Every finding on record at Tallwoods Care Center

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean, safe and sanitary manner as evidenced by the following. On 11/19/25 at 10:47 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen:1. The can-opener blade had brown debris under the blade and screw area. The black interior removable sleeve of the can opener mount on the counter when removed had sticky, gelatinous substance on the outside and interior where the can opener shaft would rest . The FSD acknowledged and agreed it had not been cleaned or washed according to facility policy. 2. The microwave had multicolored food debris on the interior ceiling. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 3. 3 of 4 convention ovens (2-upper and 1-lower unit), had baked on food debris on the two glass doors and on the inside surfaces. The 4th unit was not operational. The FSD did not have a cleaning schedule and acknowledged and agreed that it was not cleaned according to facility policy. 4. 1 of 3 coffee dispenser nozzles (center), had white hard build up on the outside of the dispenser and the top of the dispenser. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 5. Two- (6 burner) stove tops, both were covered with debris on the grates and around the cooker hats. The catch trays (covered with foil) on both units were also filled with burnt food debris. Under the foil was a gelatinous slippery/greasy substance. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 6. The steam table, (a 6 water well unit) had debris and sediment in every water well consisting of rice, peas, white and black flakes. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 7. 4 slot-Toaster, white in color, had orange, brown splatter around the outside of the unit, the top of the unit was discolored and had food debris, the two catch trays were filled with brown and black debris up to and including the grip handle. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 8. The ice machine had a black discoloration around the white rim on the interior of the unit. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 9. The Ice Scoop on the side of the ice machine was in a blue holder. At the base of the blue holder there was discoloration in the corners and a piece of cardboard garbage at the base. The FSD acknowledged and agreed that it was not cleaned according to facility policy. He further stated, the cardboard looked to be the ripped top off a disposable glove box and it should not be there. 10. 7 of 7 -Cutting boards all had etching and black discoloration. The FSD stated that there were on the clean rack and had already been put through the wash machine. The FSD acknowledged and agreed that they were not cleaned according to facility policy. He further stated, he did not know when the cutting boards were replaced last. 11. The Oil Fryer- the oil was very dark in color; the interior bottom heating element was not visible to the surveyor or the FSD. The top of the oil had a ring of food debris and white sediment. The fryer interior ledge was filled with food debris and crumbs. The exterior sides of the unit had a clear greasy substance. The FSD stated it had not been used since the Wednesday (11/12/25, 1 week prior) before surveyor observation. The FSD acknowledged and agreed that it was not cleaned according to facility policy.12. The Griddle catch tray had copious amounts of black sediment and debris. The FSD acknowledged and agreed that it was not cleaned according to facility policy. On 11/19/25 at 11:30 AM, the surveyor interviewed the FSD, stated that the cleaning of equipment should be done on a schedule to prevent food borne illness and maintain a safe and sanitary environment for the staff. The FSD acknowledged the surveyors concerns and agreed they were not done according to facility policy.On 11/24/2025 at 09:16 AM, the surveyor met with Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged the surveyor's concerns. He stated that the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury; to ensure the safety of the residents and staff.On 11/26/25 at 11:25 AM the survey team met with the LNHA and Director of Nursing, they acknowledged and agreed with the concerns of the team and had no more information to provide. A review of the facility's undated policy, Kitchen equipment Policy, revealed. Purpose: ensure all kitchen equipment is used, cleaned and maintained safely and in compliance with NJ department of Health requirements, CMS food safety standards and manufacturer guidelines.All food contact equipment must be cleaned and sanitized after use and at the minimum of daily.Cleaning must follow manufacturer's instructions and facility procedures. A review of the facility's policy, Kitchen Cleaning and Sanitation, dated November 5, 2023, revealed. this policy is to ensure all food service areas are maintained in a clean, sanitary and safe condition in compliance with state health codes and the FDA food Code. Proper cleaning reduces contamination risks, prevents food borne illness, and promotes a safe working environment. sanitize food-contact surfaces before and after each use.Immediately clean spills to prevent slips, pests, and contamination.keep all cleaning logs accurate and up to date.clean and sanitize equipment after each use (slicers, mixers, blenders, etc.clean stovetops, griddles, oven doors, microwave interiors, steam tables and warmers.A review of the facility policy, Tray Line Process dated 2/2025, to ensure.safe preparation.to residents in compliance with.food safety regulations.the tray line must be cleaned and disinfected after each meal service.water must be changed DAILY. A review of the facility undated, Can opener policy revealed.wash with hot soapy water. the blades and cutting area must be scrubbed to remove any residue, inspect for metal shavings, dullness, or residue.store in a clean, dry area (preferably .mounted)A review of the undated facility policy, Deep Fryer Policy revealed.daily cleaning on days used, skim crumbs and debris from oil, wipe fryer exterior after cooling, clean nearby surfaces and floors to remove grease and spills.drain oil, clean inside fryer following manufacturer guidance, rinse thoroughly, dry complexly and refill with fresh oil. NJAC 8:39-17.2(g)

Complaint # 2638538Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure adequate procedures for maintaining accurate records, tracking, and timely investigation of discrepancies related to controlled substances leading to actual and potential drug loss or diversion. This deficient practice was identified for a.) 1 resident (Resident #78) reviewed for pharmaceutical services and for b.) 5 unsampled residents (Residents #45, #115, #134, #142, and #168) identified during medication storage inspection of 2 of 4 medications carts (Maple High, Pine Low, and Pine Swing) and was evidenced by the following:1.) On 11/19/2025 at 11:30 AM, the surveyor observed Resident #78 in bed awake. The resident stated that they were not in pain. When resident was asked if they have missed any dose of their pain medication in the facility, the resident stated they have not missed any pain medication and had no complaints. On 11/20/2025 at 9:39 AM, the surveyor reviewed the medical record for Resident #78.A review of the admission Record (admission summary) indicated that Resident #78 was admitted to the facility with diagnoses which included but was not limited to cellulitis (bacterial infection of deeper tissues causing pain in the area affected) of the right lower limb and changes in skin texture.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 9/12/2025, indicated that Resident #78 scored a 15/15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had intact cognition. The MDS also reflected that the resident did not exhibit any untoward behaviors.A review of the Order Summary Report active as of 11/20/2025 included a physician's order for Percocet oral tablet 7.5-325 mg (oxycodone w/ acetaminophen) give 1 tablet by mouth four times a day for chronic pain started on 7/14/2025.A review of the September 2025 Medication Administration Record (MAR) reflected that the physician order for Percocet was administered to Resident #78 with no missed dose.A review of the form AA-45 (Facility Reportable Event) dated 10/7/2025, indicated that on an unspecified date, a suspected narcotic diversion of 1 blister pack (bingo card) containing 60 tablets of Percocet from a Registered Nurse (RN #1) was identified and reported by the facility to the Consultant Pharmacist, New Jersey Department of Health (DOH), New Jersey Board of Nursing (BON), the Drug Enforcement Agency (DEA), and the local law enforcement.A review of the facility investigation revealed that on 9/18/2025, two 60-count cards of Percocet was received by the facility from the pharmacy for Resident #78. On 10/5/2025, the first 60-count Percocet card was depleted. On 10/6/2025, the facility request for a refill of Percocet for the resident was declined by the pharmacy due to recent refill. Facility investigation identified discrepancies, including alterations and use of white-out eraser on the September 2025 narcotic inventory sheet NIS) of the Maple low unit, where Resident #78's medications were stored, dated 9/20/2025 on 11-7 and 7-3 shifts and on 11-7 shift of 9/21/2025. The facility concluded that the diversion was isolated to one agency nurse, RN #1 who worked on 9/20/2025 3-11 and 11-7 shifts until 4:00 AM of 9/21/2025.A review of September 2025 narcotic inventory sheet (NIS) for the Maple low unit by the surveyor revealed no signatures from the incoming and outgoing nurses on the 11-7 shift of 9/21/2025. According to the NIS, Must be counted and signed each shift. Supervisors to initial for all new additional narcotics. The box where the supervisor was supposed to sign when the 2 bingo cards of Percocet were delivered on 9/18/2025 at 11-7 shift was blank. A review of the NIS from 9/1/2025 to 9/30/2025, did not reveal any supervisor signature for all narcotics added to the inventory count. The surveyor noted white-out erasures and alterations on the number of cards for 11-7 and 7-3 shifts of 9/20/2025, and on 11-7 shift of 9/21/2025. On 9/20/2025, 26 narcotic cards were counted for 7-3 shift and out of the 26 cards, 2 cards were removed. Further review of the NIS revealed that the Individual Patient's Controlled Drug Record (IPCDR) sheets were not being counted to match the number of narcotic medication cards, boxes, bottles, and/ or bags and for comparison with every new narcotic medication received by the facility from the pharmacy. On 11/21/2025 at 11:32 AM, the surveyor interviewed the Pharmacy Consultant (PC) by telephone who stated that shift-to-shift report includes narcotic counting between 2 nurses must match and must be signed by 2 nurses.On 11/24/2025 at 10:22 AM, during an interview with the surveyor, Registered Nurse (RN #2) confirmed that they counted the narcotics in Maple low cart with RN #1 on 9/21/2025 at 4:00 AM. RN#2 was asked why the shift-to-shift NIS form was blank on 11-7 shift of 9/21/2025. RN #2 stated because there was no space on the form to sign at 4:00 AM.On 11/25/2025 at 9:43 AM, during an interview with the surveyor, the Director of Nursing (DON) was asked how the lost Percocet bingo card was not noted until 10/6/2025 when RN #1 last worked at the facility on 9/20/2025. The DON stated that RN #1 changed the bingo card count from 27 to 26 on 11-7 and 7-3 shifts of 9/20/2025 and 2 bingo cards were subtracted from the count resulting to just 24 cards which matched the number of cards counted by RN #2 who counted with RN #1 at 4:00 AM of 9/21/2025. The DON further stated that the nurses counted the narcotics bingo cards without confirming the medications in the cards they counted. The DON confirmed that the IPCDR for the Percocet sheet 1 went missing together with the medication. The DON was asked what happened to the 2 bingo cards that were removed from the narcotics inventory count on 7-3 shift of 9/20/2025. The DON stated that they have a tracking form for removal of narcotic cards, bottles, boxes, or bags. The DON stated that the 2 bingo cards removed from the inventory log on 9/20/2025 should have been entered on the tracking form but they were not entered. The DON stated that the unit managers review the tracking forms and submit them to the DON monthly. The DON was asked who reviewed the tracking form submitted by the unit managers for the month of September 2025. The DON confirmed that they reviewed it.A review of facility-provided undated policy titled Narcotic Medication process indicated the following under Counting controlled substances with transfer of the cart between nurses: .3.) Both nurses must look at each sheet and each card to ensure accuracy. 4.) Both nurses sign the controlled substance book immediately upon completion of a correct count. Under Discrepancies or changes in narcotic count: 1.) Must be reported to the DON immediately. 2) An investigation is conducted to reconcile any reported discrepancies. 3.) Any irreconcilable discrepancies get reported to the administrator and a further investigation is completed which may include law enforcement and other agencies. The policy did not address the monitoring and review of tracking form for narcotic card/ bottle/ box/ bag removal. The policy did not address the monitoring of IPCDR count to match the number of IPCDR sheets with the number of IPCDR of new narcotics delivered. 2.) On 11/21/2025 at 12:06 PM, during medication storage inspection of the Pine unit low and swing medication carts with unit manager (UM) #1, the surveyor noted multiple cross-outs on the November 2025 IPCDR (Individual Patient's Controlled Drug Record). A review of the narcotic logbooks revealed the following:Resident #115's IPCDR for tramadol 50 milligram (mg) tablet (tab) was crossed out on amount # 38 dated 8/4/2025 at 10:20 AM. Across it was another date 8/6/2025 at 2:00 PM with an arrow pointing to the crossed-out date and time. Amount #35 dated 8/29/2025 at 9:00 AM was crossed out. An arrow pointed to another date 9/2/2025 at 11:22 (unspecified whether AM or PM) from the crossed-out line.Resident #168's IPCDR for fentanyl 50 microgram/ hour patch was crossed out on amount # 5 dated 11/16/2025. An error was written above it and across it was written the date of 11/17/2025. On 11/21/2025 at 12:17 PM, during medication storage inspection of the Maple unit high medication cart with UM #2, the surveyor noted multiple cross-outs on the November 2025 IPCDR sheets. A review of the narcotic logbook revealed the following:Resident #45's IPCDR for hydromorphone 4 mg tab was crossed out on amount #49 dated 10/6/2025 at 9:00 AM. Waste was written on the same line. Amount #44 dated 10/18/2025 at 18:13 was crossed out and an arrow pointed to a written date of 10/19/2025 with illegible time. Amount #22 dated 11/14/2025 at 2:00 PM was crossed-out and on the same line another date and time were written, 11/15/2025 at 11:40 AM. Amount #21 dated 11/16/2025 at 9:05 was crossed-out and across the page was written an encircled #21 dated 11/17/2025 at 12:00 PM. Amount #20 dated 11/17/2025 at 12:00 PM was crossed out. Across the page was written an encircled #20 dated 11/20/2025 at 1:00 PM. Amount #56 dated 10/29/2025 at 5:45 AM was crossed out and an arrow pointed to another date 11/14/2025 at 2:00 PM.Resident #142's IPCDR for morphine sulfate 15 mg tab dated 11/14/2025 at 4 AM was crossed out at amount #59. Across it was written 11/14/2025 at 9:00 AM. Below it was dated 11/14/2025 at 9:00 PM was crossed out and marked error.Resident #134's IPCDR for pregabalin 25 mg capsule dated 11/5/2025 at 9:00 AM, was crossed out and marked refused.On 11/21/2025 at 12:17 PM, during an interview with the surveyor, UM #2 was asked why the residents were refusing pain medications that were already removed from the blister packs. UM #2 stated I guess because the nurses don't ask the residents if they want their meds.On 11/25/2025 at 9:43 AM, during an interview with the surveyor, the DON stated that cross-outs meant errors.On 11/25/2025 at 11:03 AM, during a meeting with the survey team, concerns for multiple crossed outs on IPCDR or narcotic declining sheets of Pine and Maple units were brought up to the administrator and DON.No further information was provided.A review of the facility-wide in-service by the DON dated 10/9/2025 titled Controlled Substance Accountability & Diversion Prevention for nurses included under Objectives: After this in-service, staff will be able to 1.) Demonstrate accurate documentation on the narcotic sign-in and count sheet. A review of the supplementary education sheet included in the in-service titled Controlled Drug Substance Accountability from the pharmacy consultant included under DO NOT . Use arrows, extraneous marks. A review of facility-provided undated policy titled Narcotic Medication Process reflected under Discrepancies or changes in narcotic count: 1.) Must be reported to the DON. 2.) An investigation is conducted to reconcile any reported discrepancies. 3.) Any irreconcilable discrepancies get reported to the administrator and a further investigation is completed which may include law enforcement and other agencies.N.J.A.C. 8:39 - 11.2 (b), 29.2 (a)(d), 29.4 (k), 29.7(c)

Based on observation, interview, review of medical records and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice, by failing to 1.) follow appropriate disinfection of a shared resident care equipment during medication administration observation, and 2.) provide residents with appropriate products for hand hygiene during mealtime. This deficient practice was identified for 6 of 6 unsampled residents (Residents #163, #164, #104, #165, #166, and # 167) observed during medication administration and 1 of 3 dining room observations (1st Floor Pine Unit dining room). This deficient practice was evidenced by the following: 1.) On 11/20/2025 at 7:36 AM, during the medication administration observation with Registered Nurse (RN) #1, Surveyor #1 observed RN #1 take the blood pressure (BP) of Resident #163 from the right arm. The BP read as 126/72. RN #1 removed the BP cuff from the resident's right arm. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/20/2025 at 7:53 AM, the surveyor observed RN #1 take the BP of Resident #164 from the right arm. The BP read as 130/65. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/20/2025 at 8:02 AM, the surveyor observed RN #1 take the BP of Resident #104 from the left arm. The BP read as 131/69. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/20/2025 at 8:23 AM, the surveyor observed RN #1 take the BP of Resident #165 from the left arm. The BP read as 141/74. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/20/2025 at 8:41 AM, the surveyor observed RN #1 take the BP of Resident #166 from the left arm. The BP read as 111/63. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/20/2025 at 9:06 AM, the surveyor observed RN #1 take the BP of Resident #167 from the left arm. The BP read as 128/62. RN #1 proceeded to administer the resident's medications. RN #1 did not sanitize the BP cuff prior to and after using it on the resident. On 11/24/2025 at 10:22 AM, during an interview with the surveyor, the Infection Preventionist/ Registered Nurse (IP/ RN) stated that nurses need to wipe down the BP cuff with the purple- top container sanitizing wipes between each patient. On 11/24/2025 at 9:30 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the nurses should be wiping down the BP cuff between residents using the purple-cap wipes. A review of the facility-provided policy revised on July 2024, titled Cleaning and Disinfection of Resident – Care Items and Equipment indicated under Policy Interpretation 1.) . c. non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical items include bedpans, blood pressure cuffs, crutches and computers. (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . 7.) Intermediate and low-level disinfectants for non-critical items include a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25 – 6.15 % diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal agents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only). N.J.A.C. 8:39 – 19.4 (a) 2.) On 11/20/2025 at 12:27 PM, Surveyor #2 observed dining for lunch on the 1st floor Pine Unit dining room. The Certified Nurse Assistant (CNA) assisted two residents with hand hygiene using alcohol free baby wipes with aloe (AFBW). She did not perform hand hygiene between assisting the residents. During an interview with Surveyor #2 on 11/20/2025 at 12:35 PM, the CNA stated that the AFBW were the type of hand wipes the facility used to perform residents' hand hygiene before meals. She acknowledged that she should have washed her hands between assisting residents to comply with infection control. During an interview with Surveyor #2 on 11/24/2025 at 12:45 PM, the Infection Preventionist (IP) reported that she has worked as the IP nurse for seven and a half months and had been employed at the facility for over one year. The IP stated that residents should have had alcohol-based wipes placed on their meal trays; however, if those wipes were not available, staff may use AFBW. She was unsure whether staff should be using AFBW for hand hygiene, noting that baby wipes did not contain alcohol and would not be effective at killing germs. She also confirmed that CNAs should perform hand hygiene between assisting each resident to maintain proper infection control. During an interview with the surveyor on 11/25/2025 at 11:20 AM, the Licensed Nursing Home Administrator (LNHA) was unsure whether staff should be using AFBW for hand hygiene. A review of the facility's undated policy titled Infection Control Policy and Procedure revealed that The facility shall establish an Infection Prevention and Control Program that will follow national standards and guidelines. The hand hygiene procedure is to be followed by staff involved in direct resident contact. Staff are required to follow hand hygiene practices consistent with accepted standards of practice. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to initiate a physician's order (PO) for a resident's code status (refers to a patient's decision regarding the level of medical intervention they wish to receive in the event of a life-threatening crisis, such as cardiac or respiratory arrest). This deficient practice was identified for 1 [one] of 29 residents (Resident #139) reviewed was evidenced by the following:On 11/20/25 at 10:03 AM the surveyor observed Resident #139 lying in bed and watching TV. The Resident stated, the staff known I do not want nothing done and that I signed papers about my choice. On 11/20/25, at 10:20 AM, the surveyor reviewed the medical record for Resident #139. The admission Record (admission summary) dated 9/12/23 reflected that the Resident was admitted to the facility with the diagnoses that included but was not limited to chronic respiratory failure with hypoxia (lung disease with low oxygen levels in the blood), chronic obstructive pulmonary disease (difficulty breathing caused by damage to the lungs), and chronic congestive heart failure (a condition that causes fluid to buildup in the body). A review of section C for cognitive patterns of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate and manage care dated 9/30/25, revealed the Resident had a Brief Interview of Mental Status of 13, meaning the resident was cognitively intact. The Advance Directive (a living will/health care proxy) status on the admission summary was blank and was not completed to indicate the Resident's code status. The signed Physician Orders for Life Sustaining Treatment (POLST), [medical orders that indicate preferences regarding treatment to sustain life], dated 10/21/23, indicated the Resident's goals of care and code status as do not resuscitate (DNR) and do not intubate (DNI). The active Order Summary Report (OSR), dated 6/24/25, did not include physician's orders (PO) for the Resident' code status of DNR/DNI as indicated in the POLST. The individualized Comprehensive Care Plan (ICCP) initiated on 5/25/25 did not contain a focus area or interventions to direct the care consistent with the Resident's POLST. A review of the Nurse Practitioner's (NP) progress notes dated 9/17/2023 at 12:28 PM, revealed the following: Spoke to POA (Power of Attorney) and brother-in-law (name redacted) and wife (name redacted) via telephone, and discussed goals of care, advance directives, and resuscitation status, and they elected a DNR/DNI status. However, the resident's status was not reflected in the PO. A review of the Nurse's Notes for 9/17/2023 at 7:06 PM indicated that Resident is DNR/DNI. Social services (SS) note on 10/12/23 at 4:11PM indicated that the SW met with the Resident at request of the POA and the Resident's sister-in-law as the Resident had requested to be DNR DNI, to let him go. A recent monthly MD/NP progress note on 11/1/25 at 11:01 PM, confirmed the Resident's code status as DNR/DNI. Yet a PO was not entered to reflect the Resident's preference. 11/20/2025 11:02 AM The surveyor interviewed the Licensed Practice Nurse/Unit Manager (LPN/UM), who stated that all residents must have an order for the code status indicated by their Advance Directive or POLST to dictate their care. When asked why it was important for staff to be aware, the UM responded, it is important so that staff provided the care to reflect the Resident's choice. On 11/20/25 at 11:21 AM, the surveyor interviewed about the process for residents' code status. The DSS explained that if a resident's code status is obtained on admission, it is verified with the resident and discussed during the initial care plan meeting, an order is obtained from the provider. On 11/24/25 at 11:56 AM, the surveyor interviewed the Director of Social Services (DSS), about the process for resident's code status. The DSS explained that the SW meets with the Resident and the Resident's family to discuss the code preferences. The Resident completes a POLST which is signed and uploaded to the chart. The MD's order is entered in the Resident's chart for the code status and is discussed in care conference. The DSS explained that having an order for a resident's code status is important especially if it is DNR/DNI so that the Resident's preferences can be honored if the Resident has to be transferred to another facility. The surveyor interviewed the Director of Nursing (DON), on 11/21/25 at 11:21 AM who explained that the ICP was resident specific and should provide an accurate description of the resident's needs. On 11/26/25 at 10:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged that he was not aware of the residents' DNR, DNI code status needed to be included in the ICP but that the code status should be included in the Resident's PO. The LNHA stated that having an order for the Resident's code status was important to respect the Resident's wishes. The facility's Advance Directive Policy and Procedure, dated 2025, indicated that the purpose was to provide an atmosphere of respect and caring and to ensure that each resident's ability and right to participate in medical and mental health decision making is maximized, and to ensure that residents have the means to establish an advance directive relating to the provision of health care in the event the resident is incapacitated. N.J.A.C. 8:39-4.1(a)4

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1 of 3 units (Pine Unit).This deficient practice was evidenced by the following: On 11/20/2025 at 9:00 AM, in the lower side Pine Unit shower room, the surveyor observed that the ceiling vent contained black debris, and a piece of the drop ceiling was missing. A section of the drop ceiling was bulging, and the metal framing of the ceiling was stained red and brown. The first shower stall had hair in the drain and tan debris on the shower tile. The third shower stall was blocked off with yellow caution tape, and the drain was missing, leaving standing water that contained brown debris. Additionally, a motorized wheelchair was stored in the shower room, covered in a white, furry substance, with a torn cushion and pieces of fabric missing. On 11/20/2025 at 9:15 AM, in the high-side Pine Unit shower room, the surveyor observed that a toilet was missing its tank and had a pink out of order sign on top, and that several pieces of the shower stall trim were missing. During an interview with the surveyor on 11/20/2025 at 9:45 AM, the Housekeeping Director (HD) stated that the unit uses both the low-side and high-side shower rooms. The shower room tiles are supposed to be power washed every Sunday; however, there is no formal schedule, and cleaning depends on staffing. Tiles should also be scrubbed monthly and cleaned twice daily. Currently, shower room tiles are not cleaned daily or monthly as required, and power washing occurs only on weekends. She was unsure who the wheelchair in the shower room belongs to and noted that housekeeping should have notified nursing staff to have it removed. During an interview with the surveyor on 11/24/2025 at 12:30 PM, the Director of Maintenance (DOM) stated he has worked at the facility for 25 years. He reported that the motorized wheelchair in the shower room, which was covered in a white, furry substance, is not acceptable, and he is unsure who it belongs to. He stated that housekeeping or nursing should have identified the owner and removed it if it was not in use. The DOM also stated that the third shower stall had a clogged drain for one week, which could not be addressed sooner due to staffing priorities. He noted that all maintenance issues should be recorded in the maintenance log at each nursing station, which is checked daily. Building rounds were completed Monday through Friday, 2-3 times per day, with additional visits as needed. Minor maintenance issues were typically resolved within 1-2 days, depending on parts availability. The toilet in the high-side shower room had been out of service for two weeks due to a needed tank part. In addition, although the shower stall floors in the high-side shower room were relatively new, the flooring and trim in the shower area had been delaminating for approximately one month. The DOM explained that the flooring company would address the issue when their schedule allowed. The DOM emphasized that the current condition of the shower rooms did not provide a homelike environment and was not acceptable for residents living standards. During an interview with the surveyor on 11/24/2025 at 12:36 PM, the Certified Nurse Aide (CNA) stated that she had worked at the facility for 17 years. She indicated that she was not sure if housekeeping cleaned the shower room every day; if staff needed something cleaned, they would request housekeeping, and it was then addressed. She was unsure who the wheelchair in the shower room belonged to but noted that it had been there for quite some time. In the high-side shower room, the third shower stall had been broken for several months and could not specify exactly how long. She confirmed that the condition of the shower room did not meet infection control standards, was not sanitary, and was not a homelike environment. During an interview with the surveyor on 11/25/2025 at 11:20 AM, the Licensed Nursing Home Administrator (LNHA) stated that showers were cleaned daily, with power washing or deep cleaning performed weekly to remove mineral deposits, which could be difficult to eliminate. The LNHA stated that maintenance repair timelines varied depending on the nature of the issue and part availability. He stated that urgent or safety-related issues were addressed immediately or within a few hours, while routine repairs were generally completed within 1-3 days if parts were available. Overall, expectations for repairs and housekeeping depended on the complexity of the issue and availability of resources. A review of the facility's undated policy titled Housekeeping Policy revealed that The purpose of this policy is to ensure that TWCC maintains a clean, safe, and sanitary environment for residents, staff, and visitors in accordance with New Jersey Department of Health (NJDOH) regulations and federal long-term requirements. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, medical record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. This deficient practice was identified for 1 (one) of 29 residents (Resident #139) reviewed was evidenced by the following: On 11/20/25 at 10:03 AM, the surveyor observed Resident #139 lying in bed, watching TV. The surveyor interviewed the resident regarding their code status (refers to a patient's decision regarding the level of medical intervention they wish to receive in the event of a life-threatening crisis, such as cardiac or respiratory arrest). The Resident stated, the staff know I do not want nothing done and that I signed papers about my choice. On 11/20/25, at 10:20 AM, the surveyor reviewed the medical record for Resident #139. The admission Record (admission summary) dated 9/12/23, reflected that the Resident was admitted to the facility with the diagnoses that included but was not limited to chronic respiratory failure with hypoxia (lung disease with low oxygen levels in the blood), chronic obstructive pulmonary disease (difficulty breathing caused by damage to the lungs), and chronic congestive heart failure (a condition that causes fluid to buildup in the body). The Advance Directive (a living will/health care proxy) status on the admission summary was not completed. The quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 9/30/25, indicated that the resident had a Basic Interview for Mental Status (BIMS) score of 13, which indicated that the resident was cognitively intact. The signed Physician Orders for Life Sustaining Treatment (POLST), [medical orders that indicate preferences regarding treatment to sustain life], dated 10/21/23, showed the Resident's status was Do not resuscitate (DNR) and do not intubate (DNI). The active Order Summary Report (OSR), dated 6/24/25, did not include physician's orders (PO) for the Resident' code status. The ICP initiated on 5/25/25, did not reflect a focus area or intervention for DNR, DNI consistent with the POLST. A review of the Nurse Practitioner progress notes dated 9/17/2023 at 12:28 PM, stated: Spoke to POA (Power of Attorney) and brother-in-law (name redacted) and wife (name redacted) via telephone, and discussed goals of care, advance directives, and resuscitation status, and they elected a DNR/DNI status. However, the resident's code status was not reflected in the physician's order (PO). On 11/20/2025 at 11:02 AM, the surveyor interviewed the Licensed Practice Nurse/Unit Manager (LPN/UM), who stated that all residents must have an order for their code status indicated by their Advance Directive or POLST to dictate their care. When asked why it was important for staff to be aware, the UM responded, it is important so that staff provided the care to reflect the Resident's choice. On 11/20/25 at 11:21 AM, the surveyor interviewed the Director of Social Services (DSS), about the process for residents' code status. The DSS explained that if a resident's code status was obtained on admission, it was verified with the resident and discussed during the initial care plan meeting. She also indicated that an order was to be obtained from the provider. On 11/21/25 at 11:21 AM, the surveyor interviewed the Director of Nursing (DON), who explained that the ICP was resident specific and should provide an accurate description of the resident's needs and preferences. On 11/26/25 at 10:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged that he was not sure of the residents' DNR, DNI code status or if it needed to be included in the ICP. He confirmed that the code status should be included in the Resident's PO. The LNHA agreed that a PO for a resident's code status was important and should be included in the ICP to direct the Resident's care. The facility's Comprehensive Person-Center Care Planning Policy and Procedure, dated 2025, indicated that the facility provide each and every resident with the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility that is consistent with the resident's comprehensive assessment and baseline plan of care that is culturally competent and trauma-informed. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to: ensure that a resident received care and services for the provision of observation, documentation, and dressing changes to IV catheter, (a small plastic tube, placed in a vein for intermittent access) site consistent with professional standards of practice and facility policy. The deficient practice was identified for one (1) of one (1) resident reviewed for medication administration (Resident #120).As evidenced by the following: On 11/19/25 at 12:12 PM, the surveyor observed Resident #120 had an IV Catheter located in the right forearm. The surveyor observed the dressing was not labeled, dated, and loose. The adhesive of the dressing was peeling the entire circumference form the skin of the resident. The clip on the IV catheter was in the un-locked position. On 11/20/25 at 10:00 AM, the surveyor observed Resident #120 had an IV Catheter located in the right forearm. The surveyor observed that the dressing was not labeled, dated, and loose. The adhesive of the dressing was peeling the entire circumference of the resident's skin. The clip on the IV catheter (a backflow device which prevents blood from flowing back inti the catheter and causing a blood clot) was in the un-locked position. On 11/20/25 at 10:30 AM, the surveyor and the Infection Preventionist (IP) together, went to observe the IV site of Resident #120. During this time, the surveyor interviewed the IP who confirmed that the IV dressing was not dated, the dressing was loose, and the lock/clip on the IV tubing was not set in the locked position. She further stated, it should not look like that and it was not maintained according to facility policy. She stated that the policy was in place to protect the residents and prevent infection or infiltration of the IV. On 11/21/25 at 12:04 PM, the surveyor reviewed the medical record for Resident #120 which reflected the following information: A review of the admission Record Sheet (an admission summary) indicated that Resident #120 was admitted to the facility with medical diagnoses which included but was not limited to, cerebral infarction (stroke), unspecified, urinary tract infection, hemiplegia (paralysis) and hemiparesis (weakness). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/14/25, reflected that the Resident #120 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated a moderately impaired cognition. A review of the Medication Administration Record (MAR) dated, 11/1/25-11/31/25, revealed the following physician orders (PO): -Vancomycin HCL IV solution 1000 milligrams/ 200 milliliters IV for infection, dated 11/17/2025. - Vancomycin HCL IV solution 750 milligrams / 150 milliliters IV, daily for 5 days for infection, start date 11/18/2025, Discontinue date 11/19/25. -Meropenem IV 1 gram every 8 hours for bacteremia for 7 days, start date 11/19/2025. -change peripheral IV site every 3 days (every 72 hours) for infection prevention and iv site maintenance with a start date of 11/21/25 at 2:30 PM. The following A review of the Treatment Administration Record (TAR) dated, 11/1/25-11/31/25, reflected an ordered: Monitor IV insertion site for redness, swelling, warmth, tenderness, drainage or dislodgement. Action: document findings per facility policy. Notify provider immediately if any abnormalities are noted, every shift monitoring, start date 11/21/25 at 11:59 PM. This PO was obtained after surveyor inquiry. A review of the Individualized Care Plan (ICP) revealed a focus of I am receiving antibiotic therapy related to a bloodstream infection.dated 11/19/2025. The interventions: monitor and change according to facility policy. On 11/21/25 at 10:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that all dressings should be dated to allow all staff to know exactly when the dressing was changed to prevent infection and incompletion of the treatment. She also confirmed that all IV sites should be monitored and maintained according to nursing standards of practice and facility policy. On 11/26/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON who all acknowledged the surveyor's concerns and had nothing more to provide. A review of the facility's undated policy titled IV policy and procedure, included steps site assessment: monitor every shift, document findings.dressing: transparent dressing applied, keep clean, dry and intact, change dressing every 72 hours and sooner if needed.documentation: record: insertion site date and time, site, size of catheter, assessments, flushes, dressing changes and removal. NJ 483.25(h)

Based on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to: a.) ensure that all oxygen supplies were cleaned and stored according to nursing standards of practice and per facility policy b.) post cautionary signage to indicate that continuous oxygen therapy was in use for 1 of 2 residents (resident # 10). These deficient practices were evidenced by the following:On 11/19/25 at 10:54 AM, the surveyor observed on the door frame of residents #10 room. There was not any indication the resident was on oxygen (O2). Upon entering the room, the surveyor observed the resident on continuous O2, the concentrator had a humidified bottle and the setting was at 3 liters per minute (LPM), the nebulizer compressor and equipment (Small volume 5 milliliter (mL) nebulizer medication cup with mouthpiece, anti-spill T-piece, tubing) were out on the resident's nightstand, and the mouth piece was attached and hooked around siderail via the extension tubing and swinging in the open air. The medication cup was still attached to the mouthpiece, and it was not emptied of residual medication or dried. It was not in a bag. On 11/20/25 at 09:58 AM, the surveyor observed resident # 10, the nebulizer equipment was in the resident's nightstand with the drawer open, tubing hanging out of the drawer and the mouthpiece with medication cup still attached was laid on top of the compressor inside the drawer. The medicine cup on the mouthpiece had not been cleaned or bagged after medication administration. On 11/21/25 at 09:58 AM, the surveyor reviewed the medical records for resident #10. The admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to chronic obstructive pulmonary disease (COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of the quarterly Minimum Data Set (MDS) reflected a Brief Interview for Mental Status (BIMS) score of 13 of 15 indicating a cognitive function and decision making were intact. A review of the Care Plan revealed a need, dated 7/31/25, I have COPD and at risk for shortness of breath (SOB), hypoxia, respiratory infections. Interventions: administer bronchodilators as prescribed. Monitor and document any side of effects and effectiveness. A review of the Treatment Administration Record dated 10/1/25- 11/30/25, revealed a treatment assessment for SOB. A review of the Medication Administration Record revealed an order for Brovana Inhalation Nebulizer Solution 15 micrograms (MCG)/ 2 milliliter (ML), inhale orally via nebulizer two daily, start date 7/24/25. On 11/20/25 at 9:35 AM, the surveyor interviewed the Licensed Practical Unit Manager (LPNUM) who stated, if a resident was on O2 the nurse should follow the prescribed order and place a sign outside of the resident's room to indicate the resident was on O2. If a resident is on nebulizer treatments her expectation and facility policy is to administer the nebulizer treatment according to standards of practice and per facility policy. the medicine cup should be rinsed out and dried, then placed in a bag with the mask or mouthpiece until the next use to prevent infection. On 11/21/25 at 9:34 AM, the surveyor interviewed the Director of Nursing (DON) who stated, O2 use, and nebulizer treatments should be administered according to policy and nursing standards of practice. The DON acknowledged and agreed with the surveyor's concerns. A review of the policy titled, Oxygen Therapy revised date 4/5/25, Place oxygen in use sign on the outside of the room entrance door. A review of the policy titled, Respiratory Equipment policy- Oxygen and Nebulizer Therapy effective date 8/25/25, indicated nebulizer machines and tubing must be cleaned per manufacturer instructions after each use.nebulizer masks and tubing must be stored in clean, sealed baggies to prevent infection. NJAC 8:39-11.2 (b); 27.1(a)

Complaint # 2638538Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to properly store a controlled substance securely inside the medication room. The deficient practice was identified for 1 of 3 medication rooms inspected during the medication storage and labeling task was evidenced by the following: On 11/21/2025 at 11:48 AM, during an inspection of the Pine unit medication room with Unit Manager/ Licensed Practical Nurse (UM/ LPN) #1, the surveyor observed the metal narcotic box unlocked. Inside the narcotic box was a packaging labeled Lorazepam Intensol oral concentrate 2 milligram (mg) per milliliter (ml). Inside the packaging was a bottle filled with fluid labeled Lorazepam Intensol 2 mg/ml and a medicine dropper. UM/LPN #1 stated to the surveyor that the narcotic box should be locked at all times. On 11/24/2025 at 9:30 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that narcotic boxes should be kept locked. A review of facility- provided undated policy titled Controlled Medication Storage Policy reflected the following under Procedures: 1.) All controlled substances must be stored in a double-locked system. N.J.A.C. 8:39 - 29.4 (h)

Based on observation, interview, and record review, it was determined that the facility failed to provide a safe environment for its staff and its residents. This deficient practice was observed in the facility kitchen and was evidenced by the following:On 11/19/25 at 10:47 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen: Two- 6 burner units in the kitchen. On 11/19/25 at 11:15 AM the surveyor interviewed the Food Service Director (FSD) who stated that only 4 burners on each stove were operational (totaling 8 of 12), They have not worked since he was employed and that he told maintenance about the issue, but it was never fixed. The FSD was unable to provide documentation of the notification to maintenance. Ie . (email, or maintenance log) of the 4 -faulty burners reporting to provide to the surveyor. He further stated the licensed nursing home administrator (LNHA) was aware. The FSD did not think it mattered since they have gotten by with 8 of the 12 burners to cook on. The surveyor observed debris in the grates, cooking hats and stove surface as cited in F812. The FSD acknowledged the surveyors concerns and agreed that it could be a safety issue and / or a fire hazard for the staff and the facility Residents.On 11/20/2025 at 09:16 AM, the surveyor met with Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged the surveyor's concerns. He stated that the equipment should be repaired timely and maintained to prevent a safety hazard or injury; to ensure the safety of the residents and staff.On 11/26/25 at 11:25 AM the survey team met with the LNHA and Director of Nursing, they acknowledged and agreed with the concerns of the team and had no other information to provide.A review of the facility's undated policy, Kitchen equipment Policy, revealed. Purpose: ensure all kitchen equipment is used, cleaned and maintained safely and in compliance with NJ department of Health requirements, CMS food safety standards and manufacturer guidelines.All food contact equipment must be cleaned and sanitized after use and at the minimum of daily.Cleaning must follow manufacturer's instructions and facility procedures. A review of the facility's policy Food Service Equipment Damage and Reporting Policy: dated 11/5/23, revealed.the procedures the food service staff must follow when equipment is damaged or malfunctioning. It ensures a safe work environment.inspect equipment at the start of each shift for damage or malfunction.A review of the facility's undated policy Maintenance Policy: revealed .the purpose is to ensure all.equipment.are in a safe, functional and sanitary condition in compliance with New Jersey Department of Health regulations and applicable federal guidelines. Proper maintenance supports resident safety, comfort and quality of life. Immediately report hazards, malfunctions or unsafe conditions to the maintenance department.staff submits maintenance requests through the facility designated system or form.NJAC 8:39-31.2(e), 31.4(a), 31.4(f),

Based on record review, review of facility documents and policy and interviews, the facility failed to ensure one resident (Resident (R) 346) was protected from sexual abuse by another resident (R347). The facility then placed resident (R348) at risk for serious harm by placing R347 in R348's room following the sexual abuse incident. On 04/11/24, a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were safe from sexual abuse. The IJ was determined to exist on 01/23/22 when an act of sexual abuse occurred to R346. The IJ was removed on 01/24/22 when R347 was placed in a private room. The Administrator was informed and provided the IJ template on 04/11/24 at 5:00 PM that the past noncompliance IJ situation existed . The facility provided an IJ Removal Plan that was accepted on 04/11/24 at 6:59 PM. The survey team validated implementation of the Removal Plan through interviews and review of training records on 04/11/24 at 7:15 PM. Based on the facility's implementation of corrective actions, the IJ was determined to be Past Non-Compliance (PNC) and the IJ was removed, with substantial compliance achieved on 04/05/22. The deficient practice was determined to be past noncompliance related to the facility identifying the IJ and implementing interventions to prevent reoccurrence of the situation, completed on 04/05/22. The facility's actions included the following: 1. The perpetrator (R347) was removed from the situation and placed on 30-minute checks. 2. The resident was moved to a private room. 3. Police department was notified, and the situation was investigated. 4. Staff were in-serviced on abuse prevention. 5. The resident was arrested and placed in custody. 6. The judge ordered the facility to readmit the resident. 7. Request sent to the judge regarding R347's continued behaviors. 8. The resident was placed on 30-minute checks. 9. Bail was revoked with R347 returning to custody and did not return to the facility. Findings include: Review of the facility's investigation on facility letterhead, dated 01/23/22, indicated .Summary of Incident: On 01/23/22 around 7:00 PM nurse for [R346 and R347] knocked on their room door several times, not getting a response she entered the room and found [R347] kneeling by the side of [R346's] bed with his head between his groin area. [R346's] adult brief was opened and it appeared [R347 had R346's] penis in his mouth .[R346] was assessed .and he had no visible injuries .[R347] was interviewed .and was asked about the incident and he said he was performing oral sex on his roommate without consent. [R347] was put in a room with an alert and oriented resident [R348] as there was not any private room available. His [sic] was placed on 30 minute checks until 01/24/2022 when he was moved to a private room . Review of the facility's undated form titled Individual Statement Form stated, .Where and when did the incident occur? 01/23/2022 7PM room [ROOM NUMBER]. Tell us step by step, in your own words, what happened .I went to give [R347] his HS (at bedtime) sandwich. The door to his room was closed. I knocked a few times but I heard no response. I opened the door and found [R347] on his knees on the floor mat with his head over the groin area of [R346]. Then it was seen that [R347] had his mouth on [R346's] penis. [R346's] adult brief was open and his blankets and sheets were at the end of his bed. [R347] saw me and he got back into his wheelchair and said to me I'm sorry. [R347] was removed from his room .Signature: [Licensed Practical Nurse (LPN) 1] . Review of R347's EMR under the Progress Notes tab from the date of R347's admission (10/16/20) through the day prior to the incident indicated no documentation of R347 attempting or performing sexually inappropriate behavior with the facility's staff or residents. Review of R347's EMR under the Progress Notes tab indicated 01/23/22 around 7:00 PM LPN1 found R347, kneeling by R346. R347 had his head between R346's legs and R346's diaper was open, and his penis was exposed. R347 immediately returned to his wheelchair. R347 was immediately removed from the room and was placed with R348 who was alert and oriented x 4. Resident 347 was placed on 30-minute checks. On 01/24/22 R347 was placed in a private room. Review of facility's policy titled, Abuse Prevention, initiated 03/13, revealed Policy: The facility will not tolerate any form of resident abuse .by another resident. The facility will have an abuse prevention program that protects residents from physical .abuse .Sexual Abuse: Any inappropriate physical contact of a resident in an sexual manner .Key components of systemic approach to prevent abuse .Train .The facility during its orientation program and through an ongoing training program provide all employees with information regarding abuse and neglect and related reporting requirements including prevention, intervention and detection .Protect The facility must protect individuals from abuse .during investigation of any allegations of abuse and neglect .Investigate The facility ensures, in a timely and thorough manner, objective investigation of all allegations of abuse .Report/Respond The facility must assure that any incidents of substantial abuse .are reported and analyzed and the appropriate corrective .action occurs . Review of R346's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R346 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, Parkinson's disease, major depressive disorder, heart disease, dementia, and functional quadriplegia. Review of R346's EMR under the Minimum Data Set (MDS) tab with an Assessment Reference Date (ARD) of 09/16/22, indicated R346 was total dependence of one person for bed mobility, dressing and toileting; total dependence of two people for transfers; and extensive assist of one person for eating. The MDS showed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating R346 was severely cognitively impaired. Review of R347's Face Sheet located under the Profile tab of the EMR revealed R347 was admitted to the facility on [DATE] with the diagnoses of Parkinson's disease, type II diabetes, major depressive disorder, anxiety disorder, heart disease, essential tremor, and muscle weakness. Review of R347's EMR under the MDS tab with an ARD of 01/23/21, indicated R347 was independent with bed mobility, transfers, and locomotion on the unit; supervision of one person for toileting and walking in room; and extensive assist of one person with dressing. The MDS showed a BIMS score of 12 out of 15 indicating R347 was moderately cognitively impaired. Review of R348's Face Sheet located under the Profile tab EMR revealed R348 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. Review of R348's EMR under the MDS tab with an ARD of 01/20/22 indicated R348 was limited assist of one person for transfers, dressing and walking in room; supervision of one person for toileting; supervision of two people for bed mobility; and set up only for eating. The MDS showed a BIMS score of 11 out of 15 indicating R348 was moderately cognitively impaired. Review of the facility's undated form titled, Resident Check for Safety indicated documentation of R347 receiving checks beginning on 01/23/22 at 11:30 PM, 01/24/22 at 12:00 AM, followed by hourly checks through 01/27/22 at 3:00 PM. Review of the facility's in-service sheet titled, Abuse Prevention, dated 01/24/22, indicated 18 Nurses and Certified Nursing Assistants attended the in-service. Review of the R347's EMR under the Progress Notes tab, dated 01/27/22, revealed On 01/27/22 around 2:30 PM [R347] was interrogated by two detectives from Ocean County and [NAME] Township. I was informed he will be arrested tonight . Review of the document from the Superior Court of New Jersey Law Division: Criminal Part Ocean County Complaint #: W-2022-000037-1505 Order Denying Pretrial Detention and Ordering Pretrial Release dated 02/11/22, revealed .Reasons for denial of pretrial detention: Further .the court does not find clear and convincing evidence that pretrial detention is necessary to reasonably assure the defendant's appearance in court when required, the protection of the safety of any other person or the community .The Court fashions a remedy that requires the defendant to be placed in an private room at [Facility Name] or a similarly situated facility that would provide a private room to the defendant .Therefore, the motion for pretrial detention is DENIED .It is ordered, on this date, February 11, 2022, that the defendant be released on Pretrial Monitoring Level III .Next Court Date: You are hereby ordered to return to court on 03/30/22 at 9:00 AM . Review of the facility's undated contract titled, [R347] Contract revealed In an effort to ensure the safety of the residents of [Facility Name] Care Center, and to protect [R347's] sexual rights and resident rights, the facility has provided the following contract about sexually appropriate behavior following [R347's] release from Ocean County Jail for a sexual offense. 1. [R347] needs to remain in his room unless escorted by a staff member. 2. When [R347] needs/wants to leave his room, he will use the call bell to ask staff to escort him where he needs to go. 3. [R347] can attend group activities under supervision. 4. [R347] cannot make any sexual advances towards other residents without their consent .I understand that if I violate any aspect of this contract the results will be as follows: 1. The IDT (Interdisciplinary Team) will be in contact with my Public Defender and I am at risk for sentencing. 2. [Facility Name] Care Center will issue me a discharge notice and will notify the Department of Health . The contract was completed/signed by R347 on 02/14/22. Review of R347's care plan, initiated on 08/25/21, indicated the Need on 01/23/22 of I inappropriately performed sexual acts on my roommate without his consent .Wishes I'll not have unconsensual [sic] sexual activity with anyone .I understand Interventions 02/28/22 I am aware that I have the right to sexual expression and self pleasure .I can not make sexual advances towards any other resident without their consent .03/28/22 Door alarm on when staff are not present to provide me with one to one . Review of R347's EMR under the Progress Notes tab, dated 02/28/22, indicated the facility Administrator notified R347's Public Defender that R347 was being sexually inappropriate with facility staff, attempting to have male residents come to his room and leaving his room without supervision. The facility's Social Worker and the Public Defender discussed with R347 the rules/guidelines he would have to adhere to remain in the facility. The Public Defender stated he would relay this information to the Judge. Review of the R347's EMR under the Progress Notes tab, dated 04/05/22, indicated R347 attended court and was incarcerated following court. R347 never returned to the facility after that court date. During an interview on 04/09/24 at 2:20 PM the Administrator stated the facility's investigation revealed that R347 had not shown a sexual interest in male staff members or other residents prior to this incident. Administrator confirmed R347 was removed from R346's room to another room immediately following the incident. During an interview on 04/10/24 at 9:31 AM Detective (D) 1, stated he did remember the case. D1 stated he interviewed R347 on 01/27/22, R347 was arrested and taken to jail. D1 confirmed that R347 admitted he committed a sexual act. During an interview on 04/10/24 at 10:03 AM, the Social Services Director (SSD) stated she was not aware of R347 having a sexual abuse history prior to the incident. SSD explained that prior to coming to [Facility Name], R347 was residing at another Long-Term Care facility and had requested to be moved to a facility located closer to where his stepbrother resided. SSD confirmed, at the time of the incident, R346 was nonverbal and had a BIMS of zero. SSD stated R346 did not exhibit any signs of emotional or physical distress following the incident. During an interview on 04/10/24 at 10:33 AM, LPN1 confirmed she entered the room of R346 and R347 and witnessed the sexual abuse occurring. LPN1 stated following the incident R347 was immediately removed from the room. LPN1 stated she did not receive any indication from R347 that he was going to sexually abuse anyone, the incident was a total surprise to her. LPN1 stated she did provide care for R347 prior to and after the incident. During an interview on 01/10/24 at 1:45 PM, Certified Nursing Assistant (CNA) 1 stated she worked for the facility for [AGE] years. CNA1 stated she did not work on the unit where R347 was residing, but remembered the incident and received an in-service regarding sexual abuse following the incident. During an interview on 01/10/24 at 1:51 PM, CNA2 stated she worked for the facility for six years. CNA2 remembered the incident and did provide care for R347 around the time of the incident. CNA2 denied having an indication that R347 was going to sexually abuse a resident. CNA2 stated R347 was moved to another room immediately following the incident, was not allowed to leave his room without someone with him, did recall safety checks being implemented and, at times, a staff member sitting outside R347's room. NJAC 8:39-4.1(a)(5) NJAC 8:39-33.2(c)(12)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the dish washer sanitizer level was maintained at a level required to sanitize the dishes. This had the potential to affect 146 of 146 residents in the facility. Findings include: Review of the undated facility's policy titled, Dish Machine Policy and Procedure revealed it was the facility policy to test the chlorine level using test strips. According to the policy the chlorine level should be 50 to 100 PPM and should be tested at the start of running the dish machine. During an observation and interview on 04/08/24 at 9:52 AM, the Dietary Manager (DM) stated the dish washer was being used as a low temperature dish machine because the booster went out on 03/28/24. He stated the employee was using it to wash breakfast dishes. He tested the chlorine sanitizer level of the dish washer rinse water, and it tested zero (0) parts per million (ppm). He stated it was supposed to be testing at 50 to 100 ppm. The dish washer was ran and tested two additional times and each time the sanitizer level of the rinse water was zero ppm. The hose running from the bottle of sanitizer was examined while the dish washer was running, and the sanitizer was not running through the hose. During an observation and interview on 04/08/24 at 10:10 AM, Dietary Aide (DA) 1 was asked what he did prior to washing the breakfast dishes and he stated he checked the temperatures on the two thermometers located on the top of the machine and wrote the temperatures on the log that was hanging on the wall across from the dish washer. The log was examined and did not contain an area to document the chemical level of the chlorine. The DM was present and verified the chlorine level was not being documented. DA1 was asked if he checked the chemical level, and he did not appear to understand so the container of test strips was handed to him, and he opened the container took out half the strips and threw them into the dishwasher tank. The strips did not change color again indicating there was no chlorine in the rinse water. The DM was present during the observation and verified the employee did not understand how to check the chlorine level of the sanitizer. Review of the manufacturer's information posted on the back of the gallon bottle of Santec Three sanitizer used to sanitize the dishes for the dish washer stated to prepare sanitizing solution to an initial concentration of 100 ppm available chlorine. The instructions stated the chlorine level must be tested and adjusted periodically to ensure the available chlorine did not drop below 50 ppm. During an observation and interview on 04/09/24 at 9:15 AM the level of the chlorine sanitizer was checked in the rinse water of the dish washer, and it was 50 ppm. The DM provided documentation titled Cleanslate Kitchen Service Report, dated 04/08/23 and timed 2:30 PM. According to the report the professional technician came to the facility to complete a preventative maintenance call. The report revealed he recalibrated the sanitizer on the dish machine and made sure chemicals were at the right levels. The DM stated that the service technician from Cleanslate told him the tubing was clogged and he replaced the tubing and rearranged/recalibrated the sanitizer and now it was running at 50 to 100 PPM. He stated that he retrained staff, and he produced a new log for them to record the chemical level of the sanitizer. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that five of 12 residents (Resident (R) 17, R19, R61, R128 and R297) reviewed for side rails had a comprehensive care plan developed that addressed the use of side rails of 32 sampled residents. Findings include: Review of facility's undated policy titled, Comprehensive Person-Centered Care Plans, revealed [name of the facility] will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A plan of care is something that describes in an easily accessible way the services and support being provided and should be put together and agreed with the person through the process of care planning and review. 1. Review of R17's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R17 was admitted to the facility on [DATE] with a diagnosis including multiple sclerosis (MS), generalized muscle weakness, and ataxia (impaired balance or coordination). During an observation and interview on 04/08/24 at 10:30 AM, R17 was sitting up in her bed with bilateral half side rails in the up position. During this observation, R17 stated that she used the side rails for turning. At 12:15 PM, R17 was sitting up in bed eating lunch with upper half bilateral side rails in the up position. During further observation on 04/10/24 at 6:30 PM, R17 was in bed with upper half bilateral side rails in the up position. Review of R17's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/24 indicated a Brief Interview for Mental Status (BIMS) was 15 out of 15, which indicated R17 was cognitively intact. Review of R17's Care Plan's under the EMR Care Plan tab, dated 09/09/22, revealed no evidence of a side rail care plan or side rails as an intervention. 2. Review of R19's Face Sheet under the Profile tab in the EMR indicated that R19 was readmitted to the facility on [DATE], with a diagnosis including difficulty walking, muscle weakness, arthritis, fracture of right humerus, and unsteady gait/balance. During initial tour observation on 04/08/24 at 10:00 AM, R19 was in bed asleep with her upper half bilateral side rails in the raised position. Review of R19's undated Care Plan under the EMR Care Plan tab, revealed no evidence of a side rail care plan or side rails as an intervention. 3. Review of R61's Face Sheet under the Profile tab in the EMR indicated that R61 was admitted to the facility on [DATE] with a diagnosis of dementia, pain in left shoulder, and history of falling. During an observation on 04/08/24 at 10:05 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Further observation on 04/11/24 at 9:00 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Review of R61's Care Plan under the EMR Care Plan tab, dated 05/31/21, indicated no evidence of a side rail care plan or side rails as an intervention. 4. Review of R128's Face Sheet under the Profile tab in the EMR indicated that R128 was readmitted to the facility on [DATE] with a diagnosis of generalized muscle weakness, restless leg syndrome (RLS), dementia, and difficulty walking. During the initial observational tour of the facility on 04/08/24 at 10:00 AM, R128 was laying in her bed with bilateral half side rails in the up position. At 12:00 PM, R128 was sitting up in her bed with bilateral half side rails in the up position. Review of R128's Care Plan under the Care Plan tab in the EMR, dated 07/11/23, indicated no evidence of a side rail care plan or side rails as an intervention. 5. Review of R297's Face Sheet under the Profile tab in the EMR indicated that R297 was admitted to the facility on [DATE] with a diagnosis of fracture left femur. During observation on 04/08/24 at 10:20 AM, R297 was in bed, with bilateral half side rails in the up position. At 12:20 PM, R297 was sitting up in her bed, eating lunch with bilateral half side rails in the up position. During further observation on 04/10/24 at 10:00 AM and 6:37 PM, R297 was in her bed with bilateral half side rails in the up position. Review of R297's Care Plan under the Care Plan tab in the EMR, dated 01/10/24, indicated no evidence of a side rail care plan or side rails as an intervention. During an interview on 04/10/24 at 3:45 PM, the Assistant Director of Nursing (ADON) confirmed that R17, R19, R61, R128, and R297 did not have a side rail care plan. NJAC 8:39-11.2(e) thru (i) NJAC 8:39-27.1(a)

Based on observation, record review, interviews, and facility policy review, the facility failed to attempt to use appropriate alternatives prior to installing bed rails; failed to assess the residents for the risk of entrapment from the bed rails; failed to review the risks and benefits of the bed rails with the resident or resident representative; and failed to obtain informed consent prior to installation or use of the side rails of 11 of 11 residents (Resident (R) 17, R19, R61, R128, R297, R6, R23, R54, R57, R196, and R197) reviewed for accident hazards of 32 sampled residents. Findings include: Review of facility's undated policy titled, Side Rail Assessment, revealed Purpose: 1. Every resident will be assessed for the need for side rails upon admission or re-admission. 2. When side rail usage is determined to be necessary and side rails meet the definition of a restraint whether to restrict movement for safety, a physician's order should be obtained, and the side rail should be addresses as an approach to a problem/need on the resident's plan of care. 3. The need for side rails will initially be determined upon admission by the admitting nurse, conferring with the resident and family members. Physical and mental status, resident wishes and history will all assist in determining initial side rail usage. 4. A screening form will be used to assist in determining the need of rationale for side rail usage. A new screen may be indicated by functional ability changes as noted by the Minimum Data Set (MDS). 5. The resident or family representative will be asked to sign a consent form upon admission. If after the screening process, bed rail usage changes or at any time thereafter, the family representative will be notified. Review of facility provided documentation titled, Side Rail Screen, revised 08/15, revealed Patient Name: __Unit: __Room number: __1. Is the patient ambulatory? 2. Is the patient comatose or semi-comatose? 3. Does the patient have alteration in safety awareness? 4. Does the patient have a history of frequent falls? 5. Does the patient have difficulty moving in bed? 6. Does the patient have difficulty sitting on or moving to the side of the bed? 7. Does the patient have difficulty with balance or poor trunk control? 8. Does the patent take any medication that would require an increase in safety precautions? 9. Is the patient currently using side rails for independent positioning or to assist with positioning? 10. Has the patient asked to have the side rails raised while in bed? Alternate to Side Rails: 1. Frequent toileting 2. Reminders to use call bell 3. Restorative care to enhance independence 4. Other: Yes/No (circle) Side rails are indicated to: 1. Provide safety 2. Promote independence of positioning of transfers 3. Fulfill resident's request Yes/No (circle) Side Rails are not indicated at the present time. Yes/No (circle) Evaluation will continue to determine the appropriateness. Comments: __Side Rails Utilization: __One __Both __1/2 Rail __3/4 Rails Signature: __ Date: __ 1. Review of R17's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R17 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), generalized muscle weakness, and ataxia (impaired balance or coordination). Review of R17's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/24 indicated a Brief Interview for Mental Status (BIMS) was 15 out of 15, which indicated R17 cognitively intact. During an observation and interview on 04/08/24 at 10:30 AM, R17 was sitting up in her bed with bilateral half side rails in the up position. During this observation, R17 stated that she used the side rails for turning. At 12:15 PM, R17 was sitting up in bed eating lunch with upper half bilateral side rails in the up position. During further observation on 04/10/24 at 6:30 PM, R17 was in bed with upper half bilateral side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails: 1/3 left and right. Review of Assessments under the Evaluation tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rail use. 2. Review of R19's Face Sheet under the Profile tab in the EMR indicated that R19 was readmitted to the facility on [DATE], with diagnoses including difficulty walking, muscle weakness, arthritis, fracture of right humerus, and unsteady gait/balance. During initial tour observation on 04/08/24 at 10:00 AM, R19 was in bed asleep with her upper half bilateral side rails in the raised position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails as enabler 1/3 to left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence that R19 had an assessment for side rails. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rails being used. 3. Review of R61's Face Sheet under the Profile tab in the EMR indicated that R61 was admitted to the facility on [DATE] with diagnoses of dementia, pain in left shoulder, and history of falling. During an observation on 04/08/24 at 10:05 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. During further observation on 04/11/24 at 09:00 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails 1/3 to left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rails being used. 4. Review of R128's Face Sheet under the Profile tab in the EMR indicated that R128 was readmitted to the facility on [DATE] with diagnoses of generalized muscle weakness, restless leg syndrome (RLS), dementia, and difficulty walking. During the initial observational tour of the facility on 04/08/24 at 10:00 AM, R128 was lying in her bed with bilateral half side rails in the up position. At 12:00 PM, R128 was sitting up in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails: 1/3 as enabler for left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or no evidence of alternatives completed prior to side rails applied. 5. Review of R297's Face Sheet under the Profile tab in the EMR, indicated that R297 was admitted to the facility on [DATE] with a diagnosis of a fracture left femur. During observation on 04/08/24 at 10:20 AM, R297 was in bed, with bilateral half side rails in the up position. At 12:20 PM, R297 was sitting up in her bed, eating lunch with bilateral half side rails in the up position. During further observation on 04/10/24 at 10:00 AM and 6:37 PM, R297 was in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails 1/3 as enabler to left and right. Review of Admit/Readmit Screener under the Evaluations tab in the EMR, dated 01/09/24, indicated both side rails were used; however, no evidence of an indication why the side rails were being used. Further review revealed no evidence of alternatives prior to side rails being applied. Review of Consent under the Miscellaneous tab in the EMR indicated no consent and/or alternatives prior to side rails being applied. During an interview on 04/10/24 at 3:45 PM, the Assistant Director of Nursing (ADON) indicated that all beds had 1/3 side rails, and these side rails were built into the bed. She stated that side rails were used for bed mobility and/or positioning. She indicated that side rails should have been assessed quarterly during the care conference; however, they were only being assessed upon admission and/or re-admission. The ADON confirmed that R17, R19, R61, R128, and R297 did not have side rail consent, quarterly side rail assessments, and/or alternatives prior to side rail usage. 6. Review of R6's quarterly MDS with an ARD of 12/20/23 revealed she had a BIMS score of 9 out of 15 indicating she had moderately impaired cognition and she required substantial assistance with bed mobility. Review of R6's physician orders located in the Orders tab of the electronic medical record (EMR) revealed she had a physician's order for 1/3 side rails as enabler with a start date of 07/28/23. Review of the Admit/Readmit screener, dated 07/27/23, under the Evaluation tab of the EMR revealed she used half side rails on both sides of the bed to promote independence with bed mobility. R6's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During an observation on 04/09/24 at 8:57 AM and on 04/11/24 at 7:37 AM, R6 was observed in bed with one-third side rails in the up position on the top of the bed. 7. Review of R23's quarterly MDS with an ARD of 03/04/24 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact. Review of R23's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 10/20/23. Review of the Admit/Readmit screener, dated 07/27/23, under the Evaluation tab of the EMR revealed she used half side rails on both sides of the bed. R23's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During an observation on 04/09/24 at 8:58 AM, 9:54 AM, and 5:05 PM and on 04/11/24 at 7:37 AM, R23 was observed in bed with one-third side rails in the up position on the top of the bed. 8. Review of R54's admission MDS with an ARD of 03/07/24 revealed she had a BIMS score of 6 out of 15 indicating she was severely cognitively impaired and required substantial/maximal assistance with bed mobility. Review of R54's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 09/29/24. Review of the Admit/Readmit screener, dated 2/29/24, under the Evaluation tab of the EMR revealed the resident used half side rails on both sides of the bed for safety and to promote independence with bed mobility. R54's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observations on 04/08/24 at 10:45 AM, 1:33 PM; on 04/09/24 at 6:53 PM; on 04/10/24 at 10:26 AM; and on 04/11/24 at 6:15 AM and 7:39 AM, R54 was observed in bed with one-third side rails in the up position on the top of the bed. 9. Review of R57's quarterly MDS with an ARD of 02/07/24 revealed she had a BIMS score of 14 out of 15 indicating she was cognitively intact, and she required partial assistance with bed mobility. Review of R57's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 12/22/23. Review of the Admit/Readmit screener, dated 12/21/23, under the Evaluation tab of the EMR was blank for the use of the side rails. R57's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observation on 04/09/24 at 8:58 AM and on 04/11/24 at 7:38 AM, R57 was observed in bed with one-third side rails in the up position on the top of the bed. 10. Review of R196's admission MDS with an ARD of 03/29/24 stated she had a BIMS score of 10 out of 15 indicating she had moderate cognitive impairment and she required supervision or touch assistance with bed mobility. Review of R196's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 03/24/24. Review of the Admit/Readmit screener, dated 03/23/24, under the evaluation tab of the EMR revealed she used two half side rails to promote independence with bed mobility. R196's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observation on 04/09/24 at 6:52 PM, R196 was observed in bed with one-third side rails in the up position on the top portion of the bed. 11. Review of R197's admission MDS with an ARD of 03/25/24 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact, and she required supervision or touch assistance with bed mobility. Review of R197's physician's orders in the Orders tab of the EMR, revealed she had a physician's order for 1/3 side rails as enabler with a start date of 03/21/24. Review of the Admit/Readmit screener, dated 03/21/24 and located under the Evaluation tab of the EMR revealed she used two half side rails to promote independence with bed mobility. R197's EMR was reviewed in its entirety and was silent for documentation to show what alternatives were attempted prior to the use of the side rails and for documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observations on 04/08/24 at 10:51 AM and on 04/09/24 at 5:01 PM, R197 was observed in bed with one-third side rails in the up position on the top of the bed. On 04/08/24 at 10:51 AM the resident stated she only used the side rails to attach her phone cords and call cord to so she could reach them. During an interview on 04/10/24 at 4:00 PM, the ADON was interviewed, and the above records were reviewed with her. She was unable to find any information related to alternatives attempted prior to putting the side rails in place; or documentation to show the residents and/or the residents' representatives were informed of the risk and benefits prior to using the side rails. She stated they did not have consent for the use of the side rails for the above residents. 03115 NJAC 8:39-27.1(a)

Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that two residents (Resident (R) 2 and R65) out of 32 sampled residents' Minimum Data Set (MDS) assessments were completed and transmitted in a timely manner. Findings include: Review of Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.181, dated 10/23 revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS .RAI OBRA-required assessment summary for quarterly assessment .MDS completion date (Z0500B) no later than assessment reference date (ARD) + 14 calendar days .Transmission date MDS completion date + 14 calendar days. 1. Review of R2's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R2 was admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI) and paraplegia. Review of R2's quarterly MDS assessment under the MDS tab in the EMR with an ARD of 03/02/24 revealed MDS completed on 03/21/24 and submitted on 04/02/24. Review of the MDS Summary under the MDS tab in the EMR, dated 03/02/24, revealed Completed MDS on 03/21/24 and accepted on 04/02/24. Review of the Assessment History under the MDS tab in the EMR, dated 03/02/24, revealed Quarterly assessment batched and accepted on 04/02/24. 2. Review of R65's Face Sheet under the Profile tab in the EMR indicated that R65 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, major depressive disorder (MDD), and mood disorder. Review of R65's quarterly MDS assessment under the MDS tab in the EMR with an ARD of 03/01/24 revealed MDS completed on 03/20/24 and submitted on 04/02/24. Review of the MDS Summary under the MDS tab in the EMR, dated 03/01/24, revealed Completed MDS on 03/20/24 and accepted on 04/02/24. Review of the Assessment History under the MDS tab in the EMR, dated 03/01/24, revealed Quarterly assessment batched and accepted on 04/02/24. During an interview on 04/11/24 at 1:40 PM, the MDS Assistant (MDSA) confirmed that neither assessments were completed and submitted within the appropriate timeframe. NJAC 8:39-11.2

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/17/2021 from 11:19 AM to 12:09 PM the surveyor, accompanied by the Food Service Manager (FSM) observed the following in the kitchen: 1. Upon entry to the dish room, the surveyor observed the dietary aide (DA) loading the high temperature dish machine with racks of dirty dishes. The DA then proceeded to walk over to the clean side of the dish machine to unload cleaned and sanitized dishes. The surveyor asked the DA if she should handle the cleaned and sanitized dishes after handling the dirty dishes. The DA stated, I can't touch the cleaned dishes because I will cross contaminate. The DA then proceeded to go to the designated hand washing sink to perform hand hygiene. The DA was observed to turn on running water via the foot pedal. The DA then placed their hands under the running water for 5 seconds. The DA then turned off the running water via the foot pedal and proceeded to don a pair of disposable gloves with their hands still wet. The DA did not apply soap to their hands or perform vigorous hand washing for 20 seconds and the DA did not dry their hands before proceeding to don gloves. The DA then went to the cleaned and sanitized dishes that had just exited the high temperature dish machine. The surveyor interrupted the DA and asked them not to touch the cleaned and sanitized dishes with their gloved hands. The surveyor requested that the DA perform hand hygiene again before having contact with the cleaned and sanitized dishes. The DA then proceeded to doff their gloves and place them in the waste basket located at the designated hand washing sink. The DA then turned on the water via the foot pedal and wet their hands under running water. The DA then applied hand soap and proceeded to wash their hands vigorously under the running water for approximately 20 seconds. Upon the 20 second mark the DA had no noticeable soap lather on their hands as the running water had effectively washed the soap off. The DA then proceeded to turn off the water and dry their hands with a hand towel. The DA then attempted to don a new pair of gloves; however, the surveyor again questioned the DA whether they had performed hand hygiene according to the facility policy and procedure. The DA became agitated and walked away from the surveyor. On interview the FSM stated, She has been in-serviced on hand hygiene by foodservice and our infection control nurse. The surveyor reviewed the facility provided policy titled Hand Washing, copyright 2019. The following was revealed under the heading Procedure: 2. How to wash hands: a. Turn on the faucet using a paper towel to avoid contaminating the faucet. b. Wet hands and forearms with warm water (minimum 110 F) and apply an antibacterial soap. c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running warm water. d. Rinse thoroughly. e. Dry hands with paper towel or use a hand blow dryer. f. Use the paper towel to turn the faucet off and open the door if needed, and then discard it. 3. Staff will be educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines. 4. Hand washing procedures will be posted by each hand-washing sink. The surveyor reviewed the facility provided Hand Washing Competency for the DA, dated 9/14/2021. Review of the competency revealed that the DA had successfully met the required hand washing competencies on 9/14/2021. N.J.A.C. 18:39-17.2(g)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility staff failed to ensure that resident's were free from verbal abuse for 1 of 30 residents reviewed for abuse, (Resident #93). This deficient practice was evidenced by the following: On 11/15/2021 at 10:17 AM, the surveyor was standing at the nurses station on the Maple unit. A staff member, later identified as a Certified Nursing Assistant (CNA #1), was in the lobby area of the unit with a resident, later identified as Resident #93. The surveyor heard CNA #1 say to the resident You don't shake your soda you weirdo. At approximately 10:35 AM, the surveyor reported this to the Administrator and Director of Nursing (DON). The DON said this was not appropriate. The Administrator said he would immediately go and start an investigation. A review of the medical record revealed Resident #93 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) an assessment tool, dated 10/1/2021, Resident #93 had a Brief Interview for Mental Status score of 11/15, indicating Resident #93 had moderately impaired cognition. During an interview with the surveyor on 11/15/2021 at 11:30 AM, the administrator said CNA #1 would be writing a statement and meeting with the DON and then be sent home. The Administrator also said he had reported this to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman. During an interview with the surveyor on 11/16/2021 at 08:04 AM, the DON said that CNA #1 was still suspended and admitted it was improper to call the resident a weirdo and didn't mean it. The DON went on to say CNA #1 thought it was a joke and the DON believed it was seriously not appropriate to say this. The DON again said CNA #1 knew she was wrong. The DON further stated that on interview Resident #93 didn't recall the CNA calling he or she a weirdo and did not want to get the aide in trouble. A review of the facility investigation revealed a handwritten statement, dated 11/15/2021 at 10:20 AM and signed by CNA #1. The statement indicated that Resident #93 started to shake the can of soda and she said to the Resident, Don't shake the can you weirdo, your gonna make it explode everywhere. A review of a summary of investigation revealed Resident #93 was interviewed by the Administrator and DON and did not remember the conversation and didn't hear the staff call him/her a weirdo. During an interview with the surveyor on 11/16/2021 at 11:45 AM, Resident #93 said no staff has been disrespectful to him/her and that the staff treats me good. Resident #93 said he/she did not recall the incident. A review of facility provided written material for the Understanding Abuse and Neglect education, undated, revealed under Section 2; Recognizing, Reporting and Preventing Abuse, Verbal Abuse includes talking disrespectfully A review of a facility provided policy titled Abuse Prevention with an initiated date of March 2013, revealed under Policy: The facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members NJAC 8:39-4.1(a)(5)

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to provide care consistent with professional standards necessary to prevent the risk of an infection from developing during a wound care observation, on 1 of 3 residents investigated for pressure ulcers, (Resident #61). The deficient practice was evidenced by the following: On 11/10/2021 at 9:40 AM, during a wound care observation for Resident #61's left heel pressure ulcer, the surveyor observed the Unit Manager (UM) use a pair of scissors to cut and remove a wound dressing that revealed a date of 11/9. After cutting the dressing, the UM placed the scissors into her shirt pocket without cleaning them. On the same date at 9:51 AM, the surveyor observed the UM remove the scissors from her pocket and used them to cut calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven fiber). After cutting the calcium alginate, she applied it to the base of the pressure ulcer. The UM did not clean the scissors before cutting the calcium alginate. A review of the Quarterly Minimum Data Set (an assessment tool) dated 10/21/21, revealed Resident #61 had a pressure ulcer. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan revised 10/6/21, revealed Resident #61 was at risk to develop complications related to infection such as dehydration, respiratory distress, pain, skin breakdown, weakness, and mental fog. The care plan further revealed a need to remain free from infection through the review date of 1/31/22. A review of the care plan revised on 10/21/2021, revealed Resident #61 had discoloration to the left heel. The care plan further revealed that Resident #61 wished to remain free from infection for the next 90 days through the review date 1/31/2022. During an interview with the surveyor on 11/10/2021 at 10:01 AM, the UM said she should have cleaned the scissors. A review of a facility policy titled Pressure Ulcer Prevention/Management Program initiated 3/2013 and revised 8/2020, did not address cleaning scissors during wound care. A review of an undated and untitled facility documentation provided by the Administrator on 11/16/21 at 10:28 AM, included steps of wound care procedures under the headings of Clean dressing of wound Preparation, Removing an old dressing, Cleaning and dressing the wound, After the procedure. There was no documentation to address cleaning of scissors during wound care. N.J.A.C. 8:39-27.1(a)

COMPLAINT # NJ 9 Based on interviews, review of Medical Records (MR), and other pertinent facility documentation on 8/16/2021, it was determined that the facility staff failed to maintain a complete and accurate MR for documentation of a resident's treatments on the Treatment Administration Record (TAR), to show that the tasks were completed for foley care, wound healing/care and prevention, and continuous oxygen was maintained for 1 of 3 residents (Resident #3) sampled. The facility also failed to follow the Facility Policy titled Charting and Documentation, This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #3 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 7/6/2021, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating Resident #3 had moderate cognitive impairment. The MDS also showed the resident required extensive assistance for Activities of Daily Living (ADLs). Review of the TAR dated 7/1/2021 - 7/31/2021, showed no documented evidence of the person who was responsible to provide the treatments for the week of 7/1/2021 to 7/6/2021, as follows: 1. Cleanse left heel with normal saline, apply clean dry dressing daily on 7/2/2021 and 7/3/2021 was blank. 2. Santyl ointment, apply to sacral wound topically every day shift for wound healing. Cleanse 2 sacral openings with normal saline, apply Santyl ointment and cover with clean, dry, dressing on 7/3/2021 was blank. 3. APM (Alternating Pressure Mattress) check function and placement every shift for wound healing on 7/3/2021, day shift was blank. 4. Float Heels every shift on 7/3/2021, day shift was blank. 5. Foley catheter care every shift for hygiene and record output on 7/3/2021, day shift was blank. 6. Continuous oxygen 5 liters via nasal cannula every shift for shortness of breath on 7/3/2021, day shift was blank. Review of the Resident's Care Plan, and Progress Notes failed to provide documented evidence as to why the aforementioned dates and shifts on the TAR were blank. During an interview on 8/16/2021 at 1:00 p.m., the Assistant Director of Nursing (ADON) agreed that the staff failed to sign Resident #3's TAR. Review of the Facility Policy titled Charting and Documentation, undated, revealed the following under Purpose: The purpose of charting and documentation is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc Under Treatments: Documentation pertaining to treatments should include: Name of the person administering the treatment. N.J.A.C. 8:39-35.2(d) 9

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that appropriate infection control practices were followed to prevent the spread of COVID-19. This deficient practice was identified for 6 of 12 staff members observed on 2 of 3 nursing units, and was evidenced by the following: 1. On 12/21/2020 at 9:40 AM, the survey team conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and a newly hired Infection Preventionist (IP). The DON stated that the facility currently had 34 COVID-19 positive residents who resided on a designated section on the first floor (Pine Unit). She added that those residents had designated nurses, house keeping and designated Certified Nursing Aides (CNA) who only worked on the Covid-19 unit. The DON also stated that 1 of the 34 Covid-19 positive residents were admitted to the facility with Covid-19 diagnosis, while 3 of 34 were residents who were newly admitted and still in their 14-day quarantine period. She stated that 30 positive Covid-19 residents were facility acquired. The DON added that the facility had a total of 19 staff members who had tested positive for Covid-19 since the current outbreak which started on 11/23/2020. The DON stated that the facility has three units - Cedar, Maple and Pine Units. She stated that they had designated areas on both Pine and Maple units, for Covid-19 positive residents and that the Covid-19 units had dedicated staff. The DON stated that the facility did not have a dedicated unit for Persons Under Investigation (PUI), and that all residents that were newly admitted or readmitted from the hospitals and residents with known exposure to a person who tested positive for Covid-19, were considered PUI and were cohorted in place on the different units. She added that Cedar Unit had no PUI residents and that all residents on Cedar Unit were negative for Covid-19. Both the DON and the LNHA stated that PUI residents remained on a fourteen-day quarantine, on a transmission-based precautions (TBP) for the whole time. The DON added that all staff members were required to don full Personal Protective Equipment (PPE; items worn to protect the wearer from contracting infectious agents) which included an N95 (respirator) mask with a surgical mask covering, eye protection, disposable gown, and gloves prior to entering any resident's rooms on both PUI and Covid-19 areas. She stated that staff were expected to doff (remove) the gown and gloves prior to exiting the room and perform hand hygiene with soap and water or an alcohol-based hand rub (ABHR). The DON stated that all staff on all units were supposed to wear full PPE during direct resident care. She stated that all the residents who were still within the fourteen-day quarantine period, had isolation and PPE cart set up outside their room and had signage for droplet precautions posted on their room doors. The DON stated that all residents and staff were tested for COVID-19 on a weekly basis. At 11:12 AM, the surveyor entered the first floor nursing unit (Pine unit) and observed that TBP signs and PPE bins were located outside each resident room door. The surveyor walked around in the hallway and observed that outside each resident's room was an ABHR dispenser mounted to the wall on the residents that were identified as PUI as evidenced by the PUI list provided by the DON. The surveyor observed several staff members as they walked around on the unit performing their duties. At 11:15 AM, the surveyor observed two Occupational Therapy (OT, #1 and #2) staff members at a resident's bedside providing rehabilitation therapy. The surveyor noted that both OT staff wore full appropriate PPE. When they finished, both of them went into the resident's bathroom, removed their gloves and performed hand hygiene. Both of them walked out of the resident's bathroom and walked onto the unit hallway still wearing the same isolation gown they wore while caring for a resident. At that time, the surveyor interviewed OT #1 regarding the isolation gown. She stated that they had completed their treatment for [REDACTED]. She added that they were going to remove the gown when they reached the main entrance to the unit. The surveyor noted that the main entrance to the unit was not close by and that they had to walk past residents' area and the nurses' station to reach the main entrance. The surveyor interviewed OT #2 and questioned her about the facility's process on removing PPE after care, however, OT #2 did not provide an explanation. OT #1 was standing by at the time, and informed the surveyor that OT #2 was new and on orientation. Review of the facility's Outbreak Response plan revised on 11/2020, indicated that staff should remove isolation gown and other PPE after providing care for each resident and dispose the PPE in the resident's trash bin inside the room. 2. From 12:30 to 12:53 PM, the surveyor observed lunch meal service on Pine unit. The surveyor observed CNA#1 take a lunch tray from the lunch truck in the hallway and serve one resident in their room. CNA #1 did not offer hand hygiene to the resident. When she finished setting up the resident's meal she left the room, preformed her own hand hygiene and went to another room with a lunch tray. CNA#1 also set up the the resident's lunch without offering hand hygiene to that resident. When interviewed at 12:37 PM, she stated that it was her second day on the job and she did not know about providing hand hygiene for residents prior to serving their meals. At 12:40 PM, CNA #2 performed hand hygiene and then took a lunch tray and served another resident without providing hygiene for the resident. The surveyor observed CNA#2 perform her own hand hygiene and then served a second resident lunch without providing the resident with hand hygiene. When interviewed at 12:55 PM, CNA #2 stated that she forgot to provide hand hygiene for the residents. At 12:50 PM, the surveyor observed a Speech Therapist (ST) as she walked into a resident's room with a lunch tray and set the tray on the resident's overbed table. The ST set up the resident's lunch and watched the resident eat. She did not offer hand hygiene to the resident. At that time, the surveyor interviewed the ST. She stated that she thought the CNAs already provided hand hygiene for the resident. Review of facility's in-service education on infection control protocols reflected that the facility provided education to these staff members. Review of the facility's policy titled: Standard Precautions and dated 4/2020, indicated that staff should perform hand hygiene before preparing meals but the policy did not address providing hand hygiene to residents before their meal, in accordance with the guidance provided by the Center for Disease Control and Prevention (CDC). The undated facility policy titled: Hand washing: Policy and procedures, and the facility's pandemic Response plan did not address hand hygiene for residents when being assisted by staff for meals and other activities. At 3:20 PM, the survey team discussed the findings with the LNHA, DON and the Infection Preventionsit. They acknowledged that staff should provide hand hygiene to residents prior to meal and should remove their PPE and discard them in the trash in the resident's room when they finish caring for a resident. 3. On 12/21/20 at 11:15 AM, the surveyor observed a Porter on the Cedar Unit, as he left the soiled utility room. The surveyor noted that the Porter wore a disposable gown, gloves, N95 respirator mask with surgical mask over, and eye protection. He then emptied the trash can which was located near the entrance to an isolation room of a resident on droplet precautions due to known exposure to a COVID-19 positive person. When finished, the Porter removed his dirty gloves and donned a new clean pair without performing hand hygiene first. At 11:17 AM, the surveyor interviewed the Porter. He stated that had worked at the facility for eight years and was in-serviced on hand hygiene. The Porter stated that he did not use the (ABHR) because I can't put on new gloves with wet hands from the ABHR. The surveyor reviewed the in-service education/infection control competency (a measurable method to evaluate the ability of personnel to apply their skill, knowledge, and experience to perform their duties correctly) and evaluations for the Porter. The Hand Hygiene Skills competency dated 11/24/20 reflected that the Porter had met and passed the critical elements of hand washing, which included Rub hands vigorously on all surfaces for 20 seconds. Review of the facility's undated Hand washing policy and procedure indicated that when using ABHR, staff should apply the sanitizer to the hands, and continue to rub hands until the sanitizer dries up. According to the CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 11/4/2020, staff should Put on clean, non-sterile gloves upon entry into the patient's room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. At 3:20 PM, the survey team discussed the findings with the LNHA, DON and the Infection Preventionsit. They acknowledged that the Porter should have performed hand hygiene after he removed his dirty gloves and prior to donning a new clean pair of gloves. NJAC8:39-19.4

Based on observation, documentation review, and interview in the presence of facility management, it was determined that the facility failed to maintain a safe environment that was free of potential hazards due to improper use of chafing fuel canisters used to keep food hot during meal service on the 1st floor resident dining area. This deficient practice posed a serious and immediate threat to residents, staff, and visitors and was identified as an Immediate Jeopardy situation on 6/20/14 at 11:43 a.m. The immediate jeopardy situation was corrected by the facility on 6/20/14 at 11:45 a.m. upon extinguishing the canned heat fuel and based on submission of an acceptable plan of correction (POC) at 1:45 p.m. This deficient practice was evidenced by the following: On 6/20/14 at 11:43 p.m., the surveyor observed that there were three long plastic tables arranged end to end in length. Covering the plastic tables were paper table covers, both of which were flammable. On top of the tables were five large chaffing trays. Under each tray were two lit canned heat (commonly known as a "Sterno" and in this case "Fancy Heat") methanol gel fuel canisters. There were 10 canisters in all and all were lit at the time of observation. The surveyor observed that there were 25 residents and 3 staff members in the main dining room at the time. The surveyor identified the fire hazard to the facility's Director of Maintenance (DOM) who acknowledged the hazard and directed staff to extinguish the fuel canisters, at 11:45 a.m. At 12:24 p.m., the Administrator was notified that an immediate threat to the safety of residents, staff, and visitors was identified and that an acceptable Plan of Correction was required to correct the Immediate Jeopardy. Review of the Material Data Safety Sheet (MSDS) for the chafing fuel canister (Fancy Heat) revealed the following: 1. The product is 70-72% methanol. 2. The product is flammable. 3. This product is to be burned in a well ventilated area. Avoid direct breathing. 4. The product has a flash point (temperature at which it will burn) of 78 degrees Fahrenheit. 5. Keep product away from combustibles (e.g. paper plates and napkins). This Immediate Jeopardy situation was corrected on 6/20/14 at 11:45 a.m., upon extinguishing the canned heat fuel and an acceptable plan of correction submitted by the facility and verified by the survey team at 1:45 p.m. The plan of correction (POC) included the following elements: 1. The methanol fuel was removed once identified. 2. Staff involved with in food preparation, including dietary, activities, and maintenance departments were in-serviced in person and by telephone to not use cooking equipment in the presence of flammable materials that could present a fire hazard. 3. The Administrator or designee will look for potential fire hazards via daily quality assurance rounds. 4. A new policy was created to give guidelines to identify and prevent potential fire hazards involved during cooking outside the kitchen area. 5. The new policy will be introduced to all new staff as part of their orientation for fire safety awareness. 6. The Activity Director will consult with the Administrator prior to functions that involve food preparation outside the kitchen. 7. During Quarterly Safety Committee meetings, the Maintenance Director will remind meeting participants to always be vigilant when using cooking equipment as to not cause potential fire hazards. NJAC 8:39-31.1(c), 31.2(e)