Every finding on record at The Arbor at Laurel Circle

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for 18 of the 52 (Employee #1 through #18) newly hired employees reviewed since last survey of 9/13/2024. This deficient practice was evidenced by the following:1/13/2026, the surveyors reviewed the provided employee files which did not reveal reference checks for the following employees.Employee #1 with a date of hire (DOH) of 10/20/2025Employee #2 with a DOH of 9/2/025Employee #3 with a DOH of 10/21/2025Employee #4 with a DOH of 10/20/2025Employee #5 with a DOH of 1/29/2025Employee #6 with a DOH of 6/4/2025Employee #7 with a DOH of 3/27/2025Employee #8 with a DOH of 12/9/2024Employee #9 with a DOH of 7/28/2025Employee #10 with a DOH of 10/18/2024Employee #11 with a DOH of 10/22/2025Employee #12 with a DOH of 9/20/2025Employee #13 with a DOH of 10/29/2024Employee #14 with a DOH of 7/28/2025Employee #15 with a DOH of 10/1/2025Employee #16 with a DOH of 9/29/2025Employee #17 with a DOH of 9/2/2025Employee #18 with a DOH of DOH 4/9/2025 On 1/13/2026 at 11:37 AM, the surveyor interviewed the Human Resources Specialist (HRS), who stated reference checks were not done because from past experience people can lie. Background checks take care of that. He stated the facility does do employment verification. On 1/13/2026 at 12:32 PM, during a meeting with the survey team and the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) stated reference checks were absolutely done by the HRS. The surveyor asked how the facility would know if a potential new employee was a good performer, the DON stated, I believe the [name redacted-HRS] calls for a reference. The LNHA stated they (the facility) would follow up. The surveyor requested reference checks for the above mentioned 18 employees. On 1/14/2026 at 10:20 AM, during a meeting with the survey team, the DON, and the Assistant Living Manager, the LNHA stated the facility policy does not speak to reference checks. He provided the team with additional information which was a typed Hiring Process document. A review revealed We only do background checks. We do not do reference checks. In our experience reference checks only provide verification of employment. The surveyor presented the facility provided Abuse Prevention Policy. The LNHA reviewed the policy at that time and acknowledged the policy included reference checks. He then acknowledged the above requested reference checks were not available. A review of the facility's Abuse Prevention Policy revised 11/2017 revealed Pre-Employment Screening of Potential Employees.Prior to a new employee starting a work schedule, this community will: Initiate a reference check from previous employer (s), in accordance with community policy. NJAC 8:39-9.3(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to change respiratory equipment in a manner to prevent contamination for infection control. This deficient practice was identified for 1 of 3 residents reviewed for respiratory care (Resident #23), and was evidenced by the following:On 1/9/26 at 11:13 AM, during the initial tour of the facility, the surveyor observed Resident #23 in their bedroom seated in their wheelchair. The surveyor observed an oxygen concentrator (device that delivers oxygen) with nasal cannula (device that delivers additional oxygen through the nose) tubing placed on the oxygen concentrator with a piece of clear tape with the date 12/5. The resident stated that they used oxygen at all times. The surveyor also observed a nebulizer machine located on the bedside table with tubing attached. The nebulizer mask tubing had a clear piece of tape with the date 12/5. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic diastolic congestive heart failure (diastolic heart failure, your heart's left ventricle becomes thick and stiff), hypoxemia (abnormally low oxygen levels in the blood), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/11/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating a moderately impaired cognition. Further review of Section O, Resident #23 received oxygen therapy while residing at the facility. A review of the Order Summary Report included a physician's order (PO) dated 10/15/24, for continuous oxygen at 3 liters per minute (lpm) via nasal cannula. If oxygen saturation (percent of oxygen in a person's blood) is below 90% every shift related to hypoxemia. Further reviewed revealed a physician's order to change oxygen tubing weekly every night shift every Wednesday. A review of the individual comprehensive care plan (ICCP) included a focus area dated 2/10/24, that the resident needed oxygen therapy related to congestive heart failure. Interventions included but were not limited to; oxygen via nasal cannula at 3 lpm continuously. On 1/13/26 at 10:19 AM, the surveyor interviewed the Registered Nurse (RN), who stated that oxygen tubing and nebulizer tubing should be changed weekly every Wednesday by the nurse. She further stated that the oxygen and nebulizer tubing should be dated when it was changed. The RN also stated that the tubing should not remain on the oxygen concentrator past 7 days. The RN further stated that the tubing should be changed weekly for infection control purposes. The RN acknowledged that the oxygen tubing and nebulizer tubing pictures taken on the initial tour were dated 12/5 and stated that they should have been changed weekly. On 1/13/26 at 10:26 AM, the surveyor interviewed the Director of Nursing (DON), who stated their expectations for their nursing staff was to check the oxygen and nebulizer tubing daily, make sure the devices were functioning properly, and to ensure the tubing was changed weekly. She stated that the tubing should be change weekly and as needed. The DON further stated that the tubing should not remain on the oxygen concentrator past 7 days. The DON further stated that the tubing should be changed weekly for cleanliness and sanitation purpose. When the surveyor presented the oxygen and nebulizer tubing pictures that were taken on the initial tour, she verified and acknowledged that the oxygen tubing and nebulizer tubing were dated 12/5. She further stated that the nurse should have changed them weekly. On 1/14/26 at 10:20 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Assistant Living Manager and the survey team, confirmed that oxygen and nebulizer tubing should be changed weekly. The DON stated that it was something that was just missed and acknowledged that the tubing was dated 12/5. A review of the facility's Humidifier and Oxygen Tubing Changes policy undated, included.this policy is to ensure the correct and safe changing of humidifier bottles on a routine basis to reduce the risk of nosocomial infections.change humidifier bottles and oxygen tubing weekly. NJAC 8:39-27.1 (a)

Complaint # NJ 169997 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to a.) thoroughly review the hospital discharge summary (After Visit Summary) and communicate the recommendations for an anti-anxiety (AA) medication to the physician, and b.) follow a physician's order for an AA medication (Clonazepam) ordered to be administered daily at bedtime. This resulted in Resident #152 not receiving the physician ordered AA medication for 14 days (from 12/5/23 through 12/19/23) which resulted in Resident #152 experiencing a change in behaviors which included: agitation, anxiety, insomnia and wandering at night. This deficient practice was identified for 1 of 7 residents (Resident #152), reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 09/10/24 at 11:15 AM, a review of the closed medical record for Resident #152 revealed the following: Review of the Admission Face Sheet reflected that Resident #152 was admitted to the facility on [DATE], and discharged [DATE]. The diagnoses included, but was not limited to, history of falling, other specified anxiety disorder, chronic heart failure and muscle weakness. A review of the After Visit Summary (hospital discharge instructions), revealed a medication list with an order for Clonazepam 1 milligram (mg), to be administered by mouth nightly. Review of the December 2023, Order Summary Report revealed a physician's order dated 12/06/2023, for clonazelpam oral tablet 1 mg (Clonazepam) give 1 tablet by mouth at bedtime for anxiety. Further review of the medical record revealed that the order was transcribed on 12/6/2023 as a telephone order. A review of the December 2023 Medication Administration Record (MAR), revealed that the Clonazepam 1 mg was not administered on: 12/5/2023, 12/6,/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/10/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/15/2023, 12/16/2023, 12/17/2023, and 12/18/2023 (14 days). The electronic boxes where the nurses were to sign for the administration of the Clonazepam were documented with code 05 and 09. Code 05 indicated to hold the medication and to see Nurses Notes; and Code 09 indicated that the medication is not available. Review of the Nurses Notes indicated medication not available. A review of the progress notes dated 12/04/23, revealed a treatment plan initiated 12/04/23, which indicated the following: Fall/Gait Dysfunction: PT (Physical) /OT(Occupational Therapy) CHF (Congestive Heart Failure: Lasix HTN (hypertension) Lisinopril Neck pain/muscle spasm: Tylenol, soft collar, Baclofen, Lidocain patch. Anxiety: Clonazepam. GERD (Gastroesophageal Reflux Disease: Carafate. Labs reviewed. PT/OT evaluation and treatment. Medications reviewed and reconciled. Transfer Records reviewed. Orders reviewed. Discussed with nursing. A review of the resident's Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/11/2023, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was mildly impaired. The assessment further reflected the resident was dependent on staff for hygienic care, and needed assistance with meals. A review of an individualized care plan initiated in December 2023, included that the resident used anti-anxiety medications (Clonazepam) related to anxiety disorder. The goal specified that the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. The care plan interventions included the following: - Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. - Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. A review of the History and Physical Assessment from the hospital record dated 12/01/23, reflected that the resident was status-post fall, had a work-up done in the emergency room and was admitted to the facility on [DATE], with a list of medications to be continued. The AA medication Clonazepam was changed to 1 mg to be administered at bedtime. The hospital discharge summary indicated that Resident #152 received Clonazepam 1 milligram (mg) on 12/03/23 at 8:24 PM. A review of the medication reconciliation sheet revealed that the AA medication Clonazepam was not transcribed as ordered on 12/04/23. A review of a Nurse's Notes dated 12/06/23 and timed 8:50 PM, reflected that Clonazepam oral tablet, 1 mg at bedtime for anxiety. Medication not available. A review of a Nurse's Note dated 12/06/23 and timed 8:50 PM, reflected that Clonazepam oral tablet, 1 mg at bedtime was not administered at bedtime for anxiety. Medication not available. The nurse's note dated 12/6/23, reflected that [Resident #152] was anxious, recent change in mood, agitated, wanders at night. A review of a Nurse's Note dated 12/07/23 and timed 12:15 PM, suggested to engage Resident #152 in activity to help with their anxiety. On 12/7/23 at 3:23 PM, the nurse's notes reflected that Resident #152 was agitated and threw all morning medications on the floor. The family was notified, the Nurse Practitioner was called and gave order to increase Zoloft an anti-depressant medication to 50 mg daily. There was no documented evidence that the physician or the Nurse Practitioner was made aware that Resident #152 had not been receiving the Clonazepam for their anxiety as ordered. A review of a Nurse's Notes dated 12/20/23, reflected that Resident #152 has period of anxiety and agitation, Resident is being followed by psychologist. A review of the Nurses Progress Notes from 12/5/23 through 12/19/23, did not address that the pharmacy was called and inquired about the Clonazepam not being available and/or notification of the physician in regards to the resident being agitated and anxious. There was no documented evidence that the family or the physician were notified. A review of the December 2023 Medication Administration Record (MAR) reflected the corresponding physician's order (PO) dated 12/05/23, to administer Clonazepam, give 1 mg at bedtime for anxiety. The order was plotted for the medication to be administered at 9:00 PM, but there was no evidence that the Clonazepam order was ever faxed to the pharmacy. On 9/10/24 at 10:30 AM, the surveyor requested all investigation reports for Resident #152. On 9/11/24 at 10:00 AM, the Assistant Director of Nursing (ADON) provided a Medication Error -Other dated 12/20/23 and timed 10:26 AM, that indicated the following: Nursing Description: Medication Clonazepam 1 mg po [orally ] at hour of sleep was not administered from 12/6/23 to 12/18/23. Pharmacy was called to find out why the medication was not sent and they replied that they needed the order. Resident Description: Resident unable to give description. Immediate action taken: The order was in the chart and had a date faxed 12/18/23. Both the order and the hard copy of the order was sent to pharmacy and requested STAT [immediate] delivery. Medication arrived physician was notified and no new orders at this time. Family to be called today. Statements: No statements found. Notes: No notes found. Further review of the December 2023 MAR revealed a PO dated 12/05/23, to administer Clonazepam, give 1 mg at 9:00 PM for anxiety. According to the MAR, the first dose was administered on 12/19/23 at 9:00 PM and was signed as administered. On 09/12/24 at 9:34 AM, the surveyor interviewed the Physician in charge of Resident #152 care. The physician stated that she cannot recall that she was notified of the Clonazepam not being administered for 14 days. The Physician further stated that Resident #152 had been on the Clonazepam for a long time. When asked about her expectations, she stated, My expectation would be that the order will be carried executed, and, if the medication was not available, I would expect to be notified. On 9/12/23 at 10:51 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN). The surveyor asked what the reasons were why the medication was not administered, as ordered by the physician. The LPN stated that Resident #152 was admitted during the night, the orders were verified and faxed and the 7:00 AM-3:00 PM shift was to review the admission order and follow up. He worked the 11:00 PM- 7:00 AM shift and was not aware that the Clonazepam was not being administered as ordered. The surveyor then inquired regarding the 24 hours chart check scheduled on the 11:00 PM-7:00 AM shift, the nurse did not have any comment. The LPN confirmed that the resident did not receive any Clonazepam from 12/05/23 through 12/19/23. He further stated that he did not know if there was documentation in the resident's medical record as to why the Clonazepam was not given or if there was any communication with the physician or the family. The surveyor asked the LPN if he was ever asked to write a statement regarding the medication as he was the nurse who admitted the resident, he replied, No. The surveyor then asked regarding the process for new admission. The LPN stated that the nurses were responsible for documenting those issues, the nurses were to call and review all orders with the physician. On 9/12/23 at 11:35 AM, the surveyor interviewed the ADON who stated he would need to get back to the surveyor with the information. On 09/12/24 at 12:42 PM, the surveyor interviewed the Registered Nurse (RN) regarding the process for medication verification with the physician. The RN stated that the physician must be called, all orders must be verified with the physician, then faxed and called to the provider pharmacy. The RN stated that some medications could be obtained from the backup [electronic medication dispensing system]. If not available, the nurses must call and notify the physician that the medication was not available. The facility could also call the pharmacy and request a stat delivery and the Director of Nursing must be informed. On 9/12/24 at 12:50 PM, the ADON provided the hospital discharge summary with the order to administer the Clonazepam 1 mg at bedtime. When inquired regarding the rationale for not calling the pharmacy or the nurses not faxing the order, the ADON did not have any comment. On 09/12/24 at 1:30 PM, the surveyor interviewed the Director of Nursing in the presence of the survey team. The DON stated that she was made aware only yesterday (9/11/24). When asked regarding the investigation, she stated, there was no proper investigation. A review of the Manufacturer's specification indicated that Clonazepam, should not be stopped suddenly or without the direct supervision and guidance of a medical professional. Potentially fatal seizures or a coma may occur with the sudden cessation of Clonazepam. On 9/12/24 at 1:45 PM, the Director of Nursing provided a form titled, Employee Education Attendance Record dated 12/20/23. Topic of in-service. Adverse Consequences and medication errors which indicated that the staff were in-serviced regarding the medication. Attached to the in-service was the policy titled, Adverse Consequences and Medication Errors . the Policy Statement included that The Interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drugs reactions (ADRs ) and side effects . and Medication Errors was defined as the preparation and administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional (s) providing services. NJAC 8:39-27.1(a)

Based on observation, interview and record review the facility failed to ensure the remote healthcare food service pantry area, and adjacent storage room was maintained in a clean and sanitary manner to prevent the potential for food borne illness. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor toured the healthcare food service pantry in the presence of the Food Service Supervisor (FSS). -During the meal set up, and placement into the steam table, the surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. At that time, the surveyor observed that there was splatters in several areas on the wall and crumbs and other debris on the floor behind the equipment and in the corners. The surveyor asked about cleaning and the FSS stated the floors are swept and mopped. The surveyor asked if a deep cleaning was performed, including moving mobile equipment and cleaning the entire pantry. The FSS stated that has not occurred since he has been in the role. -The steam table used to hold the food items, had an attached cutting board which was grooved, when the FSS lifted up the cutting board, there was various debris in the crevice along the length of the steam table. -A red bucket was lodged behind a metal table, the wall and blue dish racks. Debris was observed on the lower shelf of the table and there were splatters on the wall. -The adjacent storage room contained debris on the floor and in the corners, the walls had splatters and stains. A soiled dust pan was on the floor next to a small plunger and a broom. There were flying insects in the storage room, and boxes of cold cereal and sugar packets were stored on a metal shelf. -An open cart used to hold resident trays during the meal preparation was cracked on the side of the top shelf and had visible debris on the cart. -Directly outside of the door from the healthcare pantry to the dining room, contained a black insulated food transportation cart which was visibly soiled with debris on the outside of the cart and the handles. A second open cart in the main dining room had visible debris and was soiled. On 09/10/24 at 12:00 PM, the surveyor accompanied the Liscensed Nursing Home Admininstrator (LNHA) to the storage area and the healthcare pantry to to share the above concerns. The LNHA acknowledged the concerns and stated, give me one hour to clean it. The surveyor requested 6 months of pest control logs. The Sanitation Policy, undated, revealed It is the policy of the community to store, prepare, distribute and serve food under sanitary conditions. Procedure: Written effective procedures regarding food procurement, storage, garbage disposal, personal hygiene, pest control, wearing of gloves, handling of ice, food preparation and infection control will be followed by all food service personnel. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to 1) have a system in place to ensure activities were conducted as scheduled, and 2) have a system in place to ensure residents were receiving their identified activity preferences to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This deficient practice was identified for Resident #34, on 2 of 2 units and was evidenced as follows: A review of the facility provided policy and procedure, Community Life Services [name redacted] Policies and Procedures revised 1/2024, included but was not limited to; Monthly Program Calendars. There are 3 neighborhood calendars. Calendars are distributed for each neighborhood. On 09/09/2024 at 6:36 PM, the surveyor toured the Seasons Unit (SU) and observed that two residents (one unsampled and Resident #34) were in the common area while the other six residents were in their rooms or in bed. One of the two residents was visiting with family and the other resident was just sitting at a table. There was a Lifestyle Programs Calendar (LPC) on a table that indicated at 6:00 PM there was an Evening Movie scheduled but there was no movie playing. The surveyor observed two Certified Nursing Assistants (CNA) working on the unit and no nurse. The surveyor walked over to the Cherry Unit (CU) and observed only one resident in the common area. The LPC indicated that at 6:00 PM there would be Evening Bingo scheduled but there was no Bingo activity happening. On 09/09/2024 at 6:39 PM, the CU Unit Clerk stated that Bingo had happened earlier in the day and there was no evening Bingo. On 09/11/2024 at 9:28 AM, the surveyor was on the SU and observed four residents who had finished breakfast were in the common area. The television was on a music channel, but no residents were watching the television. At that time, the surveyor reviewed the LPC which noted that at 9:30 AM Morning Meet-Up (SL) [Seasons Lounge], 10:00 AM Morning Exercise Group (SL), and 10:30 AM Daily Chronicle Reading Group (SL). On 09/11/2024 at 9:32 AM, the surveyor observed two CNAs assigned to the SU. CNA #1 stated, the residents usually relax after breakfast and there usually will be activities. On 09/11/2024 at 9:41 AM, Resident #34 self-propelled to the surveyor and asked, where do I go now? A review of Resident #34's Admission Record revealed diagnoses which included but were not limited to; unspecified dementia, depression, muscle weakness, and lack of coordination. A review of most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate resident care dated 06/04/2024, included but was not limited to; Section C: Brief Interview for Mental Status (BIMS) of 01 out of 15 indicating severe cognitive impairment. A review of the resident-centered on-going care plan included but was not limited to; a focus area of at risk for mood disorder and/or cognitive decline with interventions that included activities to develop activity plan dated 02/26/2024 upon admission. A focus area enjoys playing balloon volleyball, listening to stories, taking care of lifelike animatronic pets, and engaging in the life stations through out the neighborhood dated 09/10/2024, after surveyor inquiry. A focus area for staff to invite the resident to programs of interest. A review of the Life Enrichment Admission Data Collection dated 05/09/2024, over 2 months after admission, included but was not limited to; enjoyed reading (audio books, newspapers, magazines) and watching television; would like to attend book club, meditation, pet care station; outings included scenic drives; times for engagement afternoon, evening, weekends; desired outcomes pleasure, success; social: table games, visits, parties/social events; education/lectures; travelogues; puzzles/games/trivia; Physical: sports play/watch, exercise, arts and crafts, service project, gardening, intergenerational, cooking/baking; Spiritual: meditation, nature appreciation, movies/TV [television], pet therapy, beauty shop/spa services/massage, music (classical, rock and roll, easy listening); social visits one to one; Programs Admission Note: Programming staff will invite and encourage Resident #34 to participate in programs of choice as tolerated. A review of Life Enrichment Quarterly dated 05/21/2024, included but was not limited to; would benefit from programs since last review: comfort, pleasure, education, creativity; social outings, family/friends visits, social events; Intellectual reading; physical: exercise; purposeful: chat, arts/crafts, intergenerational; Emotional interest: art, movie/TV, music, pet therapy, spa, social visits, . loves utilizing the pet care life stations; attend in morning, afternoon, evening, weekends; outings trips to the garden; Group Programs of Interest: pet therapy, pet life stations, live music, current events, reading, conversations; Resident resources: activity calendar, assistance to groups, reminders/encouragement, small groups, 1:1 resident programming. A review of the Life Enrichment Quarterly dated 08/16/2024, included but was not limited to; Benefits from: comfort, pleasure, self-esteem, success, independence, education, creativity; Interest/participation: visits, groups, social events/parties, table games; Intellectual: book club, reading, education/lectures, newspaper/current events, puzzle/games/trivia, travelogues; Physical exercise; purposeful cooking/baking, gardening, intergenerational; nature appreciation, medication, Emotional: art, movie/TV, music, pet therapy, spa, social visit; morning, afternoon, weekends; Interest: reading, daily chronicle news, reading, stretching, pet care station; Reminders: activity calendar, assistance to groups, reminders/encouragement, small groups, 1:1 resident programming. On 09/11/24 at 10:19 AM, CNA #1 reviewed the activities calendar and stated, I don't know what to do except they don't do anything. I know Resident #34 roams around. The surveyor asked what Resident #34 likes to do and if there was any guideline for staff to follow to see what the residents enjoy. CNA #1 stated, no. On 09/11/24 at 10:30 AM, the surveyor observed that there was still no activities staff on the SU. On 09/11/24 at 10:32 AM, during an interview with the surveyors, the Community Life Services Manager (CLSM) stated that activities would be scheduled based on resident preferences. The CLSM stated she was responsible for the SU and that the activities staff would meet every morning for their assignment and that there were 3 activity staff not including herself. The CLSM further revealed that she reviewed daily activities and which residents would like to attend those activities and stated, We invite everyone always. We keep attendance and will write which activity and check off who attended. We have residents who stay in their room, and we ask what independent activities that resident wants. There are designated times for room visits from 1:00 PM to 2:00 PM and it is recommended to spend 20 minutes for each room visit. Where conduct nighttime activities and an activity coordinator will run that. The CLSM stated that it was important for evening activities as well because, we want to ensure we are enriching their lives. I noticed after dinner about 6:00 PM, is the most engagement. When asked the process to monitor how many activity hours residents receive, the CLSM stated they were tracked via attendance. When asked about the system in place to quantify how much time a resident receives in their preferred activities, the CLSM stated through attendance. The CLSM stated that they review the resident care plans also but could not say the process to determine if the goals were met or not. On 09/11/24 at 10:57 AM, the Community Life Services Director (CLSD) arrived and stated she works in the assisted living but would help in long term care. The CLSD stated, Our goal is to have everyone engaged all the time. She further stated that the current system of monitoring was via attendance. The CLSD was unable to provide a process for tracking resident activity attendance and added there was no system to quantify. The CLSD explained that the activities department had conversations daily, but she was not sure if anything was documented or updated in the resident care plans. She stated, I expect programs to start on time. I make rounds and talk to residents. The CLSD stated she was not aware that the evening bingo on CU and the evening movie on SU had happened. The CLSD stated, we are leaning on nursing to assist that was the plan. There is no excuse for no program and no help from nursing. When asked about no activities all morning from 9:00 AM through 10:30 AM, she stated she was not aware. On 09/11/24 at 12:42 PM, the CLSD stated in presence of the survey team, that there were no activity records to provide to the surveyors. A review of the facility provided job description, Community Life Services Manager revised June 2023, included but was not limited to; . responsible for the overall planning and implementation of a varied activity program designed to meet the requirements of Lifestyles & Health Services . Plans, develops, organizes, implements, evaluates, and directs the activity programs in the health center. Wellness Focus: . employees are expected to promote a health community culture for all residents and employees. This is a whole-person approach to health and wellness with includes eight dimension of wellness: emotional, environmental, health services, intellectual, physical, social, spiritual, and vocational. Through these efforts we can ensure and exceed residents' wellness needs relating to their mind, body and soul . NJAC 8:39-4.1 (22); 7.1 (a); 7.2; 7.3; 8.1; 8.3; 8.4 (a)

Based on observation, interview, and record review it was determined that the facility failed to ensure fall prevention interventions were consistently implemented, revised after each fall and supervision was provided for residents at risk for falls. This deficient practice was identified for 2 of 2 residents (Resident #9 and Resident #34) reviewed for falls and was evidenced by the following: 1.) On 09/09/24 at 7:04 PM, Surveyor #1 observed Resident #9 in bed, the bed was in a low position, the resident was non verbal and would not respond to the surveyor. Surveyor #1 observed a folded floor mat on the side of the bed in the resident's room. On 09/10/24 at 8:42 AM, Surveyor #1 observed Resident #9 sitting in a wheelchair at the bedside. Resident #9 was awake and alert and able to feed themselves after the breakfast tray was set-up. On 09/11/24 at 9:32 AM, the surveyor observed Resident #9 in bed. The bed was in a low position. the surveyor observed a floor mat on the right side of the bed in the resident's room. On 09/11/24 at 12:20 PM, Surveyor #1 observed Resident #9 sitting in the dayroom and there was no staff in attendance, and there was no activity in progress. Most of the residents were observed in the dining room at that time. On that same day at 12:45 PM, the surveyor interviewed the Certified Nursing Aide (CNA) observed in the hallway. The CNA stated that the resident was cognitively impaired, and should not be left alone in the dayroom. The CNA further added, I have been doing this type of work for many years, the residents need to be supervised while in the dayroom. On 09/11/24 at 1:15 PM, the surveyor reviewed the medical record of the resident. The medical record reflected Resident #9 was admitted to the facility with medical diagnoses which included dementia, specified persistent mood disorder, unspecified psychotic disorder, restless and agitation. Review of the 8/23/24, Quarterly MDS (Minimum Data Set), an assessment tool used for the management of care, indicated that Resident #9 required extensive assistance of two person for bed mobility and transfers. The MDS was coded as 01 for activity of daily living which indicated that the resident was dependent on staff for ambulation and transfer. Resident #9 had Dementia and had a BIMS (Brief Interview for Mental Status score of 99 and was unable to recall. Review of the Progress Notes dated 8/7/23, revealed that Resident #9 was found on the floor in their room. Resident #9 was noted with an abrasion to the left posterior arm measuring 25 centimeters in length. The fall event summary dated 8/07/23, indicated the resident fell asleep, and slipped out of the chair. The suggested intervention was to place Resident #9 back to bed after lunch. On 8/28/23 at 6:20 PM, Resident #9 was found lying on the left side in the activity room with the head against the floor. The CNA assigned to the resident revealed that she was assisting another resident and could not visualize Resident #9 in the activity room. The suggested intervention was that Resident #9 needs to participate in activities but the facility does not know what he/she liked. On 9/27/23 at 8:10 PM, Resident #9 was observed lying on the floor on their right side with the wheelchair nearby. No Incident/Accident Report was provided for this fall. The current DON stated that she could not comment regarding this fall. On 10/05/23 at 3:38 PM, Resident #9 was left in the activity room for supervision. At 1:38 PM, Resident #9 was observed on the floor laying on their right arm in front of the wheelchair. The suggested intervention was to pay attention to all residents. On 1/15/24 at 6:45 PM, Resident #9 was found face down lying in their room. Resident #9 was unable to explain what happened. Suggested interventions, Tell the resident to use the call bell for help. On 5/23/24 at 6:00 PM, Resident #9 was found in the activity room on the floor in front of the wheelchair. Fall Unwitnessed. Suggested intervention: Put the resident to bed after dinner. On 7/3/24 7:10 PM, Resident #9 was found face down in the Cherry Unit. Resident noted with bruises on forehead and above right eye. Resident unable to explain cause of the incident. Resident was transferred to the Emergency Department for evaluation and treatment. The surveyor requested the New Jersey Universal Transfer Form and it was not provided. On 8/26/24 at 2:10 PM, Resident #9 observed sliding of the wheelchair in the dayroom. Review of the fall risk evaluation dated 8/22/24, indicated Resident #9's fall risk score was 11 indicating high risk for falls. Further review of the Interdisciplinary Team (IDT) fall note revealed current fall interventions in place included, floor mat, call system and personal items within reach, check for activity and toileting. keep bed in low position. Keep room well-lit and free from clutter. The facility was not consistently following their interventions. On 09/09/24 at 7:42 PM during the initial tour, Resident #9 was observed in bed and the floor mat to minimize fall with injury was not in place. On 09/10/24 at 11:05 AM, Surveyor #1 reviewed the September 2024 Order Summary Report which revealed that fall preventions measures including low bed, keep personal items and call bell within reach, keep room well lit and clutter free, and the floor mat had been initiated since 10/24/23. On 09/10/24 at 12:15 PM, the DON provided a Care Plan Report initiated 7/21/22, which indicated that on 8/7/23, Resident #9 was observed in the Television Lounge face down on the floor. Resident noted with bruises to middle of forehead, and above right eye. Resident #9 was transferred to the hospital for evaluation. The fall was not witnessed. The facility did not indicate who was responsible to monitor the dayroom when residents were in attendance. The Care Plan Report dated 8/17/23, revealed that Resident #9 was at risk for fall. The goal was that the resident will not sustain a fall with related injury. Supervision was not included in the Care Plan. On 09/12/24 at 1:46 PM, the Liscensed Nursing Home Administrator provided the surveyor a copy of Incident/Accident (I/A) Report dated 08/17/23. A review of the I/A Report revealed that Resident #9 was found on the floor in the hallway, sustained an abrasion to the left posterior upper arm. The causal factor was not identified. Further review of the 8/17/23, Incident /accident Report report showed that the immediate action taken to prevent further incidents was to put the resident to bed after lunch. There was no documented evidence that the resident was being supervised in the dayroom during the falls. On 09/12/24 at 12:45 PM, the surveyor and the CNA went to the activity room and observed Resident #9 sitting alone and unsupervised in the dayroom. The CNA stated that the resident should not be left unsupervised in the dayroom. During an interview with the Director of Nursing (DON) that same day at 1:15 PM, the DON informed the surveyor that the facility's fall process was that the team will discuss the resident's fall incident, will place an intervention as agreed by the team, put an order and will update the care plan for the intervention. The DON confirmed that a staff was to be in the common area when residents were in the dayroom. On 9/12/24 at 1:40 PM, the DON provided a copy of the recent Care Plan and Interdisciplinary Fall notes. The Current Care Plan did not reflect that the care plan was revised after each fall. The Incident/Accident Report of 8/3/24 notes revealed that on 8/3/24 there was no Interdisciplinary Fall Note (IFN) that indicated the fall was addressed. The DON confirmed that the fall process was not followed as she was unable to identify what interventions were added to further prevent falls. 38079 2.) On 09/09/2024 at 6:32 PM, Surveyor #2 observed Resident #34 in the Seasons Unit (SU) day room visiting with a family member. The family member stated that there was usually no staff in the area and Resident #34 had fallen many times trying to get up and walk. On 09/11/24 at 8:23 AM, observed one staff member in the day room area on SU. The staff member was identified as a unit clerk who stated that there was just one CNA on the unit who was in a room helping a resident and no nurse on the unit. She stated the nurse works on another unit as well. On 09/11/24 at 8:24 AM, Surveyor #2 observed Resident #24 in the SU day room sitting in a wheelchair eating breakfast. At that time, there was no nurse or CNA present while three residents were eating breakfast. On 09/11/24 at 8:31 AM, CNA #3 stated that Resident #34 required total staff assistance, could stand only a few seconds, and has had falls. A review of the Admission Record for Resident #34 listed diagnoses which included but were not limited to; Dementia; fall on same level from slipping, tripping, and stumbling; abnormality of gait and mobility; and difficulty in walking. A review of the quarterly MDS dated [DATE], included but was not limited to; a BIMS of 01 out of 15 indicated severe cognitive impairment. Resident #34 was noted as having a behavior of wandering which occurred 1 to 3 days in a 7-day look back period. Resident #34 was coded as totally dependent or requiring maximal assistance from staff for activities of daily living. Resident #34 was noted as having had two or more falls since the previous MDS assessment. A review of the resident-centered ongoing Care )which included but was not limited to; focus area at risk for targeted behaviors of yelling out, wandering with purpose with an intervention to monitor targeted behaviors; and a focus area of falls with a goal of not sustaining a fall related injury and with interventions including but not limited to; if awake encourage to come in lounge area for distance supervision, after dinner offer transfer to sofa per preferences, and place call system and most frequently used items within resident reach. The care plan documented only six of eight actual falls and five of the falls having documented updated interventions. A review of the facility provided Incident reports included eight falls from admission in February 2024 through September 9, 2024. Of those eight falls, six were unwitnessed including the following: 03/21/2024 at 6:58 AM, the staff statement the last time staff saw resident before fall and documented 6:00 AM (almost an hour prior). 05/21/2024 at 8:58 AM, with no staff statement as to when the resident was last supervised or observed by the staff. 06/17/2024 at 9:30 PM, resident was found in the SU dayroom and last supervision by staff was documented at 9:00 PM. The physician ordered Resident #34 to be sent to the emergency room for evaluation of their head. 09/03/2024 at 11:05 PM, with no staff statement as to when the resident was last supervised or observed by the staff. The Incident reports failed to identify causal factors or identify any staff supervision. On 09/12/24 at 10:10 AM, the DON stated, Resident #34 required supervision but it is not always direct and things happen. She stated that during the over night shift, the SU had only one CNA and the other two shifts there were two CNAs. The DON stated that Resident #34,can't call for assistance and feels like [Resident #34] can get up and walk. On 09/12/24 at 10:35 AM, the DON stated it was not appropriate if the staff had not observed a resident within 30 minutes. On 09/12/2024 at 12:45 PM, in the presence of Surveyor #1 and Surveyor #2, the DON stated that the facility fall process was that the team would discuss the resident's fall incident, will place an intervention as agreed by the team, put an order and will update the care plan for the intervention. The DON confirmed that a staff was to be in the common area when residents were in the dayroom. On 09/12/24 at 1:37 PM, the DON confirmed that the facility had no policy or procedure to define what constitutes close supervision and distant supervision or the criteria to determine which resident needs what type of supervision. A review of the facility's Fall Policy last revised 1/2024,indicated the following: It is the policy of this facility to evaluate all residents for falls. Purpose: A system to prevent and/or minimize accidents and incidents. Procedure: All residents will be assessed for risk for falls upon admission, quarterly and as needed. Based on the completed fall risk assessment, resident medical condition and history, appropriate preventive interventions and referrals to the team (OT,PT,etc) will be initiated, care plans developed and documented in the resident's chart. Adapt care plan and actions according to the resident's specific disease process. NJAC 8:39-27.1(a)

Based on observation, interview and document review it was determined that the facility failed to have an effective system in place to self- identify concerns and develop and maintain an effective data-driven Quality Assurance Performance Improvement (QAPI) program for: a) reviewing adverse events, including medication errors and falls, b) ensuring an effective pest control program was maintained, c) ensuring kitchen sanitation was maintained, and d) ensuring activity programs occurred as scheduled. The deficient practice was as evidenced by the following: Refer: 679E, 684G, 689E, 812F, 925E On 09/12/24 at 1:44 PM, the Liscensed Nursing Home Administrator (LHNA) provided the QAPI minutes for August 2024. The document revealed the following QAPIs: Admin [LHNA]-N/A [not applicable]; Community Life-N/A; EVS [environmental services]- Turnover of rooms after discharge; Nusing-Infection Control, Anti-biotic Stewardship, Falls [# of falls per LNHA], Rehospitalization s; Dietary-Continue to address monthly weights; Food Services-Continue to address labeling of food products, Continue to address equipment wear and tear, Continue to monitor and document dishwasher temperatures, Social Services-N/A, Rehab [rehabilitation]-w/c[wheelchair cushions and appropriateness. At that time the surveyor asked if the identified concerns during survey had been addressed by the QAPI, which included concerns with: hand hygiene, activities, pests, failure to complete thorough Iinvestiations, review of significant events and care planning and the LNHA confirmed those concerns were not part of the QAPI. On 09/12/24 at 1:48 PM, the surveyor asked the LNHA to expand on what was reviewed at QAPI regarding falls. The LNHA stated, the number of falls, and nothing else regarding falls. The surveyor asked about significant events and investigations being brought to the QAPI and then asked what should be included in an investigation. The LNHA stated for a fall, a root cause analysis was his expectation to be included as part of an investigation. The surveyor asked the LNHA how the facility determined what should be reviewed at QAPI and the LNHA stated that he would ask the department heads what were the concerns in their respective departments. On 09/13/24 at 8:45 AM, the surveyor interviewed the LNHJA regarding how the facility determined what would be reviewed with the QAPI. The LNHA stated he would ask the department heads about the concerns for each area. The surveyor asked what was supposed to be monitored with each QAPI. The LNHA stated, you are supposed to show progress. The surveyor asked about the the pests and the pest management reports also identifying sanitation concerns with the kitchen as a cause. The LNHA stated it was not handled in appropriate way. The surveyor asked what should have happened, and the LNHA stated it should have been brought to the QA (Quality Assurance). The LNHA further stated there was a gap in communication and it [pests] was not brought up. The LNHA also confirmed that the QAPI does not review significant event, including facility reportable events. The LNHA also confirmed that activities was not reviewed at the QAPI. The QAPI Improvement Activity Progress Form provided by the LNHA for Labeling of food items was reviewed, Activity Start Date: 1/12024. The QAPI did not contain cleanliness of the kitchen. The Quality Assurance Improvement Plan, dated 2019 revealed: III. Guidelines for Governance and Leadership: a. The QA Comittee and administration are responsible and accountable for developing, leading, and closely monitoring the QAPI program. IV. Feedback, Data Systems, and Monitoring: b. The following data is monitored through the QAPI Committee: i. Input from staff, residents, families, and others; II. Adverse events . c. Process for collecting the above information: i. Gather input from caregivers, residents, families, and others (surveys, council meetings .) ii. Adverse events (incident reports, 24 hour reports). NJAC 8:39-33.2(a)(b)(c)

Based on observation, interview and document review it was determined that the facility failed to maintain an effective pest control program for the healthcare dining room, attached meal service pantry and food storage area. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor observed the meal preparation in the healthcare pantry, located on the 2nd floor, with the Food Service Supervisor (FSS) present. The trays were being assembled for distribution to the resident and for dining room service. The surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. At that time, the surveyor observed that there was splatters in several areas on the wall and crumbs and other debris on the floor behind the equipment and in the corners. The surveyor asked about cleaning and the FSS stated the floors are swept and mopped. The adjacent storage room contained debris on the floor and in the corners, the walls had splatters and stains. A soiled dust pan was on the floor next to a small plunger and a broom. There were flying insects observed in the storage room, and boxes of cold cereal and sugar packets were stored on a metal shelf. During the observation, the surveyor exited the pantry into the main healthcare dining room and observed. dead insects on the window sill and multiple insects on the wall molding. On 09/10/24 at 12:00 PM, the surveyor showed the Liscensed Nursing Home Administrator (LHNA) the insects and condition of the healthcare pantry, attached storage area and adjacent dining room. The surveyor requested 6 months of pest control documentation. On 09/10/24 at 2:09 PM, the surveyor reviewed the Pest Sighting/ Evidence Log which revealed: Date/Time; Pest/Issue; Exact Locartion/Description; Person Reporting; Date/Time [Vendor] Called; Name/Date/Action Taken. On 08/21/24, ants inspected and treated [3 room numbers listed]; 08/15/24 inspected/treated for ants weekly kitchen. The surveyor requested the reports associated with the pest control treatments which were provided by the LNHA. The reports revealed: -06/18/24 Pest Company Report: Service Related Comment: I inspected 10 drains in 2nd floor kitchen and bar for small fly activity. Pest Activity Found, Location, Kitchen Area-Interior, Finding: Small flies noted during service, I treated small flies by drains in kitchen, Action Needed/Taken: This area was inspected and serviced. -8/15/24 Pest Company Report: Service Related Comment: I inspected the kitchen and office space and treated for ants in mds (Material Data Set) office on 2nd floor and main kitchen and secondary kitchen on first and 2nd floor. Structural Concerns: Receiving-introduction Point, Finding: -Exit door doesn't close/seal properly, Action Needed/Taken: Install/replace door sweep. Install weather stripping. Exclusion measures here will reduce the number of pests entering the area. Sanitation Issues: Kitchen, Area- interior, Finding: Floor drains need cleaning, Action Needed/Taken: Please clean in and around drains frequently to help prevent pest breeding sites; Kitchen, Area-interior, Finding: excess water noted. Found standing water in containers under juice and coffee maker, wet rag and leaking hoses under soda machine leaks and drippings on the floor, small fly active areas where they reproduce in these wet areas and drips, Action Needed/Taken: Keep area dry; Kitchen, Area-Interior, Finding: Main kitchen 2nd floor great job on keeping the cook lines and floors clean your sanitation efforts speak volumes, Action Needed/Taken: Please address sanitation issue. On 09/12/24 at 2:58 PM, the surveyor, in the presence of the survey team, reviewed with the LNHA the observations of pests and sanitation concerns that have been observed during the survey, and about the reports of sanitation concerns regarding the kitchen areas related to pests that was documented by the Pest Company. The surveyor asked the LNHA if he was aware of the concerns and if he made rounds of the different areas. The LNHA stated, I'm not going to say anything. On 09/13/24 at 9:33 AM, during the Exit conference conducted with the facility, there was no additional information provided regarding the pests observed during survey. NJAC 8.39-31.5(a)

Based on observation and interview it was determined that the facility failed to maintain the healthcare dining room in a clean and homelike manner. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor observed the meal preparation in the healthcare pantry, located on the 2nd floor, with the Food Service Supervisor (FSS) present. The trays were being assembled for distribution to the residents who eat in their rooms. At that time the surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. At that time, the surveyor observed that there were splatters in several areas on the wall and crumbs and other debris on the floor behind the equipment and in the corners. The surveyor asked about the pantry cleaning and the FSS stated the floors are swept and mopped. The adjacent storage room was observed and contained debris on the floor and in the corners, the walls also had splatters and stains. A soiled dust pan was on the floor next to a small plunger and a broom. There were flying insects observed in the storage room, and boxes of cold cereal and sugar packets were stored on a metal shelf. The surveyor then exited the pantry into the main healthcare dining room and observed the following: -Dust and debris on the window sill with several dead insects. -Multiple insects appeared to be stuck to the wall molding. -Chairs and tables had visibly worn table legs and chair legs. -There was a visible crack in the painted ceiling above the resident meal tables which appeared to be approximately one foot long. -Two rugs outside of the door from the pantry to the dining room were visibly soiled with various debris. -There were stains and debris on the floor, including white splatter type stains on the floor and under the resident dining tables. -A black piano in the dining room was visibly dusty. On 09/10/24 at 12:00 PM, the surveyor showed the Licensed Nursing Home Administrator (LNHA) the above concerns and he acknowledged and stated, give me one hour to have it cleaned. NJAC 8:39- 4.1(a)11

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to revise a resident-centered on-going care plan for a resident who sustained multiple falls. This deficient practice was identified for 1 of 13 residents (Resident #34) reviewed for care plans and was evidenced by the following: A review of the facility provided policy, Care Plans, Comprehensive Person-Centered revised March 2022, included but was not limited to; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. On 09/09/24 at 6:32 PM, the surveyor observed Resident #34 in the Seasons Unit (SU) day room visiting with a family member. The family member stated that the resident had fallen multiple times. On 09/11/24 at 8:24 AM, the surveyor observed Resident #34 in the SU day room eating breakfast while sitting in a wheelchair. On 09/11/24 at 8:31 AM, the Certified Nursing Assistant (CNA) #1 stated Resident #34 needed total assistance, could stand only a few seconds, and has had falls. On 09/11/24 at 10:25 AM, the direct care Registered Nurse (RN) stated if a resident had a fall, the process was to assess the resident, ask alert and oriented residents what happened, call the physician and family, monitor the resident, follow the physician orders, and document in the medical record. The surveyor then reviewed the Medical Record which revealed: The Admission Record revealed diagnoses, including but not limited to; fall on same level from slipping, tripping, and stumbling; abnormalities of gait and mobility; muscle weakness; difficulty walking; lack of coordination; and muscle wasting. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care dated 06/04/2024, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 01 out of 15 indicating Resident #34 had a severely compromised cognition. Additionally, Resident #34 was documented as being dependent on staff for hygiene, bathing, and dressing. It was also documented that the resident did not walk due to medical condition or safety concerns. Resident #34 was noted as having had two or more falls since the previous assessment. A review of the facility provided fall incident reports included the following fall dates: 02/26/2024, 02/27/2024, 03/07/2024, 03/21/2024, 05/21/2024, 06/17/2024, 08/09/2024, and 09/03/2024. A review of the resident-centered ongoing care plan included but was not limited to; a focus area of falls and listed the following fall dates: 02/26/2024, 02/27/2024, 03/07/2024, 03/21/2024, 05/21/2024, and 06/17/2024. The care plan failed to include the 08/09/2024 and 09/03/2024 falls or any interventions put in place. The interventions included but were not limited to; dated 02/26/2024, offer to have (Resident #34) transfer to sofa per preference; and dated 03/07/2024, provide reclining chair if (Resident #34) prefers to stay in the lounge area. On 09/12/24 at 10:10 AM, the Director of Nursing (DON) was in the conference room with two surveyors and stated Resident #34, required supervision but it was not always direct, and things happen. The DON further stated that resident falls should be documented on the care plan. It would include the date of the fall and interventions if appropriate. The DON stated updating the care plan was important but that she would not usually list the dates of the falls just the interventions. When asked about the reclining chair listed as an intervention, the DON stated that the resident refused the recliner and there was no documentation. The surveyor informed the DON of the concern regarding the missing fall dates and missing updated information. On 09/13/24 at 10:07 AM, the DON again acknowledged that there was no documentation regarding use of the recliner and if it was offered to Resident #34 per the documented care plan intervention. There was no further information provided regarding the care plan not being revised or updated with Resident #34's two most recent falls. NJAC 8:39-11.2 (h)(i)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that oxygen and respiratory related treatments were provided in a manner to prevent the spread of infection and injury for 1 of 1 resident (Resident #153) reviewed for respiratory care. The deficient practice was evidenced by the following: On 9/10/24 at 10:55AM, in the room of Resident #153, the surveyor observed an oxygen cylinder by the chair in a canvas carrier, unsupported, not in a cylinder holder. The oxygen tubing was wrapped around top of cylinder with a label dated 8/30/24. The surveyor did not observe an oxygen in use sign on the door or over the bed. The surveyor also observed a nebulizer machine on Resident #153's bedside table, with a mask wrapped in a paper towel. The surveyor did not observe a label on the nebulizer tubing/mask. Resident #153 stated to the surveyor that their breathing was ok and that they were on oxygen when they first came to facility but they had not used it for at least two weeks. Resident #153 also stated that they no longer received breathing treatments. On 09/10/24 at 11:03 AM, the surveyor interviewed the Unit Manager (UM) regarding the oxygen tank. The UM stated, that should be gone, only thing that should be there is the concentrator. The UM stated that the resident #153's orders are prn (as needed). She also stated that the tubing should be in the bag and the oxygen tank shouldn't be on the floor, it should be in a cylinder holder. When asked about the nebulizer machine, the UM stated that the nebulizer mask and tubing should be in a bag with a label and date. On 09/10/24 at 12:43PM, the surveyor reviewed the medical record which revealed an order dated 09/02/24 for oxygen at 2 liters/minute via nasal cannula as needed for shortness of breath. The Medication Administration Record for September 2024 revealed an order for Ipratoplum-Albuterol inhalation 0.5-2.5milligrams/3milliliter application four times a day for cough for 7 days, start date 8/25/24; last dose administered was 11:00 AM on 09/01/24. The Treatment Administration Record for September 2024 revealed an order for oxygen at 2 liters/minute via nasal cannula around the clock every shift with a start date of 08/25/24 and a discontinued date of 09/02/24. According to the medical record, Resident #153 was admitted from the hospital after treatment for acute respiratory failure due to congestive heart failure and pneumonia. The Admission Minimum Data Set (MDS), an assessment tool, dated 09/01/24, indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. On 09/12/24 at 10:41 AM, the surveyor interviewed the Director of Nursing (DON) about the oxygen tank leaning against a chair and she stated, that an oxygen tank should not be propped up in a corner, because it could blow up. She also stated that if oxygen tubes and masks are used and soiled, they should be discarded, and the tanks should be off the floor. She further stated that she was not made aware of the oxygen tank issue. On 09/12/24 at 02:24 PM, the surveyor interviewed the DON about oxygen signs, and she stated that the staff usually puts a sign in place when the resident is using oxygen. A review of Oxygen Administration policy provided by the Administrator on 9/11/22 revised on October 2010 included: Steps in Procedure 2. Place an Oxygen in Use sign on the outside of the room entrance door. 3. Place an Oxygen in Use sign in a designated place on or over the resident's bed. Review of Replacement of Respiratory Disposables policy provided by the Assistant Director of Nursing on 9/11/24 included: Authority: Night shift nurses or designees are responsible for changing disposables weekly Instruction: Replace all disposable respiratory equipment weekly for infection control Change O2 tubing, nebulizer and humidifier bottles weekly Nasal cannulas and patient bag to be changed weekly Changes should be dated Nasal cannulas and nebulizers are to be kept in the patients' bag at bedside when not in use A policy for proper storage of oxygen tanks was not provided by the facility. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) proper administration technique for an insulin pen injector as per manufacturer specifications and b.) vital parameters, (blood sugar, blood pressure, heart rate), were obtained just prior to administration of medications that had physician's orders which based the results of the parameters on whether to administer the medications for four (4) of seven (7) residents, (Resident #39, #44, #153 and #252), observed for one (1) of two (2) nurses during the medication administration observation. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 1. On 9/11/24 at 8:00 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN #1) preparing to administer insulin (a medication used to lower blood sugar) to Resident #44. The surveyor observed the RN #1 refer to a paper on the medication cart that had resident's names on it and stated that the resident's blood sugar (BS) result was 181 and that according to the physician's order (PO) that she was reading on the electronic medication administration record (EMAR) indicated to administer two (2) units (U) of insulin. The RN #1 removed the resident's Humalog KwikPen (an insulin pen injector) from the medication cart, added a needle to the pen injector and dialed the dose indicator to read 2 U in the dose window. At that time, the RN #1 stated that she had taken the resident's BS earlier when she came in on her shift at approximately 7:30 AM. The surveyor had not observed the RN #1 obtain a BS from Resident #44 just prior to insulin administration. On 9/11/24 at 8:10 AM, the surveyor observed the RN #1 inject the resident's right arm subcutaneously (SC) using the resident's Humalog KwikPen that had been dialed to a dose of 2 U by pushing the dose knob down. The RN then held the insulin pen injector dose knob down for less than four (4) seconds. The surveyor had not observed the RN #1 follow manufacturer specifications for priming the Humalog KwikPen before administration of the required dose The surveyor had not observed the RN #1 follow manufacturer specifications after pushing the dose knob down, hold the pen injector in and count slowly to five (5) seconds. On 9/11/24 at 9:26 AM, the surveyor interviewed the RN #1 at the medication cart who stated that My usual routine is to come in for my shift at 7 AM, get report and then would do rounds on my residents and obtain vitals. The RN #1 added that the approximate time that she was obtaining vitals was usually around 7:30 AM. The RN #1 added that she obtained vital parameters before she started her morning medication pass because it helped with timeliness. The RN #1 also stated that she was unaware of any instructions for using the insulin pen injector and thought it was similar to a subcutaneous injection with a needle. The RN #1 then reviewed the labeling of the resident's Humalog KwikPen in the medication cart and stated there was no special instructions that she could see. The RN #1 then described the technique she used for the Humalog KwikPen which included checking to make sure she had the resident's correct medication, correct needle, correct dose and rotated the sites of injection. The RN #1 was unable to speak to priming the insulin pen injector or holding the pen injector in the site for a specific time after pressing the dose knob down. The RN #1 added that she was a per diem employee as of May 2024 but worked two days every week and was usually on a different unit but could float. The RN #1 added that she was unsure if there were any inservices on medication administration or the insulin pen injectors and that the Assistant Director of Nursing (ADON) usually did inservices. The surveyor reviewed the electronic medical record for Resident #44. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/10/24, reflected the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report (OSR) revealed a PO with a start date of 8/3/24 for Humalog KwikPen Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Lispro)(a fast acting insulin), Inject as per sliding scale: if 150-199=2 U; 200-249=3 U; 250-299=6 U; 300-349=8 U;350-400=10 U, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM)(high blood sugar levels) A review of the EMAR reflected the above PO. On 9/11/24 at 9:31 AM, the surveyor interviewed the ADON who stated that he was the staff educator. The ADON also stated there was a specific technique for insulin pen injector administration that included priming the insulin pen injector. The ADON added that an inservice on the insulin pen injector technique had not been done. The ADON stated that he would provide a policy regarding the technique for insulin pen injectors. On 9/11/24 at 9:43 AM, the surveyor interviewed the RN #2 who stated that she has worked at the facility for approximately four (4) years and was familiar with Resident #44. The RN #2 stated that she was unsure if there had been an inservice regarding the insulin pen injector technique. The RN #2 then explained that the insulin pen injector technique included priming the insulin pen with a small amount of insulin that you would visualize coming out of the needle prior to dialing the dose that was ordered. The RN #2 added that after injecting, the plunger had to be held in for approximately 10 seconds to make sure all the insulin was administered. The RN #2 also added that she tried to obtain a BS as close to before a meal as possible and then administered the insulin following taking the BS. On 9/11/24 at 12:03 PM, the ADON provided the surveyor with an undated policy and procedure for Administering Insulin Pen. The ADON stated that he had a Medication Observation completed by the Consultant Pharmacist for RN #2 but had no Medication Observation completed for the RN #1. The ADON also stated that usually the Consultant Pharmacist (CP) does medication observations but was seeing that there was a gap in time for when nurses were having a completed medication observation after they were first employed. A review of the facility undated policy and procedure for Administering Insulin Pen revealed that the procedure required Prime pen with two units of insulin while pointing upwards. In addition, Hold insulin pen in place for 10 seconds. On 9/11/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON) who stated that she would expect vital parameters such as a BS to be obtained right before administering the medication when there was a sliding scale PO. The surveyor, with the DON, reviewed the facility policy for Administering Medications which indicated The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The DON acknowledged that the policy had not indicated a specific timeframe prior to administering a medication but would expect the BS be taken just prior to the administration of the insulin. On 9/12/24 at 10:43 AM, the surveyor, in the presence of another surveyor, interviewed the CP via the telephone who stated that he was not the CP who services the facility but was the owner and that the CP who services the facility was no longer employed and he could speak to any questions. The CP stated that he was unsure if inservices on medication administration and the technique for insulin pen injectors was completed but that the ADON would have the records if there was an inservices. The CP explained that insulin pen injectors had a specific technique which included priming the pen injector before administering a dose and holding in the plunger as per manufacturer specifications to ensure proper insulin administration. The CP also stated that a BS should be taken just prior to administering the dose of insulin and that results could change if they were taken too early. On 9/12/24 at 11:25 AM, the surveyor interviewed Resident #44 who stated that they had their BS taken several times a day and also received insulin several times a day. The resident was unable to speak to the timing of the BS in accordance with the insulin being administered. On 9/12/24 at 2:19 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON acknowledged that the nurses should obtain a BS immediately before administration of insulin for a sliding scale PO. A review of the current facility policy for Administering Medications with a revision date of April 2019 provided by the ADON which reflected The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. A review of the manufacturer's specifications for Instructions for use Humalog KwikPen (Insulin Lispro) reflected that the steps required to properly administer an insulin pen included Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The instructions also revealed Step 6: To prime your pen, turn the dose knob to select 2 units. Step 7: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the Dose Knob in and count to 5 slowly, You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8. In addition, the instructions for giving the injection reflected Step 11: Insert he needle into your skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle. 2. On 9/11/24 at 8:11 AM, during the medication administration observation, the surveyor observed the RN #1 preparing to administer five (5) medications to Resident #44 which included one tablet of 12.5 milligrams (MG) of Coreg (a medication used to treat high blood pressure). The surveyor observed the RN #1 refer to a paper on the medication cart that had residents names on it and stated that the resident's BP was 155 and the pulse (heart rate) (HR) was 100 so she was allowed to administer the Coreg according to the PO on the EMAR. The surveyor had not observed the RN #1 obtain a BP or HR from Resident #44. On 9/11/24 at 9:26 AM, the surveyor interviewed the RN #1 at the medication cart who stated that My usual routine is to come in for my shift at 7 AM, get report and then would do rounds on my residents and obtain vitals. The RN #1 added that the approximate time that she was obtaining vitals was usually around 7:30 AM. The RN #1 added that she obtained vital parameters before she started her morning medication pass because it helped with timeliness. The surveyor reviewed the electronic medical record for Resident #44. A review of the Order Summary Report (OSR) revealed a PO with a start date of 8/3/24 for Carvedilol (Coreg) oral tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for hypertension (HTN) (high blood pressure) hold for systolic BP (SBP)(maximum pressure during one heartbeat or the top number) less than 100 and HR less than 60. A review of the EMAR reflected the above PO. On 9/11/24 at 12:48 PM, the surveyor interviewed the DON who stated that she would expect vital signs such as a BP and HR to be obtained right before administering the medication when there was a PO indicating that a medication be held for specific vital parameters. The surveyor, with the DON, reviewed the facility policy for Administering Medications which indicated The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The DON acknowledged that the policy had not indicated a specific timeframe prior to administering a medication but would expect the vital parameters be taken as close to the administration time of the medication as possible. The DON added that she would allow up to 15 minutes prior to the administration of the medication. On 9/12/24 at 10:43 AM, the surveyor, in the presence of another surveyor, interviewed the CP via the telephone who stated that he was not the CP who services the facility but was the owner and that the CP who services the facility was no longer employed and he could speak to any questions. The CP stated that he was unsure if inservices on medication administration were completed but that the ADON would have the records if there was an inservice. The CP acknowledged when a PO had hold parameters that vital parameters were to be obtained from a resident. The CP stated, Vital signs were to be obtained just before pouring meds [medication] because vital signs can change. The CP added that Getting vital signs during rounds can be a good marker but when there is a hold order the BP should be done just prior to the med being administered. On 9/12/24 at 2:19 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should obtain vital parameters immediately before administration of a medication when there was a PO with hold parameters and would give a grace period of 15 minutes to take the vital signs before administering the medication. 3. On 9/11/24 at 8:37 AM, during the medication administration observation, the surveyor observed the RN #1 preparing to administer morning medications to Resident #39. The surveyor observed the RN #1 refer to a paper on the medication cart that had resident's names on it and stated that the resident's BP was 93/56 so she was not going to be administering the Coreg and the Diltiazem (Cardizem)(a medication used to lower blood pressure) because according to the PO on the EMAR she had to hold both medications because the SBP was less than 100. The surveyor observed the RN #1 enter electronically a BP of 93/56 and HR of 75. The surveyor had not observed the RN #1 obtain a BP or HR from Resident #39. On 9/11/24 at 9:26 AM, the surveyor interviewed the RN #1 at the medication cart who stated that My usual routine is to come in for my shift at 7 AM, get report and then would do rounds on my residents and obtain vitals. The RN #1 added that the approximate time that she was obtaining vitals was usually around 7:30 AM. The RN #1 added that she obtained vital parameters before she started her morning medication pass because it helped with timeliness. The surveyor reviewed the electronic medical record for Resident #39. A review of the OSR revealed a PO with a start date of 8/20/24 for Carvedilol (Coreg) oral tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN Hold SBP less than 100, hold HR less than 55 Administer with food/meals. Further review of the OSR revealed a PO with a start date of 8/20/24 for Diltiazem (Cardizem) hydrochloride ER oral tablet Extended Release 24 hour 120 MG Give 1 tablet by mouth in the morning for HTN Hold SBP less than 100, hold HR less than 55. A review of the EMAR reflected the above POs. On 9/11/24 at 12:48 PM, the surveyor interviewed the DON who stated that she would expect vital signs such as a BP and HR to be obtained right before administering the medication when there was a PO indicating that a medication be held for specific vital parameters. The surveyor, with the DON, reviewed the facility policy for Administering Medications which indicated The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The DON acknowledged that the policy had not indicated a specific timeframe prior to administering a medication but would expect the vital parameters be taken as close to the administration time of the medication as possible. The DON added that she would allow up to 15 minutes prior to the administration of the medication. On 9/12/24 at 10:43 AM, the surveyor, in the presence of another surveyor, interviewed the CP via the telephone who stated that he was not the CP who services the facility but was the owner and that the CP who services the facility was no longer employed and he could speak to any questions. The CP stated that he was unsure if inservices on medication administration were completed but that the ADON would have the records if there was an inservice. The CP acknowledged when a PO had hold parameters that vital parameters were to be obtained from a resident. The CP stated, Vital signs were to be obtained just before pouring meds because vital signs can change. The CP added that Getting vital signs during rounds can be a good marker but when there is a hold order the BP should be done just prior to the med being administered. On 9/12/24 at 2:19 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should obtain vital parameters immediately before administration of a medication when there was a PO that had hold parameters and would give a grace period of 15 minutes to take the vital signs before administering the medication. 4. On 9/11/24 at 8:31 AM, during the medication administration observation, the surveyor observed the RN #1 preparing to administer five (5) medications to Resident #153 which included one tablet of 25 MG of Metoprolol (Lopressor)(a medication used to treat irregular heart rhythms). The surveyor observed the RN #1 refer to a paper on the medication cart that had resident's names on it and stated that the resident's BP was 102/54 and the HR was 62 so she was allowed to administer the Metoprolol according to the PO on the EMAR. The surveyor had not observed the RN #1 obtain a BP or HR from Resident #153. On 9/11/24 at 9:26 AM, the surveyor interviewed the RN #1 at the medication cart who stated that My usual routine is to come in for my shift at 7 AM, get report and then would do rounds on my residents and obtain vitals. The RN #1 added that the approximate time that she was obtaining vitals was usually around 7:30 AM. The RN #1 added that she obtained vital parameters before she started her morning medication pass because it helped with timeliness. The surveyor reviewed the electronic medical record for Resident #153. A review of the OSR revealed a PO with a start date of 8/23/24 for Metoprolol Tartrate oral tablet 50 MG (Metoprolol) Give 0.5 tablet by mouth every 12 hours for A Fib (atrial fibrillation)(an irregular heart rhythm) Hold SBP less than 100, Hold HR less than 655. Administer 1/2 tab of Metoprolol Tartrate 25 MG = 12.5 MG with food. A review of the EMAR reflected the above PO. On 9/11/24 at 12:48 PM, the surveyor interviewed the DON who stated that she would expect vital signs such as a BP and HR to be obtained right before administering the medication when there was a PO indicating that a medication be held for specific vital parameters. The surveyor, with the DON, reviewed the facility policy for Administering Medications which indicated The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The DON acknowledged that the policy had not indicated a specific timeframe prior to administering a medication but would expect the vital parameters be taken as close to the administration time of the medication as possible. The DON added that she would allow up to 15 minutes prior to the administration of the medication. On 9/12/24 at 10:43 AM, the surveyor, in the presence of another surveyor, interviewed the CP via the telephone who stated that he was not the CP who services the facility but was the owner and that the CP who services the facility was no longer employed and he could speak to any questions. The CP stated that he was unsure if inservices on medication administration were completed but that the ADON would have the records if there was an inservice. The CP acknowledged when a PO had hold parameters that vital parameters were to be obtained from a resident. The CP stated, Vital signs were to be obtained just before pouring meds because vital signs can change. The CP added that Getting vital signs during rounds can be a good marker but when there is a hold order the BP should be done just prior to the med being administered. On 9/12/24 at 2:19 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should obtain vital parameters immediately before administration of a medication when there was a PO that had hold parameters and would give a grace period of 15 minutes to take the vital signs before administering the medication. 5. On 9/11/24 at 9:13 AM, during the medication administration observation, the surveyor observed the RN #1 administer five (5) medications to Resident #252 which included one tablet of 50 MG of Metoprolol. Upon returning to the medication cart, the surveyor observed the RN #1 refer to a paper on the medication cart that had resident's names on it and electronically entered a BP of 158/73 and a HR of 69 for the Metoprolol PO and electronically signed for administration. The RN #1 stated that she had taken the BP and HR earlier on her rounds and knew that the Metoprolol was allowed to be administered. The surveyor had not observed the RN #1 obtain a BP or HR from Resident #252. On 9/11/24 at 9:26 AM, the surveyor interviewed the RN #1 at the medication cart who stated that My usual routine is to come in for my shift at 7 AM, get report and then would do rounds on my residents and obtain vitals. The RN #1 added that the approximate time that she was obtaining vitals was usually around 7:30 AM. The RN #1 added that she obtained vital parameters before she started her morning medication pass because it helped with timeliness. The surveyor reviewed the electronic medical record for Resident #252. A review of the OSR revealed a PO with a start date of 8/23/24 for Metoprolol Tartrate oral tablet 50 MG (Metoprolol) Give 1 tablet by mouth two times a day for HTN Hold SBP less than 110, or a HR less than 60. To be given with food. A review of the EMAR reflected the above PO. On 9/11/24 at 12:48 PM, the surveyor interviewed the DON who stated that she would expect vital signs such as a BP and HR to be obtained right before administering the medication when there was a PO indicating that a medication be held for specific vital parameters. The surveyor, with the DON, reviewed the facility policy for Administering Medications which indicated The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The DON acknowledged that the policy had not indicated a specific timeframe prior to administering a medication but would expect the vital parameters be taken as close to the administration time of the medication as possible. The DON added that she would allow up to 15 minutes prior to the administration of the medication. On 9/12/24 at 10:43 AM, the surveyor, in the presence of another surveyor, interviewed the CP via the telephone who stated that he was not the CP who services the facility but was the owner and that the CP who services the facility was no longer employed and he could speak to any questions. The CP stated that he was unsure if inservices on medication administration were completed but that the ADON would have the records if there was an inservice. The CP acknowledged when a PO had hold parameters that vital parameters were to be obtained from a resident. The CP stated, Vital signs were to be obtained just before pouring meds because vital signs can change. The CP added that Getting vital signs during rounds can be a good marker but when there is a hold order the BP should be done just prior to the med being administered. On 9/12/24 at 2:19 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should obtain vital parameters immediately before administration of a medication when there was a PO that had hold parameters and would give a grace period of 15 minutes to take the vital signs before administering the medication. NJAC 8:39-11.2(b), 29.2 (d)

Based on observation, interview, record review and other pertinent facility documents it was determined that the facility failed to document attempted non-drug interventions and the need for an as needed (PRN) psychoactive medication (Xanax) to be administered. The deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications, (Resident #25) and was evidenced by the following: On 9/9/24 at 7:15 PM, the surveyor observed the Resident #25 sleeping in the room on an air mattress bed. On 9/10/24 at 8:58 AM, the surveyor observed the resident in the room sitting on a recliner. The resident stated, I've been here for five years. I'm working with therapy a couple of times a week because I try to move my legs and arms. I would like to walk again that's why I feel sad, but I really love it here and working towards that. On 9/10/24 at 1:03 PM, a record review of the electronic health records (EHR) revealed diagnoses which included but not limited to unspecified fracture of left femur subsequent encounter for closed fracture with routine healing; anxiety; depression; and unspecified psychosis not due to a substance or known physiological condition. A review of the order summary revealed: Xanax Oral Tablet 0.25 MG (Alprazolam) *Controlled Drug* Give 0.5 tablet by mouth every 6 hours as needed for Anxiety for 60 Days Administer 0.125mg only = half tablet of 0.25 mg (milligrams); ordered 8/1/24; end date 9/20/24. Monitor for behaviors: List targeted behaviors related to Xanax. Monitor and document every shift. If behavior is observed document the behavior, any contributing factors, interventions, and outcomes in progress notes, every shift if behaviors are observed document Yes and document in progress notes. Observe for significant side effects: sedation, drowsiness, agitation, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, weight changes, photosensitivity, dizziness, insomnia, somnolence, nausea, vomiting, confusion, falls, SPECIAL ATTENTION: heart disease, glaucoma, chronic constipation, seizure disorder, edema. every shift for depression document N-No side effects observed, and Y-Yes Side effects observed, enter progress note describing side effects and notify the physician. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care with an assessment reference date of 8/2/24, reflected that the resident had a brief interview for mental status (BIMS) score of 10 out of 15, indicating that the resident had a moderately impaired cognition. Furthermore, the resident reflected the health questionnaire-9 (PHQ-9), a mental health screening revealed no behaviors. A review of the care plans revealed psychotropic medications-Xanax for anxiety, Mirtazapine for depression and Seroquel for psychosis. On 9/11/24 at 10:53 AM, the surveyor interviewed the Registered Nurse (RN) #1, who has been working in the facility for four years, the RN stated, The resident can be confused, can be anxious, restless, but we re-direct the patient. What eases the patient the most is a call from the son. The patient is on medication for it, and it works. The patient is seen by psychiatry. The patient is on Xanax PRN ordered for 60 days, usually it's ordered for 14 days. The Psychiatry Nurse Practitioner (NP) ordered it for 60 days. They're usually here every Thursday. On 9/11/24 at 11:09 AM, the surveyor interviewed the Unit Manager (UM) License Practical Nurse (LPN), who has been working in the facility for one year, regarding the Xanax PRN. The UM stated, I am aware that the Psychiatry NP, ordered it for 60 days because the resident has been on this long term, she sees the resident all the time. The NP knows the PRN (as needed) regulations are ordered for 14 days but this resident will probably continue it per NP. On 9/11/24 at 11:15 AM, the surveyor observed the resident in the room sitting on a wheelchair. The resident stated, I generally don't feel anxious or sad. I am okay, I love everybody here, they treat me very well. On 9/11/24 at 12:40, PM, a record review of the electronic medication administration record (eMAR) revealed Xanax ordered as PRN for June 2024, July 2024, were not given for two months; on August 2024, Xanax Oral Tablet 0.25 MG (Alprazolam) Give 0.5 tablet by mouth every 6 hours as needed for Anxiety for 60 Days Administer 0.125 mg only = half tablet of 0.25 mg.-Start Date 8/1/2024 1:00 PM, was administered for one day on 8/1/24 at 3:46 PM, by RN #2, with no documentation on the nursing progress notes indicating why the medication was given; no documentation of a target behavior; and no documentation of any non-drug interventions done prior to medicating. Furthermore, the RN #2 documented on the eMAR on 8/1/24 under monitor for behaviors as NO behaviors. A review of the physician progress notes on 8/5/24 revealed, Continue Remeron for anxiety/mild depressed mood and poor appetite. Continue to monitor patient's mood/mental status. Continue Xanax 0.125 mg every 6 hours as needed for anxiety attack, and 0.125 mg in the morning and 0.25 mg at bedtime. A review of the nursing progress notes of RN #3 on 8/1/2024 at 2:40 PM, revealed, The psychiatry NP came to visit the resident and renewed Xanax 0.125 mg tablet every 6 hours as needed for anxiety x 60 days. On 9/11/24 at 3:18 PM, the surveyor interviewed RN #2, who administered the Xanax PRN on 8/1/24, via telephone call, and she stated, I've been working at the facility for a year, full time 3-11 PM shift. The resident is fine, sometimes the resident has this confusion, you must explain every situation with the resident. Sometimes the resident has agitation but easily calmed after you explain things to the resident, re-directing works at times. I don't really remember the situation on 8/1/24 when I gave the Xanax PRN, but I usually will give it if I see anxiousness is high and there is agitation. If I did everything to re-assure the resident and nothing else worked, that would be the time I would give the PRN Xanax. The next thing I would do I would be to re-assess the resident to see if it was effective or not and I would ask the resident how they feel and then I will have to document it. I don't remember why I did not document on that day. On 9/12/24 at 9:03 AM, the Certified Nursing Assistant (CNA), who has been working in the facility for [AGE] years, full time, stated, Sometimes the patient gets anxious because the patient doesn't know where [they] are and looking for [their] family but then [they] call the family and [they] calm down. The patient has no other behaviors I see. On 9/12/24 at 9:10 AM, the Director of Nursing (DON) provided the Psychiatry consult dated 7/5/24 which revealed the resident, Reports anxiety/worry and consult dated 8/1/24 which revealed, Renew Xanax 0.125 mg PRN x 60 days. May renew as indicated for increased anxiety. On 9/12/24 at 9:41 AM, in the presence of another surveyor, the surveyor interviewed the DON, the Psychiatry NP, the Psychiatrist from the [name redacted] Psychiatry group stated, The collaborating doctor and I have been here for 2-3 years. The psychiatrist stated regarding the Xanax PRN, The resident has a history of anxiety, and the order was ordered for 60 days with the documented rationale of the resident showing increasing anxiety. The PRN has an end date of 9/20/24. I cannot speak for why there was no nursing documentation on 8/1/24. The NP stated, On the day I ordered it on 8/1/24 the nurse should have documented the symptoms on 8/1/24. The DON acknowledged that the nurse did not complete a narrative note and stated they should have documented the target behavior/s, what occurred on 8/1/24 that required the use of PRN Xanax and if any other non-drug interventions were implemented prior to administration of the Xanax. On 9/12/24 at 2:35 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA) and DON, to discuss the use of Xanax PRN. The surveyor informed that on 8/1/24 there was no nursing documentation, no documentation of target behaviors, symptoms, or non-drug interventions prior to medicating Resident #25 with Xanax. The DON stated, I totally agree that the nurse should have documented the targeted behavior, symptom/s at that time and what other interventions were taken before medication administration. The surveyor requested for any other additional documentation. On 9/13/24 at 9:55 AM, the facility did not provide any additional documentation. On 9/13/24 at 10:02 AM, a review of the most current facility Policy and Procedure for Psychotropic Medication Use, with a revised date in July 2022 revealed, Psychotropic medications are not given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. The most current facility policy and procedure for Administering Medications, revised in April 2019, revealed, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: any complaints or symptoms for which the drug was administered. NJAC 8:39 11.2(b), 27.1(a), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control and hand hygiene practices to prevent the spread of infection. This deficient practice was identified for 6 of 6 resident's observed during the meal delivery. The evidence was as follows: On 9/10/24 at 8:10 AM, the surveyor observed the Certified Nursing Assistant (CNA) delivered the breakfast meals to the Unit. The surveyor followed the CNA to the rooms and observed there was no sani-wipe on the tray, The CNA delivered the tray, adjusted the bedside table, set the tray up and left the room. The CNA did not provide the residents with opportunities to cleanse their hands prior to the meals. The CNA left the room and used Alcohol Base Hand Rub (ABHR) to cleanse his hands prior to deliver the next tray. The surveyor followed the CNA to the next room and observed that the resident was not provided with opportunities to cleanse their hands. The surveyor followed another CNA in the next hallway and observed that none of the residents served were provided with opportunity to cleanse their hands. On 9/11/24 at 12:15 PM, the surveyor observed the lunch meals being delivered to the residents at the table. The residents were not provided with opportunity to cleanse their hands. On 9/12/24 at 12:35 PM, the surveyor observed the CNA delivered the lunch tray to the residents in their rooms. The residents were not provided with opportunity to wash their hands. On 9/12/24 at 12:45 PM, an interview with a random resident who was awake and alert confirmed there was no sani-wipe delivered with the tray and no hand sanitizer was being offered also prior to the meals. On 9/12/24 at 1:30 PM, the surveyor interviewed the CNA. The surveyor asked the CNA about hand hygiene for the residents prior to consume their meals. The CNA stated, If the resident requested hand sanitizer we will provide but we do not offer regularly. The surveyor then asked the CNA where the sani-wipes were located. The CNA accompanied the surveyor to the storage room and showed the wipe used when the residents requested. The surveyor reviewed the instructions on the bag with the CNA and informed the CNA that these wipe were indicated to clean the perineal area, not the hands prior to meals. The CNA was not aware. On 09/12/24 at 1:42 PM, the surveyor reviewed the facility's policy and procedures. A Review of the facility's Handwashing Policy and Procedure dated 2001, included that this facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Residents, family members and/or visitors are encouraged to practice hand hygiene. On 9/12/24 at 2:00 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the residents should be provided with hand sanitizer. She stated the facility used to provide sani-wipes on the tray but the facility stopped the process after COVID. NJAC 8:39-19.4(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following: On 7/12/23 at 2:10 PM, the surveyor requested from the Director of Nursing to provide the most recent performance evaluation for five randomly selected Certified Nursing Aides (CNA #1; #2; #3; #4; and #5). On 7/13/23 at 9:05 AM, the Licensed Nursing Home Administrator (LNHA) provided the survey team with the five selected CNAs performance evaluations. The LNHA stated the facility had not completed any performance evaluations for the employees since 2021, that the facility wanted to change their performance evaluation process from completing on the date of the employees anniversary to a set date for the year for all employees. The surveyor reviewed the performance evaluations provided by the LNHA which revealed the following: 1. CNA #1 was hired on 1/2/19. The last performance evaluation was completed January 2021, and signed by the employee on 1/15/21. 2. CNA #2 was hired on 11/19/18. The last performance evaluation was completed 12/13/21, and signed by the employee on 12/13/21. 3. CNA #3 was hired on 11/24/17. The last performance evaluation was completed on 2/11/21, and signed by the employee on 2/11/21. 4. CNA #4 was hired on 10/11/11. The last performance evaluation was completed December 2020, and signed by the employee on 12/7/2020. 5. CNA #5 was hired on 7/24/21. There was no performance evaluation provided. On 7/14/23 at 8:37 AM, the surveyor interviewed the LNHA who stated that Human Resources (HR) was responsible for performance evaluations in combination with the Director of Nursing (DON) and himself. On 7/14/23 at 8:56 AM, the surveyor conducted a telephone interview with HR, who confirmed she was responsible for performance evaluations. HR stated that the facility identified performance evaluations were not being completed yearly, that no evaluations were completed in 2022. HR stated that the facility has piloted a program that all employees were to be reviewed at the same time each year for consistency. At this time, there are no completed evaluations. On 7/14/23 at 9:34 AM, the LNHA in the presence of the DON, Assistant Director of Nursing/Infection Preventionist (ADON/IP), and survey team confirmed there were no additional performance evaluations; that they were not completed annually as required. A review of the facility provided In-Service Training Program, Nurse Aide policy dated revised October 2017, included the facility will complete a performance review of nurse aides at least every twelve months. In-service training will be based on the outcome of the annual performance reviews, addressing weakness as identified in the reviews . NJAC 8:39-43.17(b)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure dietary staff had the appropriate competencies and skill sets to effectively use and maintain the facility's high temperature dish machine. This deficient practice had the potential to affect all residents, and was evidenced by the following: During a follow-up visit to kitchen on 7/13/23 10:09 AM, the surveyor conducted an inspection of the dish machine, that was not currently in use, in the presence of the Executive Chef. The Executive Chef stated the facility utilized a high temperature dish machine and the gauges should read minimum of 160 degrees Fahrenheit (F) for wash and minimum of 180 F for rinse. The Executive Chef sent an empty tray through the dish machine, and the surveyor observed the wash gauge which read 150 F and the rinse gauge that read 148 F. The surveyor questioned the temperatures, and the Executive Chef stated that he might be mistaken, that the machine might be a low temperature dish machine that utilized a chemical sanitizing solution that required lower temperatures. The Executive Chef picked up a bottle that contained a pink solution which he stated was sanitizer. At this time, the surveyor requested to see the facility's dish machine temperature log for the month of July 2023. The surveyor reviewed the July 2023 High Temperature Dishwasher Log in the presence of the Executive Chef which revealed for the month of July, the final rinse was recorded between 145-165 F when checked three times a day. The log indicated final rinse should be between 180-190 F; to report temperatures higher than 190 F or below 180 F for the final rinse to the manager. The Executive Chef, who during a previous kitchen visit informed the surveyor that he had worked at the facility for eight months now, stated that he was unsure the type of dish machine used at the facility, and he needed to contact the [Dish Machine Repair Company] to follow-up and he would let the surveyor know. On 7/13/23 at 2:10 PM, the surveyor in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) that they were still waiting to hear back from the Executive Chef what type of dish machine the facility used. The LNHA informed the survey team that he was unsure the type of dish machine the facility used, but the [Dish Machine Repair Company] was currently in the kitchen. At this time, the surveyor requested to speak with the Dish Machine Repair Employee #1. On 7/13/23 at 2:19 PM, the Food Service Director (FSD) in the presence of the LNHA, DON, and ADON/IP informed the survey team that from my understanding the dish machine was high temperature. The FSD stated that Dish Machine Repair Employee #1 conducted a test with a digital temperature recording plate that measured the maximum surface temperature in the dish machine which was 160 F that was okay. The surveyor informed the FSD that the July 2023 High Temperature Dishwasher Log for the entire month was recorded that the dish machine did not reach 180 F for the entire month. The FSD acknowledged this. On 7/13/23 at 2:20 PM, Dish Machine Repair Employee #1 in the presence of the FSD, LNHA, DON, and ADON/IP informed the survey team that the facility had a high temperature dish machine that should reach 160 F for the wash cycle and 180 F for the final rinse cycle. Dish Machine Repair Employee #1 stated that when he tested the internal temperature of the machine using digital temperature recording plate, the surface temperature reached 160 F which was acceptable per federal code, and in his opinion, the gauges were not operating correctly. At this time the surveyor requested to view the test. On 7/13/23 at 2:32 PM, Dish Machine Repair Employee #1 in the presence of the surveyor, FSD, and Executive Chef ran the digital temperature recording plate through the high temperature dish machine. The surveyor observed the gauges on the dish machine to read 155 F for wash and 148 F for rinse, and the digital temperature recording plate indicated the surface temperature was 160 F. Dish Machine Repair Employee #1 showed the surveyor the manufacturer's specifications which indicated at 160 F, the temperature effectively sanitized ware surfaces in accordance with the Food and Drug Administration (FDA) Food Code section 4-501. On 7/13/23 at 2:32 PM, the surveyor in the presence of the Executive Chef and FSD interviewed Utility Worker #1 who stated he worked at the facility for almost a year, and his job along with Utility Worker #2 was to wash dishes. Utility Worker #1 stated he recorded the dish machine temperatures yesterday, but Utility Worker #2 completed the log for today. Utility Worker #1 stated that he thought the temperatures needed to be between 160 F and 180 F, that the temperatures were not specific for the wash and rinse, just a temperature range. Utility Worker #1 stated that the wash temperature usually went up to 170 F. The surveyor reviewed the High Temperature Dishwasher Log with Utility Worker #1 and showed him where it indicated final rinse 180-190 F. Utility Worker #1 stated that he was aware the log indicated 180 F, but no one at the facility educated him that the temperature had to be above 180 F. At this time, the FSD and Executive Chef confirmed they educated kitchen staff with in-services and confirmed they had not conducted a dish machine in-service. The FSD and Executive Cook both confirmed they do not review the High Temperature Dishwasher Log unless staff gave it to them. At this time, the surveyor reviewed the May and June 2023 High temperature Dishwasher Logs with the FSD, which revealed for the months of May and June, temperatures were recorded within acceptable range. The FSD confirmed the recorded temperatures in question were just for the month of July 2023. On 7/13/23 at 2:47 PM, the Executive Chef in the presence of the LNHA informed the surveyor that Dish Machine Repair Employee #1 contacted the usual service technician (Dish Machine Repair Employee #2) who informed them that there was a third gauge located towards the back of the dish machine that recorded the final rinse temperature, that no one was aware of. The Executive Chef stated that gauge was reading 180 F. The Executive Chef confirmed no one in the kitchen was aware of this gauge, and he acknowledged that was concerning. On 7/14/23 at 9:10 AM, the surveyor observed the FSD with Dish Machine Repair Employee #1 and Dish Machine Repair Employee #2 at the facility's dish machine. Dish Machine Repair Employee #2 stated that the two water gauges in the front of the dish machine were the internal temperature gauges for the wash cycle, and the third temperature gauge towards the back of the machine recorded the final rinse temperature which had to be 180 F. Dish Machine Repair Employee #2 stated the facility only had a high temperature dish machine meaning that the final rinse needed to reach 180 F to sanitize; that the machine did not use a chemical sanitizing solution. Dish Machine Repair Employee #2 stated that the pink solution the Executive Chef mistook for sanitizer, was dish detergent and did not sanitize. The surveyor observed an empty dish rack run through the dish machine and the final rinse gauge read 180 F. At this time, the FSD stated that the facility had utilized paper products since surveyor inquiry yesterday while the [Dish Machine Repair Company] has been here. The FSD acknowledged that he was unaware of the third water gauge that was for the final rinse temperature; as well as no other staff in the kitchen was aware. On 7/14/23 at 9:34 AM, the LNHA in the presence of the DON, ADON/IP, and survey team confirmed the facility had been utilizing paper products since survey inquiry; that there have been no reported gastrointestinal issues for the month for residents. The LNHA acknowledged the above concerns. No additional information was provided as to how the High Temperature Dishwasher Logs of May and June of 2023 where documented within acceptable range. The facility did not provide any dish machine in-services conducted prior to surveyor inquiry. A review of the facility provided Sanitation policy dated 2013, included .utility workers will be trained in the proper use of the dish machine and three-compartment sinks. Dish machine temperatures will be taken three times a day and recorded in log . NJAC 8:39-17.1(a)

NJ Complaint #162847 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop their abuse policy in accordance with the requirement to report any allegation of abuse to the New Jersey Department of Health (NJDOH) immediately or within two hours, and b.) implement their abuse policy by immediately notifying administration, starting an investigation, and contacting the NJDOH for an allegation of abuse that occurred on 3/18/23. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #17), and the evidence was as follows: On 7/7/23 at 11:31 AM, the surveyor observed Resident #17 in the dayroom participating in activities. The surveyor reviewed the medical record for Resident #17. A review of the Face Sheet (admission summary) reflected the resident was admitted to the facility in March of 2016 with diagnoses which included dementia with behavioral disturbance, brief psychotic disorder, osteoarthritis, unspecified mood disorder, and generalized muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/20/23, included a brief interview for mental status (BIMS) score of a 7 out 15, which indicated a severely impaired cognition. A review of the Clinical Notes Report included a Nursing Note authored by Licensed Practical Nurse (LPN #1) dated 3/18/23 at 3:00 PM, that as per the 11:00 PM to 7:00 AM (11-7) nurse, resident had almost sleepless night, asking to see [spouse], and that some lady hit [him/her] on [his/her] left arm. [He/she] remained confused most of the shift without incident. [He/she] can be seen propelling [him/herself] on [his/her] wheelchair on the hallway. A further review included a Nursing Note authored by LPN #1 dated 3/22/23 at 2:53 PM, that the resident complained of pain on [his/her] left wrist this morning when the Certified Nursing Aide (CNA) was about to do morning care. I went and assessed the situation, the area was slightly swollen and warm, no discoloration. The Physician was made aware, and she ordered a STAT (immediately) X-ray of the left wrist to rule out fracture. The order was carried out and X-ray was done. The paper result was pending. An as needed Tylenol was given with very good effect as resident was observed using left arm without moaning. A review of a Nursing Note authored by the Unit Manager dated 3/22/23 at 4:32 PM, included X-ray result to left wrist shows an acute non-displaced fracture to the distal ulna shaft (forearm bone). I assessed the left wrist that is slightly swollen and warm to touch. There is a yellow fading discoloration noted around the wrist. On 7/10/23 at 10:00 AM, the surveyor requested from the Director of Nursing (DON) to provide all investigations, accidents, incidents, grievances, and reportable events for Resident #17 from the past year. On 7/11/23 at 8:52 AM, the DON provided the requested investigations and confirmed they were complete investigations with all statements. A review of the reportable event submitted to the NJDOH on 3/24/23, indicated on 3/22/23 at 4:00 PM, the resident (Resident #17) stated to the CNA that [he/she] was hit on the left hand; no individual was identified. (This was documented in the Nursing Notes that the resident alleged someone hit them on their left hand on 3/18/23, on 3/22/23, it was documented in the Nursing Notes that the resident complained of pain and an X-ray was obtained which resulted in a left-wrist fracture.) The reportable continued that an investigation was started; skin checked was completed; physician and family notified; staff interviews were conducted; and summary and conclusion to follow. A review of the statement provided included a Nurses/CNA Incident/Accident Statement Form dated 3/18/23 and signed 3/23/23 by Registered Nurse #1. The statement indicated that resident claimed a woman came in and hit [him/her] with a box on the left arm; resident was assessed with no bruising, swelling, or complain of pain. The resident denied that CNA #1 (his/her assigned CNA) hit them. A review of the Statement Form dated date of incident 3/17/23 and signed by CNA #1 on 3/27/23, indicated that she was assigned to Resident #17 on 3/17/23 during the 11-7 night shift, and around 12:00 AM (on 3/18/23), the resident transferred themselves from their bed to wheelchair and was very confused stating they wanted to go home. I informed the supervisor who assisted the resident back to bed, and around 6:00 AM (on 3/18/23), I went to change the resident who stated they wanted their spouse called because someone hit them. CNA #1 continued that she notified RN #1 who assessed the resident, and the resident reported that CNA #1 was not the person who hit him/her. A review of an undated Statement Form signed by CNA #2 dated 3/23/23, indicated on 3/20 and 3/21, he took care of Resident #17 with no concerns, and on 3/22/23, they complained of their left wrist hurting stating they fell , and I called the nurse. A review of the undated Investigation Summary indicated on 3/18/23 during the 11-7 night shift, [RN #1] reported to the oncoming [LPN #1] for the 7:00 AM to 3:00 PM (7-3) day shift that the resident was up all night and confused looking for their spouse. The resident informed [CNA #]1 that he/she was hit on the left hand by a woman. The resident was assessed by the nurse and no redness or swelling noted to their left arm, and declined pain medication. On 3/22/23 the resident complained of left hand pain and he/she was assessed by the nurse with noted swelling and the resident was administered pain medication and the physician ordered an X-ray. The X-ray revealed left wrist fracture of a nondisplaced fracture of the distal ulna shaft. The resident was sent to the emergency department (ED) for a splint, and the physician documented the resident had demineralized bones with degenerative changes suggesting osteopenia (bone loss) or osteoporosis (bones become weak and brittle). Staff and patient interviews conducted, and staff did not observe any incident. Conclusion was abuse cannot be substantiated. On 7/11/23 at 9:17 AM, the surveyor interviewed the DON who stated that any incident or allegation of abuse was immediately investigated. Staff attempt to interview the resident if possible and any staff who might be involved based on the incident that occurred. The facility went back two shift and interviewed all nurses and CNAs that were assigned to the resident and any staff who may have come in contact with the resident. The DON stated the facility investigated skin tears, wounds, swelling, falls, allegations of abuse, and injury of unknown origin. The DON stated abuse was reported right away to the NJDOH along with unknown events with injury and elopements. On 7/12/23 at 12:30 PM, the surveyor interviewed LPN #1 stated there was an incident that occurred one night, cannot recall the exact date but the night nurse informed him that the resident had complained of pain in the left wrist that had observed swelling, so an X-ray was ordered, and the resident had a left wrist fracture and was sent to the ED for a splint. LPN #1 stated he was the one to call the physician to get the order for the X-ray and administered the Tylenol, but the night nurse was the nurse who assessed the resident; the incident was only endorsed to him because it was change of shift. On 7/13/23 at 9:50 AM, the surveyor interviewed RN #1 via telephone who stated there were two situations with Resident #17; the first the resident stated someone hit him/her but the resident was assessed and there was no bruising, swelling or pain. RN #1 stated the resident on another day, complained of pain to arm when the CNA was changing them, so I went in and assessed the resident and saw swelling, but no bruising or redness. RN #1 stated it was at change of shift, so he endorsed it to the oncoming nurse. RN #1 thought he documented it in the computer. On 7/13/23 at 10:26 AM, the surveyor re-interviewed the DON who stated that any allegation of abuse, staff went back three shifts and interviewed all staff members who were a witness or took care of the resident immediately. The surveyor reviewed with the DON the reportable dated 3/24/23, that indicated that the resident complained someone hit them on 3/22/23. The surveyor reviewed the Nursing Notes with the DON, and reviewed the note dated 3/18/23, which the DON confirmed the allegation of abuse occurred on 3/18/23. When questioned why the nurse and CNA's statements were for 3/18/23, but dated signed on 3/23/23 and 3/27/23 respectively, the DON stated sometimes staff was not in the building and could not interview right away. On 7/14/23 at 9:34 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and the survey team stated that when the facility investigated the resident's wrist on 3/22/23, it was then brought to administration's attention that the resident had an allegation of abuse on 3/18/23. The DON stated that staff never reported to them the allegation of abuse from 3/18/23, so the facility investigated both situations together. The DON stated that both RN #1 and LPN #1 were written up for not reporting an allegation of abuse, and abuse was ruled out for the fracture because the physician documented the resident had demineralized bones with osteopenia and osteoporosis. The DON stated everything was investigated together since the facility only learned through investigating the fracture that the resident alleged abuse on 3/18/23. At this time, the surveyor requested to see abuse training for RN #1, LPN #1, CNA #1, and CNA #2 as well as if the four staff members had allegations of abuse against them. On 7/14/23 at 10:41 AM, the LNHA provided abuse training for all four staff members and stated there have been no allegations of abuse made against them. The LNHA stated all staff including nurses and CNAs have been educated on reporting abuse, and any staff member could have informed the DON or LNHA of the abuse allegation. The LNHA stated the incident occurred on the weekend, and staff should have contacted the DON or himself so the situation could have been immediately investigated. A review of the facility's Abuse Prevention Program policy dated November 2017, included it is the policy of this community to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Identification of Allegations and Internal Reporting Requirements: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator or the person in charge of the community, acting on behalf of the administrator, or immediate supervisor who must then immediately report it to the administrator .if a crime, particularly physical or sexual abuse, is suspected, it must be reported to the state agency and local law enforcements under the following timeframes: serious bodily injury - immediately but no later than two hours after forming a suspicion .Investigation of Abuse, Neglect, or Misappropriation Allegation and Response: all incidents will be documented, whether or not abuse occurred, was alleged or suspected. any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation .upon discovery of a bruise, skin tear, or any resident injury of unknown origin, an investigation will be initiated .Initial Reporting of Allegations: any allegations of abuse will be reported to the administrator immediately and the State Department of Health and resident's representative as soon as possible with twenty-four hours within five working days after the report of occurrence, a complete investigation and conclusion of the investigation, including steps the community has taken response to the allegation, will be sent to the Department of Health . NJAC 8:39-4.1(a)(5); 13.4 (c)2i-2vi

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a visually impaired resident who was dependent on staff for activities of daily living (ADL) was physically assisted with meals to prevent weight loss. This deficient practice was identified for 1 of 15 residents reviewed for ADL care (Resident #13), and was evidenced by the following: On 7/10/23 at 12:17 PM, the surveyor observed Resident #13 in their room eating lunch feeding themselves. The resident questioned the surveyor several times what they were eating, they stated they could not see what was on the plate. The surveyor observed that the resident was eating a whole sweet potato and grilled chicken that was cut in large pieces, and part of the chicken was not cut all the way through and still intact whole; a salad with ranch dressing, pudding, macaroni salad, and an unopened container of apple juice and water. The surveyor observed an empty chair next to the resident's tray table, and the surveyor asked the resident if someone should be assisting them with feeding, and the resident stated no. The surveyor observed the resident pick-up food with a fork from the plate and dropped the food off the fork. The surveyor asked the resident if they had difficulty seeing, and they did not respond. On 7/10/23 at 12:20 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that Resident #13 was legally blind and could not see anything at all. The LPN continued that the resident was fed by staff because they had a poor appetite needing encouragement and could not see what was on the plate, so they often dropped food from their fork. The LPN stated the resident was not at risk for choking as to why they needed to be fed, but staff needed to physically sit with the resident to feed them. On 7/10/23 at 12:23 PM, the surveyor accompanied by the LPN went into the resident's room, and the LPN confirmed someone should be feeding Resident #13. The LPN introduced themselves to the resident and informed them that they would assist them with feeding as the resident confirmed they could not see what they were eating. The LPN opened the resident's apple juice and offered them a drink, which the resident accepted as the LPN proceeded to feed him/her. On 7/10/23 at 12:34 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated he generally took care of Resident #13 daily, so he was familiar with the resident. The CNA stated the resident had blurry vision, but he/she fed themselves as long as staff cut the food for them. The CNA stated that he did not have to feed the resident; he just had to bring in the tray and cut the food up. The surveyor asked the CNA how they were informed of the resident's ADL assistance needs, and the CNA brought the surveyor to the computer system at the wall. The CNA showed that he documented the level of assistance provided to the resident for their ADLs each shift, but he stated the program did not include what level of assistance the resident needed. The CNA went under the care plan tab in the computer system, which did not include the resident's feeding assistance needs. On 7/10/23 at 12:42 PM, the surveyor asked the Director of Nursing (DON) how the CNAs were informed of the level of assistance and care residents needed, the DON stated that the nurses received a daily report, and the aides could view the care plan. The DON provided the surveyor with a list of all residents, which included Resident #13 was a feeder. The surveyor asked the DON what a feeder meant, and she replied that someone would be physically assisting them with feeding. The surveyor asked how the CNA would be made aware, and she informed the surveyor to ask the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who was also the staff educator. On 7/10/23 at 12:48 PM, the surveyor interviewed the ADON/IP who stated the nurses were aware of the resident's assistance needs for their ADLs from the report provided to the surveyor by the DON. The surveyor reviewed the report with the ADON/IP who confirmed Resident #13 was a feeder, so they needed assistance with feeding. The ADON/IP stated the nurse was responsible for letting the CNA know that, but if the CNA was their regular aide, then they should know that. The ADON/IP confirmed that the CNA did not have any task or report to know the resident's required ADL assistance. On 7/10/23 at 12:55 PM, the surveyor re-interviewed the LPN who confirmed she received a copy of that report that indicated Resident #13 was a feeder, but the CNA was not provided that report. On 7/10/23 at 1:01 PM, the DON informed the surveyor that the CNA would know the resident's ADL assistance needs in the Cares section of the computer program, and to ask the ADON/IP to show me. On 7/10/23 at 1:04 PM, the ADON/IP reviewed the Cares section of the computer program with the surveyor for Resident #13, and the ADON/IP confirmed it did not include the resident's need for physical assistance with meals. The surveyor reviewed the medical record for Resident #13. A review of the Face Sheet (admission summary) reflected that the resident was admitted to the facility in May of 2023 with diagnoses which included difficulty walking, dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, dementia, unspecified infantile and juvenile cataract to right eye (changes in the lens of eye cause it to become unclear and cloudy), dry eye syndrome of bilateral lacrimal glands (do not produce enough tears), and cataract extraction status (surgery removal of the cloudy lens from eye). A review of the admission Minimum Data Set (MDS), an assessment tool dated 6/3/23, reflected the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A further review in Sect G. Functional Status, that the resident required extensive assistance of a one-person physical assist for eating. A review of the individualized comprehensive care plan effective 5/19/23 to present, that the resident had impaired vision. Interventions included to offer cues/assistance as needed such as identifying location of food on plate .A further review included a problem area for a decline in functional ADL. Interventions included physical, occupational speech therapy to evaluate and treat per physician order, assist with feeding; identify level of assistance needed and complete resident summary or nursing assistant assignment of care. A review of the July 2023 Physician Order Sheet included a physician's order dated 5/23/23, to assist with meals. The surveyor reviewed the CNA Assignment sheets from 7/1/23 until 7/10/23, the date of the observation, which revealed the CNA was assigned to Resident #13 on 8 of the 10 days. On 7/14/23 at 9:34 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), ADON/IP, and survey team confirmed that Resident #13 should have been assisted by staff with meals, which included a staff member being present. A review of the facility provided Activities of Daily Living (ADL), Supporting policy dated revised March 2018, included residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with plan of care, including appropriate support and assistance with: .d. dining (meals and snacks) . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and b.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 7/7/23 at 10:14 AM, the surveyor toured the kitchen with the Executive Chef and observed the following: 1. On a rack in the walk-in freezer, six baked pies, not dated or covered. The pies were exposed to air. The Executive Chef confirmed the pies should be dated and covered. 2. On a drying rack, one large white cutting board discolored yellow and deeply pitting. The Executive Chef confirmed the cutting board should be discarded because of the potential for bacterial growth. The Executive Chef stated that cutting boards were usually discarded after six months of use, but he could not speak to the last time cutting boards were changed. 3. On a spice storage rack, one 32-ounce (oz) bottle of lime juice labeled opened 6/26/23. The packaging indicated to refrigerate after opening. 4. On a spice storage rack, one 48-oz bottle of lemon juice dated received 6/27/23. The Executive Chef confirmed the bottle was opened and not dated when opened. The packaging indicated to refrigerate after opening. 5. On a storage rack under the preparation table, four large white, two large green, and six large red cutting boards. The cutting boards were all deeply pitted and discolored. The Executive Chef confirmed they should not be used. 6. In dry storage, one bulk container of thickener that contained a scoop stored directly in the thickener. The Executive Chef confirmed scoops should not be stored inside the bins. On 7/14/23 at 9:34 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team acknowledged the above concerns. A review of the facility provided Sanitation policy dated 2013, included it is the policy of the community to store, prepare, distribute and serve food under sanitary conditions . A review of the facility provided Food Storage policy dated 2013, included .all exposed foods should be stored tightly covered . A review of the undated facility provided Labeling and Dating policy included .pies and cakes desserts made in house once product has been made in house, it will be marked with an expiration date of three days from when the product was made . A review of the facility provided Equipment Maintenance policy dated 2013, included .all food service equipment will be operated, maintained, serviced and cleaned according to manufacturer's directions. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure their infection control policies were followed and maintained for water management to minimize the risk of legionella and other opportunistic pathogens in building water systems. This deficient practice had the potential to affect all 42 residents and was evidenced by the following: On 7/13/23 at 9:47 AM, the surveyor interviewed the Director of Facilities (DOF) who stated that he was not sure how often the facility tested the water for legionella (bacteria that can cause a serious type of pneumonia), that the facility had a scheduled testing in August. The DOF stated he was not aware when legionella testing was last done in the facility and would reach out to the Licensed Nursing Home Administrator (LNHA) in order to obtain that information. On 7/13/23 at 2:00 PM, the survey team met with the LNHA, Director of Nursing (DON) and Infection Preventionist/Assistant Director of Nursing (IP/ADON) and requested further information regarding the facility's water management program for legionella including a copy of the policy and any testing completed if applicable. On 7/14/23 at 9:35 AM, the LNHA in the presence of the DON and IP/ADON, provided the survey team with a copy of the facility's undated water management program, and confirmed that it was facility policy to test annually for legionella. The LNHA stated that he was unable to locate any pervious water testing for legionella; that he did not know where the previous Director of Facilities stored the documentation. At this time, the IP/ADON informed the survey team it was important to test the water for legionella because any bacteria in the water could be widespread and could cause gastrointestinal upset. The ADON/IP stated he had spoken to the Medical Director who stated the facility would conduct additional legionella testing if the residents were symptomatic. A review of the undated facility provided Legionella Water Management Program policy included .our facility is committed to the prevention, detection and control of water-borne contaminants, including legionella .the purposes of the water management program are to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's Disease .the water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a legionella water management program .the Water Management Program will be reviewed at least once a year . A review of the Centers for Disease Control and Prevention (CDC) Water Management in Healthcare Facilities dated last reviewed March 25, 2021, included the CDC encourages healthcare facilities included in the scope of ASHRAE Standard 188 (Section 5.2) to develop and implement comprehensive water management programs. Water management programs can help reduce the risk of legionella growth and transmission. Water management programs should therefore be monitored for their efficacy in reducing the risk for a variety of pathogens. NJAC 8:39-19.1; 19.4

Based on observation, interview and record review, it was determined that the facility failed to provide pressure relief to a resident's heels who was identified as high risk for pressure ulcer development. This deficient practice lead to the development of a facility acquired unstageable left heel pressure ulcer and a facility acquired Stage III right heel pressure ulcer. Once the ulcers developed, the facility failed to obtain measurements in a timely manner in order to monitor and track ulcer progression. The facility also failed to ensure that treatment modalities were consistently being performed to promote healing. This deficient practice was identified in 1 of 3 residents reviewed for pressure wounds (Resident #8) as evidenced by the following: On 8/23/12 at 10:15 a.m. during the initial tour of the facility, the tour nurse stated to the surveyor that Resident #8 was alert and oriented and required the assistance of staff for bed mobility and transfers. The tour nurse stated that the resident's heels were reddened on admission to the facility and that the resident currently had blisters on both heels. On 8/23/12 at 11:15 a.m., the surveyor reviewed the medical record of Resident #8 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Minimum Data Set ((MDS) dated [DATE], indicated that the resident's skin was intact and required the extensive assistance of 1 staff member for bed mobility and transfers. It revealed that the resident had bilateral lower extremity limitations with range of motion. The Nursing Admission/Readmission Assessment of 8/2/12 indicated that Resident #8's skin was intact. A review of the "Skilled Daily Nursing Notes" revealed the following: On 8/2 and 8/3/12 the resident had bilateral 2 + lower leg [MEDICAL CONDITION]. On 8/7/12 at 10:00 p.m. "pressure ulcer st. II (R) foot. N/S + [MEDICATION NAME] to (R) malleolus BID (twice daily). Skin prep (R) heel BID. Spanco boots in bed." On 8/9/12 at 10:30 p.m. "Fluid filled blister noted to L heel intact. Heel booties in place. Measurements 3.6 x 2.7 x 0." On 8/21/12 at 11:00 a.m., "Made MD aware of B/L heels pressure ulcers and R malleolus that are not healing well." A physician's orders [REDACTED]. Skin prep to (R) heel BID. Bilateral Spenco booties when in bed." A physician's orders [REDACTED]." A physician's orders [REDACTED]. A physician's orders [REDACTED]. On 8/23/12 the surgical consult was completed and indicated that the resident developed a Stage III right heel ulcer from a blister. It revealed that the resident had 2 + [MEDICAL CONDITION] and that [MEDICATION NAME] was not recommended. It indicated "do not change dressing" on the right leg. Review of the "Wound/Skin Healing Record" revealed the following: On 8/7/12 a right ankle ulcer was identified. However, ulcer measurements and staging were not done until 8/13/12 (6 days later). At that time, the ulcer was identified to be a Stage III which measured 3.5 centimeters (cm) x 4.5 cm. On 8/21/12 (8 days later) the right ankle ulcer was unstageable and measured 3.5 cm x 3 cm. On 8/7/12 a right heel, closed blister was identified. However, ulcer measurements and staging were not obtained until 8/13/12 (6 days later). At that time, the ulcer was identified to be a Stage II which measured 6.3 cm x 5 cm. On 8/21/12 (8 days later) the right heel ulcer had progressed to a stage III which measured 3.5 cm x 5.5 cm. On 8/7/12 a left heel, closed blister was identified. On 8/13/12 the ulcer was identified to be a Stage II and measured 1.2 cm x 2 cm. On 8/21/12 (8 days later) the left heel ulcer was identified as unstageable and measured 1 cm. x 1.5 cm. Review of the August "Treatment Record" revealed the following: The treatment to the resident's right lateral malleolus was not initialed by the nurse as being completed during the evening shift on 8/9 and on the day shift on 8/10 and 8/18/12. The resident's bilateral Spenco booties were not initialed by the nurse as being applied 7 times from 8/9 to 8/23/12. The skin prep treatment to the resident's left heel was not initialed by the nurse as being applied during the day shift on 8/10, 8/17 and 8/18/12. The heel cup to the resident's bilateral heels was not initialed by the nurse to ensure placement on 8/18 and 8/22/12. Review of the 8/3/12 care plan identified the resident to be at risk for impaired skin integrity. Some of the identified interventions included; "full body skin assessment weekly as scheduled; assess for environmental moisture; assess skin during AM/PM care; avoid shear and friction of resident's skin during ADL's; Assess the surfaces that the resident spends the majority of time on; Encourage resident to frequently shift weight in chair and ensure resident has adequate nutrition and hydration." The care plan did not address the resident's lower leg [MEDICAL CONDITION] or bilateral reddened heels on admission to the facility. On 8/7/12 when ulcer development was identified, the care plan was not updated to address the areas of ulcer development. The care plan did not identify interventions to protect the skin integrity of the resident's heels. On 8/23/12 at 12:00 p.m., Resident #8 stated to the surveyor that when admitted to this facility a right ankle wound existed and both heels were reddened as a result from friction against the bedsheets during hospitalization . The resident further stated that assistance was required from staff to move in and out of bed and that the heel boots were applied after the heel blisters had developed while in this facility. On 8/23/12 at 12:30 p.m., the surveyor interviewed the Certified Nurses' Aide (CNA) for Resident #8. The CNA stated to the surveyor that the resident was compliant with care and required the assistance of 1 staff member for bed mobility and transfers. The CNA also stated that the Spenco boots were applied after the heel blisters had developed and the nurse did not give her care instructions related to the residents heels when she was admitted to the facility. On 8/23/12 at 1:15 p.m., the Charge Nurse stated to the surveyor that care plans were to be updated as problems were identified. She stated that this had not been done for Resident #8. On 8/24/12 at 9:45 a.m., the Charge Nurse stated to the surveyor that the nurse was to initial the treatment record to ensure that treatments were being done. When a treatment was omitted, the reason for the omission was to be identified on the back of the treatment record or in the nursing notes. The Charge Nurse further stated that the nurse is then to circled his/her initials on the treatment record. The charge nurse was not aware that this was not being done for Resident #8 when the surveyor brought this to her attention at this time. The Charge Nurse was unable to provide documentation to support the reason the treatments were not completed as ordered and the boots/heel cups were not consistently applied by the staff. The charge nurse further stated to the surveyor that pressure ulcers were to be measured and staged when identified and then weekly. The Charge Nurse agreed that this had not been done for Resident #8. On 8/24/12 at 11:15 a.m., the Director of Nursing (DON) stated to the surveyor that pressure ulcers were to be measured and staged when discovered and then weekly to track ulcer progression. She stated that care plans were to be updated as problems were identified. The DON also stated at this time that when a treatment/medication was omitted, the nurse was to circle his/her initials on the treatment record and document the reason for the omission in the nurses' notes or on the back of the treatment record. The DON was not aware that the nursing care for Resident #8 as noted above was not being performed by the staff. On 8/24/12 at 12:10 p.m., the surveyor interviewed the resident's physician. The physician stated that Resident #8 was at risk for ulcer development related to [MEDICAL CONDITION] and a chronic history of a right ankle ulcer. The physician further stated that the right ankle ulcer was present on admission to the facility. The physician also stated that the resident's heels were offloaded in bed with the Spenco boots. However, the physician was unaware that the Spenco boots were applied after the resident's ulcer development. A Review of the facility's "Pressure Ulcers: Prevention" policy dated 2/98 provided by the DON on 8/24/12, revealed that bed or chair-bound individuals or whose ability to reposition was impaired should be considered at risk for pressure ulcers. It indicated to "use devices that relieve pressure on the heels. Avoid positioning directly on bony prominences and known pressure points, e.g., ears, shoulders, elbows, hips, knees, heels." A Review of the facility's "Skin Treatment Protocol" policy dated 6/09 provided by the DON on 8/24/12, indicated that "...pressure ulcers were to be re-evaluated with the "weekly skin assessment." There was no documented evidence that these policies were consistently followed. On 8/27/12 at 10:15 a.m., the surveyor in the presence of the nurse observed the resident's left heel. An unstageable 0.7 cm x 0.1 cm black scab was noted on the left heel. The surveyor was unable to observe the resident's right ankle and right heel during the survey because a physician order [REDACTED]." NJAC 8:39-27.1(e)