as the Activities Director (AD). The AD stated she had been the AD for two weeks and prior to that, she had been with the facility as a unit clerk for [AGE] years. When asked what the process was for residents, the AD stated upon admission there would be an activities admission assessment completed and that would go into the electronic medical record (EMR). The AD stated after that, each resident would have quarterly activity assessments. Surveyor #1 inquired about Resident #25's daily newspaper and the AD replied she was familiar with the resident but was not sure who was responsible to deliver the newspaper. At 10:12 AM, Surveyor #1 asked the process of documentation to determine which residents were at which activities or offered any activities or room visits. The AD replied she had no idea who conducted resident room visits or documentation of resident activity participation. On 12/05/24 at 11:17 AM, the SC/LCNA (who introduced herself to Surveyor #1 as the AD) and Social Worker addressed the survey team regarding the Activity Director and stated another facility Activity Director would help at times, but that there was no trained Activity Director currently at the facility since the summertime when the last AD left the position. The SC/LCNA stated she will now be the Activity Director. The SC/LCNA stated that there has not been a consistent activity Director since July, other people for a week or so. The surveyor asked if the SC/LCNA had a Bachelor's degree and she stated the facility told her she would take an online course. The surveyor asked if she has ever been to a Quality Assurance meeting or a resident care plan meeting and she stated, I have not been to one yet. On 12/5/2024 at 9:08 AM, Surveyor #1 requested the activity policy and the AD job description. On 12/5/2024 at 10:34 AM, Surveyor #1 was provided only the signed AD job description. A review of the facility provided, Recreation Director job description date of hire 11/17/2024, included but was not limited to; Qualifications: Bachelor's degree from an accredited college with a major area in Recreations, Creative Arts, Therapy, Therapeutic Recreation, Art Education, Psychology, or Music Therapy. A Master's degree preferred. 2-3 years of experience in recreation and/or management experience. NJAC 8:39-8.2

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, b.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days, and c.) documented an admission History and Physical (H&P) within 72 hours of a resident's admission to the facility. This deficient practice was observed for 4 of 18 residents and 1 closed record (Resident #13, #33, #81, #83 and #85) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 12/05/24 at 09:42 AM, the surveyor observed Resident #33 sitting in the wheelchair, in their room. The resident informed the surveyor that he/she did not see a doctor regularly. The resident stated I saw a doctor about 2 weeks ago and I did not know who he was, and he stated, I am your doctor. Resident #33 further stated I saw him for the 1st time in 4 years. The surveyor reviewed the medical record (MR) for Resident #33. A review of the Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), and Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. A review of the Electronic Medical Record (EMR) revealed a Physician Annual history and physical (H&P) note from the resident's attending physician with an effective date of 1/26/24 and had a created date of 8/8/24. The note was marked as a Late Entry. 2. On 12/03/24 at 10:03 AM, during an initial tour, the surveyor observed Resident #81 watching TV in their bed. The surveyor reviewed the MR for Resident #81. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a chemical imbalance in the blood which can cause difficulty thinking clearly), Type 2 diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar), and Cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS of 9 out of 15, indicating the resident was moderately cognitively impaired. A review of the EMR revealed an attending physician H&P note dated 2/16/24. A review of the Physician progress notes (PN) revealed the attending physician documented a visit for the resident on 8/1/24. Further review of the EMR revealed the Nurse Practitioner (NP) also documented visits for the resident on 5/23/24, 5/30/24, 6/24/24, 7/5/24, 9/26/24, 11/12/24. A review of the EMR did not reveal a PN from the attending physician or the attending NP for March 2024, April 2024, and October 2024 or that the physician and NP were consistently alternating monthly visits. 3. On 12/5/24 at 12:00 PM, the surveyor observed Resident #13 sitting in their wheelchair, in the dining room. The resident was waiting for lunch calmly. The surveyor reviewed the MR for Resident #13. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Hypertension (high blood pressure), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges.), Cerebral infarction (blood vessel blockage in the brain) and anxiety disorder. A review of the Comprehensive MDS dated [DATE], revealed the Resident #13 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating the resident was moderately cognitively impaired. A review of the EMR revealed an attending physician H&P note dated 10/15/24. It did not reveal any additional physician progress notes. A further review of the EMR revealed the resident was admitted to the facility in October 2024. On 12/11/24 at 11:31 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN #1) stated physicians make rounds every month for monthly visits and they document in EMR while at the facility. The LPN was unsure how soon the H&P would be completed for a new admission. On 12/11/24 at 11:43 AM, during an interview with the surveyor, the LPN Unit Manager (LPN/UM) stated H&P for a new admission should be done within 48 hours to 72 hours. The LPN/UM further stated the physician has to see their residents every 60 days. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. 38079 5. On 12/06/2024 at 8:25 AM, a surveyor observed Resident #83 in the main dining area. A review of the AR revealed that Resident #83 was admitted [DATE] to the facility. A review of the EMR Progress Notes (PN) documented a Late Entry 09/17/2024, type: Physician H&P. The PN documented a chief complaint: very forgetful, unable to live alone. The remainder of the H&P contained areas such as HPI, ROS (review of systems), Family History, Mod History/Diagnosis on file, Social History, physical exam, diagnostics/labs, assessment, and Plan of Care (draft) were all blank. A review of the Late Entry Draft assessment revealed the effective date as 9/17/24 but the created date as 10/6/24. The assessment also contained the chief complaint, but all other assessment areas were blank. On 12/11/2024 at 11:36 AM, the Registered Nurse (RN) on the [NAME] Unit stated that upon admission, the staff would call the doctor. The expectation would be that the doctor would be in to see the resident for an H&P within 24 to 48 hours. 31654 6. On 12/03/24 at 4:07 PM, a surveyor conducted a closed medical record review of Resident #85's electronic medical record (EMR). The EMR revealed a nursing progress note that on 10/12/24 Resident #85 was discharged home with a visiting nurse referral made. On 10/15/2024 at 12:33 the Physician completed a History and Phyisical (H & P) which revealed the following physician note: Effective Date: 10/15/2024 12:33 (completed 3 days after the resident was discharged ) Type: Physician H&P Cheif Complaint: HPI: Patient evaluated at side, spoke to [spouse], has history of dementia, had viral gastroenteritis and became weak. All questions and concerns answer with [spouse]. is reportedly doing a lot better per [spouse]. Spoke to nurse and reviewed chart no concerns at this time Time spent, including counseling and coordination of care: 50 minutes Rendering Provider, [Physician Name] Author: [Physician Name] - Physician [e-SIGNED] On 12/11/2024 at 11:43 AM, a physician who has residents at the facility was on the telephone with the survey team. The physician stated that he had been one of the physician's at the facility for 2 to 3 years and that upon a resident's admission, the resident should be seen within 48 hours. On 12/12/2024 at 2:10 PM, the survey team conducted a telephone interview with the Medical Director (MD). The MD was asked about his expectations regarding physician's at the facility entering late entry notes months after the supposed visit with the resident. The MD specified that the notes should be entered into the EMR immediately. The survey team asked the MD if it was appropriate for a physician to document an actual visit progress note after a resident was discharged and the MD stated, no, because the resident was not there. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. At 3:01 PM, during exit conference, the facility had no additional information to provide. The surveyor reviewed the facility's policy titled Physician Visits with last revised date of 4/2008 included under Policy Statement: The Attending Physician must make visits in accordance with applicable sate and federal regulations. Under Policy Interpretation and Implementation: 1.) The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. 2. After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A Physician assistant or nurse practitioner may make alternate visits after the initial 90 days following admission, unless restricted by law or regulation. The facility policy failed to address the physician visit upon admission. The surveyor reviewed the facility provided undated Guidelines for Charting and Documentation included under Physician Orders 1. a.) Each resident must be under the care of a licensed physician authorized to practice medicine and must be seen by the physician at least every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter. NJAC 8:39-11.2(c); 23.2(a)(d)

Based on interview and document review it was determined that the facility failed to ensure that residents were explicitly informed of and understanding was assessed prior to having the residents enter into a arbitration agreement which was identified as a mandatory part of the Admission Agreement for 9 of 9 Residents who attended a resident council meeting (Resident #6, #11, #20, #21, #24, #27, #40, #71, #78) and was evidenced by the following: On 12/03/24 at 10:07 AM, during the facility entrance conference held with the Liscensed Nursing Home Administrator (LNHA) and the [NAME] President of Clinical Services Registered Nurse (VPRN). The surveyor asked if the facility utilized arbitration agreements. The LNHA stated absolutely, we offer arbitration and it is in their admission agreement. The LNHA then stated, but it is a separate area, and it is overseen by legal. The surveyor requested a list of all the residents that had signed the arbitration agreements. The VPRN stated there is no one in an active arbitration agreement, and stated the Admission Director was responsible for the arbitration agreements. On 12/03/24 at 10:30 AM, the surveyor reviewed the survey binder provided by the administration which revealed under the arbitration agreement section, a typed document revealed:[facility name] does have any current resident that have entered into a binding arbitration agreement. The survey binder included a copy of the 19 page Admission agreement which revealed the following: k. Arbitration: All claims arising out of this Agreement must be handled pursuant to the terms of the annexed Mandatory Arbitration Sub-Agreement. By signing this Agreement Resident/Sponsor expressly confirms having reviewed the Agreement and Mandatory Arbitration sub-agreement and agree to all the terms in their entirety including the terms of the annexed Mandatory Arbitration sub-agreement. Resident expressly agrees to having had the opportunity and time to read the Argeement and Mandatory Arbitation Sub-Agreement in their entirety and to having the option of having both reviewed by an attorney of Resident's choice prior to signing. Page 8 of the Admission Agreement revealed Resident/Sponsor confirms that these exhibits were provided to resident prior to signing of the Admission Agreeement and that such exhibits are part of the Admission Agreement. Index of Exhibits: Resident/Sponser Initials: Exhibit 1- Mandatory Binding Arbitration Agreement. Exhibit 1 (Page 9) revealed: Mandatory Binding Arbitration Sub-Agreement. Arbitration Explained: Arbitration is a specific process of dispute resolution instead of utilizing the traditional state or federal court system. Instead of a judge and/or jury determining the outcome of a dispute . Mandatory arbitration has been selected with the goal of reducing the time, formalities and cost of utilizing the court system . Page 11 of the AA revealed I agree to the terms Mandatory Arbitration Sub Agreement in it's entirety (Subsections A-K). I acknowledge and confirm that I was given ample opportunity to read the Mandatory Arbitration Sub-Agreement in its entirety, that I have in fact read and understood the Mandatory Arbitarion Sub-Agreement and had the opportunity to have it reviewed by an attorney of my choosing prior to signing. Print Resident Name, Signature Line and Faciltiy Admission Director signature and date. There was no option to refuse the agreement contained within the Admission Agreement. On 12/03/24 at 11:22 AM, the facility General [NAME] (GC), in the presence of the LNHA, addressed the survey team regarding the requested entrance documents and the list of residents who entered into an arbitration agreement. The GC stated there was an arbitration agreement and there is an admission agreement and obviously everyone signs the admission agreement. The GC stated, we don't track who signed the arbitration agreements and we have no way to track them. The LNHA stated we can go manually and track them and the GC stated, we would have to track them manually and it would be a slow process. On 12/04/24 at 11:06 AM, a resident council meeting was conducted with nine residents (Resident #6, #11, #20, #21, #24, #27, #40, #71, #78 ). The surveyor asked the residents if they had been aware of what an arbitration agreement was and 9 of 9 responded, no. The surveyor asked if anyone had explained it to them and 9 of 9 residents responded, no. The surveyor then asked if the residents had signed an arbitration agreement during the admission process and 9 of 9 residents responded yes. On 12/04/24 at 1:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #11. The EMR revealed the Admission Agreement was signed on 09/16/24 by the Resident and the AD, and Exhibit 1 was signed by the resident and undated and was not signed by the Admission Director. On 12/04/24 at 1:52 PM, the Surveyor interviewed the Admission Director (AD), in the presence of the survey team and LNHA.The surveyor asked what the admission process was and the AD stated they worked with all departments to confirm the admission and then met with the family to explain resident rights, smoking and they sign the Admission Agreement(AA). On 12/04/24 at 1:55 PM, the surveyor showed the AD the AA and asked her what the Mandatory Binding Arbitration Agreement (AA) was. The AD stated if the resident had a complaint, we discuss it at the facility. The surveyor asked if the AD director read over and explained the AA as part of the admission process. The AD stated, they can read it and ask questions if they have questions. The surveyor asked the AD what the Mandatory part of the AA was and the AD stated, it must be signed. The surveyor asked if the AD had a list of residents who either signed the agreement or refused to sign it and she stated she did not. NJAC 8:39-4.1(b)

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to a.) ensure a process was in place to identify residents who were on Enhanced Barrier Precautions (EBP) (an infection control intervention used to reduce the transmission of resistant organisms in accordance with the Centers for Disease Control and Prevention), by posting clear signage outside of resident rooms indicating the type of Protective Personal Equipment (PPE) to be worn and defining the high risk resident care activities associated with EBP for 8 of 8 EBP rooms, b.) provide residents with hand hygiene (hh) and ensure staff performed hh in between serving and setting up residents with meals, c.) remove contaminated gloves prior to walking around in a non-clinical area, the dining room and making contact with multiple residents, d.) ensure the ice containers on 2 of 2 units were dated and had self-draining holders, and e.) use hh after touching a cell phone and prior to assisting to feed a resident who was dependent on staff for eating for 1 resident (Resident #48). This deficient practice was evidenced by the following: 1. On 12/04/24 at 12:28 PM, the surveyor observed a resident room on the East unit with an orange dot sticker next to a Resident #21's name. The surveyor asked the Certified Nursing Assistant (CNA) #1 what the orange sticker meant. CNA #1 replied that it meant the resident was on a special diet like thick liquids. CNA #1 stated he had worked at the facility full-time for about 1 year. There was no other signage on the resident's door and no PPE available by the room entrance. A review of the Admission Record (AR) revealed Resident #21 was admitted with diagnoses which included but were not limited to; osteomyelitis right ankle and foot (infection of the bone), sepsis, and diabetic food ulcer. A review of the Care Plan included a focus area that Resident #21 was on EBP due to diabetic wound with interventions that included ensure PPE is accessible and ensure PPE is worn during direct care. On 12/05/2024 at 8:35 AM, Surveyor #1 observed a resident room on the [NAME] unit with signage for enteric contact isolation, stop and see the nurse, how to don (put on) and doff (remove) PPE, and the steps to take for care, housekeeping, transporting, workflow, and visitor instructions. There was a bin with PPE available outside the resident's door. During observations on both units, Surveyor #1 observed the East and [NAME] unit had a total of 8 resident rooms with an orange dot sticker next to a resident name. Surveyor #1 observed that PPE bins were not readily available outside those resident doors. On 12/05/2024 at 10:09 AM, Surveyor #1 requested all Transmission Based Precaution (TBP) categories, the signage and the precautions required with each TBP used in the facility. The [NAME] President of Clinical Services (VPC) #1 provided Surveyor #1 with only the EBP policy at that time. Surveyor #1 questioned the other TBP categories and the signage for EBP. VPC #1 stated that the EBP rooms only needed an orange dot and no signage. Surveyor #1 asked about how staff and visitors would know what to wear or what precautions to take. Surveyor #1 inquired what if a visitor was to assist a resident to the bathroom or with dressing? VPC #1 replied the facility does not encourage visitors to assist residents. On 12/06/2024 at 10:10 AM, the Licensed Practical Nurse Infection Preventionist (LPN/IP) in the presence of three surveyors stated that EBP was an extra precaution and not isolation. She stated that the PPE was located at the nurses station and that if visitors did not stop at the nurses station to ask, they would not know that the orange dot indicated EBP. She stated that the staff was all aware that PPE was required for direct care. Surveyor #1 inquired if tasks such as changing linens and dressing required PPE. The LPN/IP stated the staff were aware. The surveyor made the LPN/IP aware of the interview with CNA #1 who was not aware of the meaning of the orange dot and it's precautions. Surveyor #2 asked if the facility followed the Centers for Disease Control and Prevention (CDC) guidelines. The LPN/IP stated yes. Surveyor #1 requested the facility staff education regarding EBP with the education material that was used. A review of the facility provided staff sign in sheets revealed that on 03/28/2024, CNA #1 signed in as having watched a video about EBP. There was no educational material provided. The facility provided EBP precautionary signage, but the signage was not posted on any EBP doors. The signage specified Stop. Enhanced Barrier Precautions everyone must: clean their hands before entering and when leaving; providers and staff must wear gloves and gown for following dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use and wound care. The facility provided a link to an Internet [name redacted] video on EBP. A review of the facility provided policy, Enhanced Barrier Precautions (EBP) effective 4/1/24, included but was not limited to; Statement . implementing effective measures to prevent the transmission of multi-drug resistant organisms within our facility. Procedures: EBP is employed when performing high-contact activities: dressing, bathing/showering, transferring, hygiene, changing linens, changing briefs, or assisting with toileting, device care, and wound care. 3. Training and Education: all HCP (health care providers) will receive training on identification, management, and prevention . including use of contact precautions and EBP *identified as orange dot on resident door name. regular education and updates will be provided to ensure compliance. A review of the CDC Long-term Care Facilities (LTCFs) Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes dated 06/28/2024, included but was not limited to; 28. Does posting signs specifying the type of precautions and recommended PPE outside the resident room violate . resident dignity? No. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the residents. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. Signs should not include information about the resident's diagnosis or the reason for the precaution (e.g. presence of resistant pathogen); inclusion of that information would violate HIPAA (Health Insurance Portability and Accountability Act) and resident dignity. A review of the facility provided policy, Infection Control undated, included but was not limited to; 5. The Administrator or Governing Board . had adopted the infection control policies and practices as outlined to reflect the facility's needs for preventing transmission of infections . as set for in CDC guidelines and recommendations. Nursing: 7. Places a sign on the resident's door including please see nurse before entering. All staff: 8. Contact nurse before entering the room for what PPE is needed to perform the task. 9. Without violating HIPAA, notify staff member what precautions are needed. 11. Educates resident and family regarding proper infection control techniques to prevent the spread of infection. 2. On 12/03/2024 from 11:45 AM through 12:23 PM. Surveyor #1 and Surveyor #2 observed the lunch meal in the main dining room. The surveyors observed the following: At 12:05 PM, a resident entered into the dining room from the door to the smoking area. The resident opened the smoking area door, touched their chair and cell phone. Two additional residents from the smoking area entered the dining room. The staff delivered the three resident's their meal trays but did not offer any hh and there was no form of hh available on the trays. At 12:13 PM, a staff identified as LPN #2 delivered a tray to a resident and walked over into the [NAME] unit. LPN #2 passed 3 alcohol-based hand rub (ABHR) dispensers and did not perform hh. LPN #2 obtained another tray and handed the tray to another staff member. Next LPN #2 obtained another tray, walked into the dining room and handed that tray to a different staff member. LPN #2 next assisted to move a resident in their wheelchair. LPN #2 did not perform hh between handling the food trays or before or after assisting the resident. At 12:17 PM, LPN #2 failed to perform hh, picked up a tray and handed the tray to a staff member. LPN #2 next took a tray and delivered the tray to one resident at a table of four residents. LPN #2 began opening up items for one of the other residents at the table without performing hh. At 12:23 PM, LPN #2 stated that the process was to use hh for the residents and staff, to set up trays and if passing a tray to another resident, I must clean my hands to prevent germs. A review of the facility provided policy, Handwashing/Hand Hygiene undated, included but was not limited to; statement . hand hygiene the primary means to prevent the spread of infection. 5. Employees must wash their hands for at least 20 seconds . under the following conditions: g. before and after assisting a resident with meals; 6. In most situations, the preferred method of hh is with ABHR . for the following situations: a. before and after direct contact with residents. On 12/12/2024 at 12:44 PM, the above concerns were addressed with the facility administrative team. Surveyor #1 requested the policy for resident meal service. The surveyor was provided the dietary department policy. The surveyor clarified which policy was requested. The facility did not provide the policy nor any additional information. 3. On 12/03/2024 at 11:52 AM, staff identified as the Occupational Therapist (OT) walked with a resident using a walker, from the therapy gym, through one small dining area, into the main dining room and to a table. The OT was wearing PPE gloves the entire time. The OT next placed her gloved hand on another resident's right shoulder. The OT went to a third resident and held that resident's hand with her gloved hand. The OT removed her gloves after having contact with all three residents and their surroundings. At 11:58 AM, the OT stated that she was wearing gloves because sometimes the resident she was assisting, can be soiled. The OT stated she had forgotten to remove the gloves before interacting with the other two residents. She stated it was important to remove the gloves because it could cause the spread of infection. A review of the CDC The National Institute for Occupational Safety and Health (NIOSH), Donning and Doffing PPE: Proper Wearing, Removal, and Disposal last reviewed 10/3/2022, included but was not limited to; remove PPE before entering any non-clinical areas. 4. On 12/04/2024 at 9:03 AM, Surveyor #2 observed an uncovered cup next to a small ice chest on the [NAME] unit. The ice bin was filled and there was a sticker dated 12/3/24. During an interview at that time, the Registered Nurse (RN) stated, they forgot to change the sticker and pulled off the dated sticker. On 12/04/2024 at 9:30 AM, Surveyor #2 observed an uncovered pink drink pitcher next to a container of ice on the East unit. The ice scoop was not self-draining. A review of the facility provided policy, Ice Machines and Ice Storage Chests revised 04/2012, included but was not limited to; statement: ice machines and storage/distribution containers will be used and maintained to assure safe and sanitary supply of ice. Methods of contamination: d. improper storage or handling of ice. Preventing contamination: g. uses a smooth-surface ice scoop to obtain and dispense the ice; h. keeps the ice scoop and bin in a covered container when not in use; k. if another receptacle such as a small chest or bin is used . do not distribute ice directly from an open container. On 12/12/2024 at 12:44 PM, the above concern was presented to the facility. The facility did not provide any additional information. 5. On 12/12/2024 at 8:11 AM, Surveyor #1 observed CNA #2 sitting in a chair next to the Resident #48 lying in bed. On the overbed table, Surveyor #1 observed the partially eaten breakfast meal. Surveyor #1 further observed that CNA #2 was actively texting on her cell phone. As the surveyor entered the room, CNA #2 closed the cell phone case and began assisting to feed Resident #48 the rest of their breakfast without performing hh. On 12/12/2024 at 8:17 AM, CNA #2 stated that she should not have been on her cell phone. She stated she should have used hh after using her cell phone and prior to resuming feeding the resident for infection control reasons. A review of the facility provided In-Service: Handwashing dated 11/28/2024, included but was not limited to; CNA #2's signature that she had attended the education which included but was not limited to; protect yourself and patients from deadly germs by cleaning your hands. clean your hands: when moving from soiled to clean . on the same patient . A review of the facility provided policy, Handwashing/Hand Hygiene undated, included but was not limited to; statement . hand hygiene the primary means to prevent the spread of infection. 6. ABHR is the preferred method for the following situations: a. before and after direct contact with residents; i. after contact with objects in the vicinity of the resident. NJAC 8:39-19.4(a)(m)(n); 19.6(d); 27.1(a); 27.5(c)

Based on observation and interview, it was determined that the facility failed to ensure a) meals were consistently provided in a dignified and homelike manner, and b) provide resident meal assistance in a dignified manner. The deficient practice was observed in the main dining room, for 2 of 2 residents (Resident #33 & #48) and on 2 of 2 units (East and West). The deficient practice was evidenced by the following: a) On 12/03/24 at 12:10 PM, Surveyor #1 observed the meal service in the main dining room. A staff member brought a tray over to Resident #33, who had just returned from the smoking area. The staff did not offer Resident #33 hand hygiene upon re-entering from the smoking area. The staff then proceeded to set up the resident's meal, without removing the food items from tray, then she dropped a peanut butter and jelly sandwich on the floor. The staff then proceeded to pick the sandwich up from the floor and placed the soiled sandwich in the tray lid that was face up, along with the other trash, which was directly in front of the resident meal tray. Surveyor #1 continued to observe the meal service and multiple staff continued to set the meal trays in front of six other residents, and placed the tray lid upright which was used as a garbage receptacle next to the resident's meal. The meal tray was also left on the table with the meal items on it. On 12/04/24 at 12:30 PM, Surveyor #1 observed the meal service in main dining room. The surveyor observed that staff were again, delivering meal trays and leaving the trays on the table in front of the residents, staff opened items and placed the garbage in front of the residents inside of the face up tray lid. On 12/11/24 at 10:16 AM, Surveyor #1, in the presence of the survey team, interviewed the Registered Dietitian (RD) and the Food Service Director (FSD) regarding the meal service. Surveyor #1 asked if leaving the garbage at the table with the residents meal tray was dignified. The FSD and RD confirmed that it was not dignified and the FSD stated there were carts in the dining room that should be used for the dirty items. b) 1. On 12/12/2024 at 8:11 AM, Surveyor #2 observed Resident #48 lying in bed and CNA #2 sitting in a chair next to the resident using her cell phone. Surveyor #2 observed the partially eaten breakfast meal on the overbed table. When Surveyor #2 entered the room, CNA #2 closed her cell phone cover and continued to assist feeding Resident #48. Surveyor #2 observed the breakfast meal garbage of a drinking lid and plastic in the plate lid on the overbed table. A review of the medical record revealed that Resident #48 had been admitted to the facility with diagnoses which included but were not limited to; muscle disorder, dementia, and severe protein-calorie malnutrition. A review of the quarterly MDS included but was not limited to; the staff was unable to establish a BIMS for Resident #48; and that Resident #48 was dependent on staff for eating. A review of the resident-centered on-going Care Plan included but was not limited to; focus areas of the potential to lose weight related to dementia and malnutrition and altered cognition related to dementia with interventions which include to assist with meals and to engage the resident in conversation to offer opportunity for reminiscing. On 12/12/2024 at 8:17 AM, CNA #2 stated that she should not have been using her cell phone, I apologize and further stated that she should have used hand hygiene after using her cell phone for infection control reasons. On 12/12/2024 at 12:44 PM, the above observation was discussed with the facility. The DON acknowledged that was not allowed. 2. On 12/12/24 at 8:14 AM, Surveyor #1 observed Resident #15 in bed, and a staff was observed feeding the resident while standing to the side of the resident. On 12/12/24 at 8:27 AM, Surveyor #1 interviewed CNA #1 regarding if staff could assist a resident with the meal, while the staff was standing. CNA #1 stated that the staff had to be seated while assisting the residents for safety concerns. The facility Admission Agreement revealed: Every resident has a legal right to the following: Physical and Personal Environment: To live in a safe, clean, comfortable and home -like environment. To be treated with courtesy, dignity and respect. NJAC 8:39-4.1(a); 27.1(a)

Based on observation, interview, and document review, it was determined that the facility failed to a) ensure a cognitively impaired resident was provided with adequate supervision to prevent falls with injury and reassess, reevaluate, and implement appropriate fall interventions to the Care Plan (CP) for a resident who was at high risk for falls, and sustained multiple falls. This deficient practice occurred for 1 of 2 residents reviewed for falls (Resident #39), and b) ensure the facility, developed and implemented a consistent smoking process to prevent potential injury or fire. The deficient practice was identified for 5 of 5 residents (#11, #33, #54, #63 and #388) reviewed for smoking and was evidenced by the following: a) On 12/04/24 at 9:30 AM, Surveyor #1 observed Resident #39 seated at a table by themselves in the main dining room, was drinking a beverage, and was observed wearing slippers on their feet and no leg rests were observed on the wheelchair. On 12/04/24 at 11:14 AM, Surveyor #1 interviewed the Rehabilitation Director/ Speech Therapist (RDST). The RDST stated the facility conducted fall committee meeting twice monthly to review falls and interventions to prevent falls and see what can be done differently to prevent falls. Th RDST stated that the Department Heads including the Director of Nursing and therapy attended. The RDST also provided Resident #39's therapy treatment notes. A 09/14/23 Occupational Therapy (OT) Evaluation revealed: referred to OT due to new onset of decrease in strength, decrease in transfers, reduced functional activity tolerance, reduced static and dynamic balance, decreased judgement, increased need for assistance from others and reduced ADL participation placing patient at risk for compromised general health, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers and muscle atrophy. Precautions: Falls. On 12/04/24 at 4:18 PM, the surveyor reviewed the medical record for Resident #39 which revealed: The Admission Record (admission summary) revealed diagnoses, which included but were not limited to; unspecified fracture of left patella (knee), and cognitive communication deficit. The Fall Risk Assessment, Full Assessment was completed on 09/20/23 which indicated that the resident was a High Fall Risk with a score of 38. An annual Minimum Data Set (an assessment tool) dated 08/28/24, which revealed the Brief Interview for Mental Status score was 05 out of 15 which indicated Resident #39 had a severe cognitive impairment. Section GG, functional abilities revealed the resident required touching assistance to roll left and right and to go from sitting to standing, and the resident required substantial/maximum assistance to transfer from the wheelchair to the bed. Resident #39 was coded yes for having two or more falls that resulted in injury (Injury= skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain). A Care Plan (CP) Focus: At risk for falls due to history of falls, which included resolved and current interventions had a Goal: Minimize the risk for falls through next review, Date Initiated: 09/01/23 revealed the date of falls: 09/10/23, 09/20/23, 10/05/23, 1/13/24, 1/17/24, 2/12/24, 3/24/24, 4/25/24, 5/25/24, 6/19/24, and 07/28/24. The Progress notes revealed the following: Effective Date, 10/05/23 18:54 (6:54 PM) revealed Resident #39 in dayroom eating dinner when yelling was heard. Staff attended. Skin tear to right and left elbow noted. Purple mark to forehead noted and resident send to hospital for evaluation. A Late Entry Progress Note by the Nurse Practitioner (NP), Effective Date 10/06/23, 10:08 AM and signed by the NP on 10/07/23 at 10:08 AM. The Chief Complaint: Status post emergency room visit after fall, head trauma. Nursing reported resident fell forward in dining room from wheelchair. A Late Entry Physician (MD) Progress note, Encounter Date; 10/26/23, Effective 10/26/23 at 14:09 (2:09 PM) revealed Given the history of falls and fractures, continue with fall risk prevention strategies including regular physiotherapy sessions to improve strength and balance, use of non-slip footwear, ensuring that living area is well-lit and free of trip hazards, and use of assistive devices as needed for mobility. A Progress Note dated 01/14/24 at 8:29 AM and signed by an LPN revealed. Roommate called nurse attention to resident being on floor. Resident was observed on floor close to the lamp and stand table. Resident stated trying to get up to dress. Small skin tear below the Left knee observed. A Progress Note Effective 01/1724 at 13:22 (1:22 PM) and signed by unidentified staff, revealed, Resident tried to reach the bingo coin from the floor and fell to the floor. Assisted off floor with two persons to wheelchair and first aid provided. A Progress Note Effective 02/12/24 at 10:22 AM and signed by unidentified staff, revealed resident observed sitting on floor at bedside. Resident noted with two skin tear right arm . Assisted off floor with two persons to bed, first aid provided. A Progress Note Effective 03/24/24 at 22:41 (10:41 PM) and signed by unidentified staff revealed Resident observed sitting on floor by the door. Resident noted with skin tear to back of upper right arm. Stated I was trying to get out of bed. A Progress Note Effective 04/25/24 at 16:24 (4:24 PM) signed by an LPN revealed Resident was found sitting on the floor of room close to wheelchair. Skin tears noted to Left inner forearm and wrist. A Progress Note Effective 07/28/24 at 22:58 (10:58 PM), signed by an LPN revealed responded to the sound from nurse's station, resident noted sitting on the floor . resident noted bruise and minimal swelling on forehead and nose bridge. A Progress Note Effective 06/19/24 at 23:57 (11:57 PM) and signed by an LPN revealed at 11:10 PM staff reported resident is on the floor, upon arrival resident noted sitting on the floor by the door, bed was low, call bell within reach, but not used, skin tear to left elbow noted. On 12/05/24 at 8:00 AM, the surveyor requested all fall investigations from the [NAME] President of Clinical Services Registered Nurse (VPRN) for Resident #39. On 12/05/24 at 9:06 AM, the VPRN provided the surveyor with the following fall incident reports and confirmed that what was provided was everything. The incident reports revealed: Fall #1 - Date: 09/10/23- Nursing Description: notified by staff that resident fell from [wheelchair] bedside and Resident unable to give description. Injuries observed at time of incident: Bruise-face, Laceration-face, Hematoma-right elbow. Under Notes: The team met to discuss residents fall, found on floor in room. Sent to emergency room for evaluation and admitted with acute urinary tract infection /sepsis [infection] and head injury. A review of the CP revealed the following interventions initiated on 09/01/23: Administer medications per physician order; Encourage to transfer and change positions slowly; Provide assistance to transfer and ambulate as needed; and Report development of pain, bruises, change in mental status/ ADL function, appetite, or neurological status per facility guidance. Under focus: Readmit 09/13/23 CP updated and the Interventions listed did not include any interventions added or revised post fall with injury that occurred on 09/19/23. Fall #2- 09/20/23-Nursing Description: Rounds after dinner found on floor near bed. Intervention added to CP on 09/20/23, staff will offer resident the opportunity to go to bed after dinner. Fall #3- 10/05/23- Nursing Description: Resident in dayroom eating dinner when yelling was heard. Skin tear to right hand and left elbow noted, purple mark to forehead and physician ordered to be sent to emergency room . Under Notes: The [NAME] met to review the fall on 10/06/23 and staff observed the resident on the floor. The intervention added to the CP on 10/05/23 was Staff to ensure leg rests in place. There were no interventions to address who was supervising the resident during meals when the resident was found on the floor yelling. Fall #4- 01/13/24- Resident attempted to get out of bed at 1:30 AM and get dressed and the CP intervention added 01/13/24, was to provide a digital clock. Fall #5 - 01/17/24- Nursing Description: Resident attempted to reach to bingo coin on floor and fell with an abrasion to back of right hand. The intervention added to the CP on 01/17/24 was resident educated to ask for staff assistance and not to bend over when objects fall on the floor. There were no interventions/revised interventions related to supervision at activities and were leg rests in place and if not effective revised. Fall #6- 02/12/24- Nursing Description: Resident observed sitting on floor at bedside, noted with two skin tears on right arm. Intervention added 02/12/24- Resident to ask for staff assistance prior to attempting to self-transfer when wants to get out of bed. Fall #7- 03/24/24- Nursing Description: Resident observed sitting on floor by the door. Noted with skin tear to back of upper right arm. Resident stated: I was trying to get out of the bed. On 03/24/24 an intervention for non-skid socks was added to the CP. The CP did not address the previous intervention added on 02/12/24 when the resident was also found with skin tears on the floor in the room trying to get out of bed. Fall #8- 04/25/24- Nursing Description: Resident found sitting on floor in room close to wheelchair and stated wanted to transfer to bed. Skin tears noted on left inner forearm and wrist. On 04/26/24 the team met to discuss the fall when resident was attempting to self-transfer to bed when noted on floor by staff. The intervention added to the CP on 04/25/24 was to provide a fall mat. The interventions that were added for the prior two falls were not modified/ addressed in the CP. Fall #9- -5/25/24- Nursing Description: Resident was found lying on the floor in room next to bed and stated, I was trying to get into bed. I was tired. On 05/25/24- the team met to discuss the fall after a failed attempt to get in bed. The intervention added to the CP was to offer a nap in the afternoon. The previous interventions that were added to prevent falls in the room were not addressed or revised. Fall #10- 06/19/24- Nursing Description: Resident found on floor by door and resident stated, going to see mom and sustained skin tear to left elbow. The CP intervention added 06/20/24 was to provide a low bed. Fall #11- 07/28/24- Nursing Description: Staff responded to a sound at the nurse's station and found resident on the floor. Resident stated was taking off sock, lost balance and fell . On 07/29/24 the team met and determined that the resident wanted to go the room before dinner, staff intercepted and placed in front of nursing station, and resident tried to remove socks and fell . The CP intervention was to encourage resident to participate in activities added 07/28/24. The previous interventions were not addressed or revised. On 12/05/24 at 12:55 PM, the surveyor interviewed the VPRN regarding the provided incident reports. The incident report for the first fall that occurred on 09/10/24 did not have attached statement and asked the VPRM if there should have been statements with the incident report. The VPRN stated, yes, when asked how the fall happened, the VPRN stated, I cannot tell you. The surveyor asked the VPRN if the facility knew the causal factor of the fall and she stated, this one they don't, and the surveyor asked the VPRN if a laceration was an injury and she stated, yes. The surveyor asked the VPRN if there was a root cause analysis and she stated, no. The surveyor asked if the 10/05/23 incident was a complete investigation to determine how the resident was found in the dining room and the VPRN stated, no. The surveyor then reviewed the 02/12/24 incident with the VPRN. There was one statement from a nurse regarding finding resident on the floor and the surveyor asked the VPRN if the investigation was complete, and she stated, no. The surveyor then reviewed the 03/24/24 incident with the VPRN and the surveyor asked what the intervention was that was added to the CP and the VPRN stated nonskid socks. The surveyor asked was that an intervention based off of the root cause of the fall and the VPRN stated, no, it is basic. The surveyor then reviewed the 04/25/24 fall, that again occurred in the resident's room. The surveyor asked the VPRN what the intervention was and she stated, the fall mat. The surveyor asked was the root cause of the fall identified and a specific intervention added and the VPRN stated, no. The VPRN stated we recognized that the old management team was not effective. On 2/12/24 at 8:27 AM, the Certified Nurse Aide (CNA #1) who was assigned to Resident #39 was interviewed after the CNA provided morning care to the resident and transported the resident to the dining room. The surveyor asked if the resident had falls and the CNA stated, yes the resident had falls and tried to transfer themselves to bed, and also did not like to stay in bed. The CNA then stated, we are supposed to keep an eye on [him/her]. The Falls and Fall Risk Management Policy (undated) revealed: Policy Statement: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Procedure: 1. The interdisciplinary team, with the input of the Attending Physician as appropriate, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall risk: 1. The staff will monitor and periodically document each resident's response to interventions intended to reduce falls or the risks of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors that continue to present a risk for falling or injury due to falls. b. On 12/03/24 at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility had residents who smoked, and the survey team requested a list of residents who smoked, smoking times and the smoking policy. On 12/03/24 at 9:34 AM, the LNHA, in the presence of another surveyor provided the Smoking Hours, the Smoker's List list with 14 resident names and the Smoking Rules and Agreement. The surveyor asked for the smoking policy and the LNHA stated the Smoking Rules and Agreement was what the facility used and there was no different policy. The LNHA stated the document was filled out for every resident who smoked and a copy was in the Electronic Medical Record (EMR). The Smoking Rules and Agreement revealed 1. Prior to being permitted to smoke, a safe smoking evaluation will be conducted by the nurse or designated member of the healthcare team. a. This evaluation will determine your ability to smoke independently, how much supervision you will need, and whether any protective devices (such as a smoking apron) may be used in order for you to be granted smoking privileges. B. Your ability to smoke and level of independence will be re-evaluated regularly and will be part of our plan of care. We will review your plan of care with you regularly and document the review in the medical record. 2. If it is determined you can safely smoke independently, you may only smoke in the designated smoking area. You may never smoke in your room or any other non designated smoking area. 3. You may never give cigarettes, lighters, matches to other residents or otherwise assist other patient or resident of the center to smoke. 4. For the safety of all staff and residents you may not retain your own lighter, matches or other course of ignition. If you have been evaluated as an independent smoker, you will be given your lighting materials before going out to smoke, and you must return them to the nurse when you return from smoking. On 12/04/24 at 9:39 AM, Surveyor #1 observed resident #388 smoking a cigarette in the courtyard. On 12/04/24 at 9:40 AM, Surveyor #1 interviewed Licensed Practical Nurse (LPN #1) regarding the cigarettes for Resident #388. She stated that she did not have any cigarettes for any of the residents who smoked that were on her assignment, and that maybe the Charge Nurse (CN) held the cigarettes and lighters. On 12/04/24 at 9:44 AM, Surveyor #1 interviewed the CN who stated that the nurses held the cigarettes and she did not hold them. Surveyor #1 asked where the lighters were kept and she stated, it depends and she confirmed that she did not have any lighters either. On 12/04/24 at 9:50 AM, Surveyor #1 interviewed CNA #3 about the smoking process and she stated, I don't know the process and stated the cigarettes are with the nurse. On 12/04/24 at 10:00 AM, Surveyor #1 interviewed Resident #11 who stated they just started smoking again. On 12/04/24 at 10:20 AM, Surveyor #1 reviewed the electronic medical record for Resident #11, which revealed the Admission Agreement, Exhibit 6, Smoking Policy. The signed and undated document revealed Resident agrees to comply with the Facility's Smoking Policy . On 12/04/24 at 10:30 AM, Aurveyor #1 reviewed the electronic medical record for Resident #388. The current 11-page Care Plan did not include a care plan for smoking, and there was no smoking assessment. The Admission Agreement, last page #19 revealed: Exhibit 6- Resident agrees to comply with the Facility smoking policy. The resident affirms that he/she has been provided a copy of the Smoking Policy, has had the opportunity to read its contents, understand the Smoking Policy and agrees to abide by the terms. The paper was signed and undated. On 12/04/24 at 12:11 PM, Surveyor #1 observed Resident #11 smoking a cigarette in the courtyard. On 12/04/24 at 12:18 PM, Surveyor #1 interviewed Resident #54 who stated they smoked and the facility held the cigarettes, but not the lighter. On 12/06/24 at 1:52 PM, Surveyor #1 while in the main dining room and observing smoking area, asked the facility Infection Preventionist (IP) and CNA #4 what the smoking process was. The IP stated that there were three residents who required a smoking apron for safety (Resident #63, #33 and an unsampled resident (UR #1) and that the CNAs would have an assignment for smoking. Surveyor #1 asked if there was a list so that the staff would know if a resident needed an a smoking apron and the IP stated it was posted on the [NAME] Wing. Surveyor #1 asked to see the list of residents who needed to wear an apron and brought the surveyor to the [NAME] Wing. The IP stated the list was not there, only a list of times to smoke and went to the Charge Nurse (CN) to see the list and the CN was unable to provide a list. Surveyor #1 interviewed CNA #4 about the presence of a list for residents who were required to wear a smoking apron and she stated there was no list. Surveyor #2: On 12/04/24 at 9:26 AM, Surveyor #3 observed Resident #63 sitting in a wheelchair being propelled by staff, at that time, Resident #63 had a cigarette in their mouth. On 12/04/24 at 11:00 AM, Surveyor #3 reviewed the electronic medical record (EMR) for Resident #63 and reviewed the Care Plan. The Care Plan had a Focus for smoking that was initiated on 09/19/22. The Goal was for Resident #63 to smoke safely through next review and be free from any injury through next review. Target Date: 12/19/24. An Intervention: Smoking supplies will be supplied. Initiated 09/19/22. On 12/11/24 at 8:39 AM, Surveyor #3 observed Resident #63 in bed with one package of cigarettes observed on the table next to the bed. Resident #63 stated, they have smoked for the past [AGE] years. On 12/12/24 at 8:50 AM, Surveyor #3 observed Resident #63 sitting in the dining room eating breakfast. Resident #63 stated that after breakfast they will go their room to get their cigarettes. 48423 Surveyor #3: On 12/05/24 at 9:42 AM, the surveyor observed the Certified Nursing Assistant (CNA #2 ) obtain a cigarette lighter from Resident #33's personal bag in presence of the surveyor. The surveyor observed a pack of cigarettes in the bag and Resident #33 stated that it was their lighter and had taken it from the CNA to go out to smoke. Resident #33 stated I keep my cigarettes with me all the time. The resident further stated, all the residents have their cigarettes with them, and they take the lighter when they go out to smoke. The surveyor reviewed the medical records of Resident #33 and revealed: A review of the Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), general weakness, and lack of coordination (means they have difficulty performing physical movements smoothly, accurately, and efficiently). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Section J Health conditions indicated that Resident #33 was a current tobacco user. A review of the Individualized Care Plan included a Focus area admitted to facility with a history of smoking, with a Goal that resident will smoke safely. Interventions included that smoking supplies will be supplied during appropriate smoking times. Smoking Rules & Agreement signed on 8/15/23. On 12/12/24 at 8:33 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 explained that the residents smoked under supervision. The staff was responsible to hold the lighter when the resident went out to smoke in the designated area. The LPN further stated smoking schedules were listed at the nursing stations. The LPN was not able to provide the surveyor information about where the cigarettes and lighters were securely kept when not in use. On 12/12/24 at 10:18 AM, during an interview with the surveyor, in the presence of the survey team, CNA #2 stated that no one had ever told him about smoking facility and he state, I don't know how it works. The CNA acknowledged Resident #33 always held their lighter and cigarettes with them in the personal bag. The surveyor asked what residents had to wear the smoking aprons and CNA #2 stated, I don't know about that. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON and presented the above findings. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-27.1(a)

48423 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment of the needs of the population of residents who smoked and included policy, services, and staff competencies for those residents, and b.) for the Asian American populations which identified ethnic, cultural, religious preferences and staff competencies. The deficient practice affected residents who resided on both the East and [NAME] wing of the facility and was evidenced by the following: Refer to F679 and F689 On 12/03/2024 at 8:50 AM, two surveyors were present in the conference room and requested the surveyor information from the Licensed Nursing Home Administrator (LNHA) regarding residents who smoked, the smoking policy, and smoking times. On 12/03/2024 at 9:34 AM, in the presence of the two surveyors, the LNHA provided smoking hours, a list of 14 residents who smoke, and a document Smoking Rules and Agreement. When asked about the smoking policy, the LNHA explained that the Smoking Rules and Agreement was the facility policy. On 12/03/2024 at 9:55 AM, entrance conference was conducted with the LNHA. At that time, additional survey documents were provided which included but were not limited to; the Facility Assessment Tool. 1. On 12/04/2024 at 9:40 AM, the Licensed Practical Nurse (LPN) was asked the process for resident's who smoke and that she did not hold any resident cigarettes. The LPN stated she did not care for any residents who smoked and that maybe the Charge Nurse (CN) kept the resident cigarettes and lighters. On 12/04/2024 at 9:44 AM, the CN stated that the nurses were responsible to hold the resident's cigarettes and lighters. On 12/04/2024 at 9:50 AM, during an interview regarding the smoking process with a Certified Nursing Assistant (CNA), the CNA stated, I don't know the process and believed the cigarettes were kept with the nurses. On 12/05/2024 at 9:42 AM, CNA #2 was observed obtaining a lighter out of a resident's personal bag in their room, which also contained a pack of cigarettes. At that time, the surveyor followed as the lighter was given to Resident #33. Resident #33 informed the surveyor, I keep my cigarettes with me all the time. The resident further stated, all the residents have their cigarettes with them, and they take the lighter when they go out to smoke. On 12/06/2024 at 1:52 PM, the surveyor was observing the smoking area which was visible from the main dining area. The LPN Infection Preventionist (LPN/IP) was present and stated there was a list of three residents who required smoking aprons and that the CNAs had an assignment for smoking observation. The LPN/IP stated the list was posted on the [NAME] unit. The LPN/IP and surveyor went to the [NAME] unit but were unable to find the list. The surveyor asked CNA #4 about the list and was informed there was no list. 2. On 12/03/2024 at 9:58 AM, the surveyor observed Resident #25 lying in bed with a family member present. The family member expressed concern that the resident was supposed to be receiving a daily newspaper in their language of Korean, but that was not happening. On 12/04/2024 at 12:28 PM, the surveyor was in the main dining room and observed residents of Asian American culture. The surveyor also observed a menu and activities calendar in Chinese. On 12/5/2024 at 9:35 AM, the surveyor observed Resident #25 lying in bed with no newspaper present. On 12/5/2024 at 9:49 AM, the Activities Director (AD) stated that she was familiar with the resident and that the resident was supposed to get the special newspaper, but she was not sure who was supposed to provide the newspaper. A review of the facility provided, Facility Assessment Tool dated 8/2024, included but was not limited to; Resident Profile which indicated the facility was licensed for 112 residents. 1.4 The admission of a resident or continuation of care with certain conditions, diagnoses or needs . to ensure the facility has the appropriate equipment, training/education and staff to provide care to ensure residents shall receive necessary care and service to attain or maintain highest practicable, physical, mental, and psycho-social well-being. On 12/12/2024 at 12:58 PM, the LNHA and administrative team were made aware that the Facility Assessment did not address the cultural needs of the Asian American population, the smoking needs of the residents, and the lack of staff knowledge with no smoking policy to follow. On 12/12/2024 at 3:01 PM, the survey team met with the facility administrative team. The facility had no additional information to provide regarding the facility assessment. NJAC 8:39-7.3(a)(g); 27.1(a)(b)

Based on observation and interview on 12/4/2024 in the presence of the Maintenance Director (MD), it was determined that the facility failed to ensure corner guards were free from sharp edges and failed to provide protective endcaps to corner guards. This deficient practice had the potential to affect all residents on the east wing and was evidenced by the following: An observation at 2:27 PM with the MD, revealed two metal corner guards by the handrails in the main dining room had a sharp edge and no protective endcaps installed to prevent an injury. In an interview at the time, the MD confirmed the findings. The facility's Administrator was notified of the deficient practice at Life Safety Code survey exit conference on 12/5/2024 at 2:45 PM. NJAC 8:39-31.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment by administering medications to a resident who was in the dining room for the breakfast meal. This deficient practice was identified for 1 resident (Resident #83) during the meal observation and was evidenced by the following: On 12/06/2024 at 8:25 AM, the surveyor observed a Registered Nurse (RN) #1 approach Resident #83 sitting alone at a table in the main dining area preparing to eat breakfast which was on the table. RN #1 administered Resident #83 medications and exited the area. The surveyor observed there were multiple other residents throughout the main dining area as well. On 12/06/2024 at 8:30 AM, the surveyor inquired about administering medications in the dining area in front of other residents during breakfast. RN #1 stated Resident #83 was already in the dining room and that the resident needed to take the medications. The RN further stated the purpose of not administering medications in the dining area was because the resident could not always be supervised. RN #1 acknowledged Resident #83 was not care planned to have medications administered in the dining room and that, it was my fault, sorry. On 12/06/2024 at 8:45 AM, the surveyor approached the RN as she was walking toward the medication cart. The Director of Nursing (DON) was in the hallway at the time of the observation and the surveyor informed the DON of the observation, who stated, Oh, that's not right. On 12/06/2024 at 8:47 AM, RN #1 stated that she administered calcium, magnesium, and vitamin D to Resident #83 and that those supplements were to be given with meals. A review of the medical record revealed that Resident #83 had been admitted to the facility with diagnoses which included but were not limited to; psychotic disturbance, mood disturbance, and anxiety. A review of the most recent Admission Minimal Data Set (MDS) an assessment tool used to facilitate resident care, dated 12/22/2024, included but was not limited to; a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe cognitive impairment. A review of the Order Summary Report dated active orders as of 12/11/2024, included but were not limited to; dated 12/04/2024, calcium 600 + D tablet 600-5 mg (milligram)-mcg (microgram) give 1 tablet by mouth one time a day for supplement; and dated 09/16/2024, magnesium oxide 400 mg give 1 tablet by mouth one time a day for supplement. The medications were not ordered to be given with meals. A review of the facility provided policy, Medication Administration undated, included but was not limited to; B. Medication administration may begin sixty minutes before the scheduled time but may not exceed sixty minutes after the scheduled time. 4. Medications ordered before meals approximately thirty minutes before meals. Medications ordered after meals are no later than thirty minutes after a meal has ended. The policy did not address administering medications in the dining room. On 12/12/2024 at 12:44 PM, the surveyor informed the facility administrative staff. The facility had no additional information to provide. NJAC 8:39-4.1(a)(12); 27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to residents who were unable to carry out activities of daily living (ADLs). This deficient practice occurred for 2 of 2 residents (Resident #19 and #33) reviewed for nail care and was evidenced by the following: 1. On 12/3/24 at 10:19 AM, during an initial tour, the surveyor observed Resident #19 sitting in their bed. The surveyor observed the resident's fingernails to be long, jagged with a brown colored substance underneath the nails. On 12/4/24 at 9:14 AM, the surveyor observed the Resident #19 lying in their bed. Resident #19 had long, jagged nails with brown colored substance underneath the fingernails. When asked by the surveyor, the resident stated staff did not cut their nails. The surveyor reviewed the medical records of Resident #19 which revealed: A review of the Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; glaucoma (an eye disease that damages the optic nerve, which sends signals from your eyes to your brain so you can see), Cerebrovascular disease [CVA] ( is a condition in which the blood supply to the brain is interrupted or severely reduced, resulting in the death of brain tissue due to lack of oxygen and nutrients), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side (the half of the body in which a person is stronger), and Contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) right elbow. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 9/1/24, revealed the Resident #19 had a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating the resident's cognition was severely impaired. Section GG documented that Resident #33 had impairment on one side of upper extremity and required maximal assistance with personal hygiene. A review of the Care Plan included a Focus area for an ADL self-care deficit related to Right hemiparesis, CVA, . Goals included will receive assistance necessary to meet ADL needs through next review. Interventions included but were not limited to .Assist with daily hygiene, grooming and oral care as needed; Grooming- Assist X 1. On 12/12/24 at 8:20 AM, the surveyor observed the Resident #19 having breakfast in their bed. Resident #19 was holding a glass of juice in their left hand and the surveyor observed long, jagged nails with brown colored substance underneath the nails. Resident #19 stated the staff did not clean their nails during care. 2. On 12/05/24 at 9:42 AM, the surveyor observed Resident #33 sitting in their wheelchair, the nails were long and jagged with a brown colored substance underneath the fingernails. Resident #33 stated I have to ask them to cut my nails. The resident looked at their hand nails and further stated they look terrible and filthy. I scratch myself in my sleep. I have weakness in my hands, and I am not able to cut my nails on my own. The surveyor reviewed the medical records of Resident #33 which revealed: A review of the Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Calculus of kidney (kidney stones), Hypertension (high blood pressure), Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), general weakness, and lack of coordination (means they have difficulty performing physical movements smoothly, accurately, and efficiently). A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/27/24, revealed the Resident #33 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Section GG documented that Resident #33 required maximal assistance with personal hygiene. A review of the individualized Care Plan included a Focus area for ADL (activities of daily living) deficit related to Spinal stenosis. Goals included will be clean, dressed and well groomed daily to promote dignity and psychosocial well-bring through next review and will receive assistance necessary to meet ADL needs through next review. Interventions included but were not limited to .Assist with daily hygiene, grooming and oral care as needed. On 12/11/24 at 11:07 AM, during an interview with the surveyor, Certified Nurse Aide (CNA) #3 stated nail care was provided twice weekly. The process was that they must ask the nurse first if it was okay to provide nail care. On 12/11/24 at 11:09 AM, during an interview with the surveyor, CNA #4 stated the process was to check resident's hands prior to meals and during their care. The CNA further stated the staff must ask the nurse if the nails needed to be cut and nails would be cleaned as needed. Nail care was explained during training and orientation. On 12/11/24 at 11:32 AM, during an interview with the surveyor, the assigned CNA #1 stated nail care was provided during morning care. The CNA #1 further stated if the nails needed to be trimmed, I would check with the nurse prior to providing the nail care. The CNA #1 stated the nail care would be documented in the book but she could not provide the book. On 12/12/24 at 8:30 AM, the surveyor observed Resident #33 eating breakfast in the dining room, and observed the nails were long, jagged and had brown colored substance underneath the fingernails. The resident shook their head sideways indicating that their nails were not trimmed yet. On 12/12/24 at 8:33 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 stated If I noticed the resident with long nails, I would ask the resident's CNA to trim resident's nails or shave a resident if they have long facial hair. The LPN further stated that grooming, trimming nails and shaving were all part of the morning care and would be done as needed. The LPN stated it was important to provide nail care for patient safety so they would not hurt themselves by scratching. On 12/12/24 at 8:57 AM, during an interview with the surveyor, the LPN/Unit Manager (UM) stated if the resident had long nails, it was expected the staff would provide nail care and if the resident was diabetic then they staff could file resident's nails. The LPN/UM further stated the nail care was important because it was a part of hygiene, dignity, and resident might scratch themselves. The LPN/UM observed Resident #19 and 33's nails in presence of the surveyor and acknowledged that the staff should have cut their nails. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. A review of the facility provided, Certified Nurse Aide Job Description dated 2/2024, included but was not limited to; 3.) Provides personal care to residents/ guests (bathing, cleaning fingernails, shaving and perineal care, etc.) and assures that resident/guest dresses appropriately. The surveyor reviewed the facility policy titled Activities of Daily Living (ADL's) Policy dated 12/23 included Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Under Policy Interpretation and Implementation: 2.) Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, assistance with: a. hygiene (bathing, dressing, grooming, and oral care). On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was stored and dated in accordance with professional standards when not in use for 1 of 1 resident (Resident #36) reviewed for respiratory care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/3/24 at 9:17 AM, during an initial tour, the surveyor observed Oxygen in use signage posted on the door. The surveyor observed Resident #36 resting in their bed with oxygen at 4 Liters (L) per minute via Nasal Cannula [NC] (a tube delivering oxygen into the nose), which was connected to an oxygen concentrator (a medical device used for delivering oxygen). The NC was not dated. On 12/4/24 at 9:30, the surveyor observed Resident #36 was not in their room. The surveyor observed Resident #36's NC was placed on top of the oxygen concentrator. The surveyor observed the NC was not stored properly in a plastic bag when not in use. On 12/4/24 at 10:02 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) #1 stated O2 equipment including NC were changed weekly by night shift staff as per facility policy. The LPN further stated the NC would be stored in a special plastic bag and the bag would be labeled with resident's name and the date when it was changed. The LPN stated the residents were sick and that's why it was important to change the NC and store it in a bag for infection control and sanitation. On 12/4/24 at 10:20 AM, during an interview with the surveyor, the LPN / Unit Manager (UM) stated the NC was changed and dated weekly for cleanliness purposes and for infection control. The LPN/UM further stated NC would be placed in a plastic bag which would be labeled with resident's name and date. The LPN/UM stated if she observed a NC placed on top of the concentrator, she would replace the NC and place it in the plastic bag. At 10:26 AM, the surveyor informed the LPN/UM about the above findings. The LPN/UM accompanied the surveyor to Resident #36's room and disposed of the undated NC. The surveyor reviewed the medical record for Resident #36. According to the Admission Record, Resident #36 was admitted to the facility with diagnoses which included but was not limited to: Chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs), Anemia (low red blood cells), depression and Anxiety. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/7/24, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that Resident #36 was cognitively intact. Further review of the MDS revealed the resident had used oxygen while a resident. A review of the resident's Care Plan (CP) included a focus area that indicated the resident is at risk for breathing patterns and/or respiratory distress related to: Diagnosis / History: COPD, Shortness of Breath; Currently on O2 4 LPM via NC continuously initiated on 10/11/24. A further review of the CP revealed that there was no plan or intervention on labeling the NC after changing it weekly and how to store the NC properly when O2 was not in use. A review of Resident #36's Order Summary Report reflected a physician orders (PO) as follows: dated 6/27/24, O2 continuously 4 LPM via NC every shift, and Change and Date oxygen tubing (NC) and humidifier bottle weekly every night shift every Sunday dated 11/1/24. The above POs were transcribed to the December 2024 electronic medication administration record (eMAR) signed by a nurse y (yes) on Sunday 12/1/24 at night shift. On 12/6/24 at 10:10 AM, during an interview with the surveyor, the Assistant Director of Nursing / Infection Preventionist (ADON/IP) stated NC should be dated, placed in a bag when not in use and the tubing should not be touching the floor. On 12/12/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional DON. The surveyor presented above mentioned concerns with the team. The surveyor reviewed the facility's undated policy titled Oxygen Administration. The policy did not address the following: 1.) Labeling of O2 equipment and 2.) Proper storage of equipment when not in use. On 12/12/24 at 03:01 PM, the survey team met with the LNHA, DON and the Regional DON for an exit conference. The facility management did not provide additional information, and did not refute the findings. NJAC 8:39-11.2(b) 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to store foods, maintain sanitation in a safe, and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/18/23 at 10:15 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1. In the freezer the surveyor found one opened box of breaded eggplant without an open and use by date. The interior bag holding the eggplant strips were opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 2. In the freezer the surveyor found one opened box of pancakes. The exterior of the box was labeled with 8/31 (no year was indicated). The FSD could not explain if 8/31 was a received on, used by, or open date. The interior bag holding 24 pancakes was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 3. In the freezer the surveyor found one opened box of strawberries. The exterior of the box was labeled with 4/6 delivery date (no year was indicated). The interior bag was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 4. In the freezer the surveyor found one opened box of blueberries without an open and use by date. The interior bag holding was opened and unlabeled. The interior bag was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 5. During rounds with FSD, the surveyor observed four (4) six in food pans stacked together with water droplets on the interior of each one. The FSD stated, these pans should have been dried thoroughly prior to putting them away to prevent infection and cross contamination while cooking. A review of [NAME] Mountain Care Center Food Storage Procedure provided by the FSD, indicated; #5) All food stored in refrigerator or freezer shall be labeled and dated and #8) Uncooked and raw animal products and fish shall be stored separately and below fruits, vegetables and other ready to eat foods. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services (VPoCS). The facility management did not provide additional information and did not refute findings. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to treat all residents in a dignified manner. This deficient practice occurred for two (2) of four (4) residents reviewed for dignity (Resident #14 and #67) and was evidenced by the following: On 9/20/23 at 10:25 AM, the surveyor met with Residents #8, #14, #27, and #67 for the Resident Council meeting (RCm) in a closed-door meeting. During the RCm, the surveyor followed the probes (the process of asking questions and examining facts in a situation) in the survey process, in question #18 for if resident rights were being respected in a dignified manner, Residents #14 and #67 both claimed they were not. On that same date and time, both residents informed the surveyor that staff at times do not knock before entering their room. Resident #14 stated that he/she was unable to remember the name of the staff and that it happened a few times on both morning and afternoon shifts. At that time, a staff wearing a green scrub (the sanitary clothing worn by physicians, nurses, and other workers involved in patient care) entered the door, walked straight through the room without notifying the residents and the surveyor of the staff purpose. The surveyor greeted the staff, the staff did not respond, and later on the staff left after going to another room that was inside the room where the RCm was being conducted. Then, Resident #14 stated that the staff who entered the room was a nurse and the same staff the resident was talking about who entered the resident's room without knocking. Resident #14 further stated I remembered her (the nurse), but was unable to remember the name. Furthermore, at that same time, during the RCm, another staff entered the room without first knocking and did not explain the purpose of why she entered the room. The Recreation Aide (RA) stated that she works in the activity department and wanted to get an activity supply after the surveyor's inquiry, and then the RA left. On 9/20/23 at 11:07 AM, after the RCm ended, at the door was the Activity Director (AD). The surveyor notified the AD of the above concerns regarding the RA who did not knock prior to entering a closed room meeting, and the AD provided the RA's name. On that same date and time, the Director of Nursing (DON) joined the AD. The surveyor notified the DON of the same concern and the surveyor asked the DON the name of the nurse who did not knock prior to entering the closed-door meeting room. The DON stated that she will get back to the surveyor. On 9/20/23 at 11:22 AM, the surveyor went to the East wing unit and found the nurse who entered the room during the RCm. The Licensed Practical Nurse (LPN) acknowledged that she was the nurse who did not knock before entering the closed-door meeting room. The LPN stated that when she saw there was a meeting ongoing in the room she thought that it was just a regular meeting within the facility of residents and staff and she did not realize that it was the surveyor who was inside the room not until she was inside the room already. At that time, the LPN informed the surveyor that she went inside the room to talk to the therapist (Rehabilitation staff) regarding her one resident. The LPN further stated I'm sorry, and that she realized afterward what she did, and that she should have knocked first before entering the room. A review of Resident #14's most recent annual Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/10/23, showed in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that resident's cognitive status was intact. A review of Resident #67's aMDS with an ARD of 9/07/23 in Section C a BIMS score of 15 which reflected that the resident's cognition was intact. On 9/22/23 at 10:07 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON, and the surveyor notified the facility management of the above findings. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA stated that the staff should have knocked first and waited to be accepted to enter, and explain what they were supposed to do, and that's our standard practice. A review of the facility's Resident Rights Policy that was provided by the LNHA, with a revised dated August 2009 included that employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: #3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. NJAC 8:39-4.1 (a)(12)

Complaint# NJ00166296 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in a) one (1) of three (3) residents, (Resident #142) reviewed for environment concerns, b) the dining, and c) the laundry area observed and reviewed for a clean, comfortable, and homelike environment of residents. This deficient practice was evidenced by the following: 1. The surveyor reviewed Resident #142's medical records. The Admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to chronic multifocal osteomyelitis (a disease that causes pain and damage in bones due to inflammation) right femur (right thigh bone), muscle weakness, anemia unspecified (when blood produces a lower-than-normal amount of healthy red blood cells), other abnormalities of gait and mobility. The admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/02/23 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of the 8/07/23 at 10:39 AM phone interview of another surveyor with the resident's Responsible Party (RP) revealed that according to the RP (also known as the caller), the resident's room was dusty, dirty, looked like not been cleaned in weeks, the air conditioner blows dust, and sheets not changed. The RP further stated that on 8/06/23 found clothes with feces in the corner of the bathroom and per RP according to Resident #142, they were there for two days. According to the Census information in the electronic medical records, the resident was in the following rooms during resident's stay in the facility: West Wing 1st Floor 24-2 Semi-Private West Wing 1st Floor 2-2 Semi-Private West Wing 1st Floor 6-1 Semi-Private A review of the provided folder of Pest Control Log (PCL) by the Licensed Nursing Home Administrator (LNHA) included invoice#430427 for a work date of 9/15/23; service description: pest-weekly service; general comments/instructions: Inspected areas on the first floor; treated rooms included room [ROOM NUMBER] as a continued preventative all baseboard heater vents in hallways were treated for roach activity. Recommend continued sanitation practices in the facility. On 9/19/23 at 10:46 AM, the surveyor and the Director of Nursing (DON) toured the [NAME] wing unit and entered room [ROOM NUMBER], there were no residents in the room at that time and the DON stated that the residents were in the activity. Upon entry, both the surveyor and the DON observed the blackish substances in the flooring edges around the door, bed one (a bed near the door) and bed two (a bed near the window) cork boards and overhead lights checked by the DON with use of her bare hands and observed an accumulation of dust. The DON stated that it should have been cleaned. Then both the surveyor and the DON went inside the shared toilet room and observed that the tissue holder was broken and no tissue paper. The DON further stated that she would have it fixed. According to the above information, this was the previous room of Resident #142. On 9/19/23 at 10:51 AM, the surveyor and the DON went to room two (2) and the two current residents were not in the room. Both the surveyor and the DON observed there was high dusting in both beds in their cork boards where the activity calendars were posted and the overbed lights. The DON confirmed the high dusting by DON touching the surfaces with her hands and noted dust accumulation. room [ROOM NUMBER] was the previous room of Resident#142. The DON stated that it should have been cleaned. On 9/19/23 at 10:53 AM, the surveyor and the DON went to room six (6) and both observed that the room was closed. The DON informed the surveyor that there were no residents in room [ROOM NUMBER] which was why it was closed, then the surveyor and the DON entered room [ROOM NUMBER] and there were two made beds (bed one and bed two), and there was an extra bed with no mattress. The surveyor asked the DON if that was appropriate to store an extra bed inside a clean room. The DON stated that it was okay to store an extra bed inside the room and that it would be removed once admission came in. On that same date and time, both the surveyor and the DON observed the adjoined toilet room between rooms 5 (five) and 6 (six). There was a broken bedpan with a minimal amount of water that was on the floor with no identification to whom the used bedpan was. The DON picked up the bedpan from the floor and the DON stated that it should not be there. There was also a urinal hung on the handrail, the used urinal had a yellow colored substance on the bottom part of the urinal and the DON stated that she did not know who was using the urinal and that it should not be there. The toilet holder was broken, the DON attempted to put the toilet paper but it would not hold. 2. On 9/19/23 at 10:38 AM, the surveyor toured the dining area. There were 16 residents and five (5) facility staff assisting the residents with activity. The surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN). The MDSC/RN informed the surveyor that the area was called the Recreation and Dining Area. Both the surveyor and the MDSC/RN observed the back wall of the dining area with scattered multiple black and brownish substances from the lower part to the top of the ceiling wall. There was a wall painting of a tree and a piano near the back of the wall. Next to the piano area were two vending machines (one machine for food/snacks and the other vending machine for drinks soda/water) at the back and bottom part were scattered papers, an empty carton of Ensure milk with a straw inside, round shape reddish candy, a coin, socket screwdriver, scattered accumulation of dust. Next to the two vending machines was the suction machine covered with plastic. The plastic covering of the suction machine had scattered holes and with accumulation of dust. The center area above the ceiling of the dining area was three (3) exhaust fans with dust accumulation. The three exhaust fans were in used. At that same time, the MDSC/RN confirmed the above findings and stated that it should have been cleaned. On 9/19/23 at 10:43 AM, the surveyor and the DON observed the Soiled Utility room in the [NAME] wing, the entrance flooring with blackish substances around the area edges and the DON confirmed that it should have been cleaned. On 9/21/23 at 8:47 AM, the LNHA stated that he was aware of the surveyor's concerns regarding facility cleanliness and environmental issues. Further review of the PCL, included invoice#426634 for a work date of 8/02/23; service description: pest-weekly service; general comments/instructions: Followed up on rooms completed in [NAME] wing rooms 24 to 33 for roach activity. Recommend cleaning each room thoroughly. Treated day room behind the piano for roaches. Treated bathrooms on the East and [NAME] side. 3. On 9/22/23 at 8:21 AM, the surveyor toured the Laundry area and observed Housekeeper#1 (HK#1), HK#2, HK#3, and Laundry Staff (LS). HK#1 stated that she will call the Housekeeping Director (HD) to assist the surveyor with the Laundry tour. HK#1 further stated that since the breakfast trays were in the units, housekeepers were in the laundry area to help in folding. Upon entry to the Laundry area there was a metal rack of donated clothes not covered, a table with folded blankets, a box of gloves, a plastic bottle of soda with below half liquid content, paper, and rolled plastic bags, across the table was another table with multiple socks on top which HK#3 putting them together and above the table where multiple socks was a hanging electric fan in use with surrounded accumulation of dust in the metal parts of the fan. There were 3 dryers not in use at that time. On 9/22/23 at 8:24 AM, the HD entered the laundry area and informed the surveyor in the presence of three housekeepers and LS that she started working in the facility for four weeks. The surveyor and the HD both observed the hanging electric fan in use with accumulation of dust and below was a folding table with multiple different clean socks. The surveyor asked the HD about the electric fan in use what was around the metal parts of the fan and how long she thinks it was not cleaned, the HD stated that it was dust and probably, a week it was not clean. The HD further stated that she would ask the Porter who was responsible for cleaning the fan to clean it. The HD stated that those socks were considered clean and being folded and that the donation clothes in the metal racks were considered clean as well. On that same date and time, the surveyor and the HD then went to the three metal racks near the table of folded blankets wherein on top of the metal rack was a plastic food container, a personal phone next to clean folded towels, in the middle of two metal racks was a feather duster touching the clean folded blankets. On the last metal rack on top were two plastic divider curtain which were dirty accumulation of dust and black and brown substances that was tucked between clean folded privacy curtain. The HD stated that the personal phone should not be placed in the clean folded towels, the feather duster used for cleaning should not be near the clean folded blankets and any other clean supplies, and the plastic divider curtain which will be replaced soon awaiting for replacement should not be tucked in a clean privacy curtain for residents due to contamination and infection control. At the same time, the surveyor also asked the HD to check the metal racks for cleanliness and the HD swiped her fingers on top of the metal rack for cleaned folded blankets and fitted sheets and informed the surveyor that there was high dusting that should have been cleaned. The HD also stated that she would ask the LS to rewashed the contaminated supplies and she educated the housekeepers and the LS regarding personal phones and personal soda not being placed on the tables used for folding clean linens, towels, socks, blankets, and fitted sheets as well as cleaning equipment and supplies away from cleaned supplies. Furthermore, the HD explained to the surveyor that the 1st room was considered a clean area where the three dryers were located, and the next room in between the plastic divider curtain was considered the dirty room where the two washers were located. The HD confirmed that the plastic curtain divider had multiple scattered black and brown substances and accumulation of dust should have been cleaned. On 9/22/23 at 8:42 AM, the surveyor observed the shared toilet room of rooms five (5) and six (6), and the toilet paper dispenser was not fixed, the metal part was apart. On 9/22/23 at 8:47 AM, the surveyor observed the shared toilet room of rooms [ROOM NUMBERS], the toilet paper dispenser was not fixed and missing a middle part that would hold the tissue paper. At that time, tissue paper was placed on top of the handrail of the toilet seat. On 9/22/23 at 8:49 AM, the surveyor, DON, and the Maintenance Director both went to the shared toilet of rooms [ROOM NUMBERS], there were no residents in the rooms at that time. Both the surveyor and the facility management observed that there was a missing part on the toilet dispenser. The surveyor also notified the facility management that it was the same in the shared toilet room of rooms [ROOM NUMBERS] and the Maintenance Director stated that he would be back to get the missing part replacement and will fix the one in rooms [ROOM NUMBERS]. On 9/22/23 at 10:07 AM, the survey team met with the LNHA and the DON and were made aware of the above findings. On 9/25/23 at 10:35 AM, the survey team met with the LNHA and the DON. The LNHA informed the surveyor that rooms in the [NAME] wing (rooms 2, 3, 5, 6, and 24) were immediately cleaned after the surveyor's inquiry. The LNHA acknowledged the high dusting and stated that the tissue holders were replaced immediately. He further stated that he acknowledged the concerns about environmental issues that were brought out by the surveyor during the environmental tour in the dining area, resident rooms, and laundry area. A review of the undated Housekeeping Policy that was provided by the LNHA included that it is the policy of this facility to provide and maintain a safe, clean, and homelike environment for residents. All equipment and environmental surfaces shall be clean to sight and touch. All toilets and bathrooms shall be kept clean to sight and touch, in good repair, and free of odors. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services. The facility management did not provide additional information and did not refute findings. NJAC 8:39-31.2 (e), 31.4(a)(f)

Complaints: #NJ00164042, # NJ00166566, #NJ00165848, #NJ00166567 Based on observation, interview, and review of pertinent documents, the facility failed to ensure that the method for filing a grievance was consistent with the facility's practice and policy. This deficient practice was identified for five (5) of five (5) residents, (Residents #10, #13, #56, #82, and #143) reviewed. This deficient practice was evidenced by the following: 1. On 8/19/23 at 11:00 AM, the surveyor asked the Licensed Nursing home administrator (LNHA) for a copy of Resident #10's grievance reports for the last five (5) months, and the LNHA stated that he will get back to the surveyor. The provided Grievance/Complaint Report (G/CR) logs showed that the months of April 2023, May 2023, and August 2023 did not reflect a grievance logged for Resident #10. A review of Complaint #NJ00164042 reflected an alleged event date on 4/28/23 showed that the resident complained about a staff member yelled and attempted to give the resident with a wrong medication. A review of Complaint #NJ00166566 reflected an alleged event on 8/15/23 showed that Resident #10 reported Resident #13 inappropriately touched Resident #82. Further review of the above G/CR logs and complaint and reported concern of Resident #10 revealed that there was no grievance documentation that was initiated on 4/28/23 and 8/15/23. The surveyor reviewed the medical records of Resident #10. The resident's Admission Record (AR; or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; dementia in other diseases classified elsewhere(a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with assessment reference date (ARD) of 7/18/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated that the resident's cognitive status was intact. The surveyor reviewed the medical records of Resident #13. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic kidney disease (involves a gradual loss of kidney function), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). The cMDS with an ARD of 8/03/23 showed that the resident's BIMS score was 4 out of 15, which indicated that the resident's cognitive status was severely impaired. The surveyor reviewed the medical records of Resident #82. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; unspecified intellectual abilities (diagnosis given when an individual is over the age of five and standardized testing is unable to be completed due to physical, motor, behavioral, or mental health factors) and Type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). The quarterly MDS (qMDS) with an ARD of 9/10/23 showed that the resident's BIMS score was 4 out of 15 which reflected that the resident's cognition was severely impaired. On 9/21/23 at 11:31 AM, the survey team met with the LNHA and the Director of Nursing (DON). The surveyor asked the facility management about the process of handling grievances. The DON stated that the staff would initiate the resident complaint form and it would be given to the Unit Manager, the DON or the LNHA. On that same date and time, the LNHA stated that once the grievance was reported to New Jersey Department of Health (NJDOH), it will be followed up, and investigated. The LNHA further stated that he should be aware, and the grievance would be logged and filed for document keeping in the grievance binder. The LNHA informed the surveyors that he manages the grievance binder. 39885 2. On 9/20/23 at 02:45 PM, the surveyor reviewed the reportable event record/report AAS-45 (FRE; Facility Reported Event) dated 7/10/23 that was provided by the facility which included the following: Today's Date: 7/10/2023 Date of Event: 7/06/2023 Time of Event: unk [unknown] Was This a Significant Event? Yes Was Significant Event Called in? Yes Date: 7/10/2023 Time: 5:15 PM Type of Incident: Staff-to-Resident Abuse Narrative: 1) Describe the event . Resident #56 allegedly told Responsible Party (RP) that while changing his/her diaper the individual described as [redacted] slapped resident's forearm. He/she said that since the alleged incident, he/she has not seeing [seen] the person again . 3) What interventions were implemented after the incident/event? . Skin assessment reveals with no redness or bruising noted and Resident #56 was assessed and does not report any pain or discomfort. Resident #56 alleged incident happened in the evening to RP but upon his/her interviewed told the nurse it happened in the day shift and stated the person did not hit him/her but was rough. After reviewing all statements and visual assessment, no bruising or discoloration noted on the patient's body, in addition to his/her discrepancies of the time of the incident and coupled with the description of the alleged perpetrators, we conclude that the allegation of abuse is unsubstantiated Review of the additional documentation attached to the report included the following: Copy of an email from Assistant Director of Nursing (ADON) to the former LNHA and the former Social Worker dated Fri. (Friday) Jul (July) 7, 2023 at 3:58 PM .Resident #56's RP will be in on Monday 7/10/2023 to discuss concerns with her/his [parent]. The surveyor reviewed the medical record for Resident #56. The AR reflected that the resident had been admitted with diagnoses which included but were not limited to wedge compression fracture of first lumbar vertebra, type 2 diabetes mellitus and cerebral infarction. The significant change in status MDS dated [DATE], reflected that the resident had a BIMS score of 10 out of 15, which indicated that the resident's cognitive status was moderately impaired. On 9/21/23 at 9:41 AM, the surveyor, in the presence of the LNHA asked the DON about Resident #56's FRE. The DON stated that she was not here at the time and that she was on vacation. She then asked the ADON to come to the office. On 9/21/23 at 9:42 AM, the surveyor interviewed the ADON in the presence of the DON regarding Resident #56's FRE. The ADON stated that Resident #56's RP was told about the alleged incident by another RP the next morning. ADON stated that the alleged event happened on 7/06/23. The surveyor asked the ADON why the allegation of abuse was not reported right away and was reported on 7/10/23. The ADON stated that she did not that information. On 9/21/23 at 11:31 AM, in the presence of the survey team, the surveyor asked the LNHA and DON what the process was for an allegation of abuse. The LNHA stated that the alleged threat is removed from the situation and that it is called in to the state and Ombudsman and then investigated [the allegation]. The surveyor then asked if there was a form that was used. The DON stated that it depended on the type of allegation but that they might fill out the AAS-45. She added that if someone alleged that they were hit by a staff member then that person would be taken off the schedule, we would talk to the resident and to staff and that the resident would have a body assessment done. The surveyor then asked if there should be documentation in the medical record and where it would be located if a family member made an allegation of abuse. The LNHA stated that it would be documented in the grievance [log]. The DON stated that if would not be in the progress notes. On 9/21/23 at 12:46 PM, in the presence of the survey team and DON, the surveyor asked the LNHA if the grievance form was used for everyone. The LNHA stated yes. He then added that the monthly log was just to track but that each incident would have a form that was filled out. The surveyor then asked why was it important to maintain a record of complaints. The LNHA stated that it was to track and see if there were any trends. A review of Resident #56's Progress Notes from 7/01/23 to 7/13/23 did not include a note that a RP alleged abuse by a staff member. A review of the facility provided Grievance Log for July 2023 did not include an allegation of abuse in regards to Resident #56. On 9/22/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the LNHA and DON the concern that Resident #56's allegation of abuse by the resident's RP was not listed as a grievance in the facility's grievance log. The LNHA stated that it seemed that the facility did not put allegations of abuse on the grievance form if it was reported to the state. On 9/27/23 at 01:38 PM, in the presence of the survey team and the DON the LNHA stated that there was no additional information but that moving forward the facility would put reportable's on the grievance form/log. 45449 3. On 9/19/2023 at 1:07 PM, in the presence of the survey team, the surveyor asked the LNHA to confirm that the requested reportable to the State Agency (SA) was submitted to the team its entirety. At that time, LNHA stated he would have to confirm with nursing. The LNHA stated that the investigation and reportable were in one sheet and section three (3) was the conclusion. Once a reportable event occurred, we (the LNHA, nursing and social worker) investigated, and interviewed all parties. The LNHA stated that the SA form AAS-45 was used to document the information gathered from the investigation, interviews, and conclusion. The witnesses, when applicable would write their statement on a piece of paper. The surveyor reviewed the Reportable Event Record/Report form AAS-45 (a facility reported event/incident; FRE/FRI) for Resident #143 which included the following: Today's Date: 8/14/23 Date of Event 8/12/23 Time of Event 11:30 PM Was this a significant event? No Was significant event called in? Yes, 8/14/23 at 2:20 PM Location of Incident: Facility enclosed patio Type of Incident: Staff to Resident Abuse 1) On 8/14/23, Resident #143 reported that on 8/12/23 at approximately 11:30 PM, [he/she] was talked to rudely by staff. 2) Prior to the event, was a plan of care developed that addressed this issue, and were planned interventions in place when the event occurred? Not Applicable 3) What interventions were implemented after the incident/event? . The employee was removed off the schedule. the physician and psych were notified of the event. administration reviewed the policy with Resident#143 about going outdoors after hours. during our investigation, it was noted that Resident #143 was observed sitting on the ground on the enclosed patio with legs crossed looking for used cigarette butts. the staff asked [the resident] to stop and return indoors because it was late. [The resident] began to yell and curse at him/her. After a short while, he/she was eventually able to coax [the resident] to their room, despite objections. Abuse in this case was found to be unsubstantiated . The surveyor reviewed the facility provided Grievance log for August 2023, which did not include the FRE for Resident #143. The surveyor reviewed the medical records for Resident #143. A review of the resident's AR reflected that Resident #143 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of supraglottis (cancer above the true vocal cords, emphysema (a lung condition that causes shortness of breath) , undifferentiated schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), dysphagia (swallowing disorder) According to the admission MDS dated [DATE], Resident #143 was documented with a BIMS score of 15 out of 15, indicated that resident was cognitively intact. Further review of the MDS section E Behavior revealed the resident was not delusional and section N revealed the resident received antipsychotic, and antianxiety medications. On 9/21/23 at 11:31 AM, during a meeting with the surveyors, and the DON the LNHA stated he was the abuse coordinator since 7/31/23, when he started with the facility. The LNHA explained the process for allegation of abuse. At that time, the LNHA stated that allegations were documented into the grievance log or risk management report. The LNHA further clarified that grievance forms, complaints, and missing items were documented into the grievance log. The Social Worker (SW) kept the grievance forms and the grievance log. The grievance log was checked by the LNHA every morning and discussed during the morning and afternoon meeting to bring awareness to everyone. At that time, the DON stated the Social Worker would conduct interviews and write a statement that is not on the electronic file. After the whole investigation the SA and the Ombudsman are notified. After the conclusion whether substantiated or not we do not assign the same Certified Nursing Assistant CNA/or staff to the same resident to prevent further issues. At that time, the LNHA stated for reported events/incident (FRE/FRI), the SA form AAS-45 is utilized. He further stated that the unreported events and if we obtain a statement, it would be on the grievance form which the SW kept. The LNHA informed the surveyor that She is the end person of the reporting process. The LNHA further stated that all staff can initiate the reporting process. On 9/21/23 at 12:46 PM, during a follow up interview with the surveyors, the LNHA and the DON stated the resident concern form was used to track all concerns with residents, family and other types. The record was important to track for trend issues and concerns. The trends were tracked by the department heads who also reported during our morning and afternoon meetings. At that time, the surveyor asked the LNHA how grievances were identified and tracked for trend since Resident #143's grievance was not documented on the grievance log. The LNHA stated we do not have a way to track the trend of grievances. On 9/22/23 at 10:09 AM, during a meeting with the survey team, LNHA and DON, the surveyor discussed the concerns regarding the facilities process failure of receiving and tracking the trend for grievances. On 9/25/23 at 10:56 AM, during a meeting with the survey team, and the DON, the LNHA stated after the surveyor inquiry, they added Resident #143' a information to the grievance log. The LNHA stated their process was that when a concern was brought to the attention of a facility representative, we then would log the information into the grievance log. At that time, the LNHA acknowledged the Resident #143's grievance regarding a staff to resident abuse should have been record into the grievance log for trend tracking. No further information was provided. A review of the facility provided policy Resident Grievance/Complaint Policy included: Policy Statement; Any resident his/her representatives (sponsor), interested family member or advocate may file a grievance/complaint concerning his/her treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of reprisal in any forms. Procedure: 1. Obtain a complaint form from the nurse's station or social services office. A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 3/18/23, included the following: Prevention 3. Encourage residents, families and staff to report concerns, incidents and grievances without the fear of retribution and provide feedback regarding the concerns that have been expressed. Reporting 1. Any witnessed, alleged, or suspected violations involving mistreatment, neglect or abuse, .MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE'S SUPERVISOR. 2. The supervisor must immediately notify the Administrator and/or the Director of Nursing. 3. Abuse allegations .will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or the Director of Nursing including but not limited to local law enforcement agencies, NJDOH, and NJ Ombudsman in compliance with regulatory requirements. 4. Reports must be submitted in writing, which may include incident report, employee statement, grievance/concern form, or other written documentation . 7. Upon receiving reports of abuse .the Charge Nurse and/or Nursing Supervisor shall immediately examine and interview the resident. 8. The information and examination will be recorded in the resident's medical record . 18. Appropriate agencies will be contacted by telephone to report instances of abuse immediately, including but not limited to NJDOH, the local police, and the Office of the Ombudsman. 19. A written report will follow as required by the reporting agency. On 9/28/23 at 01:30 PM, the survey team met with the LNHA, DON, and [NAME] President of Clinical Services. The facility management did not provide additional information and did not refute findings. NJAC 8:39-4.1(a)(35);13.2(c)