Every finding on record at St Mary's Center for Rehabilitation & Healthcare

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the physician's orders for fluid restrictions for 1 of 3 residents sampled for dialysis (a treatment that removes waste products from the blood), (Resident #232).This deficient practice was evidenced by the following:During the initial tour on 04/23/2026 at 11:47 AM, the surveyor observed Resident #232 resting in bed.A review of the admission Record revealed Resident #232 was admitted to the facility with diagnoses including, but not limited to, end-stage renal disease (a medical condition where the kidneys stop functioning) and hypertension (high blood pressure).A review of Resident #232's electronic medical record (EMR) revealed the resident was on a fluid restriction of 1500 milliliters (ml) daily prior to hospitalization on 03/02/2026. Resident #232 was readmitted on [DATE], and per the hospital discharge summary, there were no fluid restrictions.A review of Resident #232's care plan revealed a focus for risk of alteration in hydration related to fluid restriction initiated on 12/11/2025. No revision was made to the care plan when Resident #232 was readmitted .During an interview on 04/29/2026 at 09:58 AM with the surveyor, the Unit Manager (UM) on the St. Mary's unit said that care plans are reviewed every three months and as needed if changes occur. When asked if Resident #232's care plan should have been updated, the UM replied, Yes.During an interview on 04/29/2026 at 1:18 PM with the surveyor, the Director of Nursing (DON) said care plans are updated quarterly or during audits, and should be updated upon readmission as orders and care can change.A review of a facility-provided policy titled Resident Evaluation/Assessment revealed, under Monitoring results and adjusting interventions, the following requirement: Periodically reviewing progress and adjusting treatments based on provider orders/guidance.NJAC 8:39-11.2(i)

Based on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 2 of 2 residents (Resident #43 and #147) investigated for Accidents.The deficient practice was evidenced by the following:1) On 04/23/2026 at 10:28 AM, during the initial tour of the facility, the surveyor observed Resident # 147 in their room in bed. The surveyor observed one floor mat on its side leaning against the wall on the far side of the room. On 04/24/2026 at 09:42 AM, the surveyor observed Resident #147 sleeping on his/her left side in bed. The surveyor observed one brown floor mat on its side leaning against the wall on the far side of the room.A review of Resident # 147's Electronic Medical Record (EMR) revealed diagnosis of but not limited to repeated falls and other abnormalities of gait and mobility (alteration in walking patterns and movements).A review of Resident # 147's EMR revealed a physician's order for bilateral floor mats every shift with a start date of 01/23/2026. A review of Resident # 147's EMR revealed under Care Plan a focus for risk of falls related to medication side effects, unsteady gait and history of falls. The focus revealed an initiated date of 06/29/2022. The care plan revealed an intervention for bilateral floor mats at bedside. The intervention revealed an initiated date of 01/23/2026. 2) On 04/23/2026 at 10:42 AM Resident #43 was observed in bed with visitors. At that time the family member of Resident #43 stated that the resident #43's floor mat in the past, had been found behind the resident's bed while they were in bed. On 04/24/2026 at 09:40 AM Resident #43 was observed sleeping in bed. At that time the surveyor observed one floor mat on the side of the bed between the resident and the roommate, no mat was observed on the other side of the bed.On 04/28/2026 at 09:43 AM Resident #43 was observed sleeping in bed. At that time the surveyor observed one floor mat on the side of the bed between the resident and the roommate, no mat was observed on the other side of the bed.A review of Resident # 43's EMR revealed diagnosis of but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (limited or no movement to one side of the body after a sudden loss of blood supply to the brain) and unspecified fall.A review of Resident #43's most recent Minimum Data Set (MDS) (an assessment tool), dated 04/02/2026, revealed under section J that Resident #43 had a fall since prior assessment. A review of Resident # 43's EMR revealed a physician's order for bilateral floor mats every shift with a start date of 01/23/2026.A review of Resident # 43's EMR revealed under Care Plan a focus for risk of falls due to history of falls. The focus revealed an initiated date of 05/25/2023. The care plan revealed an intervention for bilateral floor mats at bedside. The intervention revealed an initiated date of 03/12/2026.On 04/28/2026 at 12:59 PM during an interview with the surveyor, the Unit Manager (UM) stated that the floor mats should be on both sides of the bed while the resident is in bed. The UM further stated that this was necessary to prevent injury in the event of a fall. On 04/29/2026 1:18 PM during an interview with the surveyor, the Director of Nursing (DON) stated that residents floor mats should not be on their sides against the wall. The DON further stated that when ordered bilaterally, the fall mats should be on floor to both sides of the resident's bed while they are in bed. The DON further stated this was necessary for resident safety. A review of the facility provided policy titled Fall and Fall Risk Management revealed under Resident-Centered Approaches to Managing Galls and Fall Risk, number 4, .staff will identify and implement relevant interventions to try to minimize serious consequences of falling. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by not having a physician's order for oxygen administration. The deficient practice was identified for 1 of 6 (Resident # 5) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 04/23/2026 at 9:58 AM, during the initial tour, the surveyor observed Resident #5 in their room lying in bed. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) applied to Resident #5. At that time the survey observed the oxygen condenser to be on and the resident was receiving 3L of oxygen through the nasal cannula.A review of Resident #5's admission record revealed that Resident #5 had a diagnosis of but not limited to, heart failure (Inability of the heart to pump enough blood) and comfort care (care focused on relieving symptoms to improve quality of life).A review of Resident #5's Electronic Medical Record (EMR) revealed an order for and comfort care (care focused on relieving symptoms to improve quality of life) and did not reveal a physician's order for oxygen. During an interview on 04/28/2026 at 1:04 PM, with the surveyor, Unit Manager (UM) #1 stated that oxygen must be administered under a physician's order. UM #1 further stated that resident #5 had been receiving oxygen for awhile and acknowledged that Resident did not have a physician's order.During an interview on 04/29/2026 1:18 PM, the Director of Nursing (DON) stated yes when asked if there should be a physician's order for oxygen if a resident is being administered oxygen. A review of the facility-provided policy titled Oxygen Administration - Resident with a revision date of 12/2024, failed to mention the need for a physician's order.A review of the facility provided policy titled Medication and Treatment Orders with an effective date 3/2020, revealed a policy statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing. N.J.A.C. S 8:39-27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility staff failed to ensure that respiratory equipment was stored in a manner that prevented contamination, in accordance with infection prevention and control standards, for 3 of 6 residents reviewed for respiratory care (Resident #5, Resident #79, and Resident #86).The deficient practice was evidenced by the following: On 04/23/2026 at 10:22 AM, during the initial tour, surveyor #1 observed Resident #86's nebulizer mask (a medical device that converts liquid medication into a fine mist for inhalation into the lungs) lying in the nightstand drawer, open to air. A review of Resident #86's admission Record revealed the resident was admitted to the facility with, but not limited to, hypertension (high blood pressure) and palliative care (care focused on relieving symptoms to improve quality of life). A review of Resident #86's Electronic Medical Record (EMR) revealed a physician's order for Ipratropium-Albuterol Solution (a medication that relaxes the muscles in the airway) every 8 hours for 5 days with a start date of 04/20/2026. During an interview on 04/28/2026 at 10:49 AM with surveyor #1, the Infection Preventionist (IP) said that the nebulizer mask should be stored in a plastic bag when not in use. During an interview on 04/29/2026 at 1:18 PM with surveyor #1, the Director of Nursing (DON) said that after the nebulizer mask is cleaned and dried, it should be stored in a bag for infection control purposes. A review of the facility-provided policy titled Respiratory Equipment failed to mention how respiratory equipment should be stored when not in use. NJAC 8:39-19.4 (k) On 4/23/2026 at 9:58 AM during initial tour, Surveyor #2 observed Resident #5's nebulizer (a machine that aerosolizes medications for inhalation) with the nebulizer mask beside it on top of the bedside table open to air. A review of Resident #5's admission record revealed that Resident #5 had a diagnosis of but not limited to, heart failure (Inability of the heart to pump enough blood). A review of Resident #5's Electronic Medical Record (EMR) revealed a physician's order for Albuterol Sulfate Nebulization solution 0.083%, inhale 1 vial via nebulizer every four hours as needed for shortness of breath and wheezing and comfort care (care focused on relieving symptoms to improve quality of life). A review of Resident #5's Care Plan in the EMR revealed a nursing focus of Comfort Care due to Terminal/End-stage disease initiated on 01/28/2026. On 04/23/2026 at 10:50 AM during initial tour, Surveyor #2 observed Resident #79 Continuous Positive Airway Pressure (CPAP) machine (Device that creates positive pressure to assist in breathing). A review of Resident 79's admission record revealed that Resident #79 was admitted with but not limited to chronic obstructive pulmonary disease (COPD), (a progressive lung disease that makes it difficult to breathe) and chronic respiratory failure (chronic condition that makes it difficult to breathe). A review of Resident #79's Electronic Medical Record (EMR) revealed a physician's order, Apply CPAP (pressure setting 5) via mask at bedtime and remove per schedule. A review of Resident #79's Care Plan in the EMR revealed a nursing focus of altered respiratory status/difficulty breathing r/t sleep apnea with intervention that included the use of residents CPAP initiated on 02/04/2026. During an interview on 04/29/2026 at 1:18 PM, the Director of Nursing (DON) stated when not in use, masks are cleaned and dried and stored in a labeled bag, for infection control purposes. A review of the facility-provided policy titled Respiratory Equipment failed to mention how respiratory equipment should be stored when not in use. NJAC 8:39-19.4 (k)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain acceptable standards of essential kitchen equipment in a safe and operable condition. This deficient practice was evidenced by the following:During initial tour of the kitchen on 04/23/2026 at 10:05 AM, the surveyor observed the following in the kitchen with the Food Service Director (FSD):The stove had no knobs. The FSD stated that the knobs had been broken for 1 month and ordered more. FSD stated we are supposed to be getting a new stove. On the portable holding temperature box, the gaskets (rubber seal) were falling off. The FSD stated the box is new, but this can happen because of the high heat. During an interview with the surveyor on 04/23/2026 at 11:48 AM, FSD acknowledged that there should be knobs on the stove top. He also stated that the gaskets on the portable temperature box should be replaced. A review of the facility provided policy titled, Facility Equipment, reflected that if an equipment in the facility is not functioning as designed, the maintenance department will work with the department head to correct the concern of that piece of equipment. Maintenance Department will orchestrate the overall maintenance of facility equipment. NJAC 8:39 31.7(d)

COMPLAINT #: 2578601, NJ00183769, NJ00185789 Based on interviews, medical record review, and review of other pertinent facility documents on 08/28/2025 and 09/08/2025, it was determined that the facility failed to notify a provider timely when prescribed treatments and medications were not administered as ordered. This deficient practice was identified for two of three residents (Resident # 1 and Resident #3) reviewed for unadministered medication or treatments. This deficient practice was evidence by the following:Complaint#: 2578601, NJ00183769, NJ00185789 1.) According to the admission Record (AR), Resident #1 was admitted to facility with diagnoses including but not limited to: muscle wasting and atrophy (loss of muscle mass), liver disease, epilepsy (brain disease that causes repeated seizures), malignant neoplasm (cancerous tumor with the ability to spread to other tissues and organs) of the colon, secondary malignant neoplasm of liver and intrahepatic bile duct (canal that carries bile between organs in the digestive system), and unspecified intellectual disabilities. A review of the Resident #1's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/24/2025, reflected the resident's cognitive skills for daily decision making were severely impaired. A review of Resident #1's Order Summary Report (OSR) revealed the following medication orders: Phenobarbital (medication used to treat or prevent seizures, treat insomnia, or as a sedative) oral tablet 32.4 milligrams (MG). Give 1 tablet by mouth at bedtime as a sleep aid. The order start date was 01/24/2025 at 9:00 P.M. The order end date was 01/25/2025. Phenobarbital oral tablet 30 MG. Give 1 tablet by mouth at bedtime as a sleep aid. The order start date was 01/25/2025 at 9:00 P.M. The order end date was 1/28/2025.Phenobarbital oral tablet 30 MG. Give 1 tablet at bedtime for seizures. The order start date was 01/28/2025 at 9:00 P.M. The end date was 02/04/2025. Phenobarbital oral tablet 32.4 MG. Give 1 tablet by mouth at bedtime for partial epilepsy. The order start date was 02/09/2025 at 9:00 P.M. The end date was 03/21/2025.Phenobarbital oral tablet 32.4 MG. Give 1 tablet by mouth at bedtime for anxiety. The start date was 03/21/2025 at 9:00 P.M. The end date was 03/25/2025. A review of Resident #1's Medication Administration Record (MAR) revealed that the Chart Code 9 was entered on Resident #1's MAR for the following medication doses: Phenobarbital oral tablet 32.4 MG. Give 1 tablet by mouth at bedtime for sleep aid on 01/24/2025. Phenobarbital oral tablet 30 MG. Give 1 tablet by mouth at bedtime for sleep aid on 01/25/2025 and 01/26/2025.Phenobarbital oral tablet 30 MG. Give 1 tablet at bedtime for seizures on 01/28/2025, 01/29/2025, 01/31/2025, 02/01/2025, and 02/02/2025. Phenobarbital oral tablet 32.4 MG. Give 1 tablet by mouth at bedtime for partial epilepsy on 02/09/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, and 03/8/2025.Further review of the MAR revealed that the Chart Code 9 was used to indicate Other/See Nurses Notes. A review of Resident #1's Progress Notes (PN) for January and February of 2025 revealed PNs indicating that Resident #1's phenobarbital was on order and that the facility was awaiting prescription delivery. There was no further documentation for the aforementioned missed medication doses. Further review of Resident #1's PN for January and February revealed no documentation of provider notification of unavailable or unadministered medications until 02/17/2025 at 4:09 P.M., when a progress note indicated that a Nurse Practitioner (NP #1) was notified. Review of PNs for March revealed no documentation of provider notification for the missed phenobarbital dose on 03/08/2025. A telephone interview was conducted with a Licensed Practical Nurse (LPN #1) on 08/28/2025 at 2:44 P.M. LPN #1 stated that when she documented on order in the PN on 02/13/2025 and 02/14/2025 it meant that the medication had not arrived from the pharmacy and was not administered. LPN #1 stated that if medications were not given, a provider should have been notified. LPN #1 further stated that if she had notified a provider that a resident's medications were not given, she should have documented that in the PNs. An interview was conducted with a Unit Manager (UM #1) on 08/28/2025 at 3:50 P.M. UM #1 stated that when ordered medications were not available the expectation was for nurses to check the medication cart and overflow supply and then call the pharmacy. If medications were still unavailable the next step was to call a provider and document their response. UM #1 stated that if there was no PN made then there is no way to know that a provider was notified. UM #1 identified that the PN on 02/17/2025 was the only documentation that a provider was notified of Resident #1's the missed phenobarbital doses. 2.) According to the admission Record (AR), Resident #3 was admitted to facility with diagnoses including but not limited to: anorexia nervosa (disorder that causes restriction of nutrient intake, significantly low body weight, fear of weight gain, and distorted body image); suicidal ideations (thoughts or feelings about suicide or self-harm); borderline personality disorder (mental health condition that causes unstable moods, difficulty managing emotions, reckless actions, and difficulty with interpersonal relationships); bulimia nervosa (disorder characterized by eating large amounts in a short period, followed by purging); protein-calorie malnutrition; post-traumatic stress disorder; gastroparesis (muscles in the stomach that do not move food properly for digestion); ulcerative colitis (inflammatory bowel disease that causes inflammation and sores in part of the digestive tract); irritable bowel syndrome (symptoms including abdominal cramps, bloating, diarrhea, and constipation); muscle weakness; and cognitive communication deficit (condition that affects a person's ability to communicate due to problems with mental processes). A review of the Resident #3's most recent MDS, dated [DATE], reflected that Resident #3 had a BIMS score of 12 out of 15 which indicated that the resident's cognition was moderately impaired. A review of Resident #3's POs revealed the following orders: Clinimix E/dextrose intravenous solution 5 % amino acid electrolyte with calcium infusion in D20W (20% dextrose in water) (a source of calories, protein, and electrolytes used when oral or nutrition is not possible or is insufficient). Use 1800 milliliters (ML) at bedtime to run at 113 ML per hour for 16 hours. The order start date was 11/25/2024 at 6:00 P.M. The order end date was 02/28/2025. Clinolipid intravenous emulsion 20 % fat emulsion (nutritional support in patients who are unable to get enough fat in their diet). Use 250 ML intravenously to run at 21 ML per hour for 12 hours. The order start date was 11/25/2024 at 8:00 P.M. The end date was 03/28/2025. A review of Resident #3's MAR revealed that the Chart Code 9 was entered for the following medication doses: Clinimix E/Dextrose (5/20) Intravenous Solution 5 % on 02/02/2025, 02/06/2025and 02/27/2025. Clinolipid Intravenous Emulsion 20 % on 02/02/2025, 02/06/2025, 02/22/2025, 02/23/2025, 02/24/2025, and 02/27/2025 A review of Resident #3's MAR revealed that the Chart Code 2 was entered on the resident's MAR for the following medication doses: Clinimix E/Dextrose (5/20) Intravenous Solution 5 % on: 02/04/2025, 02/05/2025, and 02/11/2025. Clinolipid Intravenous Emulsion 20 % on: 02/04/205, 02/05/2025, and 02/11/2025. Further review of the MAR revealed that the Chart Code 2 was used to indicate Drug refused. Review of Resident #3's PNs revealed no documentation that a provider was notified that the aforementioned medication doses were not administered or of the resident's refusals. A telephone interview was conducted with a Unit Manager (UM #2) on 09/08/2025 at 2:27 P.M. UM #2 stated that when ordered medications or treatments were not available follow up should have been conducted with the pharmacy and a provider. UM #2 further stated that documentation of the follow up should have been made in the PNs. An interview was conducted with the Director of Nursing (DON) on 09/08/2025 at 3:29 P.M. The DON stated that the only documentation of provider notification that Resident #1 did not receive the aforementioned phenobarbital doses was on 02/17/2025. The DON reviewed the MAR and PNs for Resident #3 and stated that she did not see documentation that a provider was notified that the resident was not administered Clinimax and Clinolipid on the aforementioned dates. During the same interview the DON stated that providers may have been made aware that the medications were not administered, and the notifications were not documented. The DON stated that it was her expectation that if a provider notification was made that a PN would be made to reflect the notification. The DON further stated that a resident's medical record should reflect the care that was given and that failure to document provider notification was not in keeping with the facility's policy. An interview was conducted with NP #1 on 09/12/2025 at 1:20 P.M. NP #1 stated that she did not recall if she was notified of the aforementioned unadministered and refused medications for residents #1 and #3. The surveyor attempted to reach the Medical Doctor (MD #2) for an interview on 09/16/2025 at 10:23 AM, and was informed that she was on leave of absence. An interview was conducted with the Medical Doctor (MD #1) on 09/19/2025 at 1:25 P.M. MD #1 stated that he did not recall if he was notified of unadministered phenobarbital doses for Resident #1. MD #1 further stated that facility staff made him aware of several times that Resident #3 did not receive Clinimax and Clinolipid but did not recall the dates. The facility policy Change in Condition with an effective date of 12/2018 and a revised date of 02/2023, was reviewed. Under Policy Interpretation and Implementation the policy revealed, The nurse will notify the resident's Attending Physician, or physician/NP of a change in condition if a concern warrants medical intervention. NJAC 8:39-13.1(d)

Complaint #: NJ183456 Based on observation, interview, and record review, it was determined that the facility failed to accommodate resident preferences with specific food items that were documented on the resident's meal tickets. This deficient practice was identified for 4 out of 6 sampled residents, Resident #1, #2, #4, and #5 and was evidenced by the following: According to the Admission Record (an admission summary), Resident #2 was admitted with diagnoses that included but were not limited to Hypertension (high blood pressure) and Abnormalities of Gait and Mobility (changes in walk pattern). According to the Minimum Data Set (MDS), an assessment tool dated 2/4/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. The Order Summary Report (OSR), received on 2/26/25, revealed Resident #2 was on a NAS (No Added Salt) thin consistency, Regular texture, Lactose intolerance with a start date on 2/12/25. Review of the Care Plan (CP) for Resident #2, initiated on 1/29/25, revealed a focus that Resident #2 was at risk for malnutrition related to (r/t) recent acute illness, variable intake. The Goal included maintain adequate nutritional status as evidenced by maintaining weight within 180-190 pounds (#) . Interventions included but was not limited to provide, serve diet as ordered. During the interview with the surveyor on 2/26/25 at 10:37 a.m., Resident #2 stated, No, I am not getting my food preference . During an interview with the surveyor on 2/26/25 at 11:29 a.m., Resident #1 stated, Most of the time I ordered something, I do not get it. I usually request coffee for breakfast, and I would check for creamer and sugar, and sometimes I do not get it. I usually requested tea for lunch and dinner, and sometimes I do not get it. Residents have been complaining about the food in the Resident Council Meetings. During an interview with the surveyor on 2/26/25 at 12:29 p.m., the Dietician revealed that she was made aware that Resident #2 had complaints about incorrect and missing items on her tray. The Dietician stated that she observed Resident #2's lunch tray delivered and she confirmed that Resident #2 did not receive what was ordered. The Dietician stated that she sent an email to the Diet Aide, Food Service Director (FSD), Unit Manager (UM #1), and Social Worker (SW). During an interview with the Surveyor on 2/26/25 at 12:54 p.m., the Food Service Director (FSD) stated that he was made aware via telephone from Resident #2 that he/she did not receive eight sugar packets as requested. The FSD stated that he personally brought the additional sugars to Resident #2. FSD stated that when he delivered the extra sugars, he looked on Resident #2's menu slip and acknowledged that he/she did request eight sugars and only received six sugars. When surveyor asked what he did, the FSD stated that he went back to the kitchen and made all the staff aware to check the menu slips. When surveyor asked if he documented the education of all staff, he stated, I need to work on that. FSD stated that he should have documented it for paper trail. FSD stated that he did not remember the date it happened. During interview with the surveyor on 2/26/25 at 1:45 p.m., the Licensed Nursing Home Administrator (LNHA) stated that she was aware that Resident #2's tray was delivered to his/her previous room. The LNHA further stated that it should not have been delivered to Resident #2's previous unit, it should have been delivered at his/her current unit. During meal tray observation on 2/27/25 at 9:07 a.m., Resident #5's meal ticket indicated that the resident should have received two juices, but the resident received one juice with his/her breakfast tray. Resident #5 stated, I ordered two juices, and I got one. I get the Select Menus. Everyday there was always something I am not getting. Resident #5 stated that he/she told the Certified Nursing Assistant (CNA) about the juice. The surveyor interviewed the CNA, and she stated that she told Resident #5 that she would see what she could do when breakfast was over. The CNA stated that she was done giving out the trays and had not brought the juice to Resident #5 yet. The CNA stated that she got sidetracked because another resident had requested care. The surveyor asked the CNA what she should have done, and she acknowledged that she should have given Resident #5 the juice because he/she had asked for it. The surveyor interviewed UM #2, and she stated that Resident #5 should have received the two juices as stated on the meal ticket. UM #2 further stated that the CNA should have brought the second juice to Resident #5 or asked someone else if she was unable to get it, because that was the resident's preference. On 2/27/25 at 9:57 a.m., the Dietician stated that she mis-spoke and that she observed Resident #2's lunch tray on 2/5/25 and sent an email on 2/6/25 to LNHA, Director of Social Services (DSS), FSD, and UM. During interview with the surveyor on 2/27/25 at 10:23 a.m., the LNHA stated that Resident #5 should have gotten his/her preference because it was the resident's rights. During interview with the surveyor on 2/27/25 at 10:32 a.m., the DSS stated that she was aware of Resident #2's food concerns and his/her preferences shortly after Resident #2 was admitted . The DSS stated that she sent email to the FSD, Dietician, and UM, copied the LNHA, and discussed in morning meeting. During interview with the surveyor on 2/27/25 at 11:04 a.m., the DSS stated that what should have happened was that the Dietitian should have addressed the concerns directly with the resident and then collaborated with the FSD and ensured that the requests were fulfilled. She stated, It was important that Dietician takes these measures because nutrition played a vital role, the overall performance and rehabilitation treatment, patient experience and recognize resident's rights regarding his/her dietary needs and preferences. During interview with the surveyor on 2/27/25 at 11:57 a.m., the LNHA stated, The Dietician should have notified the dietary department regarding the inaccuracy, and she should have ensured that Resident #2 received the items requested if available. It is important that these steps are taken because it is the resident's rights and preference. On 02/27/25 at 12:30 a.m., the surveyor entered the Main Dining Room on the first floor along with UM #2 and observed the following: 1. Resident #1 had a select menu on his/her tray and Resident #1 did not receive the tomato juice as ordered. This item was circled on the select menu. 2. Resident #5 had a select menu on his/her tray and did not receive one out of two juices and garlic spinach as ordered. These items were circled on the select menu. Review of the Dietary Department policy dated 03/2020, on Resident Trays revealed that Resident will be provided with meal trays as ordered. The Food Services Manager or supervisor will check trays routinely. Nursing staff shall check each food trays routinely before serving residents. Review of the Department of the Dietary Department policy dated 03/2020, on Menu Standards revealed, Tray tickets print specific to the physician order and patient preferences. NJAC 8:39-17.4 (a)1

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to explicitly contain any language to inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and failed to contain any language allowing the resident or anyone else to communicate with federal, state, or local officials. The deficient practice has the potential to affect all residents that signed the binding arbitration clause. The deficient practice was evidenced by the following: A review of the the facility admission packet included an Arbitration Agreement, titled, Voluntary, Binding Arbitration. The arbitration agreement at no time contained any language that explicitly informs the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. Further review of the facility Arbitration Agreement located in the Admission Packet did not reveal any language that allowed the resident or anyone else to communicate with federal, state, or local officials and a representative of the Office of the State Long Term Care Ombudsman. On 12/02/2024 at 10:16 AM during the Entrance Conference, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility includes Arbitration Agreements in the facility Admission Agreement. The LNHA informed the surveyor that no residents have entered into binding arbitration or resolved disputes through binding arbitration on or after 09/16/2019. On 12/05/2024 at 12:30 PM during an interview with the Admissions Director, the surveyor asked does the arbitration agreement state that neither the resident or his or her representative is required to sign the binding arbitration. The Admission Director replied, The document is titled voluntary. On 12/06/2024 at 9:29 AM during an interview with the Licensed Nursing Home Administrator (LNHA), the surveyor asked if the arbitration agreement explicitly says neither the resident nor his or her representative is required to sign this agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. The LNHA replied, I don't see it in this section. On the same date at 10:01 AM during an interview with the LNHA, the surveyor asked does the binding arbitration agreement allow the resident or anyone else to communicate with federal state, or local officials such as federal and state surveyors, other federal or state health employees and representatives of the Office of the State Long Term Care Ombudsman. The LNHA replied, Not in the arbitration agreement but we have the Ombudsman notification form in the admission agreement. The surveyor then asked does the arbitration agreement explicitly state neither the resident nor his or her representative is required to sign this agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. The LNHA replied, No, it does not state in there. N.J.A.C. S 8:39-4.1 (8)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/02/2024 from 9:35 until 10:00 AM, the surveyor, accompanied by the Dietary Director (DD) observed the following in the kitchen: 1. In the walk-in refrigerator, on an orange tiered cart, 15 bags of hot dog rolls with a received by date of 11/11/24. The DD stated he will get rid of them. 2. In the walk-in refrigerator on the second shelf, an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. The DD stated he will get rid of the cucumbers. 3. In the walk-in freezer on top of an opened box, an opened clear plastic bag with pizza dough with no label and no date. The DD stated the pizza dough should have been labeled and dated. The DD threw the pizza dough in the trash. 4. In the prep area, a large container of food thickener and large container of flour were opened and exposed to air. The DD stated the containers should be covered. The DD closed the containers. On 12/04/2024 at 01:49 PM, the surveyor, accompanied by the Nurse Manager #1 observed an unlabeled, covered plate with fish, pork, and fries in the St. [NAME] unit pantry refrigerator. The Nurse Manager #1 stated the plate should be labeled and dated and removed the plate from the refrigerator. On 12/04/24 at 02:00 PM, the surveyor, accompanied by the Nurse Manager #2 observed a plastic container of fresh blueberries dated 11/23/2024 in the [NAME] Garden pantry refrigerator. A few of the blueberries appeared to be dry. The nurse manager was not aware of the expiration date of fresh fruit. The Nurse Manager #2 removed the blueberries from the refrigerator. A review of the facility policy titled Food Storage, revised 2/2024, reflected that refrigerated and ready to eat food shall be held at a temperature of 40 degrees Fahrenheit or less for a maximum of 7 days and refrigerated bread increases shelf life to 14 days. A review of the facility policy titled Freezer with a revised date of 10/2022 reflected that items that require dates in freezers will be dated per industry standards and when items are open or not labeled in freezers items will be discarded. A review of the facility policy titled Foods Brought by Family/Visitors dated 01/02/2024 reflected that perishable foods must be stored in re-sealable containers with tightly fitted lids in the refrigerator/unit pantry. Containers will be labeled with the resident's name, the item and the use by date. A review of the facility policy titled Dietary Practices with a revised date of 02/2024 reflected that all foods are to be protected from other sources of contamination and after food preparation is completed, food items should be stored and covered appropriately. NJAC 18:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to keep all areas clean specifically the hallways by leaving linen bundled up outside the linen cart and in the soiled-utility rooms by leaving trash bags on the floor, stacked up, and untied. The deficient practice was identified on 2 of 4 units reviewed under the Environment Task. The deficient practice was evidenced by the following: On 12/03/2024 at 11:08 AM in the St. [NAME] hallway, the surveyor observed linen including towels and blankets unfolded and piled onto the outside handle of the linen cart. On the same date at 12:15 PM in the St. [NAME] Soiled Utility room, the surveyor observed linens overflowing and not bagged from the receptacle, two trash bags were placed on top of the trash receptacle also. On the same date at 12:19 PM in the St. Mary's soiled utility room, the surveyor observed linens in an untied trash bags left on the floor. On 12/04/2024 at 11:07 AM during an interview with the surveyor, the Infection Preventionist said soiled utility rooms should not be piled up. She confirmed that she makes sure nothing is on the floor. On 12/05/2024 at 1:10 PM during an interview with the Licensed Nursing Home Administrator (LNHA) said soiled utility rooms are to checked twice during the day shift however, they did ask housekeeping to make additional checks. At that time, the LNHA confirmed trash bags should be in receptacles and not on the floor. S 8:39-19.7 (a), (b)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that facility staff failed to use appropriate infection control practices, specifically by failing to wear a gown during high-contact activity in a resident's room who was under Enhanced Barrier Precautions. The deficient practice was identified for 1 of 3 residents (Resident # 190) reviewed for Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 190's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Enhanced Barrier Precautions every shift for [catheter]/wound. The order continued, Enhanced Barrier Precautions (EBP) adherence during high contact resident activities. Must wear Gown & Gloves during: Dressing, Bathing, Transfers, Linen changes, Providing hygiene, Brief changes, toileting assistance, indwelling medical device care, and wound care. DON/DOFF and cleanse hands before and after care . A review of Resident # 190's Care Plan located in the EMR revealed an intervention to, Maintain Enhanced Barrier Precautions-Utilize PPE when performing high-contact resident care. The date initiated was 11/07/2024. On 12/04/2024 at 12:04 PM, the surveyor observed Certified Nurse Aide (CNA) # 1 in Resident # 190's room with the door open and curtain partially drawn. On the door of the room was an Enhanced Barrier Precautions sign indicating that staff are to wear a gown when performing high-contact activities including but not limited to providing hygiene and dressing. At that time, the surveyor was able to see a clean, incontinence brief unfolded near the foot of the resident's bed. At that time, the surveyor observed CNA # 1 in the room providing care to Resident # 190 with gloves and a mask on. CNA # 1 was not wearing a gown. At that time, in the presence of the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) # 1 observed CNA # 1 in the room. UM/LPN # 1 confirmed CNA # 1 was performing incontinence care without wearing a gown. On 12/04/2024 at 11:07 AM during an interview with the surveyor, the Infection Preventionist confirmed Resident # 190 is under Enhanced Barrier Precautions. Further, she confirmed that if the CNA is providing incontinence care, they are expected to wear a gown. On 12/05/2024 at 1:10 PM during an interview with the surveyor, the Director of Nursing (DON) confirmed staff should be wearing a gown and gloves when a resident is on Enhanced Barrier Precautions and incontinence care is being provided. During the same interview, the DON stated, It's Enhanced Barrier Precautions, so it's infection control. A review of the facility policy titled, Enhanced Barrier Precautions dated 3/2024 revealed under, General Overview that, Enhanced Barrier Precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDROs [Multiple-Drug Resistant Organisms]. Further, the policy revealed, Examples of high-contact resident care activities requiring gown and gloves for EBP include but are not limited to: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting . N.J.A.C. S 8:39-19.4 (a)

Complaint: NJ170170; NJ169828 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for a resident that had repeated falls. This deficient practice was identified for 1 of 2 Residents (Resident #347) reviewed for falls and was evidenced by the following: On 12/03/2024 at 11:40 AM, the surveyor requested all accidents and/or investigations from the facility for Resident #347 during the year of 2023. The facility provided fall investigations for incidents that occurred on 2/27/23, 4/23/23, and 4/28/23. Upon review of document titled, Incident Audit Report (IR) dated 2/27/2023 at 4:00 PM revealed under Nursing Description: Called to room [ROOM NUMBER] by CNA [Certified Nursing Assistant] and noted resident sitting on floor next to bed. Identified under Resident Description revealed: Resident said [they were] getting up from [their] bed to go the bathroom and fell to the floor. The IR contained a signed conclusion by the Unit Manager, and a handwritten signed statement from the identified CNA that identified the fall as unwitnessed. Upon review of IR dated 4/23/2023 at 10:30 PM, it revealed under Nursing Description: Resident sitting on the floor next to [their] bed, and [their] wheelchair behind [them]. Identified under Resident Description revealed: Resident said [they're] trying to get up from bed to go to the bathroom but slid down to the floor. Identified under Description of Action Taken revealed: Resident helped up from the floor and assisted to the bathroom. Attached to the IR was an undated and unsigned document dated 4/23/23 at 10:30pm that included, Resident found by CNA during rounds sitting on the floor next to his bed. Prior [to] the incident, resident was in [their] wheelchair which was behind [them]. Resident stated [they were] attempting to go to the bathroom and slid to the floor. No injuries noted upon assessment. Denies hitting [their] head. Resident assisted back to wheelchair and then assisted to the bathroom. Resident was wearing non-skid socks. Wheelchair cushion was inspected with no issues noted. Anti-roll back breaks applied to wheelchair. The IR did not include statements from the identified CNA, vital signs, and did not specify if the fall was witnessed or unwitnessed. The surveyor reviewed the IR dated 4/28/2023 at 1:15 PM that revealed under Nursing Description: This writer summoned to resident room at [approximately 1:15 PM] by Certified Nursing Assistant (CNA) assigned who stated, [the resident] fell to the floor. Identified under Description of Action taken indicated: Resident assisted into wheelchair with the assist of one staff member-unit manager in to evaluate. [Neurological] checks initiated. [Range of Motion] unchanged to upper/lower extremities. Message with [doctor] . Attached to the IR was an undated and unsigned document dated 4/28/23 at 1:15pm indicated, Resident found on the floor next to [their] wheelchair in [their] room. Prior to the incident, resident was sitting in [their] wheelchair after eating the room meal. Denies hitting [their] head and upon assessment, no visible injuries. Resident was assisted back to wheelchair and assessed by Unit Manager. [Neurological] checks were [within normal limits]. Resident has not been feeling well. [Doctor] ordered labs which are pending. Post incident, resident [complained of] back pain. Call placed to [doctor] with order for x-ray of spine. Results noted with age-indeterminate compression fracture of L2. Resident sent to [emergency department]. admitted to facility with hyponatremia. The Incident Audit Report did not include statements from the identified unit manager or CNA, did not specify if the fall was witnessed or unwitnessed, and did not have documentation of vital signs. The surveyor reviewed the medical record for Resident #347. A review of the Admission Record face sheet (an admission summary) reflected that Resident #347 was admitted to the facility with diagnosis that included, but not limited to cardiomegaly (enlarged heart), hypomagnesemia (low magnesium), and repeated falls. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/13/2023, reflected a brief interview for mental status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. On 12/4/2024 at 12:16 PM, the surveyor interviewed CNA#1 who reported that following a resident fall, whether it is witnessed or unwitnessed, the CNA complete a handwritten report of everything that they they did and saw during the incident. On 12/4/2024 at 12:21 PM, the surveyor interviewed Licensed Nurse Practitioner (LPN #1) who advised that following a resident fall, the cart nurse and supervisor/unit manager work together complete a thorough fall investigation. LPN#1 confirmed that nursing is responsible for ensuring that statements are obtained from nursing as both a progress note and risk management assessment in the EMR (electronic medical record), and any witnesses (including the CNA) will be on paper. LPN #1 further explained that the nursing progress note should include the resident assessment, including the resident's vital signs, environmental concerns, resident presentation, where they were found in the room, etc. On 12/5/2024 at 9:18 AM, the surveyor interviewed Licensed Nurse Practitioner Unit Manager (UM/LPN #1) who advised that nursing works together to complete the fall investigation. UM/LPN #1 confirmed that statements are obtained from everyone that witnessed or was involved in the fall. UM/LPN #1 advised the CNA would fill out a form since they do not have access or the EMR progress notes. The UM/LPN #1 advised that the nursing documentation should include vital sings, if the resident is prescribed any blood thinners, reports of pain, etc. UM/LPN #1 confirmed that the Director of Nursing would review the fall investigation to ensure completeness. UM/LPN #1 reviewed the IR completed for 4/23/23 and 4/28/23 and confirmed that were no statements obtained, no vital signs documented, and no name, title, or date of the investigation summary. On 12/5/2024 at 11:12 AM, the surveyor interviewed the Director of Nursing (DON) who reviewed the 4/23/23 and 4/28/23 IRs and confirmed that statements were not obtained and that she could not identify who completed the IR conclusion summary since it was not signed. The DON also acknowledged that thorough nursing documentation was not completed since there were not vitals signs documented on the IR. When asked if the two IRs were thoroughly completed, the DON stated no. On 12/5/202 at 10:09 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, and Regional Clinical Nurses acknowledged that the facility does not require handwritten statements or names of witnesses in their fall investigations but could not speak to the facility policy. A review of the facility's policy titled, Fall Prevention/ Management, with an effective date of 6/2017 and revised date of 3/2023, documented under Procedure: An incident report will also be initiated for any unwitnessed or witnessed fall . A review of the facility's policy titled, Accident and Incident Investigation, with an effective date of 10/2018 and revised date of 1/202, documented under Policy Interpretation and Implementation: The following data, as applicable, shall be included on the Report of Incident/Accident Form: E. The name(s) of witnesses and their accounts of the accident or incident; I. The condition of the injured person, including his/her vital signs; M. The signature and title of the person completing the report. NJAC 8:39-9.4(f)

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F 804 F During the standard survey, the surveyors conducted meal observations on 10/5/23 and on 10/10/23. On 10/5/23 beginning at 12:25 PM, the surveyor observed the lunch service in day room one. The surveyor observed the lunch tray preparation begin at 12:25 PM, and ended with the last lunch tray served at 1:05 PM. During the observation, some trays were handed to the residents in the day room one, and some tray were placed on an open tray cart to be delivered to the resident rooms. On that same day at 12:45 PM, the open food cart contained the resident lunch trays and left the day room and were placed in the hallway. On that same day at 1:05 PM, as the last tray was to be hand to the resident, the surveyor requested the FSD to obtain food temperatures on that tray. The FSD obtained the food temperatures which were not within acceptable ranges. The FSD stated that none of the hot and cold food items met acceptable food temperatures. On 10/13/23 beginning at 7:58 AM, the surveyor observed breakfast service on the second floor day room two. At 7:58 AM, the breakfast arrived to day room two. The Dietary Cook (DC) obtained the temperatures of the breakfast food, and returned the food to the kitchen because the food was not hot enough. On that same day at 8:19 AM, the Dietary Cook (DC) returned to dayroom two with the breakfast food, and obtained the temperatures. The surveyor observed the that the first tray was plated at 8:28 AM. The last tray was plated at 9:41 AM and was served at 9:59 AM. At that time, the surveyor requested the FSD to obtain food temperatures on the last tray. The FSD obtained the food temperatures and none of the hot and cold food items met acceptable food temperatures. The FSD stated the temperatures taken were not with in regulation and that the breakfast should not have taken more than one hour to be served. A review of the resident council minutes revealed the following concerns regarding food temperatures: January 2023- Food did not stay hot, waited too long for dinner to be served. Administrator stated dietary department was working to correct that by using insulated lids, plate warmers, and putting trays on fewer carts. The Administrator acknowledged tray delivery time must be improved. February 2023-food was cold at breakfast- Administrator stated measures had been taking including insulated lids, fewer trays on a cart, plate warmers, hot boxes, additional staff handing out trays, and cart covers to keep food hot. Resident stated only a few trays were delivered as soon as the cart arrived, and the rest were left sitting in the hallway. March 2023 - a resident stated the steam table or plate warmer was not plugged in day room [ROOM NUMBER], and there were concerns with tray pass and roommates not being served at the same time. June 2023- the eggs were often cold. A resident stated plate warmers were not plugged in early enough to get the food warm. July 2023- plated food was sometimes cold tray passing must be a priority. Food plated in the day room was usually cold by the time it was served. September 2023- food often cold at night. A resident asked if tray cart covers could be purchased to keep the food hotter. During an interview with the surveyor, in the presence of the survey team on 10/18/23 at 1:16 PM, the Administrator stated that QAPI was held monthly, and all department heads attended. The Administrator stated the QAPI was held for tracking and logging with a current focus on meal temperatures and ticket tray accuracy. The Administrator stated that they set goals and see what can be put into place to reach the goals. At that time, the surveyor explained the deficiency regarding food temperatures from the prior survey, the resident council concerns regarding food temperatures and the temperature and tray pass observations on survey. The surveyor asked what the facility's QAPI plan was and how it was reviewed for effectiveness. The Administrator stated that the facility always looks to see what may need to improve and they are currently thinking outside of the box. The Administrator stated that the temperatures were not met during the meal observation on on survey because the hot box was not being utilized. The surveyor was provided with the facility's documentation for their QA on the dietary concerns. A review of an undated document titled, Resident Tray Distribution revealed that the challenge was to ensure that all resident meal trays were passed in a timely manner (with in 7 minutes) once the trays have been delivered to the unit. The goal was to have trays passed in less than 7 minutes from the time the trays are delivered to the unit, until the time the trays were in front of the residents. The plan was to have weekly audits of resident meal tray distribution, with a minimum of 8 per month. The evaluation included monthly meeting with the Administrator, Unit Managers, Director of Nursing, Assistant Director of Nursing, Food Service Director, and Assistant Food Service Director to review the audits and create a plan of action if required. The findings would be reported to the quarterly QA meeting. A review of a document, titled, Food and Nutrition Tray Distribution Audit completed and signed by the FSD included the following questions: What time trays start getting made for test tray cart; What time trays get to unit/hallway; What time did the first tray get passed from the cart, on the unit/hallway; What time was the last tray passed from the cart, on the unit/hallway and What was the time elapsed from beginning the trays were being made to the last tray delivered on unit/hallway. There was no documented evidence on what unit or hallway the trays were observed. A reviewed of the FSD's monthly Dietary Focused QA Summary from January 2023 to September 2023 revealed, trays are not always being delivered in a timely manner to residents. A review of an undated document titled, Food Temperature & Ticket Accuracy 2023 revealed that the challenge was ensuring all foods were at the correct temperature. The goal was to strive for 90% or better meal temperature. The plan was to conduct weekly audits of resident meal trays with a minimum of 16 per month. The evaluation included weekly meeting with Administrator, Dietician, Department Heads, FSD, AFSD, to review audits and create a plan of action if required. The findings would be reported to the quarterly QA meeting. A review of the audits revealed that in January 2023, nine (9) trays for food temperature were audited, February 2023, eight (8) trays for temperature were audited, June 2023, eight (8) trays for food temperatures were audited, August 2023, eight (8) trays for food temperatures were audited, and in September 2023, nine (9) trays for food temperatures were audited. For the aforementioned audits, tray temperatures came back with a score of 90%. Those that did not have correct temperatures, lid covers were placed, plates were placed in the plate warmer, and insulated bases were implemented each time. During an interview with the FSD in the presence of the survey team on 10/19/23 at 9:33 AM. The FSD stated he completed his own in-services for his staff. He stated he attended QAPI every quarter and had a QAPI in place due to a deficiency the prior survey. He stated his QA was to take test trays of food temperatures and the temperatures came back fairly well with a score of greater than 90%. The surveyor reviewed the FSD's audits in the presence of the FSD who stated that there was no way to identify which unit the audit was completed on his documentation. The FSD stated that the audits should have included the unit where the temperatures where taken to be able to identify. When asked what process had changed, the FSD stated that they had opened up the dining rooms and fallen short and it had not been effective. The surveyor reviewed the FSD's monthly Dietary Focused QA Summary with the FSD which indicated from January 2023 through September 2023, trays are not always being delivered in a timely manner to residents. The FSD stated he had notified the Director of Nursing and the Administrator during the monthly QA meeting and explained that trays were not passed in a timely manner which make the residents wait and the food was losing temperature. The FSD stated that he reports his concerns during the monthly QA meeting and was not provided feedback on his findings to remedy the problem. During an interview with the survey team on 10/19/23 at 10:19 AM, the Assistant FSD stated he attends as many resident council meetings as he could and the residents generally complain of cold food. He stated the cold food complaints were reported to the Administrator. He stated hot boxes were purchased, and once the trays go to the cart, they sit for at least twenty minutes before they were passed. During an interview with the survey team on 10/19/23 at 11:55 AM, the surveyor reviewed the dietary audits with the Administration. The audits did not identify a location of where the audits were conducted. The surveyor reviewed the January 2023 through September 2023, summary of QA dietary department which revealed that every month, trays are not always being delivered in a timely manner to residents and asked how this was addressed. The Administrator replied, I understand, I understand. The Administrator stated dietary should not be doing the audits. The Administrator added, we changed service areas, we have to think outside of the box, either it's not coming hot enough off steam table. When asked about data collection monitoring, root causes analysis to monitor the effectiveness of their QAPI, the Administrator responded, I have never done it like that. Review of an undated facility's QAPI Purpose Statement included the facility strived to provide high quality of life for the residents, improved quality measures by evaluating present time data collected, and taking action when needed. Guiding principles included, Our organization uses quality assurance and performance improvement to make decisions and guide our day to day operations the outcome of QAPI in our organization is the quality of care and quality of life of our residents .QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals .Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care practitioners, families and other stakeholder .sets goals for performance and measures progress towards those goals .The goals of QAPI are to improve the quality of life, care and services for individuals in nursing homes. The QAPI philosophy is to ensure a systemic, comprehensive, data-driven approach to care. The results of QAPI may prevent adverse events, promote safety and quality and reduce risks for residents and care givers. NJAC 8:39-31.6 (g); 33.1 (d); 33.2 (a)(b)(c)

REPEAT DEFICIENCY Complaint # NJ 159503, NJ 160417, NJ 162667 Based on observation, interview, and review of facility documentation it was determined that the facility failed to consistently serve foods at safe and appetizing temperatures. This deficient practice was identified for 2 of 2 units reviewed and was evidenced by the following: 1. On 10/05/23 At 12:25 PM, the surveyor observed large stainless trays with lunch food arrive to the day room one steam table. There were 13 residents seated in day room one waiting for lunch to be served. All of the other unit residents from the first floor had lunch in their rooms. The food service staff began making lunch trays from the steam table. As the trays were being prepared for the residents some trays were handed to the residents in day room one and other trays were placed on a silver open tray cart to be distributed to resident rooms. Trays were placed on the cart for delivery to rooms prior to all of day room one residents receiving their trays. On 10/05/23 at 12:45 PM, the open cart with the resident trays left the dining room and was placed in the hallway on the unit. On 10/05/23 at 12:49 PM, the unit staff began handing out the seven trays for the first-floor wing being observed. At 01:05 PM, just prior to the final tray being handed to the resident the surveyor requested the FSD to obtain food temps on that selected tray. The temperatures were as follows: Cheeseburgers @ 121.5 degrees Fahrenheit (F), Onion rings @ 101.3 degrees F Green bean salad (warm salad per FSD) @ 111.6 Four ounce carton of milk @ 58 degrees F. The tray was discarded after temperatures were obtained. Immediately following completing the temperature checks, the FSD responded, I know none of them meet temp. 36419 2. On 10/10/23 at 7:58 AM, the surveyor observed large stainless trays with breakfast food arrive to the second floor day room [ROOM NUMBER] steam table. There were no residents in day room [ROOM NUMBER]; all residents who reside on the second floor were served breakfast in their rooms. The Dietary Cook (DC) in the presence of the surveyor took food temperatures with his calibrated thermometer. The following temperatures were obtained: Strawberries with syrup @ 100 degrees Fahrenheit (F) Pureed French toast @ 138 degrees F Boiled eggs @132 degrees F At that same time, the DC stated that he would have to bring the above items back to the kitchen because the temperatures needed to be at least 145 degrees F and that all other food temps were above 145 degrees F. On 10/10/23 at 8:07 AM, the DC brought the above items back to the kitchen. On 10/10/23 at 8:19 AM, the DC returned to day room [ROOM NUMBER] with the aforementioned foods and again sampled the temperatures. The following temperatures were obtained: Boiled eggs @ 155 degrees F Pureed French Toast @145 degrees F Strawberries with syrup @ 130 degrees F On 10/10/23 at 8:28 AM, the surveyor observed the following: At 8:28 AM, the first meal was plated. At 8:34 AM, the first silver open food cart was brought to the Ivy Unit for distribution. At 9:40 AM, the Food Service Director (FSD) arrived to day room [ROOM NUMBER] with an additional large stainless tray with cream of wheat which he placed on to the steam table. At 9:41 AM, the last meal was plated. At 9:42 AM, the last open cart was brought to the [NAME] Garden Unit for distribution. At 9:43 AM, the surveyor asked the DC to temp the french toast, strawberries with syrup and sausage patty. The DC stated he misplaced his thermometer. At 9:46 AM, the DC dumped all the bowls out of a large box and discovered the thermometer. The DC told the surveyor that he still couldn't take temps with that thermometer because it was, acting up. The FSD stated that he would go get a new calibrated thermometer. On 10/10/23 at 9:59 AM, the surveyor observed the last tray served which contained french toast, ground sausage patty and coffee. At that time, the surveyor requested the DC to again sample the food temperatures. Then with a new calibrated thermometer the following temperatures were obtained: french toast with strawberries in syrup @ 127 degrees F ground sausage patty @ 111 degrees F. The DC stated that the temperatures were not within regulation. The DC further stated that meal service should have been completed within one hour, not two hours and that he didn't know what happened. On 10/10/23 at 10:30 AM, the surveyor interviewed the Food Service Director (FSD). The FSD stated that hot foods should be above 140 degrees F and cold foods should be below 41 degrees F in order to prevent food-born bacteria. The FSD agreed that the temperatures were not maintained at appetizing temperatures for the residents. The FSD stated that meal service should take no more than an hour, definitely not two hours. On 10/11/23 at 9:36 AM, the surveyor observed the last breakfast tray delivered to the room of an unsampled resident. On 10/11/23 at 9:38 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager ( LPN/UM) #2, who stated that meal service should be completed within one hour and that all available staff were expected to help pass out trays. The LPN/UM #2 further stated that she did not have a list of residents, nor was she aware of which residents preferred to receive early meal trays so that they could attend activities of their choice including church services. On 10/18/23 at 12:16 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Clinical Nurse. The DON stated that when the DC removed the trays of food from the steam table they should have been placed back into the heated truck and transported back to the kitchen. No further information was supplied. A review of a facility policy titled, Food Temperatures, with an effective date of 11/30/17 indicated that the foods are stored, prepared, and served at proper temperatures. Under the process section of the policy, it revealed that all time/temperature control for safety food must maintain an internal temperature of 41 degrees Fahrenheit or lower for cold foods and 140 degrees Fahrenheit or higher for hot foods while being held for service, internal cooking temperature, and holding temperatures of foods. NJAC 8:39-17.4(e)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) practice appropriate hand hygiene between residents after direct contact with residents during meal service on 1of 2 units (day room [ROOM NUMBER]) b.) perform hand hygiene when handling a contaminated item from the floor on 1 of 2 units (day room [ROOM NUMBER]) and c.) ensure that a urinary catheter drainage bag was stored in a manner to prevent the spread of infection forone of five residents reviewed for urinary catheters and urinary tract infections (UTIs), Resident #137. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:13 PM, the surveyor observed meal service on the second floor day room [ROOM NUMBER]. At 12:13 PM, the surveyor observed the food truck arrived on the second floor day room [ROOM NUMBER]. At 12:14 PM, the surveyor observed a certified nurses aide (CNA) #6 assisting 4 unsampled residents with hand hygiene using hand wipes. CNA #6 proceeded to cleanse the hands of each unsampled resident without sanitizing or performing hand hygiene between the 4 residents. At 12:18 PM, CNA #7 entered day room [ROOM NUMBER] and began cleansing the hands of Resident # 80, Resident #108 and two unsampled residents with hand wipes without performing hand hygiene between residents. On 10/13/23 at 12:05 PM, the food truck arrived on the second floor in day room [ROOM NUMBER]. At 12:09 PM, the surveyor observed CNA #6 use hand wipes to clean the hands of 8 unsampled residents. The surveyor observed that CNA #6 did not perform hand hygiene between residents. At 12:15 PM, the surveyor interviewed CNA #6 who acknowledged that she had not performed hand hygiene before and after cleaning the residents hands because she was rushing today. The surveyor explained to CNA #6 that during meal service on 10/4/23 she observed CNA #6 using hand wipes to clean residents hands and did not observe CNA #6 perform hand hygiene after touching and cleaning each residents hands. CNA #6 stated that she was also rushing on that day but acknowledged the importance of performing hand hygiene in order to prevent the spread of infection. On 10/16/23 at 9:43 AM, the surveyor interviewed CNA #7 in the presence of the Licensed Practical Nurse Unit Manager (LPN/UM) #2. The surveyor asked CNA #7 her process for providing hand hygiene for residents prior to meals. CNA #7 stated she used hand wipes to clean the residents hands. The surveyor asked CNA #7 what she did after cleaning the hands of one resident before assisting another resident. CNA #7 replied, dry their hands. The surveyor asked LPN/UM #2 if it was her expectation that the CNA performed hand hygiene between residents. LPN/UM replied, of course. CNA #7 acknowledged that she should be performing her own hand hygiene between residents but stated that she had not been doing that. 48964 2. On 10/04/23 at 1:19 PM, during dining observation in the 1st floor day room, the surveyor observed Activities Aide #2 (AA #2), pick up a cup that had fallen on the floor and without performing hand hygiene continued to assist with passing lunch trays to the residents. On 10/13/23 at 11:05 AM, the surveyor interviewed AA #2, who stated that when assisting with meal service, if something fell on the floor he would pick it up and put it to the side, so it was not used. He stated he was unaware of the need for hand hygiene after picking up an object off the floor; however, he verbalized the need to perform hand hygiene. 44833 3. On 10/03/23 at 10:41 AM, the surveyor observed Resident #137 resting in bed watching television (TV). The resident had an indwelling catheter for urine collection. The collection bag was observed to be resting on the floor under the resident's bed without a privacy bag and with no protective barrier between it and the floor. The resident informed the surveyor that they have had an indwelling catheter for a couple years and had experienced multiple urinary tract infections in the past, with the most recent being approximately a couple months ago. On 10/11/23 at 9:22 AM, the surveyor observed the resident eating breakfast in bed with the indwelling catheter's urine collection bag resting on the floor under the bed with no privacy bag or barrier between it and the floor. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included but not limited to retention of urine, neuromuscular dysfunction of bladder (miscommunication between the nerves and muscles), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous prostate enlargement), and urinary tract infection. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 7/3/2023, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A further review reflected the resident had an indwelling catheter. A review of the resident's individualized resident-centered Care Plan included a focused care area with an initiation date of 11/23/2021 indicating the resident had an indwelling urinary catheter, with interventions including but not limited to providing catheter care as ordered. A review of the resident's physician's orders (PO) included an active order started on 5/31/2023 for catheter care every shift. On 10/13/23 at 9:36 AM, the surveyor interviewed Certified Nurse Aid #3 (CNA #3) who stated that indwelling urinary catheter bags should be hanging from the side of the bed below waist level in a privacy bag and not on the floor, stating the reason it should not be on the floor is for infection control, since residents can get an infection through the tubing if it was on the floor. On 10/13/23 at 10:38 AM, the surveyor interviewed Licensed Practical Nurse #2 (LPN #2) who stated that indwelling catheter urine collection bags should never be unprotected on the floor and should be in a privacy bag hanging from the side of the bed below waist level. LPN #2 further added that if the bag was on the floor, it was definitely an infection control issue and it should be changed. On 10/13/23 at 10:48 AM, the surveyor interviewed the Infection Preventionist nurse (IP) who stated that indwelling catheter collection bags should not be on the floor due to infection control, and that having the bag on the floor was not appropriate. On 10/13/23 at 10:59 AM, the surveyor interviewed the DON who confirmed that having the catheter bag on the floor was not acceptable and was an infection control concern. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns. Review of the facility's Handwashing/Hand Hygiene policy and procedure with an revised date 06/10/2022, revealed the following: The facility considers hand hygiene the primary means to prevent the spread of infections. The policy reflected that .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, soap (antimicrobial or non-antimicrobial) and water . Review of the facility's Urinary Catheter Care policy with a revision date of 3/2021 under the section labeled Infection Control included: Be sure the catheter tubing and drainage bag are kept off the floor. NJAC 8:39-19.4 (a)1(m)(n);27.1(a)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) ensure activity staff were wearing hair nets when entering the kitchen. This deficient practice was observed and evidenced by the following: 1. On [DATE] at 09:45 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the Assistant Food Service Director (AFSD) attempt to remove two boxes of croissants that were not properly labeled with open or discard dates. The first box contained 7 unwrapped croissants and the second box was unopened and did not include a received or a discard date. The surveyor interviewed the AFSD, who confirmed that the 2 boxes of croissants were being discarded because they were not properly labeled. In the walk-in refrigerator, there was a large cart full of sandwiches that not properly labeled. The FSD stated the items were taken from the boxes that were labeled and placed in the cart that they use daily. The FSD confirmed that the sandwiches should have been dated. In the walk-in freezer, there were three large silver trays that contained unwrapped food exposed to the air. The AFSD placed a piece of paper over the top of the trays with a date of [DATE] which was the date of the tour. The FSD confirmed that the trays should have been thoroughly wrapped, labeled, and stored properly. Upon exiting the walk-in refrigerator, the surveyor observed the AFSD with a black marker writing on large containers from the spice rack. The surveyor observed 13 large bottles of spices and sauces to include soybean oil, barbeque sauce, and soy sauce that were not properly labeled with received, opened, or discard dates. The FSD confirmed that the spices and sauces should have been dated when they were received and should include an expiration date. On that same day at 9:57 AM, the surveyor observed two boxes of white coffee filters that were open, uncovered and exposed to air in the paper product storage area. The FSD stated that the coffee filters should have been covered to prevent dust, debris, and any dirt from coming in contact with them. The surveyor observed a dented can in the non-dented can area in the dry storage area. The FSD confirmed the dented can should not be with the non-dented cans. On [DATE] at 10:06 AM, the surveyor observed two tall food warming carts that had buildup of a black, greasy substance on the inside doors, on three trays that were inside, and on the warmer bottoms. The FSD stated the warmers were used for breakfast and acknowledged there were lunch items in the warmers. The FSD confirmed there was debris in the warmers and stated the warmers should have been cleaned between each meal preparation to prevent cross contamination. On the same day at 10:12 AM, the surveyor observed an uncovered mixing bowl exposed to the air. The FSD stated that the mixing bowl was clean and should have been covered. On [DATE] at 10:17 AM, the surveyor observed the dumpster area which had debris on both sides of the compactor to include used face masks, wooden sticks, 2 broken florescent bulbs, plastic bags, newspapers, a juice cup, and a milk carton. The FSD acknowledged the debris. 40744 2. On [DATE] 11:18 AM, the surveyor observed 18 place settings for lunch meal in the main dining room. The place settings included an inverted plastic blue mug, two clear plastic cups, utensils, and a napkin. The surveyor observed the inside of the mugs. Two of the mugs had a brown powder like debris, one had a brown powder like debris and a piece of a wet white substance, one had a brown powder like debris and several white spots. The surveyor interviewed a cook who acknowledged that the mugs were not clean and stated, Not at all, I'm sorry. Upon further interview the cook stated there was no specific staff member who was responsible for the place settings. On [DATE] at 11:01 AM, the surveyor observed 18 place settings for lunch meal in the main dining room which included inverted plastic blue mugs. Two of 18 mugs had a brown powder like debris and one mug also had two brown particles. On [DATE] at 10:39 AM, the surveyor interviewed a dietary staff member (DS) regarding the table settings. The DS told the surveyor that the task of setting the tables was rotated among staff, and it changes daily. She stated, I haven't done this in four months. The DS further stated that the staff check the cups for cleanliness. She also described the cleaning process for the mugs as follows: They get soaked every Sunday only, we can't do it every day because if it's lunch time and we would be behind because there are only so many cups, and we only have enough cups for one meal setting. If cups are soiled, we would remove it and sometimes we have an extra staff person who can soak a few cups on that day. On [DATE] at 11:52 AM, the surveyor interviewed the Food Service Director (FSD) regarding the cleaning process of the plastic mugs. The FSD stated the mugs were de-stained on Sundays, Every Sunday, we soak them in an urn with cleaner, then each one gets hand wiped on the inside and then sent through the dish machine. The FSD stated, I notice a few of them have not been completely clean and they should be checked before they put them out. 37217 3. On [DATE] at 12:03 PM, the surveyor was conducting a dining observation in the main dining room. The surveyor observed a sign by the entrance to the kitchen that read, Hair nets All staff members are required to wear a hairnet prior to entering the kitchen. Located below the sign was a mounted bin that contained hair nets. On [DATE] at 12:26 PM the surveyor observed Activity Aide (AA) #1 enter the kitchen, walk around, exited and reentered the kitchen. AA #1 had long hair and was not wearing a hair net. At 12:26 PM, the surveyor observed AA #2 enter the kitchen walked around kitchen, left the kitchen, entered the kitchen again and exit the kitchen. AA #2 had visible hair on his head and was not wearing a hair net. During an interview with the surveyor on [DATE] at 12:28 PM, AA #2 stated that she was getting cups and was not sure if she needed to wear a hair net. The surveyor showed the sign by the kitchen entrance to AA #2. AA #2 replied that she didn't know. During an interview with the surveyor on [DATE] at 12:55 PM, AA #1 stated he was not aware he needed to wear a hair net when entering the kitchen. During an interview with an additional surveyor on [DATE] at 10:29 AM, the FSD stated that hair nets need to be worn before entering the kitchen so there's no hair or foreign debris in the food and also for the plates and the cups. The surveyor reviewed the facility's revised policy dated [DATE] titled, Received on Date/Expired Items which revealed the facility would follow established methods for dating items that were delivered and discarding out of date items immediately. Procedure: 1. When receiving any food items from the vendors, each item will have a Received on Date written on the packaging. If an item is removed out of the packaging (i.e. Apple Pie) the received on date will be written on the individual item, using the original date. 2. During opening and closing rounds, the management team or designee will check to make sure all appropriate dating is found and accurate. The surveyor reviewed the facility's revised policy dated for [DATE] titled, Labeling and Dating of Pulled Frozen Items, which revealed the purpose was to safely and correctly label and date frozen foods being thawed. Procedure: 1. Any item that is pulled from the freezer to the refrigerator for thawing shall have the following information listed on the parchment paper/label a. item description, b. pulled on date, c. amount pulled for thawing, d. which meal the item is for, e. use by date, f. employee initials. 2. Parchment paper/label will be replaced when soiled using the same information listed above. The surveyor reviewed the revised policy dated for [DATE] titled, Dented Cans which revealed the facility will ensure that no dented cans were utilized in daily production. Procedure: Any employee that comes across a dented can must remove said can and place on the dented can rack which is clearly labeled and visible in the kitchen. 2. The employee shall alert a manager who will then take the appropriate actions. The surveyor reviewed the policy dated for [DATE] titled, Cup Destaining. The purpose of the policy was to maintain a clean and stainless hot beverage cup. Under the section titled process, it included the process for the cup destaining and that the cups were destained every Sunday. The policy did not have a process to destain if needed on any day other than a Sunday. A review of a facility policy with a subject titled, Hair Covering and Beard Covering revised on [DATE] included that the facility would follow established methods for use of hair nets and beard covers. The purpose was to ensure no foreign items specific to bodily hair, are to contaminate not only food items, but also other equipment. The procedure indicated that any employee or guest entering the food and nutrition department, kitchen or tray line service area will be required to wear at all times a hair covering for the head. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to monitor and document the amount of fluids administered on a resident on hemodialysis with fluid restriction. This deficient practice was identified for 1 of 2 residents reviewed for dialysis, Resident #171, and was evidenced by the following: On 10/04/23 at 12:09 PM, the surveyor observed Resident #171 in their room and observed an unmarked white cup with a lid on the overbed table. The resident stated the cup contained water and would drink the water but not too much. The resident opened the cup and showed surveyor the contents of the cup. The resident further stated that they received hemodialysis three times a week and was also on a fluid restriction. The surveyor observed a picture of a water pitcher taped next to Resident #171's room number and name on the door. On 10/04/23 at 12:12 PM, the surveyor interviewed the Certified Nurses Aide (CNA #5) who stated the water pitcher on the resident's door meant the other resident in the room was on water with thickener. On 10/04/23 at 12:24 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #5) outside the resident's room, who stated Resident #171 received hemodialysis and was on a fluid restriction. LPN #5 stated the resident was on a fluid restriction of 800 milliliters (ml) for the 7-3 shift, 500ml for the 3-11 shift, and 200 ml for the 11-7 shift. At that time, the LPN saw the white cup with water on the resident's overbed table. LPN #5 stated residents on fluid restrictions were not supposed to have a water cup at their bedside and removed the cup. On 10/05/23 at 11:37 AM, the surveyor observed a white cup with dark liquid with ice in it on top of Resident #171's overbed table. On 10/10/23 at 7:54 AM, the surveyor observed a white cup half-filled with water on the resident's bedside table. According to the Admission Record, Resident #171 had diagnosis which included but were not limited to End Stage Renal Disease, Anemia, Heart Failure, Type 2 Diabetes Mellitus. A review of the resident's Annual Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. A review of the resident's care plan initiated 07/27/2022 revealed resident was on 1500ml Daily Fluid Restriction which included; Nursing-7-3 800ml, 3-11 500 ml, 11-7 200 ml with fluid preferences of water and coffee. A review of the resident's Physician's Orders (PO) dated 01/25/23 revealed an order for: 1500 ml Fluid Restriction, Nursing serve (7-3 800 ml, 3-11 500 ml, 11-7 200 ml) fluid preferences of coffee, water. A review of the resident's Medication Administration Records (MAR) revealed the aforementioned PO with following dates that Resident #171's fluids per shift were not documented: July 2023 MAR from 07/01/23 to 07/31/23; August 2023 MAR from 08/01/23 to 08/31/23; September 2023 MAR from 09/01/23 to 09/30/23; and October 2023 MAR from 10/01/23 to 10/03/23 On 10/10/23 at 8:21 AM. the surveyor interviewed the Unit Manager LPN (UM/LPN #3) who stated Resident #171 was on hemodialysis with a fluid restriction of 1500ml a day. She further stated nurses would give the resident fluids in the amount scheduled for the shift and then would document the amount of fluid that was given in the resident's electronic Medication Administration Record (eMAR) at the end of their shift. On 10/10/23 at 9:45 AM, the surveyor interviewed the Director of Nursing (DON). who stated residents who were on fluid restriction must have an order from the physician. The DON further stated staff would know if residents were on fluid restriction because of the water pitcher picture next to a resident's name on the door. The DON stated only nurses would give fluids to residents who have a fluid restriction and that residents should not have water cups at their bedside. The DON stated nurses would document the amount of fluids the resident had at the end of their shift in the eMAR. DON stated the nurses of resident #171 should have documented the amount of fluids in the medication administration record. A review of the facility's Policy & Procedure on Restricting/Encouraging Fluids General Policy Guidelines with revised date of 04/2021, #4 stated to record fluid intake in milliliters (ml) in the eMAR, #8 when resident is placed on restricted fluids, remove the water pitcher and cup from the room, and #6 document the amount in mls of fluids consumed by the resident during the shift. NJAC 8:39-2.9

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to inform, and provide written information to all adult residents concerning the right to formulate an advance directive. This deficient practice was identified for 1 of 35 residents reviewed (Resident #19) and was evidenced by the following: 1. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair next to the left side of the bed. The resident greeted the surveyor with a smile. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed with their eyes closed. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in a chair eating breakfast. A review of the resident's Admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. On 10/11/23 at 12:33 PM, the surveyor interviewed the Director of Social Services who stated that the facility's policy was to discuss Advance Directives on admission and then quarterly but for some reason Advance Directives were not discussed for Resident #19. On 10/12/23 at 10:50 AM, the surveyor interviewed the Social Worker who stated that after the surveyors inquiry the Social Worker sent an email to Resident #19's family with information regarding Advance Directives. On 10/18/23 at 12:16 PM, the survey team met with the Administrator, Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns. No further information was provided. A review of the facility's policy and procedure titled Advanced Directives, revised 11/2020 reflected . on admission the facility will determine whether the resident has an advance directive, and if not, determine whether the resident wishes to formulate an advance directive. .If an adult individual is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility will give advance directive information to the individual's resident representative. NJAC 8:39 - 4.1 (a); 9.6(a) (e)

Complaint # NJ 159668 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to maintain the call bell within reach for two of thirty-five residents (Resident #19) and (Resident #82) reviewed for accommodation of needs and was evidenced by the following: 1. A review of Resident #19's Admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair by the left side of the bed with the call bell wrapped around the upper right side rail. On 10/11/23 at 10:26 AM, the surveyor observed Resident #19 in their wheelchair with the call bell wrapped around the upper right side rail. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed. The surveyor observed the call bell wrapped around the upper right side rail. The NA stated that she had assisted Resident #19 into the wheelchair sometime before 9:00 AM. At that time, the NA told Resident #19 it was lunch time, assisted Resident #19 back into their wheelchair, and left the resident's room with the call bell still wrapped around the upper right side rail. On 10/11/23 at 11:59 AM, the surveyor asked the NA to enter Resident #19's room and the surveyor showed the NA the call bell wrapped around the upper right side rail not within Resident #19's reach. The NA stated that she should have put the call bell within the resident's reach first thing that morning when she assisted Resident #19 into their wheelchair but she forgot, it wasn't intentional. On 10/11/23 at 12:02 PM, the surveyor interviewed LPN/UM #2 in the presence of the NA. The LPN/UM #2 stated that the NA received an in-service on keeping call bells within residents' reach, beds in the lowest position, and providing [NAME] every shift. The NA acknowledged that she had received that information during orientation. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in chair of the left side of the bed, eating breakfast meal with the call bell wrapped around the right upper side rail. On 10/12/23 at 9:49 AM, the surveyor interviewed CNA #8 who stated that she provided morning care to Resident #19 and assisted her/him to the chair before 8:00 AM that morning. On 10/12/23 at 9:50 AM, the surveyor showed LPN/UM #2 and CNA #8 Resident #19's call bell which was wrapped around the right upper side rail. The LPN/UM #2 stated that CNA #8 had not been present for the speech she gave to all the CNAs reminding them that all call bells should be kept within residents' reach when in or out of bed but acknowledged CNA #8 should have already known this. CNA #8 acknowledged the call bell should be kept within the resident's reach. 2. On 10/3/23 at 11:42 AM, the surveyor observed Resident # 82 seated in a wheelchair positioned on the right side of the bed, with the call bell on the left side of the bed not within Resident #82's reach. A review of Resident #82's Admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, depression, anxiety, difficulty walking, and repeated falls. A review of Resident #82's Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/1/23, indicated Resident #82 had a moderate cognitive impairment, and required extensive assistance from staff for bed mobility and was dependent on staff for dressing, toilet use and personal hygiene. On 10/16/23 at 9:07 AM, the surveyor observed Resident #82 in bed with the call bell hanging down of the left side of the bed towards the floor. The surveyor asked the resident how they contacted staff for assistance. Resident #82 replied, I push the button on the call bell when I can reach it. Resident #82 further stated that when the resident couldn't reach it, their roommate would use their call bell to call for them. The surveyor asked Resident #82 how often they were unable to reach the call bell. Resident #82 replied that they were not sure but stated that the roommate helped a lot. On 10/16/23 at 9:14 AM, the surveyor interviewed the resident's alert and oriented roommate who stated that Resident #82 asked the resident to call nursing staff at least two times a day. On 10/16/23 at 10:22 AM, the surveyor observed Resident #82 seated in their wheelchair with their call bell within reach. Resident #82 stated with a big smile on their face, I can reach my call bell now! On 10/16/23 at 10:38 AM, the surveyor interviewed CNA #7 who stated that she had recently answered the call light for Resident #82's roommate. When CNA #7 answered the call light, the roommate stated that it was actually Resident #82 that needed assistance. Resident #82 told CNA #7 that they were unable to find their call bell. CNA #7 stated she picked Resident #82's call bell up off the floor and handed it to the resident. CNA #7 further stated that she had not had a chance to make rounds that morning, so she was not sure how long Resident #82's call bell was on the floor. On 10/16/23 at 10:45 AM, the surveyor interviewed LPN/UM #2 who stated that her expectation was that the unit Nurses and CNAs made rounds every morning making sure all residents are okay, call bells are within reach and the beds are in the lowest positions. On 10/16/23 at 10:53 AM, the surveyor interviewed RN #1 who stated that she did not make morning rounds so she had not been aware that Resident #82's call bell was on the floor. RN #1 further stated that she had not gone into Resident #82's room until after breakfast but should have made rounds to ensure the resident was okay and that the call bell was within reach. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing and Regional Registered Nurse to discuss the above concerns. Review of the facility's policy and procedure titled Call Bell Response, revised on 12/2021, reflected . staff is to ensure that the call bell is within reach for ease of use. NJAC 8:39- 31.8 (c) (9)

Based on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promoted his/her quality of life for a.) a resident whose preference was to attend church services and was not provided their breakfast tray in a timely manner for 1 of 35 residents (Resident #108) and b.) a resident whose preference was to get out of bed was not honored 1 of 35 residents, (Resident #55) reviewed for Resident Rights. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:34 PM, during the lunch meal observation on the second floor day room, Resident #108 stated that they didn't receive their breakfast tray until 9:30 AM yesterday morning, which made them late for church. Resident #108 stated that they were uncomfortable going into church late and felt bad holding up the transportation staff. A review of the resident's Admission Record revealed that the resident had diagnoses that included but were not limited to Atrial Fibrillation, hypertension, and difficulty walking. A review of Resident #108's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/13/23, reflected the resident has a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating Resident #108 had an intact cognition and required the assistance of one staff for locomotion off the unit. On 10/5/23 at 12:10 PM, during the lunch meal observation, Resident #108 told the surveyor that they did not have breakfast this morning because it wasn't delivered until 9:30 AM, and the resident didn't want to be late for church again. On 10/10/23 at 9:51 AM, the surveyor observed Resident #108 in their room waiting for breakfast. At that time, the activity coordinator announced that they were there to transport Resident #108 to church. Resident #108 stated that they were hungry but didn't want to hold up the transporter and did not want to be late for church so the resident left for church without having eaten breakfast. On 10/11/23 at 9:15 AM, the surveyor observed Resident #108 in their room waiting for breakfast to be delivered. The resident stated that they were so hungry yesterday that the resident ate every last bite of their lunch. On 10/11/23 at 9:25 AM, the surveyor observed Certified Nursing Assistant (CNA) #9 deliver the breakfast tray to Resident #108. The resident told CNA #9 and the surveyor that they would like their breakfast earlier so that they could attend church services which began at 10:00 AM and that the transporters arrived between 9:30 AM and 9:50 AM. On 10/11/23 at 9:38 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that she expected all residents to have their breakfast trays delivered by 9:00 AM. The surveyor asked the LPN/UM #2 if she had a list of residents who attended church services or any other morning activities to ensure these residents received their trays with enough time to eat before attending the activities. LPN/UM #2 replied, no. LPN/UM #2 further stated that she should have had a system in place so that residents who leave for church at 9:30 AM receive their trays first. On 10/11/23 at 11:37 AM, the surveyor interviewed the Food Service Director (FSD) who stated that all residents should have their breakfast trays by 9:00 AM, and further stated that he was not provided with a list of any residents who attended morning church services/ activities or medical appointments nor was he aware of any residents who require early breakfast trays. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns. 48617 2. On 10/03/23 at 11:50 AM, the surveyor observed Resident #55 in bed watching TV. The resident stated they did not get out of bed that day. A review of the Admission Record indicated the resident had the following diagnoses: major depressive disorder, mood affective disorder, weakness, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, and a contracture of their left hand. A review of Resident #55 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/2023 revealed resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #55 was cognitively intact. A review of the Resident #55's care plan dated 04/6/23 reflected the resident enjoyed and benefited from involvement in activities. A review of the October Treatment Administration Record (TAR) reflected an order to apply the left leg brace when the resident was out of bed every day shift. The TAR had been signed by the nurse from 10/01/23 to 10/11/23. A review of the Activities Consult/Recommendation dated 04/28/23, 07/11/23, and 10/10/23/2023 reflected that Resident #55's preference as to attend activities including activities held in the day room. On 10/04/23 at 11:26 AM, the surveyor observed Resident#55 in bed watching TV who stated, they did not get me out of bed today. On 10/05/23 at 11:50 AM, the surveyor observed Resident #55 in bed watching TV who stated, I did not get out of bed today. On 10/13/23 at 10:09 AM, the surveyor observed Resident #55 in bed watching TV. Resident #55 stated that they used to get transferred to the reclining chair and brought to the dayroom for bingo activities. Resident #55 stated it had been a month since they had gotten out of bed. On 10/13/23 10:24 AM, the surveyor interviewed the resident's routine Registered Nurse (RN#3) who stated Resident #55 got out of bed 3-4 days ago but varied at times according to the resident's mood. On 10/13/23 10:30 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #2) who stated that the resident did not like to get out of bed. UM/LPN #2 further explained that Resident #55 would be transferred by Hoyer lift, but once in the chair would want to go back to bed right away. UM/LPN #2 stated the resident refused to get out of bed and that the physician and family were aware. UM/LPN #2 stated Resident #55's refusal was documented in progress notes and being signed in the Treatment Administration Record (TAR). The surveyor reviewed the TARs for September and October 2023 which did not indicate that the resident refused to get out of bed. The surveyor reviewd Resident # 55's progress notes from June 2023 - October 13, 2023. There was no documentation that indicated that the resident refused to get out of bed. On 10/13/23 at 10:38 AM, the surveyor interviewed the resident's regular Certified Nursing Assistant (CNA#6). CNA #6 stated Resident #55 refused to get out of bed all the time. CNA #6 further stated if the resident refused to get out of bed, they would notify the unit manager and the nurse. On 10/13/23 at 11:00 AM, after surveyor inquiry, the surveyor observed the resident in a gerichair being transported out of their room and to the hallway by 2 CNAs and in the presence of the UM. The resident's left leg brace was on the resident. The resident told the surveyor that they were happy. A review of the facility's Resident Rights policy and procedure, revised 12/31/22 reflected, employees and staff will treat all residents with kindness, dignity, and respect the rights of each resident .Resident Rights to independent choices are outlined and explained .residents are entitled to fully exercise their rights and privileges possible. NJAC 8:39-4.1 (a) (12)(21)(24)(28)

Based on observation, interview and record review, it was determined that the facility failed to monitor the nutritional status and adjust nutritional services accordingly to all residents at risk for weight loss. Resident #26 experienced a 1 month, 11 pound weight loss which corresponded to a 9 % loss of body weight. This deficient practice was identified for Resident #26, 1 of 8 residents reviewed for nutritional concerns, and was evidenced by the following: During a tour of the facility on 2/20/14 the Unit Manager (UM) told the surveyor that Resident #26 had mild dementia, vertebral fractures and [MEDICAL CONDITION] reflux disease. The UM said the resident had requested a pureed diet and had experienced an 11 pound weight loss in the previous month. On 2/26/14 at 9:50 a.m. the surveyor spoke with Resident #26 in the bedroom. The resident was alert and oriented and told the surveyor about current medical issues including an ongoing upset stomach for which he/she had received medication that morning. The resident had a bowl of hot cereal on the overbed table of which a few bites had been taken. The resident told the surveyor he/she was not very hungry but forcing some food down. The resident was very pleasant, smiling and conversational. On 2/26/14 at 10:03 a.m. the UM told the surveyor that Resident #26 was alert and oriented and had adjustment issues when he/she first came to the facility. The UM said the resident had experienced a weight loss but that the addition of the antianxiety drug, [MEDICATION NAME], had helped with the resident's mood and weight. According to the medical record Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's 1/2/14 "Diet Requisition and Dietitian Communication" form, Resident #26 had an order for [REDACTED]. a. the RD indicated the resident was receiving "Ensure x 1/day," a therapeutic nutritional supplement. No order was found for this supplement and it was not listed on the 1/2/14 admission "Diet Requisition and Dietitian Communication" form. b. the resident's weight was listed as 115 pounds with a usual body weight of 125 pounds. c. the resident had experienced an unplanned weight loss. d. the resident's intake met greater than 75% of the planned meal. The resident had been residing at the facility for less than a day, so it was unclear where this information was obtained. e. the resident was "at nutritional risk due to self-imposed limited food variety and unintentional 10 pound/8 % weight loss in 2 weeks." f. in the narrative section of the assessment the following was noted: the resident had a [DIAGNOSES REDACTED]. (It was not clear how many observations were made of the resident eating or what the resident had consumed.) The RD listed the resident's food preferences and aversions and indicated the resident's weight was within the ideal body weight but the resident had lost weight in the last 2 weeks while residing at another facility. The RD quoted the resident who said he/she "couldn't eat the food there" but did not identify what the issues had been. The RD indicated that 4 oz. of Resource supplement per day would be provided to the resident "to aid with weight stability." On 1/3/14 the RD wrote an order for [REDACTED]. The surveyor reviewed the resident's Progress Notes (PN) starting upon admission on 1/2/14 and noted the following: a. there was no mention of the resident's food intake until a 1/19/14 PN at 3:30 p.m. The PN indicated Resident #26 consumed all juices (amount not indicated) and 2 bowls of oatmeal. The resident told the nurse he/she was nauseated and could not eat. b. a 1/23/14 PN indicated Resident #26 consumed 75 % of dinner and a bedtime snack. c. a 1/29/14 RD PN indicated Resident #26 requested a change from a regular diet to a pureed diet. There was no information documented in the note regarding the nutritional intake of the resident. Although the RD mentioned the resident's diet included Resource, the surveyor found no PN which mentioned the resident's actual consumption of Resource for the month of January 2014. d. a 2/2/14 PN at 2:05 p.m. indicated Resident #26 had a "fair" appetite for 2 meals that day. e. a 2/4/14 RD PN indicated Resident #26 was happy with pureed food. There was no information documented in the note regarding the nutritional intake of the resident. f. on 2/6/14 at 10:06 a.m. an Activities PN indicated Resident #26 told the writer he/she felt "nauseous" many days. On 2/6/14 at 3:01 p.m. the RD PN indicated Resident #26 had lost 11 pounds or 9 % of body weight in 1 month. The RD indicated the resident's 1/2014 weight was 116 pounds and 2/14 weight was 105 pounds. The RD re-iterated the resident's preferences and aversions and indicated a 3-day calorie count would be initiated. At this time the RD indicated Resident #26 declined additional food or supplements. The surveyor reviewed the 1/14 Medication Administration Record [REDACTED].) When interviewed on 2/26/14 at 9:45 a.m. and 10 a.m., 2 Certified Nursing Assistants said meal intake was not routinely monitored or documented but that the nurses would be notified if there were any issues. When interviewed on 2/26/14 at 10:30 a.m., the UM said intake was monitored by exception, meaning that if nothing was documented, the resident was eating adequately. The UM said if the resident's eating pattern changed, then the nurse would be notified by the nursing assistant. The surveyor reviewed the facility's "Meal Documentation Protocol" which stated "If the dietitian or nurse determines that there is a nutritional problem, nursing staff will begin documentation using a 3-day calorie count. If after 3 days the resident is determined to be eating adequately (greater than 50 % and resident appears to be adjusting), documentation can be discontinued. If meal completion form verifies poor intake (less than 50 % for more than 3 days), the following steps are to be taken: place resident on weekly weights and notify dietitian." There was no evidence a 3-day calorie count was initiated upon admission for this resident who had a history of [REDACTED]. When interviewed on 2/27/14 at 8:19 a.m., the RD said the facility policy was to perform weekly weights times 4 weeks upon admission. The RD said it was not the facility policy to conduct 3- day calorie counts upon admission. The surveyor asked the RD where the resident's weekly weights for 1/14 could be found. The RD confirmed that none had been done and said this was "my oversight." The surveyor asked if Resident #26 had other nutritional interventions besides 4 oz. Resource once daily. The RD said there were none ordered for the resident. When asked about fortified food at the facility, the RD said that the Super Cereal, Super Puddings and Magic Cup foods all contained lactose, which the resident avoided. The RD said the resident refused snacks and refused to have Resource increased. The surveyor asked the RD if the resident's refusals were documented and the RD said they were. (Note that the first mention of increasing or adding supplements or the addition of other foods did not occur until 2/6/14, after the significant weight loss was discovered.) The RD said the resident took fluids well and that "If (he/she) gets what (he/she) likes, (he/she) does eat." On 2/27/14 at 8:50 a.m. the resident told the surveyor that he/she would take Resource more often, in between meals. The resident said that at one time, he/she thought Resource was bothering his/her stomach but then realized it was not the Resource. There was no documentation in the medical record regarding this statement. The resident confirmed that he/she had weighed 125 pounds prior to hospitalization and had lost weight in a previous nursing facility due to their inability to meet his/her many nutritional needs due to [MEDICAL CONDITION] Bowel Disease and diverticulitis. The resident told the surveyor he/she requested a pureed diet at the facility as it was easier to swallow. When interviewed on 2/28/14 at 10:02 a.m., the surveyor asked the RD how the facility monitored resident nutritional intake. The RD said this was done via resident feedback, talking to nursing staff and review of resident weights. The RD said that supplement intake was monitored by verbal communication between the nursing staff and the RD. When interviewed on 2/28/14 at 9:50 a.m., the Director of Nursing (DON) said the facility should have performed weekly weights upon admission for Resident #26. The DON said a 3-day calorie count would not necessarily be done on admission in order to give the resident some time to acclimate to the facility. When asked what would precipitate a 3-day calorie count for a new admission, the DON said perhaps after a weekly weight had shown a weight loss. NJAC 8:39 - 17.1 (c) 17.2 (c) 27.1 (a)