Every finding on record at Total Rehab Moorestown

Complaints: NJ1875890, 2681814 Based on interviews, review of medical records, and review of facility documents, it was determined that the facility failed to develop and follow adequate fall prevention interventions on the care plan of a resident (Resident #2) who was at risk for falls. This deficient practice was identified for 1 of 3 residents (Resident # 2) reviewed for accidents and was evidenced by the following:A review of the admission Record for Resident #2 revealed the resident was admitted to the facility with diagnoses that included but were not limited to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (condition where the heart does not pump blood as well as it should); type 2 diabetes mellitus without complications (condition where the body cannot use insulin correctly and sugar builds up in the blood); muscle weakness; other abnormalities of gait and mobility; need for assistance with personal care; and presence of left artificial hip joint. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 06/13/2025, revealed Resident #2 had a Brief Interview for Mental Status of 6 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident required substantial or maximal assistance (a helper does more than half of the effort and lifts or holds the resident's trunk or limbs) from staff to shower or bathe. A review of the facility, Fall Risk Predictive Factors, section of the Resident Evaluation- V2 document dated 06/06/2025, revealed that Resident #2 was assessed as a high risk for falls. A review of the Care Plan for Resident #2 revealed a focus initiated on 06/07/2025 related to Resident #2's need for assistance with activities of daily living (ADLs), interventions included provision of limited assistance from one staff member to shower or bathe. The CP for Resident #2 further revealed a focus initiated on 06/07/2025 related to the resident being at risk for falls due to a history of falls. Interventions related to falls included supervision of the resident at all times while in the shower, initiated and revised on 06/17/2025; and placing a towel on the shower chair to prevent the resident from slipping, initiated on 06/19/2025. Review of the untitled facility document dated 06/17/2025 at 11:40 AM, revealed under, Incident Description, that Resident #2 was observed laying on the bathroom floor with their legs outstretched. This section of the facility document further revealed that Certified Nursing (CNA) #1 stepped out of the resident's bathroom and into the resident's room to get a towel. When CNA #1 returned to the bathroom she observed Resident #2 sliding off the shower chair to the floor. Review of a Progress Note dated 06/17/2025 at 3:38 PM, written by Licensed Practical Nurse (LPN)#1 revealed that CNA #1 stated that she stepped into Resident #2's room to get another towel and when she returned to the bathroom, she observed the resident on the floor. The PN further revealed that Resident #2 explained that they slipped off the bath chair. An Accident/Incident Statement Form, dated 06/17/2025 at 11:40 AM, and signed by CNA #1 was reviewed. The handwritten statement revealed that CNA #1 took Resident #2 to the shower and realized that she needed another towel. CNA #1 left Resident #2 sitting on the shower chair while she got a towel from a few feet away. CNA saw Resident #2 sliding off the shower chair but could not reach the resident in time to prevent them from sliding off the chair. The surveyor attempted to reach CNA #1 for a telephone interview of 01/02/2026 but was unsuccessful. An interview was conducted with CNA #2 on 01/20/2026 at 1:52 PM. CNA #2 stated that when assisting residents with showering CNAs were supposed to bring everything needed for the task into the room. CNA #2 stated that CNAs were not supposed to leave residents alone in the shower or on the toilet. An interview was conducted with the Unit Manager (UM) on 01/02/2026 at 2:32 PM. The UM stated that typically staff should not leave residents on the shower chair in the shower. The UM stated that staff should bring everything they need into the bathroom before starting to bathe a resident and if they forgot something they should use the call bell to get assistance. The UM stated that if residents were left alone in the shower they could have fallen. The UM further stated that CNA #1 stepping out of the room while Resident #2 was seated on the shower chair could have led to the resident's fall. An interview was conducted with the Director of Nursing on 01/02/2026 at 2:40 PM. The DON stated that her expectation was that Resident #2 should have received bathing assistance of cueing and guiding as per their CP. During a follow up interview on 01/02/2026 at 3:36 PM, the DON stated that she considered it acceptable for CNA #1 to leave Resident #2 on the shower chair to step out of the bathroom to get a towel. The DON did not explain the difference between the level assistance Resident #2 required as indicated on the MDS and the level of assistance indicated on the CP. The facility's, Comprehensive Care Plans, policy with a review date of 08/2025 was reviewed. Under, Policy, the document revealed that it was the policy of the facility to develop and implement a comprehensive person-centered CP for each resident to meet the resident's needs as identified on the resident's comprehensive assessment. The facility policy further revealed, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's Incident and Accident, policy with reviewed date of 01/2025 was reviewed. The facility policy revealed that an accident/incident was any unusual event that may or may not result in injury to the resident. The policy revealed that accident/incidents involving resident care were investigated to enable the facility to evaluate care given to residents; to assist in incident prevention; and to evaluate intervention implemented in the event of an incident. NJAC 8:39-27.1 (a)

Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to a.) ensure a cognitively impaired resident (Resident #222) with a history of aspiration (inhaling food and liquids into the lungs) without a sensory response (reaction to a stimuli) and who was at risk for aspiration, received the appropriate physician ordered nectar thickened liquids (liquid thickened with an agent for a nectar-like consistency) and b.) ensure special dietary instructions of no straws were followed according to Resident # 171's treatment plan. This deficient practice was identified for 2 of 2 residents reviewed for food (Resident #171 and Resident #222). 1. During the initial tour on 4/10/25 at 8:40 AM, Surveyor #1 observed the Certified Nurse Aide (CNA #1) provide a ceramic mug containing thin liquid consistency coffee to Resident #222. An observation of the resident's meal ticket revealed that the resident was prescribed nectar thickened liquids (NTL). An observation of the resident's half filled cup of thin liquid coffee, and an interview with Resident #222, confirmed that the resident drank the coffee. An interview with the Registered Nurse (RN #1) confirmed that the resident received thin liquid coffee; there was a packet of unopened nectar thickened coffee drink mix on the resident's meal tray; and the resident could aspirate from drinking thin coffee. 2. On 4/10/25 at 12:18 PM, Surveyor #2 observed during the lunch meal, that Resident #171 had a cup of water with a straw. A review of the resident's meal ticket indicated No Straws which was highlighted in yellow, and a white board in the resident's room had instructions dated 4/10/25, for NO STRAWS. An interview with CNA #2 confirmed that she provided the straw to Resident #171; she had not read the meal ticket; and she was unaware that the resident could not have straws. An interview with the Registered Dietitian (RD) confirmed that the resident had a straw; the resident could not have a straw; and the RD removed the cup with the straw. An interview with the Speech Therapist (ST #1) confirmed that Resident #171 could not have straws because their video swallowing exam indicated that the resident could aspirate (inhale food into the lungs and increased the risk of aspiration pneumonia and death) when using a straw to drink liquids. The facility's failure to ensure cognitively impaired residents received and consumed liquids in the appropriate form as prescribed by a physician and special dietary instructions of no straw were followed, posed the likelihood of aspiration which results in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 4/10/25 at 8:40 AM, when CNA #1 was observed providing Resident #222 with thin liquid coffee. The facility's Administration were provided the IJ template on 4/10/25 at 3:45 PM. The facility submitted an acceptable Removal Plan (RP) on 4/11/25 at 2:27 PM. The survey team verified the implementation of the RP on-site on 4/11/25 at 2:27 PM, during the continuation of the survey. The evidence was as follows: A review of the facility provided policy Thickened Liquids dated 1/30/25, included but was not limited to; Policy: All liquids requiring thickening including mealtime liquids, nutrition supplements, [medication] pass hydration and bedside hydration cups will be thickened by a nurse, excluding soup, prepared in the dietary department .A physician order, based on the Speech Therapist evaluation, is required for thickened liquids. The Purpose: To allow residents/patients with swallowing problems to consume beverages with no adverse effects and prevent dehydration. Drinking thickened liquids for residents with identified swallowing problems may help prevent choking and aspiration . A. During the initial tour conducted on 4/10/25 at 8:40 AM, Surveyor #1 observed CNA #1 remove a tray from the meal cart and pour thin liquid coffee. CNA #1 then placed the mug on that meal tray, that also contained a container of nectar thickened milk and nectar thickened juice, and entered Resident #222's room. On 4/10/25 at 8:56 AM, Surveyor #1 entered Resident #222's room, and observed the resident sitting on a chair next to the bed. Their meal tray had a fork in the pancakes as if the meal was eaten, and the nectar juice and nectar milk were both opened. The coffee mug was observed less than half full of thin liquid coffee with what appeared to be drips of coffee towards the inside rim of the mug. Surveyor #1 observed an unopened packet of thickened coffee drink mix, nectar consistency, next to the thin liquid coffee. The meal ticket had Nectar Thickened Liquids, Nectar Juice, and Nectar Milk highlighted in yellow, and Coffee and Nectar packets listed on the meal ticket. Surveyor #1 interviewed Resident #222, who was wrapped in a blanket, and stated they were cold at that time. When asked if they drank the coffee, the resident stated, yes. On 4/10/25 at 9:05 AM, Surveyor #1 opened the resident's room door and without exiting the room, requested RN #1 to enter Resident #222's room to observe the meal. RN #1 picked up the meal ticket, observed the tray, and picked up the packet of unopened nectar thickened coffee drink mix. Surveyor #1 asked if that was a concern, and RN #1 stated, yes, if [they] drank thin liquids they could aspirate, I will tell [their] [assigned] nurse. On 4/10/25 at 11:22 AM, Surveyor #1 interviewed the Director of Dietary (DD) regarding the process for nectar thickened coffee. The DD stated the facility used the thickened coffee packets, and showed Surveyor #1 the same packet that was observed on Resident #222's meal tray. Surveyor #1 asked if that packet would be added to the thin coffee? The DD stated, No, this is the coffee that is used. On 4/10/25 at 11:30 AM, Surveyor #1 interviewed CNA #1 about the observations made during the breakfast meal regarding pouring the thin liquid coffee and providing it to Resident #222, and then asked if she had known that Resident #222 was on NTL. CNA #1 stated she knew the resident was on NTL because she saw the NTL milk and juice on the meal tray. CNA #1 stated, the nurse did not give her the thickener packet for the coffee. The surveyor then showed CNA #1 the same packet of thickened coffee drink mix that was unopened on Resident #222's meal tray. CNA #1 then stated, I never saw that before, and confirmed that she left the non-thickened coffee with the resident. On 4/10/25 at 11:49 AM, the surveyor interviewed ST #1 about Resident #222, and asked why the resident required a NTL diet. ST #1 stated Resident #222 had a Modified Barium Swallow (MBS -a video swallowing exam using an x-ray with barium in different consistency foods to determine swallowing ability) on 3/3/25, and ST #2 (her colleague) assessed Resident #222 and the MBS showed that the resident aspirated on thin liquids. The surveyor asked if Resident #222 was at risk for aspiration, and ST #1 confirmed Resident #222 was at risk for aspiration as the resident had no cough response when they drank the thin liquids during the test. ST #1 provided the surveyor with a copy of the hospital MBS and the Speech Therapy Evaluation and Plan of Treatment (SLP Eval) for Resident #222 at that time. A review of the hospital MBS dated 3/3/25, revealed: Resident #222 was referred for a video swallow evaluation to assess the efficiency of their swallow function, rule out aspiration, and make recommendations regarding safe dietary consistencies, effective compensatory strategies, and safe eating environment. Pharyngeal Stage (a rapid, involuntary process that occurs when coordinated muscles propel food down the throat into the esophagus). Pharyngeal Phase Summary: Aspiration thin liquids before/during the swallow due to premature spillage .The Aspiration/Penetration Scale: Score 8 (material enters the airway, passes below the vocal folds, and no effort is made to eject). Recommendations and Strategies: Risk for Aspiration: Reduced with Compensatory strategies. Liquids Recommendation: Mildly thick .No Straws .Short Term Goals: Patient will consume a mechanical soft/ altered/ (minced and moist-Level 5) with nectar thick/mildly thick liquids . A review of the SLP Eval for Resident #222 for the Certification Period of 3/6/25-4/15/25, revealed: Current Referral .hospitalized with sepsis secondary to Right Lower Lobe Pneumonia. Speech Therapy Evaluation recommended due to concern for aspiration and MBS was completed (See below for results). Resident referred for Speech Therapy evaluation secondary to dysphagia with food resident remaining on tongue and recommendation for minced and moist diet and nectar thick liquids .Per patient, was living alone and independent with activities of daily living. Prior Tests: MBS completed on 3/3/25 . Pharyngeal Phase: aspiration of thin liquids before and during the swallow. On 4/10/25 at 12:00 PM, Surveyor #1 reviewed the electronic medical record (EMR) for Resident #222 which revealed the following: A review of the Admission Record face sheet (an admission summary) reflected that Resident #222 had diagnoses which included but were not limited to; dysphagia (difficulty swallowing) and oropharyngeal phase (the first phase of swallowing). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/11/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. A review of the Physician Order dated 3/21/25, included a dysphagia advanced texture, nectar fluid consistency diet. A review of the individualized comprehensive care plan (ICCP) included a focus area for nutritional status with a risk for malnutrition initiated 3/6/25. Interventions included to provide dysphagia advanced-foods minces, gravy or thickened broth to moisten foods, and NTL. A review of the hospital records included a Physician Progress Note with a date of service of 3/4/25 at 12:40 PM, which indicated an Assessment and Plan: that Resident #222 had Right Lower Lobe Pneumonia likely aspiration pneumonia . aspiration was observed with thin liquids on video swallowing study, and was on a minced moist, mildly thick (nectar consistency) diet. 27193 B. On 4/10/25 at 12:18 PM, during the lunch observation, Surveyor #2 observed Resident #171 in their room with their lunch meal. A half filled cup of water was observed next to the resident on the bedside table with a straw inserted into the cup. A white board was observed in the room with the following instructions: Date: April 10, 2025, Precautions: NO STRAWS!! Surveyor #2 observed the meal ticket on the resident's meal tray which had printed on it Renal-Dysphagia Advanced NO STRAWS. Surveyor #2 attempted to interview the resident, but the resident was unable to proceed with the interview. Surveyor #2 again checked the meal ticket and the order for NO STRAWS was highlighted in yellow. On 4/10/25 at 12:35 PM, Surveyor #2 exited the room and met with the Registered Dietitian (RD), who confirmed that Resident#171 had an order for no straws, and it was not appropriate for the resident to have straws. The RD stated that Resident #171 should not have a straw because they were at a high risk for aspiration. Surveyor #2 accompanied the RD into Resident #171's room, and they both observed the water cup at the bedside with a straw. The RD, at that time, removed the straw and cup of water and informed the surveyor that the water was a fresh cup provided by the staff that day. On 4/10/25 at 12:50 PM, Surveyor #2 interviewed CNA #2, who cared for Resident #171. CNA #2 stated that she assisted Resident #171 with care and provided the water to the resident that day. CNA #2 stated that she had not read the instructions written on the white board in the room regarding No Straws. CNA #2 stated she was not aware that Resident #171 could not have straws, and that she usually received a report from the nurse and reviewed the instructions on the board in the room. CNA #2 stated that she reported to work late that day, and did not receive a report from the nurse. CNA #2 further added that after providing care to the resident that morning, she cleaned the bedside table, and had removed old cups with straws that were left on top of the bedside table. On 4/10/25 at 12:59 PM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN #1) on the unit, and he revealed that he administered medication to the resident that morning, and did not notice the cup of water with the straw. On 4/10/25 at 1:15 PM, Surveyor #2 interviewed ST #1, who stated that Resident #171 was at high risk for aspiration and should not have straw with liquids because the resident's vocal cords would not be able to close in time and the liquid would go into their lungs and cause aspiration. When the surveyor inquired where that information was located, ST #1 stated that the information was forwarded from the hospital with the admission package and she would provide the surveyor a copy. On 4/10/25 at 1:20 PM, Surveyor #2 reviewed Resident # 171's EMR which revealed the following: A review of the Admission Record face sheet reflected that Resident #171 was admitted to the facility with diagnoses which included but were not limited to; encephalopathy (a disease in which the functioning of the brain is affected by a condition), altered mental status, dysphagia, oral pharyngeal phase (swallowing difficulty), gastric contents in respiratory tract, part unspecified causing asphyxiation (suffocation), and the need for assistance with personal care. A review of the comprehensive MDS dated [DATE], reflected that Resident #171 had a BIMS score of 00 out of 15, indicating that the resident had severe impaired cognition. A review of Section K revealed the resident received a mechanically altered diet and therapeutic diet. A review of the Physician Order dated 4/4/25, revealed a diet order for a 2 gram sodium, dysphagia advanced texture diet with thin liquid consistency. A review of the ICCP included a focus area dated 4/4/25, that the resident was at risk for nutrition related to inadequate intake, weight loss, and wounds. An intervention included to provide a 2 gram sodium, dysphagia advanced diet as ordered. On 4/10/25 at 2:55 PM, Surveyor #2 interviewed the Director of Dietary (DD), who stated that the kitchen staff plated the resident's meal tray, and that the instructions were highlighted in yellow for the staff to follow. The DD stated that Resident #171's meal card was highlighted in yellow, and the meal tray did not have a straw prior to leaving the kitchen. On 4/10/25 at 3:15 PM, the surveyor continued to review the medical record. A review of the hospital records dated 3/19/25, revealed that the resident had a video swallowing study completed, and it was recommended to not use a straw with liquids. A review of the video swallow evaluation provided by ST #1 revealed the test had been completed at the hospital on 3/19/25 at 2:27 PM. The video swallow evaluation was completed to assess the efficiency of their swallow function, rule out aspiration, and make recommendations regarding safe dietary consistencies, effective compensatory strategies, and safe eating environment. The video swallow evaluation reflected that Resident #171's epiglottic movement (flap of tissue by the voice box that prevents liquids and particles from entering the lungs during swallowing) was sluggish. Laryngeal vestibule closure (part of the voice box) was marked by deep penetration with thin liquid via continuous straw sips. This was deep, but cleared from below the epiglottis. It did not occur with thin liquids via cup sips. (The resident did not aspirate when drinking from a cup.) Recommendations and Strategies: Liquid recommendations: Level 0- Thins. Compensatory Swallowing Strategies: NO Straws Medication Administration: Crushed with puree. A review of the facility's Physician Progress Notes included a note dated 4/3/25 at 8:45 AM, that revealed the resident was seen and examined. Available hospital records reviewed in their entirety. Goals of care were discussed with the resident. The medications and orders were reviewed, and a discussion with nursing regarding diagnosis treatment and plan. A review of the Unit Manager Narrative Skilled Note dated 4/3/25 at 9:08 PM, revealed the following: lungs clear to auscultation (technique performed to listen internally). All medications were administered as prescribed, and taken whole with water, no straw. (According to the recommendations from the swallow evaluation, medications were to be crushed and administered with puree.) A review of a Physician Note dated 4/7/25 at 3:17 PM, indicated to continue with speech language pathology to address deficits in swallow functioning. A review of the Physician Notes revealed that the Nurse Practitioner wrote on 4/10/25 at 7:19 PM, Cough with mucus production, chest X-Ray suspicious for pleural effusion (build up of water between the lungs and chest cavity). Encourage nutritional support, Nebulizer (respiratory device that converts liquid medication into a fine mist) for secretion management. A review of the Narrative Skilled Note dated 4/12/25 at 6:21 PM, revealed the following: Resident vomiting early this morning, COVID Test was negative. On 4/14/25 at 9:15 AM, Surveyor #2 observed Resident #171 in bed. The resident reported not feeling well, and they reported the concerns to the nurse. On 4/14/25 at 1:45 PM, the resident was evaluated by the Physician. Per the notes, the resident was complaining of dyspnea on exertion (shortness of breath during physical activity) and productive cough. On 4/15/25 at 8:40 AM, the surveyor observed Resident #171's room door was closed, and the staff informed the surveyor that the resident was being transferred to the Emergency Department for abnormal laboratory values. On 4/15/25 at 9:38 AM, Surveyor #2 interviewed LPN #2 regarding the resident's change in condition. LPN #2 revealed that she assessed the resident that morning and Resident #171 was coughing. LPN #2 stated that she listened to the resident's lungs and wheezing (high- pitched, whistling sound that occurs when breathing, often caused by narrowed airways) could be heard on both lungs. LPN #2 reported the resident had shortness of breath and their oxygen saturation was 88% with 4 liters of oxygen (normal 95 to 100%). On 4/17/25 at 12:05 PM, during the facility exit conference held with the survey team, Medical Director (MD), Licensed Nursing Home Administrator (LNHA), ST #2, and Director of Nursing, the facility's Administration confirmed that no straws was a special instruction, and the order was placed on the diet requisition to be carried out through the kitchen. The acceptable Removal Plan on 4/11/25 at 2:27 PM, indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included; the facility immediately checked the charts of all the residents and created a list by unit of any resident with orders for thickened liquids and those who have restrictions regarding use of straws, and reviewed the lists with the CNAs and nursing staff on 4/10/25. Any staff not re-educated will be re-educated prior to the start of their next shift, the rooms of all residents with restrictions on the use of straws and/or those who require liquid thickeners were immediately checked to be sure no straws were at the bedside and liquids were properly thickened, a list of residents with thickened liquids and/or restriction from the use of straws was placed at each nursing station by the CNA assignment and provided to Activity Staff, signage indicating special dietary restrictions/instructions will be placed in rooms as applicable, the charts of residents with thickened liquids and/or straw restrictions were reviewed and updated as needed in the EMR system to include the restrictions on the system used by the CNAs, and the Nurse Educator initiated staff reeducation regarding the procedure for thickening liquids and any staff not re-educated will be educated prior to the start of their next shift. The Removal Plan was verified by the survey team on-site on 4/11/25 at 2:27 PM, during the continuation of the on-site survey. NJAC 8:39-17.4(a)1; 27.1(a)

Based on interview and review of documents it was determined that the facility failed to ensure who required Medicaid were admitted to the facility per their SNF/NF (Skilled Nursing Faciality/Nursing Facility) designation with the Centers for Medicare/Medicaid (CMS) and per the New Jersey Department of Health (DOH). The deficient practice affected all residents admitted to the facility and was evidenced by the following: Reference: Certificate of Need approval dated [DATE] and signed by the Acting Deputy Commissioner of the DOH, Health Systems revealed: .Approval of this application is conditioned upon the applicant's compliance with the following: Approval of the relocation of the 120 LTC (Long Term Care) bed .is subject to [company name redacted] satisfying the Medicaid-eligible resident utilization requirement at N.J.A.C. 8:33H-1.15(a) or a higher standard that was imposed in a previous certificate of need approval for the LTC facility being relocated. Application for a Long-Term Care Facility License application signed and dated [DATE], by the facility representative. The Primary Type of Facility: Long-Term Care T,d+[DATE] (Medicare/Medicaid). On [DATE] at 9:30 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Licensed Nursing Home Administrator (RLNHA #1). The surveyor asked those present what the resident population was and the LNHA stated all Rehab (short term admissions for therapy purposes) when asked if the facility accepted Medicaid residents the RLNHA stated, this is a special facility, we only have Rehab in this facility and do not have Medicaid residents. The surveyor asked the LNHA for clarification regarding not accepting Medicaid residents and the LNHA stated, we do not have Medicaid, we are only short term, and the average length of stay was 30 days or less. The surveyor requested a list of payer source for all residents at that time. On [DATE] at 10:38 AM, the LNHA provided a list of payer sources and stated the facility had two private pay residents and the rest were insurance or Medicare and stated, there is no Medicaid. When asked what residents were supposed to do if they were unable to be discharged due to needing different placement. The LNHA stated, if people needed to stay until they decide where they are going, after their insurance is cut and they need to figure it out, they will pay privately. The list of payer sources indicated 121 resident names and none of the resident were listed as utilizing Medicaid as the payer source. A review of the Admission Agreement provided by the facility on [DATE] revealed a section 3. titled Medicaid.In the event that Resident or Responsible Party intends to seek Medicaid benefits for the Reisdent, Resident or Responsible Party shall give the Facility written notice when Resident's remaining personal funds reach approximately fifteen thousand dollars, so that the facility may request a Pre-Admission Screened and Annual Review (PASSAR, clinical approval for Medicaid . A. ii. Resident and/or Responsible Party are obligated to apply for Medicaid benefits at such a time as Resident's resources will no longer be sufficient to pay all the Facility charges for Resident's care and stay or when directed to do so by the Facility . In the event Resident applies for continue to pay and apply all of Resident's available resources toward the fulfillment of Resident's financial obligations under this agreement while the Medicaid application is pending and eligibility . iii. In the event that Resident receives Medicaid benefits at any time while receiving services from the facility, Resident and/or Responsible Party shall pay to the facility all available income, as determined by Medicaid . the Facility will assist Resident and/or Responsible Party in establishing a direct deposit of available income to the Facility. The Appendix B part of the Admission Agreement, 4. In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continues stay in the facility . c Transfer and discharge (1) Facility requirements .E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at that facility .For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid . [The Admission Agreement or Appendix B does not indicate that the facility does not accept Medicaid and is only designated as a short stay facility and that the resident must be transferred to another facility if required Medicaid as the payer source]. A review of the facility's application for Medicare and Medicaid received on [DATE] indicated that the facility had 0 Medicaid residents. On [DATE] at 9:56 AM, the surveyor interviewed the Admission Director (AD). The surveyor asked if the Admission Agreement (AA) was reviewed with residents prior to admission. The AD stated that AA was signed electronically upon admission and not before they were admitted . The surveyor asked regarding the Medicaid portion of the AA and if Medicaid was accepted as a payer source. The AD stated that the Medicaid reference did not apply for anyone in our facility because we don't have anyone up for Medicaid. The AD stated everyone that was admitted to the facility knew they were just coming for rehabilitation only. The surveyor asked the AD if the facility took any residents with Medicaid as a payer source and she stated, we don't keep anyone for long term care, the Social Worker would help the resident transfer to another facility that accepted Medicaid. On [DATE] at 10:21 AM, the surveyor, in the presence of two other surveyors, interviewed the Director of Social Services (DSS) who was responsible for residents on the second floor and the Social Worker (SW) that was responsible for residents on the third floor. The surveyor asked the DSS what her role was regarding the discharge process for residents. The DSS stated that care conferences were held within 7 days of admission to discuss plans with the resident. The surveyor asked what would happen if a resident needed a different level of care and could not return to their prior level. The SSD sated that sometimes residents would have a change in lifestyle and required placement into a long-term care facility. The surveyor asked if the facility transferred residents to other nursing homes and asked for an example of the process. The SSD stated, Resident #40 was someone that the facility was working on to have transferred to another facility since that resident lived alone previously, the family lived far away and the resident was unable to care for themselves. The SSD stated the family was looking at long term care facilities, the resident still had Medicare days left and the family was working on processing the application for Medicaid. The surveyor asked if Resident #40 could stay at the facility for long term care. The SSD stated, we are sub-acute only, always, we are 100% sub-acute (only for rehabilitation for a short term admission). The surveyor asked what if the resident needed to have long term care and the reimbursement for rehabilitation care expired, what would the resident have to do? The SSD stated the facility worked with a company, then showed a business card to the surveyor that the resident/family would be provided by the facility. The SSD stated that [company name of redacted] would look into the funds that the resident had, and what type of facility the resident needed to be transferred to. The SSD stated the company did not charge the resident for their services, they were free. The surveyor asked if the company was related to the facility and the SSD stated, no, they were a private company that the facility would refer to when funds for payment would run out. The SSD stated the company had facilities that would take Medicaid pending residents and the facility would always make sure to leave plenty of Med A (traditional Medicare as a payment source) so the resident could continue rehabilitation there (at a facility they would be transferred to) The surveyor asked what if the resident wanted to continue to stay at the current facility? The SSD stated, we don't accept any Medicaid, we tell them that we only take Medicare and private insurance. The SSD stated, we are never able to keep anyone that was Medicaid pending. The surveyor asked about the AA and the mention of Medicaid. The SW stated, we questioned it too. The SW (in position since February) and SSD since [DATE] stated she had asked the facility LNHA and AD during her first week of employment regarding accepting Medicaid and it was very firm that we did not accept Medicaid. The surveyor asked about the language in the AA and the SSD stated the families did not review the agreement with them. On [DATE] at 10:53 AM, the surveyor reviewed Resident # 40's electronic medical record (EMR) which revealed: a Care Plan Focus, Date Initiated [DATE]: I am admitted as short-term placement; Goal, I will be discharged home appropriately as per desired goal, Date Initiated: [DATE]; Interventions included, assess any need for referral to local community/agency/home-care services, Date Initiated [DATE]. On [DATE] at 10:00 AM, the surveyor again reviewed the EMR for Resident #40 which revealed a Social Services Note effective [DATE] at 10:39 AM, competed by the SSD. The Note revealed PLOF (prior level of function) resident was independent in own home and cared for self. A discussion had previously been held regarding a transfer to a facility that would be able to service the patient needs on a more permanent basis if needed. Family was provided a second application for Medicaid to completed and the return address provided. On [DATE] at 12:05 PM, an exit conference was held with the facility administration, including the LNHA, [NAME] President of Clinical Services, Medical Director and Director of Nursing. The surveyor asked about the facility not accepting Medicaid. The LNHA stated it is an in and out building, it is short stay. The LNHA stated, when the current company took over the facility it was understood that it was Medicare and Medicaid. The surveyor asked when the last Medicaid resident was at the facility, the LNHA stated, Long -term? not with me here, we don't have Medicaid. The LNHA stated that it has been the same since he has been at the facility since 2023. The surveyor asked was there a facility contract with the company that the facility provided for residents to use that were not allowed to stay long term. The LNHA stated, no, not with the facility, and that the company that was used to find placement was contracted with assisted living facilities and other facilities. The surveyor asked the LNHA if he had ever reached out to the DOH Licensing Department regarding the facility requirements and he stated, no. NJAC 8:,d+[DATE].1(c)

Based on observation, interview and document review it was determined that the facility failed to ensure personal privacy was maintained when implementing a video monitoring device and ensured written consent was obtained prior to implementing video monitoring devices inside resident rooms for 2 of 2 units and for 2 of 2 residents reviewed for Resident Rights (Resident #25 and 40). The deficient practice was evidenced by the following: On 04/10/25 at 8:22 AM, the surveyor observed a camera device across from Resident #25 who was awake and in bed. Resident #25 appeared confused and did not engage with the surveyor at that time. On 04/11/25 at 11:49 AM, the surveyor conducted a telephone interview with the Responsible Party (RP) for Resident #25. The surveyor asked the RP if they had placed a camera device in the room and the RP stated, no, the facility placed the camera. On 4/11/25 at 12:30 PM, the surveyor reviewed the electronic medical record for Resident #25 and did not locate a consent or documentation related to using a camera device in the resident's room. On 04/14/25 at 11:34 AM, the surveyor interviewed the Director of Nursing (DON) regarding the camera and asked the DON if the facility allowed families to place cameras in resident rooms. The DON stated, no, the only monitoring was for fall risk and they were baby monitors and did not record. The surveyor asked where a signed consent would be located and the DON stated, we usually get verbal consent over the phone. The DON stated that they do not have written consent, it was verbal. The surveyor then asked the DON how many cameras were in use and the DON stated, I don't know off the top of my head. The surveyor asked how long the cameras have been in use, and the DON stated, that she and the Interdisciplinary Team were responsible for them and she did not know how long they had been in use. The surveyor asked if there was a policy, and the DON stated yes, and the surveyor requested a copy. On 04/14/25 at 12:11 PM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) regarding Resident #40's falls and the surveyor observed a camera device on the table in front of both the surveyor and ADON and asked the ADON what it was used for. The ADON stated we used the cameras to reduce falls and it was usually with the certified nurse aide or nurse and they would walk around with the camera and confirmed it was audible. The surveyor asked how many cameras were being used and he stated, two on the third floor and two on the second floor. When asked for a list of residents with cameras the ADON stated there was no list. The ADON stated Resident #40 had a camera and the surveyor asked the ADON if it would be documented on the Care Plan (CP) and he looked at the CP and stated, I don't see it. The surveyor asked if there was a signed consent for the use of the camera, and he stated, we usually just get verbal consent. On 04/14/25 at 12:22 PM, the surveyor interviewed the Nurse assigned to Resident #40 regarding the camera and asked if she could show it to the surveyor. The Nurse went to the assigned Certified Nurse Aide (CNA) who then pulled a monitor out of her pocket and provided it to the Nurse who showed the surveyor the video monitor. The Nurse explained the camera would usually sit on top of the nurse's cart or the CNA would keep it with them. The Nurse also confirmed it was audible. On 04/14/25 at 12:27 PM, the surveyor entered Resident #40's room and observed the camera facing the resident. The surveyor asked the resident if they were aware that the white object was a camera and the resident put both hands up and waived. The resident informed the surveyor that they were very hard of hearing, and stated they just came back from the doctor and pissed self twice. On 04/17/25 at 12:25 PM, during an exit conference held between the survey team and the facility administration, including the Licensed nursing Home Administrator (LNHA), [NAME] President of Clinical Services (VPCS), and Director of Nursing. When asked about the video camera and obtaining documented consent for use, the VPCS stated, this not a recording, it is a virtual monitor for remote observation. The surveyor asked the LNHA how long the cameras have been in place and he stated he doesn't recall. The Virtual Monitoring Device, Policy, created 3/2024 revealed the protocol, 2. Facility staff will discuss with the patient and/or representative the utilization of the virtual device . [There was no mention of a documented consent in the policy.] The Comprehensive Care Plans Policy, Last Revised 1/2025 revealed: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that have to be furnished to attain or maintain the resident's highest practicable physical, and psychosocial well- being. NJAC 8:39- 4.1(12)

Complaint #: NJ 170732 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care and personal hygiene care for 7 of 13 residents (Resident #15, #66, #73, #76, #81, #169 and #322) reviewed for Activity of Daily Living Care, and for 2 of 2 resident units (2nd and 3rd Floor). The deficient practice was evidenced by the following: On 4/10/25 at 8:16 AM Surveyor #1 entered the 300's wing and observed a strong smell of feces and urine permeating throughout the hallway by the lower numbered rooms. Surveyor #2: 1. On 4/10/25 at 8:18 AM, Surveyor #2 observed Resident #15 sitting in a wheelchair in the room and was calling for help. Surveyor #2 entered the room and the resident stated that they needed to go to the bathroom. The resident was wearing a tee shirt and an incontinence brief that was observed bulging while the resident was seated in the wheelchair. The surveyor went to the hallway and informed the Licensed Practical Nurse (LPN #1) that the resident needed assistance to use the toilet. LPN #1 wheeled the resident to the bathroom, and in the presence of Surveyor #2 removed the incontinent brief and placed it on the floor. The brief was observed soaked and stained with urine. Upon inquiry, Resident #15 stated that they had not received care yet. 2. At the same time, Surveyor #1 summoned Surveyor #2 to the next hallway (low side rooms) where a strong urine and feces odor permeated. Surveyor #2 observed a random Certified Nurse Aide (CNA) perform an incontinence check on Resident #169, in their room while the urine odor was very strong. Surveyor #2 observed Resident #169's incontinence brief was soaked with urine and the sheet was also stained with urine. The resident could not comment on the last time incontinence care was provided. On 4/10/25 at 11:00 AM, Surveyor #2 reviewed the following medical records: The Admission Summary for Resident #15 revealed the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia and hemiparesis, and difficulty in walking and urinary tract infection. The Admission Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 2/15/25 reflected that Resident #15 had a BIMS Score (Brief Interview for Mental Status) of 14 out of 15 which indicted intact cognition. Section GG of the MDS which addressed Functional Abilities revealed Resident #15 was dependent on staff for toileting. The Comprehensive Care Plan initiated 2/08/25 had a Focus area for assistance with ADL (Activity of Daily Living) functions. The goal was for Resident #15 to maintain current level of functioning. The interventions were to assist with toileting as needed, implemented 2/18/25. The Admission Summary for Resident #169 revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; Syncope and collapse, acute respiratory failure, and cognitive communication deficit. The Admission MDS assessment dated [DATE], reflected that Resident #169 had moderately impaired cognition. Resident #169 scored 11 out of 15 on the BIMS. A review of Section GG which addressed Functional Abilities, Resident #169 was coded as being dependent on staff for toileting. Resident #169 received 01 for coding. The Comprehensive Care Plan for ADL initiated 3/30/25, revealed the following: Resident #169 depended entirely upon someone else for grooming needs. 3. On 4/10/25 at 9:06 AM, Surveyor #2 observed Resident #73 in bed, after morning care had been provided with nails long and jagged, black substance underneath the fingernails, and Resident #73 was unshaven. On 4/11/25 at 11:18 AM, Surveyor #2 observed Resident #73 in the elevator going out for an appointment. Their nails were still long, jagged with dark coated substances underneath the fingernails. On 4/14/25 at 9:26 AM, the surveyor observed the resident sitting in a wheelchair by the bed. Their nails remained long, jagged with a dark substance underneath. Upon inquiry, Resident #73 stated that they would like their nails to be trimmed and cleaned. On 4/14/25 at 9:50 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN #1) regarding nails care. LPN #1 stated the nurses were responsible to trim and clean the nails of the dialysis (when kidneys do not work and a machine removes toxins from the blood) residents. The surveyor accompanied the LPN to the room where we both observed the resident with long and jagged nails. LPN #1 stated, oh, they are long, and exited the room. On 4/15/25 at 9:48 AM, Surveyor #2 observed Resident #73 in bed, the nails were long, jagged and the dark coated substances were still observed underneath the fingernails. The surveyor accompanied the Unit Manager (UM) to the room and we both observed the nails long, jagged with the dark coated substances underneath the fingernails. The Unit Manager stated, I saw them, referring to the nails. A subsequent review of the medical record revealed the Admission Sheet revealed Resident #73 was admitted to the facility with diagnoses which included but were not limited to; fracture of unspecified part of neck right femur, pain due to internal orthopedic prosthetic, and difficulty in walking. The Admission MDS assessment dated [DATE], indicated that Resident #73 scored 12 out of 15 BIMS indicative of moderate cognitive impairment. The Comprehensive Care Plan initiated 3/08/25, reflected that Resident #73 needed assistance with ADL functions. One of the interventions was for someone to assist the resident with grooming, initiated 3/10/25. 4. On 4/10/25 at 9:12 AM, Surveyor #2 observed Resident #76 in bed. The resident informed the surveyor that they received incontinence care around 5:00 AM that morning and was again soiled. A random CNA assisted the surveyor with an observation and Surveyor #2 observed Resident #76's incontinence brief was soaked and yellow stained with urine. Resident #73's nails were long and jagged. Surveyor #2 then asked asked about nail care, the CNA stated that she observed the nails were long and she would trim them. On 4/15/25 at 9:49 AM, Surveyor # 2 interviewed the Unit Manager regarding nail care. The UM stated that the CNAs were to clean and trim the nails. The UM added, if the resident was a diabetic (required medication to control blood sugar levels) the nurse would trim and clean the nails. if the resident was on a blood thinner the nails would be filed only. On 4/15/25 at 12:34 PM, Surveyor #2 went to the room and observed the resident's nails were still not trimmed. The resident stated that they would like their nails to be trimmed and cleaned. A subsequent review of the the medical record by Surveyor #2 revealed: Resident #76 had diagnoses which included but were not limited to; overactive bladder, morbid obesity, and muscle weakness. The Admission Minimum Data Set, dated dated dated [DATE], revealed that the resident was moderately cognitively impaired. Resident had a BIMS score of 12 out of 15. The care plan for ADL initiated 03/06/25, had a focus area for assistance with ADL functions. The interventions indicated that Resident #76 was independent for toileting use. However, the resident was dependent on staff for toileting. Section GG which addressed Functional Abilities, revealed Resident #76 was coded as 01 which indicated that Resident #76 was dependent on staff for toileting. 5. On 4/10/25 at 11:14 AM, Surveyor #2 observed Resident #66 in bed, and interviewed the resident who answered questions appropriately. Resident #66 informed the surveyor that their call bell was not being answered in a timely manner. Resident #66 stated that they activated the call bell because they needed to use the toilet and they were told by staff not to attempt to use the bathroom unassisted unless they had the walker or the wheelchair at their side. The resident stated that they were assisted by staff to the recliner chair in the room (could not recall the date), and they did not have the walker or the wheelchair accessible to them in the room that day. The resident informed the surveyor that they activated the call light for 30 minutes and no staff entered the room to assist. They could not wait further and they urinated on their clothes and on the recliner chair they were sitting on in the room. On 4/10/25 at 11:35 AM, Surveyor #2 interviewed Resident #66 in the presence of the Unit Manager (UM), and the resident relayed that calls bell were not being answered in a timely manner, staff would ask why they activated the call bell, they asked for ice and staff told them they could get out of the bed and get ice themselves. At that time, Surveyor #2 asked the resident how they felt regarding the incident. The resident stated, I am [AGE] years old; how do you think that makes me feel, I had to urinate on my good clothes, the cushion from the chair had to be taken out, I was quite annoyed. The surveyor then observed that the recliner chair in the room was missing the seat cushion. The surveyor asked the facility Director of Nursing for any investigation, or documentation regarding the above incident and none was provided. Surveyor #2 then reviewed the electronic medical record which reflected that Resident #66 was admitted to the facility with diagnoses which included but were not limited to; morbid obesity, repeated falls, and need for assistance with personal care. The Admission MDS, dated [DATE], revealed that Resident #66 was moderately cognitively impaired. Resident #66 scored 10 out of 15 on the BIMS. Resident #66 was able to make their needs known. Resident #66's Comprehensive Care Plan initiated 3/25/25 reflected a Focus for assistance for ADLs. The goal was for Resident #66 to show improvement in ADL functions, initiated 3/25/25. The interventions included: Bathing and showering required limited assistance by 1 staff member. Bed mobility: Supervision and cueing; Toileting: require set up assistance by 1 person for toilet use; Transfers: One assist with transfer; Another care plan for falls initiated 3/28/25, indicated that Resident #66 was at risk for falls related to history of falls. One of the interventions initiated on 3/28/25 was to encourage Resident #66 to use the call light and wait for assistance. another intervention initiated on 3/30/25 was to encourage the resident to ask for assistance when attempting to transfer. On 4/14/25 at 9:20 AM, Surveyor #2 interviewed Resident #66 and they again reported a delay in answering call lights of 30 minutes or more. Surveyor #3: 6. On 4/10/25 at 8:41 AM, during an initial tour, Surveyor #3 observed Resident #322 in their bed. The surveyor observed Resident #322's both hands with long fingernails with jagged edges and right-hand fingernails had brown colored substance underneath them. On 4/11/25 at 8:28 AM, the surveyor observed Resident #322 sitting up in their bed. The resident had long fingernails with jagged edges on their both hands and right-hand nails had brown colored substance underneath them. On 4/14/25 at 9:32 AM, Surveyor #3 observed CNA #1 assisting the resident with a shower in their bathroom. Later at 10:10 AM, after the shower, CNA #1 brought Resident #322 to the nursing station in their wheelchair. Surveyor #3 observed the resident's both hands with long, jagged edges fingernails and right-hand fingernails had brown colored substance underneath them. On 4/14/25 at 10:20 AM, the surveyor reviewed the electronic medical records for Resident #322. A review of Resident 322's Admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; cognitive communication deficit, altered mental status and need for assistance with personal care. A review of Resident #322's Admission MDS, an assessment tool dated 4/13/25, revealed Resident #322's brief Interview for mental status (BIMS) could not be conducted due to resident was rarely/never understood. The MDS further revealed the resident required maximal staff assistance for personal hygiene. A review of Resident #322's Individualized Care Plan (CP) initiated on 4/7/25, reflected that the Resident required assistance with ADL (Activities of Daily Living) functions. On 4/14/25 at 10:24 AM, during an interview with Surveyor #3, CNA #1 stated she checked all her resident's fingernails daily when she worked. CNA #1 pointed towards Resident #322's room and stated, like this resident is confused and total care (dependent on staff for their care) so I check their fingernails daily when I am here. CNA #1 further stated it was important to check and clean their nails daily because the residents would sometimes eat with their hands and food gets stuck under the nails. CNA #1 stated that cleaning fingernails was important for hygiene, for infection control and safety because the residents could scratch themselves on their faces. Surveyor #3 inquired about Resident #322's fingernails and CNA #1 stated she would have to go check resident's nails. Surveyor #3 accompanied CNA #1 to Resident #322 to check their fingernails and the CNA #1 confirmed that left hand nails were long and right hands nails were long and dirty and she should have provided nail care. On 4/14/25 at 10:42 AM, during an interview with Surveyor #3, LPN #2 stated she would check resident's nails during medication administration. LPN #2 further stated nail care was important because the food can get stuck underneath the nails and we don't want anything under the nails. LPN #2 further stated the nails should be clean and short because sometimes the resident can scratch themselves. In the presence of Surveyor #3, LPN #1 observed Resident #322's fingernails and acknowledged that the resident's nails needed to be cleaned and cut down shorter in length. On 4/14/25 at 11:02 AM, Surveyor #3 presented the above-mentioned concerns to the Registered Nurse/Unit Manager (RN/UM). The RN/UM stated she was not sure of the facility policy regarding the staff being able to trim resident fingernails at the facility. The RN/UM asked the desk Nurse/LPN (DN/LPN) about facility policy and procedures regarding nail care. The DN/LPN stated if the residents were diabetic then the staff could not trim their nails. The DN/LPN observed Resident #322's nails in the presence of Surveyor #3 and the RN/UM and stated, they are daggers. 7. On 4/10/25 AM at 9:14 AM, during an initial tour, Surveyor #3 observed Resident #81 sitting up in their bed. At 9:25 AM, Surveyor #3 returned to Resident #81's room accompanied by the Registered Nurse (RN) for incontinence rounds. The RN exposed Resident #81's incontinence brief. The RN and Surveyor #3 observed the brief was saturated with urine and feces. The RN stated that usually the night shift Certified Nurse Aides (CNAs) changed residents before they left. The RN was not able to identify when the last time was Resident #81 had received incontinence care. On 4/15/25 at 10:00 AM, the surveyor reviewed the electronic medical records (EMR) for Resident #81. On 4/15/25 at 1:17 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and presented the above-mentioned concerns. On 4/16/25 at 10:49 AM, during an interview with Surveyor #3, the RN stated the night shift CNAs completed incontinence rounds between 5:00 AM and 6:30 AM daily. The RN stated the incontinence care rounds were completed usually every 2 hours to prevent skin breakdown and other injuries. A review of Resident #81's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hypertension (high blood pressure), cognitive communication deficit (a condition in which a person has difficulty communicating due to cognitive impairments), altered mental status (a disruption in how your brain works that causes a change in behavior), and need for assistance with personal care. A review of Resident #81's Admission MDS, an assessment tool dated 3/24/25, revealed Resident #81 had a BIMS score of 8 out of 15 which indicated the resident had moderately impaired cognition. The MDS further revealed the resident required staff assistance for toileting hygiene. A review of Resident #81's Individualized Care Plan (CP) initiated on 3/18/25, reflected that the Resident was at risk for skin breakdown related to bowel incontinence and impaired mobility. Interventions included keep resident skin clean and dry. Further review of the CP reflected that the resident required assistance with ADL (Activities of Daily Living) functions. Interventions included Toileting: I require extensive assistance of (1) person for toilet use. A review of the Bladder and Bowel Continence toileting task reflected the resident had received last incontinence care was at 1:33 AM [8.0 hours prior to the observation]. A review of the facility's policy titled, Activities of Daily Living (ADLs) created 1/2024 revealed the following: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral hygiene. Policy Explanation: A resident who is unable to carry out activities of daily will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. On 4/17/25 at 12:42 PM the facility provided staff in-service education regarding incontinence and nail care, and no additional information was provided. NJAC 8:39-27.1(a) 31654 48423

Based on observation, interview and record review, it was determined that the facility failed to limit the potential spread of infection by failing to ensure a) appropriate transmission based precautions (TBP) were in place and consistently followed during a Covid-19 outbreak, b) staff consistently utilized Personal Protective Equipment (PPE) appropriately, and c) appropriate hand hygiene was performed and shared medical equipment was appropriately disinfected during the medication administration observation for Resident #40 and Resident #45 and for 2 of 2 residents reviewed for Covid-19 (Resident #8 and # 222). This deficient practice had the potential to affect all residents residing on 2 of 2 units and was evidenced by the following: a) On 4/10/25 at 7:40 AM, upon entrance to the facility, the Infection Preventionist Registered Nurse (IPRN) informed the survey team that the facility was currently in an outbreak of COVID-19 and RSV (Respiratory Syncytial Virus-a virus dangerous to older adults and infants < 6 months of age). During the initial tour on 4/10/25 at 8:40 AM, Surveyor #1 observed a Certified Nurse Aide (CNA #1), remove a tray from the meal cart. CNA #1 then, filled a ceramic mug with thin coffee and then placed it on a resident tray next to a container of nectar thickened milk and nectar thickened juice. CNA #1 was observed wearing a surgical mask, no goggles or shield, then donned (put on) an isolation gown, then entered Resident #222's room with the meal tray at 8:48 AM. The surveyor observed a Red Stop Sign affixed to the outside of Resident #222's door. The sign indicated Special Droplet/Contact Precautions in addition to Standard Precautions, In yellow: Only essential personnel should enter this room (if you have questions ask nursing staff: Everyone Must: Including visitors, doctors, and staff: Clean hands when entering and leaving he room, Wear Mask, Fit tested N-95 or higher required when performing aerosol generating procedures, Wear Eye Protection (face shield or goggles), Gown and gloves at the door. During this observation, Surveyor #1 observed a Registered Nurse (RN #1) in the hallway who identified herself as the Unit Clerk. Surveyor #1 asked RN #1 to clarify what Personal Protective Equipment (PPE) needed to be worn when entering Resident #222's room and asked if the resident had COVID-19. RN #1 informed the surveyor to read the sign on the door, and RN #1 stated she did not know if Resident #222 had COVID-19. During the interview, CNA #1 exited the room wearing the same surgical mask, no goggles or shield, doffed (removed the gown and gloves and used hand hygiene) and proceeded to provide a breakfast meal to Resident #8 who was across the hallway. Surveyor #1 asked if was important to wear the appropriate PPE when going into a Droplet precaution room and to confirm if entering without wearing an N-95 mask and goggles, or face shield was acceptable. RN #1 stated it was important to wear the proper PPE, but it was okay to not wear an N-95 mask because it was only needed if aerosol generating procedures were performed. Surveyor #1 asked specifically about CNA #1 and her PPE when entering Resident #8's room with the same surgical mask, and was observed setting the resident up for the breakfast meal. RN #1 observed CNA #1 in Resident #8's room at that time, and removed CNA #1 from Resident #8's room and stated that CNA #1 should have worn eye protection but did not need an N-95 mask. RN #1 stated, I think the regular mask was okay. RN #1 went to the PPE bin to look for a face shield and stated they were none in the bin. On 4/10/25 at 8:59 AM, when Surveyor # 1 opened the door to Resident #222's room and asked asked RN #1 (in the hallway at that time) to enter the room, RN #1 proceeded to put on an N-95 mask. Surveyor #1 asked RN #1 about the change from her previous directions and she stated, I am only doing what my supervisor told me to do and confirmed that an N-95 was required, and informed Surveyor #1 that Resident #222 had COVID-19. On 4/10/25 at 10:46 AM, Surveyor #1 interviewed the Director of Nursing (DON) about the observations and the posted sign that was on Resident #222's door. The DON stated, you're supposed to wear an N-95 mask for a COVID-19 room, the signs were not correct. On 4/10/25 at 11:05 AM, the DON was observed placing new droplet precaution signs on Resident #222's door. When asked why RN #1 did not know about the proper PPE, she stated that was standard of practice for a droplet precaution room and both CNA #1 and RN #1 should have known what to do even though the signs were incorrect. The DON provided a copy of the new Droplet/Contact Precaution sign to the surveyor which indicated to Wear N-95 mask and did not indicate only when performing aerosol generating procedures. On 4/10/25 at 11:37 AM, Surveyor #1 interviewed the Infection Preventionist Registered Nurse (IPRN) regarding the above observations. The IPRN stated, RN #1 knew Resident #222 had COVID-19, and both the CNA #1 and RN #1 should have worn the proper PPE. b) On 4/11/25 at 9:25 AM, during the observation of the medication administration pass, Surveyor #2 observed Liscensed Practical Nurse (LPN #1) obtain Resident #172's vital signs before administering medications. LPN #1 retrieved a manual pulse oximeter (device to measure oxygen saturation) from the medication cart and placed it in their pocket, then a manual blood pressure cuff and entered the room. LPN #1 placed the manual blood pressure cuff on the resident's bed after entering the room. LPN #1 then informed the resident of the procedure, retrieved the manual pulse oximeter from his pocket, check the oxygen saturation, then returned the manual pulse oximeter in his pocket without being disinfected. LPN #1 checked the resident's blood pressure, placed the blood pressure machine on the bed, administered the medications, washed his hands prior to exit the room. LPN #1 retrieved the blood pressure machine from the bed, placed it on top of the medication cart without a barrier underneath. LPN #1 administered medications to two other residents and left the manual blood pressure machine on top of the medication cart. On 4/11/25 at 10:22 AM, the surveyor interviewed LPN #1 regarding the medical equipment not being disinfected after use. Liscensed Practical Nurse (LPN #1) confirmed that he did not disinfect the pulse oximeter nor the manual blood pressure cuff. LPN #1 then stated, I should have to prevent cross contamination. On 4/11/25 at approximately 10:15 AM, Surveyor #2 toured the 300's Unit with another surveyor and observed the following: A staff member near the nurse's station with a surgical mask below her chin. Surveyor #2 approached the staff and inquired if the facility was in an outbreak, the staff replied, yes and adjusted the surgical mask at that time to cover their mouth and nose. On 4/11/25 at 10:30 AM, the surveyor toured the 300's Unit (high side) and observed LPN #2 in the hallway with their surgical mask not covering their nose. When questioned regarding why the mask was worn below their nose, LPN #2 stated, I need some air. On 4/11/25 at 12:30 PM, Surveyor #2 observed staff who delivered lunch to Resident #222's room. Resident #222 was on contact and droplets precautions for COVID-19. The surveyor observed LPN #3 in the room with an isolation gown that was not secured in the back. The strings were loose and touching the floor. The Director of Nursing (DON) was in the hallway and also observed LPN #3 with the isolation gown not secured and the strings touching the floor. The surveyor approached the DON and inquired if the isolation gown should be secured and the string not touching the floor. The DON declined to comment and stated, I have to consult with my Infection Control Nurse. On 4/14/25 at 11:30 AM, Surveyor #2 observed a Certified Nurse Aide (CNA) in the hallway with the surgical mask below the chin. When questioned regarding the surgical mask observed below her chin, the CNA adjusted the mask and stated I just finished care, I forgot to adjust the mask. On 4/14/25 at 11:37 AM, Surveyor #2 asked the DON if LPN #3 should ensure that the isolation gown was secured and tied prior to enter the room, the DON stated in the presence of the survey team, that the isolation gown should be tied and worn properly, and that the string should not be touching the floor for infection control purposes. On 4/14/25 at 1:15 PM, Surveyor #2 shared the above concerns regarding staff not wearing PPE correctly with the IPRN. The IPRN stated that the staff were very resistive and she continued to educate the staff. Regarding the gown with string touching the floor, the IPRN stated that she was not aware and stated, what would be the purpose to wear PPE if it not secured correctly? On 4/15/25 at 8:43 AM, Surveyor #2 again observed LPN #2 at the medication cart in the hallway with her mask below the chin. When questioned regarding not wearing the surgical mask correctly, she stated, I was just catching my breath, I do not have nobody around me. On 4/15/25 at 9:38 AM, during an interview with LPN #2, regarding not wearing her mask correctly, she stated that mask should be worn in the building at all times, because the facility is in an outbreak for COVID-19 to prevent widespread and protect the residents and other staff. c) On 4/10/25 at 9:49 AM, the Surveyor #3 observed LPN #4 for medication administration to three (3) residents. LPN #4 prepared four (4) medications to administer to Resident #45 and removed the following medications which included: Timolol eye drops, Biotin 1 tablet for supplement, Eliquis 1 tablet for blood thinner, and Colace 100 mg one (1) orange colored soft gel capsule for constipation. Surveyor #3 then observed LPN #4 use scissors to cut open the Colace soft gel capsule to squeeze the liquid medicine out of the capsule. LPN #4 then placed the scissors on top of the medication cart. Surveyor #3 did not observe LPN #4 disinfect the scissors prior to and after using the scissors. LPN #4 crushed the other 2 tablets and mixed all the medications in apple sauce for administration. The LPN #4 donned a pair of gloves and went into Resident #45's room to administer medications. Surveyor #3 did not observe LPN #4 perform hand hygiene prior to donning gloves. On 4/10/25 at 10:03 AM, Surveyor #3 observed LPN #4 prepare medications for Resident #40. The LPN #4 removed ten (10) medications which included: Protonix 1 tablet for Gastroesophageal reflux disease, Aspirin 1 tablet for secondary prevention of cardiovascular disease, Plavix 1 tablet for blood clot prevention, Felodipine Extended Release 1 tablet for lowering blood pressure [BP], Pakonza Powder 10 MeQ 1 Packet supplement for low potassium, Vitamin D3 1 tablet for supplement, Cozaar 1 tablet for lowering BP, Folic Acid 1 tablet for supplement, Ferrous Sulfate 1 tablet for supplement and Hydralazine 1 tablet for lowering BP. Surveyor #3 observed LPN #4 use her scissors to cut the edge of the Pakonza Powder packet. Surveyor #3 did not observe LPN #4 disinfect her scissors prior to using it and placed it on top of the medication cart after use. Surveyor #3 observed LPN #4 donning gown and gloves before she entered in Resident #40's room with their medication. LPN #4 did not perform hand hygiene prior to putting on gloves for medication administration. On 4/10/25 at 10:26 AM, Surveyor #3 observed LPN #4 administer medications to unsampled resident. After medication administration, LPN #4 informed the resident that she was coming back to check their blood pressure (BP). LPN #4 removed manual BP cuff from the drawer of the medication cart and her stethoscope out of the case. LPN #4 brought medical equipment to resident's room and checked resident's BP. After checking the BP, LPN #4 came out of resident's room and placed the BP cuff back in the drawer of the medication cart and wiped the diaphragm (top) of the stethoscope with alcohol swab and placed it back in her case with scissors. Surveyor #3 did not observe LPN #4 disinfect the manual BP cuff before or after use and the stethoscope before use. On 4/10/25 at 10:37 AM, during an interview with Surveyor #3, LPN #4 acknowledged that she did not perform hand hygiene each time before she donned gloves during medication administration, neither wiped off or disinfected her scissors and other medical equipment. LPN #4 stated she should have cleaned her scissors prior to use so that she would not contaminate the medications that the residents are taking and for infection control. LPN #4 further stated that hand hygiene should have been performed before and after contact with each resident and before donning gloves for infection control. LPN #4 stated she should have wiped off medical equipment before and after each use for infection control. On 4/11/25 at 9:03 AM, Surveyor #3 notified the Registered Nurse/Unit Manager (RN/UM) and the Assistant Director of Nursing (ADON) above the above-mentioned concerns. During an interview with Surveyor #3, the Registered Nurse/Unit Manager (RN/UM) and the Assistant Director of Nursing (ADON), ADON stated hand hygiene is important for infection prevention and patient safety. ADON further stated the staff should not be going room to room without performing hand hygiene. RN/UM and ADON both stated the medical equipment should be disinfected between each use and it was important for infection control, and you don't want to use the BP cuff on resident to resident and cause an outbreak. On 4/15/25 at 1:17 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The surveyor presented above mentioned concerns. A review of the facility policy Transmission Based Precautions, Dated 4/1/24 revealed Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 3. The facility will use standard approaches, as defined by the CDC, for transmission based precautions, airborne, contact, and droplet precautions . 8. Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident. 12. Droplet Precautions: a. Intended to prevent transmission of pathogens spread through close respiratory mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking). A review of the facility provided policy, Hand Hygiene, revised 8/1/24, included but was not limited to; all staff will perform proper hand hygiene to prevent the spread of infection. 1. Staff will perform hand hygiene when indicated . A review of the Medicatin Administration Policy, Reviesed 1/2025 revealed Policy: Medicains are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. 4. Wash hands/sanitize prior to administering medication per facility protocol and product. NJAC 8:39-19.4(a)(1)(5) 31654 48423

Based on observation, interview and documents review it was determined the facility failed to identify the causal factor for falls (including falls with injury) and implement interventions, which included adequate supervision, to prevent further falls for a resident who was moderately cognitively impaired and sustained falls on [DATE], [DATE] and [DATE]. The deficient practice occurred for 1 of 4 residents reviewed for accidents (Resident #40) and was evidenced by the following: On [DATE] at 9:36 AM, the surveyor observed the resident resting in bed and was holding the television (TV) remote. The resident communicated they were hard of hearing and could hear better on left ear and was unable to turn the volume up on the TV. There appeared to be a camera in the resident's room opposite of the bed. On [DATE] at 9:40 AM, the surveyor observed the resident in bed and was calling for help. The resident did not activate the call bell. On [DATE] at 1:00 PM, the surveyor reviewed the electronic and paper medical records for Resident #40 and at 1:54 PM, the Director of Nursing (DON) provided three fall investigations for the [DATE], [DATE] and [DATE] falls, and the DON confirmed the investigations were complete. At that time, the surveyor asked the Director of Nursing (DON) what was the causal factor for the [DATE] fall and the intervention added to prevent recurrence. The DON reviewed the investigation in the presence of the surveyor and stated, it was about Resident #40 not asking for assistance, the DON stated, this resident was more confused at night due to my knowledge. The DON stated the intervention was to encourage the resident to call for assistance. The surveyor asked if the fall was reported to the Department of Health, and the DON stated, there was no reason to report the fall and the resident was confused and impulsive. On [DATE] at 2:07 PM, the surveyor continued to review the medical record and the fall investigations which revealed: An Admission Record which revealed, but was not limited to, the following diagnoses; peripheral vascular disease, unspecified lack of coordination and difficulty walking. The Admission Minimum Data Set (MDS), an assessment tool dated [DATE] revealed the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was moderately cognitively impaired. A Resident admission fall risk assessment dated [DATE] which indicated the resident scored 11, which was identified as High Risk. The Care Plan Focus initiated on [DATE] for Resident #40 was at high risk for falls due to unsteady gait, included the following interventions initiated on [DATE]: Provide a well-lit environment; Anticipate and meet the needs of the resident to avoid falls; Maintain bed in low position; Non-skid socks to be used for safety; Place personal items within reach; Provide a clutter free environment; Provide a well-lit environment. A Care Plan initiated on [DATE], for needing assistance with Activities of Daily living revealed interventions dated [DATE], that included, Resident #40 was totally dependent on two staff for toileting and bathing and showering, and Total assistance from staff for bed mobility. -[DATE] at 2:32 AM, Note Text: .Note Text: AAOX 2 (alert and oriented to person and place) with forgetful . Incontinence of B/B (bowel and bladder) . call bell and personal belongings within reach . -[DATE] at 8:00 AM, SBAR-Change in Condition, Situation: Resident fell out of bed . no injuries noted at the time of incident. Active ROM (Range of Motion) to all extremities. pupils were equal round and reactive to light accommodation. Vital signs within baseline. Appearance (Licensed Practical Nurse): in their baseline . denied pain or getting hurt. No signs of skin tear, or bumps or bruising to any body parts. Response: Supervisor, provider, and family notified. Recommendations: Neurological checks initiated. Bed kept in low position. Patient education provided on not to get up without any assistance. -[DATE] at 10:46 AM, Nursing/Clinical Note , This nurse heard patient calling for help, so walked in to the direction voice was coming from. Upon entering the resident's room, was observed on the floor next to the bed and refrigerator. Had nonskid socks on and heel booties on bilateral feet, bed was in low position; call light was in reach on the bed. Assessed by this nurse and other two nurses, and the supervisor on duty for any types of injury, no injuries noted at the time of incident. Active ROM to all extremities, pupils were equal round and reactive to light. Supervisor notified, provider notified, neuro checks initiated, vital signs within their baseline, denied pain or getting hurt. No signs of skin tear, or bumps or bruising to any body parts. The Fall Investigation dated [DATE] indicated: Nursing Description: nurse heard patient calling for help .resident was observed on the floor next to bed and refrigerator, patient had non skid socks on and heel booties on bilateral feet, bed was in low position, call light within reach but not activated . Resident description: resident stated wanted to walk to get a ride; Immediate Action Taken: plan of care updated. The Care Plan intervention added on [DATE] Encouraged resident to ask for assistance when attempting to transfer. The At Risk for Falls Care Plan, revealed: a Focus dated [DATE], for unwitnessed fall. Intervention added [DATE] revealed: Encouraged resident to ask for assistance when attempting to transfer. A Certified Nurse Aide Statement dated [DATE], revealed after the fall resident was hoyered (transfer using a mechanical lift) to the recliner chair. [There was no causal factor identified for the fall, and specific intervention, including supervision, to prevent further falls for Resident #40 who was assessed as forgetful, found with call light in reach and did not activate, was totally dependent on two staff for toileting, and required total assistance from staff for bed mobility.] -[DATE] at 12:34 AM, Nursing/Clinical, Late Entry by Nursing Management, revealed, upon entering the room resident was observed lying on the floor in the prone (on face)-position next to the right side of the bed. A Registered Nurse (RN) assessment completed, Small Open area on face, wound care provided. Resident was kept by the nurses' station for observation . -[DATE] at 3:37 AM, SBAR (Situation, Background, Assessment, Recommendation), Situation: Resident fell face down on the floor, Appearance (Licensed Practical Nurse- LPN): Resident had small amount of blood coming from nose, stopped soon after and cleaned, no skin tears, no bruising, Recommendations: frequently rounding frequently toileting/changing, floor mats. -[DATE], 5:12 AM, SBAR, Situation: Resident fell to the floor while being transferred from bed to wheelchair, Recommendations: frequent rounding floor mats, mechanical lift. -[DATE] at 9:44 AM the IDCT (Interdisciplinary Care Team Note), Late Entry: Note Text: The IDCT meet with resident, to discuss resident's unwitnessed fall at 12:00 AM on [DATE]. Resident was observed laying on the floor in the prone position next to the right side of the bed. Resident had non-skid socks on and bilateral heel booties (used for presure ulcer prevention-not ambulation). Bed was in lowest position; call light was in reach but not activated. Registered Nurse (RN) assessment completed. small open area on face, wound care provided. Resident was kept by the nurses' station for observation. Neuro checks initiated, family and provider notified .The resident is currently receiving Physical and Occupational therapy to increase core strength, endurance, and mobility . Resident had a fall care plan in place with included interventions of anticipate and meet the needs of the resident to avoid falls, keep call light within easy reach, maintain bed in low position, Encourage resident to ask for assistance when attempting to transfer. However, despite the interventions attempted to transfer OOB (out of bed) without assistance. The care plan was reviewed and revised to include to encourage resident to be in supervised areas as tolerated for close monitoring and every 1- hour safety checks x 48 hours. -[DATE] at 10:52 AM Late Entry note revealed the IDCT met with Resident #40 to discuss unwitnessed fall at 8:00 AM on [DATE]. Resident was noted lying on the floor by the bedside. Upon entering the room. Resident was observed on the floor next to bed and refrigerator, wearing non-skid socks and heel booties on both feet (used to prevent pressure ulcers and not for ambulation purposes), bed was in low position, call light was in reach but not activated . Resident had a fall care plan in place with included interventions of anticipate and meet the needs of the resident to avoid falls, keep call light within reach and maintain bed in low position. However, despite the interventions the resident attempted to transfer out of bed without assistance. The care plan was revived and revised to include to encourage resident to ask for assistance when attempting to transfer. [There was no causal factor identified by the IDCT and no interventions specific to prevent further falls]. The Fall Investigation dated [DATE] revealed: Nursing Description: Upon entering the room .resident observed lying on the floor in the prone position next to right side of the bed .scant blood coming from edge of nostril . Resident Description: I was going to the kitchen. Mental Status, Notes: Resident had a small nosebleed, Face Right side is slightly red. A staff statement dated [DATE] revealed: I heard someone screaming and found resident face down on the floor in room. The At Risk for Falls Care Plan, revealed: a Focus dated [DATE], for unwitnessed fall. Intervention added [DATE] revealed: Encourage resident to be in supervised areas as tolerated for close monitoring, and 1 hour safety checks X 24 hours. [There was no causal factor identified for the 2nd fall per the IDT team, and specific interventions, including supervision to prevent further falls for Resident #40, who was assessed as forgetful, and did not activate the call light.] An Investigation dated [DATE] revealed: Nursing Description: Resident was observed becoming restless by nurse. The Certified Nurse Assistant (CNA) provided and then CNA and nurse were transferring Resident from bed to wheelchair when the resident's knees began to bend, and CNA and nurse lowered Resident to floor. The at Risk for Falls Care Plan, revealed: a Focus dated -[DATE], lowered to floor. Intervention added [DATE] revealed: Therapy Evaluation as needed and Urinalysis due to increased restless behavior [There was no causal factor identified for the fall, appropriate transfer method for the resident and who required total assistance from staff for bed mobility and per a CNA Statement dated [DATE], the mechanical lift was utilized for transfer on [DATE]] resident was hoyered to the recliner chair. On [DATE] at 12:11 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding Resident #40's falls and asked the ADON if the interdisciplinary team discussed falls after they had occurred. The ADON stated we meet every morning. The surveyor asked the ADON to show the surveyor what interventions were implemented after the [DATE] fall for Resident #40. The ADON reviewed the Care Plan and stated, encourage to call to ask for assistance. The surveyor asked if Resident #40 was cognitively intact and the ADON, stated, no, the resident was forgetful and did not understand to call for assistance. The surveyor asked if there were any other interventions and the ADON stated, no, not that I see was documented. The ADON stated the Resident #40 should be in a supervised area or an activity. The surveyor asked the ADON if the Care Plan was used, and he stated, yes, for care. The surveyor asked about the [DATE] fall, and the ADON stated the resident was lowered to the floor and a urine culture was completed. On [DATE] at 2:34 PM, asked DON about interventions related to causal factor of falls, and requested timeline and interventions with falls from the Director of Nursing (DON), including what should be completed per the facility fall policy. On [DATE] at 11:43 AM, the DON provided a Fall Management Timeline for Resident #40 which revealed: Resident fall occurrences are outlined as follows: -[DATE], at 8:00 AM, the fall occurred from bed .The resident was provided with encouragement to call for assistance when attempting to transfer. -[DATE], at 12:00 AM, the fall occurred from bed, scant nosebleed noted, one hour wellness checks X 24 hours and encouraged to be in supervised areas when out of bed. -[DATE], at 12:00 AM, the fall occurred during 2 staff transferring to wheelchair from bed and lowered to floor. Therapy evaluation. On [DATE] at 12:51 PM, during an exit conference held with the facility administration, including the Director of Nursing (DON) and Licensed Nursing Home Administrator, the DON confirmed that Resident #40 was a fall risk and the prevent further falls the resident was encouraged to call for assistance. A review of the Clinical, Fall Policy, created [DATE], revealed: Policy: To provide a system whereby resident's falls are reported, their causes identified when possible and timely interventions are established to reduce the probability of repeated incidents. Procedure: The IDCT will review the incident report during the clinical meeting to review by the team appropriate interventions. NJAC 8:,d+[DATE].1(a)

Based on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections. This deficient practice was identified for 1 of 1 resident reviewed with an indwelling urinary catheter (Resident #20), and was evidenced by the following: On 4/10/25 at 8:55 AM, the surveyor entered the room and observed Resident #20 in bed. The resident had a Foley catheter (medical device that helps drain urine from the bladder) drainage bag was resting directly on the floor. On 4/10/25 at 9:00 AM, the surveyor exited the room and asked a Certified Nursing Aide (CNA) in the hallway to assist with an observation of Resident #20. The surveyor along with the CNA, Director of Nursing (DON) put on personal protective equipment (PPE) and entered the room. The surveyor observed the CNA then checked the resident's incontinence brief, and the resident had a dressing to the right leg amputated area that was connected to a wound vac (vacuum assisted wound drainage that used negative pressure to help difficult wound heal faster). The surveyor exited the room, and returned to the room around 12:30 PM, and observed the Foley catheter drainage bag was still directly rested on the floor. At that time, the surveyor then re-entered the room with the Infection Control Nurse (from another facility) who raised the bed of Resident #20 and provided a privacy bag to the CNA so the Foley catheter drainage bag could be protected. On 4/11/25 at 10:30 AM, the surveyor reviewed Resident #20's medical record. The admission Face Sheet reflected that Resident #20 had diagnoses which included but were not limited to; Type 2 Diabetes Mellitus, acquired absence of right leg, above the knee, gangrene not elsewhere classified, acute osteomyelitis right femur, infected right femur stump. Resident #20 had a Foley Catheter in place for urinary retention and was treated for Urinary Tract Infection (UTI) from 2/19/25 to 2/22/25 with Amoxicillin. The Admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care, reflected that Resident #20 had severe cognitive impairment. Resident #20 scored 04 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #20 had a care plan in place which addressed the indwelling catheter. The goal was for Resident #20 will not show no sign and symptoms of infection. The interventions were to position the Catheter bag and tubing below the level of the bladder and away from entrance room door and privacy cover. Secure catheter per facility protocol. The facility policy dated last revised, reflected that the Foley Catheter Drainage bag should be stored in a dignity bag not on the floor to prevent infection. A review of the facility titled, Infection Control, Urinary Catheter, dated 1/2023 last revised 1/2025 which revealed the following: Policy: To provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control program. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. Procedure #6, Do not allow the catheter tubing, bag, or spigot to touch the floor. Procedure #15, Keep the collection bag below the level of the bladder and place in a privacy bag. NJAC 8:39-19.4(5)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census for 2 of 6 observations This deficient practice was evidenced by the following: On 4/15/25 at 12:00 PM, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted on the wall, in the reception area of the lobby. The NHRCSR posted for day shift from 7:00 AM through 7:00 PM and night shift 7:00 PM through 7:00 AM were dated 4/13/25. There was no NHRSCR posted for 4/15/25 day shift 7:00 AM through 7:00 PM. On 4/15/25 at 12:01 PM, during an interview with the surveyor, the receptionist stated the Staffing Coordinator (SC) was responsible for posting NHRCSR daily. The receptionist was not able to tell at what time the SC would post the NHRCSR. On 4/16/25 at 8:00 AM, the surveyor observed the NHRCSR posted in the lobby. The NHRCSR posted for day shift was dated 4/15/25 from 7:00 AM through 7:00 PM. There was no NHRSCR posted for either 4/15/25 night shift or 4/16/25 day shift. On 4/16/25 at 9:51 AM, during an interview with the surveyor, the SC stated she was responsible for posting NHRCSR and it would be posted twice a day. The SC further stated she would email the NHRCSR to an evening receptionist to post it and when I come in the morning, I see it posted there. The SC stated NHRCSR was important to post every day so that visitors and residents were aware of the staffing ratios. The surveyor informed the SC of above-mentioned concerns for 4/15/25 and 4/16/25. The SC stated, I would say that was my error and I am the one responsible to change it. On 4/16/25 at 1:13 PM, in the presence of the survey team, the surveyor informed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) about the concern that the NHRSCR was not posted daily. A review of the facility provided policy Nurse Staffing Posting Information dated 1/2025, included but was not limited to; Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. In Section under Policy Explanation and Compliance Guidelines: 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. NJAC 8:39-41.2

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of three (3) residents (Resident #40) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/10/25 at 10:13 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) prepare ten (10) medications to administer to Resident #40. The LPN prepared ten (10) medication for Resident #40 which included Protonix 40 mg tablet (medication for Gastroesophageal reflux disease), Aspirin 81 mg tablet (secondary prevention of cardiovascular disease), Plavix 75 mg tablet (for blood clot prevention), Felodipine Extended Release 10 mg (medication for lowering blood pressure [BP]), Pakonza Powder 10 MeQ 1 Packet (supplement for low potassium), Vitamin D3 50 microgram tablet (supplement), Cozaar 25 mg (medication for lowering BP), Folic Acid 1 mg tablet (supplement), Ferrous Sulfate 325 mg tablet (supplement) and Hydralazine 25 mg tablet (medication for lowering BP). The surveyor observed Hydralazine 50 mg was ordered and the LPN removed 25 mg 1 (one) tablet from blister pack / bingo card (most commonly used medication packaging in long-term care facilities). The LPN confirmed with the surveyor that she removed only 1 tablet. On 4/10/25 at 10:43 AM, in the presence of the surveyor, the LPN reviewed the Medication Administration Record (MAR) for Resident #40. The LPN checked the Physician Order (PO) for Hydralazine and stated that the resident was supposed to receive Hydralazine 50 mg 1 (one) tablet. The LPN confirmed that the resident received Hydralazine 25 mg 1 tablet. The LPN further stated that she should have checked the PO prior to removing medication to make sure the resident was getting the right medication and right dosage. The LPN acknowledged that she should have removed Hydralazine 25 mg X 2 tablets to administer. On 4/11/25 at 9:03 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) and the Assistant Director of Nursing (ADON) stated it was important to check the 5 rights during the medication administration process: right patient, right medication, right time, right route and right dose. The surveyor notified the RN/UM and the ADON about the above-mentioned concerns. The RN/UM stated the nurse should have made sure it was the correct dose of the medication before administration. On 4/14/25 at 10:50 AM, the surveyor reviewed the medical record of Resident #40. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; hypertension (elevated blood pressure), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), and difficulty in walking. A review of Admission Minimum Data Set (MDS), an assessment tool dated 3/4/25 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that Resident#40 had moderately impaired cognition. A review of the April 2025 order summary report (OSR) revealed a PO dated 4/7/25 for Hydralazine HCl Oral Tablet 50 MG (Hydralazine HCl). Give 1 tablet by mouth every 6 hours for hypertension. Hold for SBP < 100. A review of the April 2025 electronic Medication Administration Record (eMAR) revealed an order dated 4/7/25 for Hydralazine HCL oral tablet 50 mg was signed off as given at 11:00 AM. A review of the Medication pass observation with consultant pharmacy dated 4/4/25 for LPN did not reflect any concerns for medication administration. On 4/15/25 at 1:17 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The surveyor presented above mentioned concerns. On 4/16/25 at 9:02 AM, during an interview with the surveyor, the DON stated if a resident was ordered Hydralazine 50 mg, the nurse had Hydralazine 25 mg then they should be administering 2 pills together. The DON further acknowledged that the nurse went back on 4/10/25 and administered the other 25 mg Hydralazine to Resident #40 after the surveyor inquiry. A review of the facility's policy for Medication Administration dated 1/2025 included Medication are administrated by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. In the section under Policy Explanation and Compliance Guidelines included 11. Compare medication source (bubble pack, vial, etc.) with EMAR to verify resident name, medication name, form, dose, route, and time. 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 properly label, store, and dispose of medications in three (3) of eight (8) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor inspected the 3 D high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Heparin multi-dose vial that had no opened date and an unopened vial of Lantus insulin that was not dated and was stored in the medication cart. At that time, the surveyor interviewed LPN#1 who acknowledge that an opened vial of multi-dose Heparin should have been dated after opening and an unopened vial of Lantus insulin should have been stored in the refrigerator. On [DATE] at 11:15 AM, the surveyor inspected the 3 D low-side medication cart in the presence of LPN#2. The surveyor observed an unopened vial of Arexvy (vaccine for RSV) that was stored in the medication cart, a vial of Humulin R insulin with an opened date of [DATE] that was expired, and an opened bottle of Pro-stat (supplement) that was not dated. At that time, the surveyor interviewed LPN#2 who acknowledge that Arexvy should have been stored in the refrigerator and that Humulin R insulin was expired and should have been removed from the medication cart. She also stated that once Pro-stat liquid was opened it should be dated. On [DATE] at 11:30 AM, the surveyor inspected the 3 C low-side medication cart in the presence of LPN #3. The surveyor observed an unopened vial of Arexvy and an unopened vial of Novolin ,d+[DATE] that were stored in the medication cart. The surveyor also observed a bottle of Pro-stat liquid that was opened and not dated. At that time, the surveyor interviewed LPN #3 who stated that both a vial of Arexvy and an unopened vial of Novolin ,d+[DATE] insulin should have been stored in the refrigerator. LPN #3 also stated that once a bottle of Pro-stat solution is opened it should be dated. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Pro-Stat bottle once opened has an expiration date of 90-days. 2. Heparin multi-dose vial once opened has an expiration date of 28-days. 3. Humulin R vial once opened has an expiration date of 31-days 4. Unopened Novolin ,d+[DATE] insulin should be stored in the refrigerator 5. Unopened Lantus insulin should be stored in the refrigerator 6. Arexvy vial should be stored in the refrigerator. On [DATE] at 1:00 PM, the surveyor presented the above concerns to the facility administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy titled Medications Storage dated [DATE] and provided by the DON included the following: 4. Refrigerated Products: a). All medications requiring refrigeration are stored in refrigerators located in each medication room. 5. Unused Medications: All medication rooms are routinely inspected by consultant pharmacist for discontinued, outdated, defective or deteriorated with worn, illegible, or missing labels. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, interview and review of the medical records and other facility documentation, it was determined that the facility failed to clarify a physician's order from 10/25/23 until 11/30/23 for 1 of 4 residents (Resident #94) observed during medication observation. This deficient was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Review of the Admission Record for Resident #94 reflected the resident was admitted to the facility with medical diagnoses which included, but were not limited to, displaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing, pain in left hip, pain in right knee, and difficulty walking. The admission Minimum Data Set (MDS), an assessment tool, dated 9/21/23, reflected that Resident #94 was cognitively intact and required limited to extensive assistance with activities of daily living. The MDS also indicated that the resident was on scheduled pain medications. On 11/30/23 at 9:14 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #94. The LPN asked Resident #94 if he/she wanted the lidocaine patch that was ordered for pain in the knee. The resident replied, yes and further stated, not on the right knee, but on the left. The LPN replied, okay and proceeded back to the medication cart to prepare the lidocaine patch for the resident. During an interview with the surveyor at that time, the LPN stated, we just ask the resident which knee and [he/she] tells us. When asked how the nurses document which knee the patch was applied to, the LPN responded, we don't. On 11/30/23 at 9:14 AM, the surveyor reviewed the Physician's Order Sheet (POS), dated 10/25/23, with a physician's order for the Lidocaine patch that read: for knee pain apply in the AM and remove at night and apply to knee topically one time a day for remove at 9p. The physician's order did not specify to which knee to apply the Lidocaine 5% patch. The Treatment Administration Record (TAR) for the month of November 2023 did not reflect an order to document location of Lidocaine patch after application. On 12/05/23 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the order for Lidocaine 5% patch for Resident #94 should have been clarified and was considered incomplete. The facility policy labeled Nursing Medication Administration with revised date of 01/18/2023 indicated that Medications are administered by licenses nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under a subsection called Policy Explanation and Compliance Guidelines, numbered 1 to 21, reflected under #11 that nursing should Compare medication source (bubble pack, vial, etc.) with MAR to verify the resident name, medication name, form, dose, route and time. Under #21 of the subsection Policy Explanation and Compliance it further directed nursing to Correct any discrepancies and report to nurse manager. N.J.A.C. 8:39-27.1 (c) (3i)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to promptly record the removal of controlled drugs from the narcotic inventory record for 1 of 3 nurses observed during medication pass observation. This deficient practice was evidenced by the following: On 11/30/23 at 9:40 AM, the surveyor asked the Licensed Practical Nurse (LPN) to complete a narcotic count for the third-floor medication cart labeled High Cart C. As the surveyor and the LPN proceeded to conduct the narcotic count the surveyor discovered that the Controlled Drug Record (CDR) sheet for the narcotic medication named Lacosamide 100mg tablets (medication used to control seizures) for Resident #80 indicated that there should have been 25 tablets available, however there was only 24 tablets in the pill packet. The LPN at stated she gave the medication earlier, but forgot to sign it in the CDR to indicate that she had administered the narcotic. She then proceeded to search the time that she administered the medication in the Electronic Medical Record (EMR). Afterwards, she proceeded to sign the CDR in the presence of the surveyor that indicated that she administered the narcotic. When the surveyor asked the LPN why it was important to sign out narcotic medications on the CDR at the time the medication was given, the LPN stated to ensure the narcotic count was correct and to avoid medication errors. The surveyor reviewed Resident #80's Admission Record which indicated that the resident was admitted to the facility with a diagnosis which included, but was not limited to, unspecified convulsions. Review of the Physician Order Report indicated that the physician had prescribed Lacosamide 100 mg to be given two times a day for seizure disorder. Review of the EMR indicated that the LPN gave the narcotic medication Lacosamide 100 mg on 11/30/23 at 09:17 am. The surveyor observed that the nurse did not sign the CDR until 9:40 am after surveyor inquiry. On 12/05/23 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the LPN should had signed the narcotic inventory log immediately after the narcotic medication was administered to Resident #80. She further stated that the LPN had already brought this to her attention after it was discovered by the surveyor and the LPN was in-serviced (educated) by the DON. The facility provided the surveyor with an individual one on one in-service untimed and dated 11/30/23, which indicated that the LPN was educated on the importance of ensuring that medications were signed out immediately after administration on the EMR and narcotic sign out sheet. Review of the facility policy titled, Controlled Substances, dated 02/08/2023, which indicated that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy also specified that controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Review of the facility policy titled, Medication Administration, dated 01/18/2023, indicated that the nurse was responsible to sign the Medication Administration Record after the medication was administrated and if the medication was a controlled substance the nurse was responsible to sign the narcotic book. N.J.A.C. 8:39-29.7 (c)

Based on observation, interview, and pertinent facility policies, it was determined that the facility failed to a.) secure a medication administration cart during the medication pass conducted on [DATE] and b.) maintain medications with appropriate label/dating for 2 of 8 medication administration carts inspected This deficient practice was evidenced by the following: 1.) On [DATE] at 9:40 AM, the surveyor observed the medication storage cart on the third floor labeled High Cart C. During the inspection Licensed Practical Nurse (LPN #2) proceeded to walk to the medication storage room with the surveyor and away from the medication cart without locking and securing it. The surveyor went over to the medication cart to wait for the LPN's return from the storage area. When LPN #2 returned to High Cart C, the surveyor asked LPN #2 if the medication cart should be unlocked. LPN #2 stated probably not and further stated she usually locked the cart, but was very nervous at this time. She then explained that it was important to lock the medication cart when out of her eyesight because if a resident was to wander through the unit, they could get in the medication cart and take the medication. She confirmed that locking the medication cart protected the residents. On [DATE] at 12:40 PM, in the presence of the survey team, the Director of Nursing (DON) stated that the medication cart should always be kept locked when out of the nurse's view to prevent any issues with unauthorized individuals gaining access to the medications. 2.) On [DATE] at 9:40 AM, the surveyor conducted a medication administration observation and inspection of the 3rd floor medication administration cart. The surveyor observed LPN #2 perform medication administration on a medication cart labeled High Cart C. At this time during the cart inspection, the surveyor observed the following opened short expiration medications were not labeled with the date they were opened: -Budesonide 0.5 9 milligrams (mg) 2ml opened foil packet. According to the manufactures recommendations after the envelope is opened the shelf-life of the unused ampules was two weeks. LPN #2 was interviewed at this time and indicated that medications should be dated when opened. On [DATE] at 08:32 AM, the surveyor conducted an inspection of the medication storage cart on the second floor labeled High Cart B. The surveyor observed that the following short expiration medications were not labled with a date when opened: -Trilogy Elipta Inhaler 200mg/62.5 mcg/25/mcg. The surveyor observed that the foil tray containing the inhaler was not dated when opened and according to manufactures recommendation, the medication was only good for six (6) weeks after opening the foil tray. - Fluticasone Furate Inhaler 100 mch/25 mcg. According to the insert on the box the medication was only good for 6 weeks after opening. The surveyor interviewed LPN #3 at this time who indicated that she was not sure why the medications were not dated when opened. She stated that all medications should be opened when dated because certain medications could expire after opening and were only good for a certain amount of time. On [DATE] at 11:21 AM, the surveyor interviewed the Pharmacy Consultant (PC) who stated that he had been coming to the facility for about 5 years. The PC stated that he was in the facility monthly and inspected the medication carts to assure proper labeling and dating. He stated that he focused on all medications in the medication cart however prioritized the medications with shortened expiration dates after they were opened. He stated that the nurses were to monitor these types of medications to assure that they kept track of the shorter expiration date medications in between his visits. He stated that the nurses needed to check that these medications were dated when opened. He stated that the medication Budesonide was light sensitive and when a pouch is opened it expires 7 days after opening. He stated that some literature regarding this medication indicated that it expired 14 days after opening, but other literature indicated that it expired 7 days after opening. He further stated that the facility followed the more stringent recommendations of 7 days. He also stated that this medication was very light sensitive and that since it could not be assured that it was out in the light too long, that he educated the nurses in the facility that it expired 7 days after opening. He continued to add that it was good practice is to assure that medications were dated when opened. He confirmed that the medications Trilogy Elipta Inhaler and Fluticasone Furate Inhaler expired 6 weeks after opening. The facility policy titled, Security of the Medication Cart dated [DATE], which indicated that the medication cart shall be secured during medication passes. The policy indicated that the nurse would secure the medication art during the medication pass to prevent unauthorized entry and that medication carts must be securely always locked when out of the nurse's view. The facility policy titled, Labeling of Medication Containers with a revised date of [DATE] which indicated that all medications maintained at the facility were properly labeled in accordance with current state and federal guidelines and regulations. NJAC 8:,d+[DATE].2(d) NJAC 8:,d+[DATE].4(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices to prevent the spread of infection. This deficient practice was identified for 1 of 3 nurses observed during a medication administration observation. The deficient practice was evidenced by the following: On 11/30/23 at 9:44 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #419. The Department Nurse Manager (DNM), with an ungloved hand, handed the LPN three (3) packets of medication for Resident #419. The medications received by the LPN included one (1) buspirone HCL oral tablet 5 milligram (mg), one (1) folic acid oral tablet 1 mg, and one (1) nifedipine 30mg 24hr extended-release oral tablet. The LPN received the packets of medication in her ungloved hands and then placed them in her pocket. The LPN then went to finish the narcotic count with the surveyor in the storage room. No hand hygiene was observed at this time. On 11/30/23 at 9:59 AM, the LPN returned to the medication cart and began to prepare the medications received from the DNM for Resident #419. The LPN removed the medication with her ungloved hand from her pocket and placed the unopened packets into a medicine cup. The LPN then removed one (1) pill of cetirizine 10mg from a medication bottle and placed that into the same medicine cup with the unopened packets. The LPN then stated she will be giving the patient the medications now. At that time, the surveyor confirmed with LPN that she will be giving Resident #419 the medications as prepared and the LPN replied, yes. The LPN failed to follow appropriate infection control practices by placing loose medication (cetirizine 10mg) into the same medication cup with unopened packets of medication which included one (1) buspirone hcl oral tablet 5 mg, one (1) folic acid oral tablet 1 mg, and one (1) nifedipine 30mg 24hr extended-release oral tablet. All medication packets had been touched by both the DNM and the LPN with ungloved hands. On 11/20/23 at 10:02 AM, the surveyor interviewed the LPN. On interview of the LPN the surveyor asked the LPN if it was acceptable to give the medications the way she had prepared them with the closed packets and the open medication in the same medicine cup, after the packets were touched by multiple staff. The LPN replied, no because it would be contaminated. It was at that time the LPN stated she will restart her medication preparation, and proceeded to appropriately waste the loose pill of cetirizine 10mg that was in the medicine cup. The LPN then discarded the old medicine cup; performed hand hygiene, donned gloves, retrieved a new medicine cup, and began preparing medications again for Resident #419, which included pouring a new tab of cetirizine10mg into a clean medicine cup from the supply bottle and then removing the medication from the pill packets before placing them into the medication administration cup. On 12/05/23 at 11:51 AM, the surveyor interviewed the Registered Nurse Infection Preventionist (RN/IP). The RN/IP explained that the LPN should not have placed medications that were still in blister packs, in the same medicine cup as loose medications because it can cause cross contamination. On 12/06/23 at 1:28 PM, the surveyor reviewed the facility policy labeled Infection Control Program and Surveillance Plan with revised date of 02/01/2023, indicated that Total Rehab + at Moorestown's infection control program will identify and reduce the risk of acquiring and transmitting infections among residents, staff volunteers, students, and visitors. The program incorporates a broad range of education, surveillance, prevention, and infection control practices involving all departments with oversight by the designated infection control preventionist nurse under the guidance of the Infection Control Committee. Under subsection called Structure and Organization it further specifies that This manual also contains information related to specific clinical conditions, including practices to prevent or minimize the spread or occurrence of infections while caring for residents including General Infection control policies and procedures that mandate routine infection control practices, including personal protective measures, hand hygiene and guidelines for Standard and Transmission-Based Precautions. NJAC 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. On [DATE] at 10:45 AM, upon arrival of the surveyors to the facility, the surveyor observed a facility sign, Total Rehab at Moorestown that had a name that did not correspond with the CMS licensed, approved name and provider registered name Promedica Total Rehab + Moorestown. Upon entrance into the facility, the survey team observed there were displayed signs and brochures with the same name Total Rehab at Moorestown. The facility name displayed in the entrance area, Total Rehab at Moorestown did not correspond with the CMS licensed and approved name of Promedica Total Rehab + Moorestown. On [DATE] at 11:57 AM, the survey team conducted the entrance conference with the Director of Nursing (DON), the License Nursing Home Administrator (LNHA), and the [NAME] President of Clinicals (VP of Clinicals). During the discussion the LNHA informed the survey team that the facility was now named Total Rehab at Moorestown and was under the new ownership of Preferred Care. The VP of Clinical stated that the ownership and name change occured in January of 2023. She further stated that the New Jersey Department of Health (NJDOH) state licensing was notified of the new ownership and name change. On [DATE] at 09:00 AM, the survey team reviewed various pertinent facility documents - the facility's website and brochures which indicated the facility was advertising as Total Rehab at Moorestown rather than Promedica Total Rehab + Moorestown. The pertinent documents provided reflected that the facility name currently in use did not match the facility's licensed name. The facility name, Total Rehab at Moorestown utilized was not approved by CMS. The Surveyor reviewed the facility license which documented, Promedica Total Rehab + (Moorestown) as the facility name. The license issued by the New Jersey Department of Health (NJDOH) Division of Certificate of Need and Licensing was issued on [DATE] and expired on [DATE]. On [DATE] at 09:20 AM, the LNHA stated in the presence of the survey team that he was unsure if the CMS 855A application for the name change was completed. On [DATE] at 09:41 AM, the LNHA in the presence of the survey team stated that the signage outside and the documents that reflected Total Rehab at Moorestown was done prior to him starting at the facility. The LNHA stated he become the LNHA two (2) months ago, and prior to that he started as the Assistant LNHA in April of 2023. On [DATE] at 12:38 PM, the LNHA provided the LSC-9 Application for a Long-Term Care Facility License that was submitted in February of 2023. On [DATE] at 01:12 PM, the surveyor interviewed the Regional LNHA who stated he spoke with the corporate office and that the CMS 855A application could not be submitted until they received approval from the state licensure. Upon further review of the documents provided by the LNHA, there was an email dated for [DATE] and [DATE] sent to NJDOH from the facility's attorney regarding the new license, reflected the following: -After approval and closing, the new name of the facility will be Total Rehab Moorestown. -Page 3: The Medicare provider number will be assigned to Moorestown Operator, LLC following approval of a CMS855A application, and a new Medicaid provider number will be issued to the applicant following the review and approval. The state surveyor met with the facility's LNHA to discuss the deficient practice of utilizing the facility name Total Rehab at Moorestown without NJDOH Licensure approval. On [DATE] at 09:22 AM, the LNHA in the presence of the Regional Nurse, the Assistant LNHA, the DON and survey team, stated that the name change, and transfer of ownership was sent in February 2023 and should be getting approval this week. He further stated that the facility reached out to their lawyer who was not aware it was an issue. The LNHA stated that the CMS 855A application could only be completed once the NJDOH gave the approval. The LNHA acknowledged they did not get official approval for the name change. No further information or documentation was provided to the survey team to refute these findings. NJAC 8:,d+[DATE].1 (a)

C#: NJ164303 Based on interviews, medical records review, and review of other pertinent facility documentation on 5/24/2023, it was determined that the facility failed to notify the Physician when a resident refused his/her medications. The facility also failed to follow its policies titled Documentation in Medical Records. This deficient practice was identified for 2 of 4 residents (Resident #1 & #2) and was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Other Intestinal Obstruction Unspecified As To Partial Versus Complete Obstruction and Essential (Primary) Hypertension. According to the Minimum Data Set (MDS), an assessment tool dated 5/2/2023, Resident # 1 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #1 needed extensive assistance with most Activities of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR) dated Active Orders as of 5/24/2023, included under Order Summary: Miralax Oral Packet 17 GM (gram) (Polyethylene Glycol 3350). Give 1 packet by mouth one time a day for constipation, order date 5/11/2023. A review of Resident #1's Medication Administration Record (MAR) dated 5/1/2023-5/31/2023 revealed the Resident refused the aforementioned Physician's Order on 5/21/2023, 5/22/2023, 5/23/2023 and 5/24/2023 at 9:00 a.m. as evidenced by the code 2=Offered and Refused . A review of Resident #1's Progress Notes (PNs) revealed no documentation that the Physician was notified of the medication refusals at the time of the survey. 2. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Idiopathic Aseptic Necrosis of the Right Femur, Direct Infection of the Right Hip in the Infectious and Parasitic Diseases Classified Elsewhere and the Presence of Other Orthopedic Implants. According to the MDS, dated [DATE], Resident #2 had a BIMS score of 14/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed limited assistance with most ADLs. A review of Resident #2's Care Plan (CP) revealed under Focus included: Nutritional Status as evidenced by patient-reported decreased intake levels r/t (related/to) medical status. Under Goal: Will consume appropriate amounts of food and fluids to promote healing/strength for therapy participation; under Interventions included: .Provide diet supplements per orders - pro liquid once/day for 21 days, order date 5/19/2023. A review of Resident #2's OSR dated Active Orders as of 5/24/2023 revealed under Order Summary included: ProMod Liquid (Nutritional Supplements) Give 30 ml (milliliter) by mouth one time a day for protein, dated 5/19/2023. A review of Resident #2's MAR dated 5/1/2023-5/31/2023 revealed the aforementioned Physician's Order revealed the Resident refused the order on 5/22/2023, 5/23/2023, and 5/24/2023 as evidenced by the code 2=Offered and Refused . A review of Resident #2's eMAR (electronic Medication Administration Record) Progress Notes (PNs) revealed on 5/24/2023 at 8:29 a.m., written by the Registered Nurse (RN) ProMod Liquid 30 mL 1 time a day for protein pt [patient/resident] does not want at this time. Further review of Resident #2 PNs revealed no documentation that the Physician was notified of the medication refusals at the time of the survey. During an interview on 5/24/2023 at 12:30 p.m., when the Surveyor asked him should the Physician be notified for a medication refusal, the Acting Clinical Director/Licensed Practice Nurse (ACD/LPN) stated: If a resident refuses meds [medications] ascertain why they [he/she] refuse[d], educate on why meds [are] important and notify [the] MD [Physician] and document if [the] refusal continues. He continued, On the eMAR, when the resident refuses, it prompts a note, a Progress Note (PNs) to generate. In the same interview, the ACD/LPN stated: If [the] Physician was notified, it would also be [documented] in that note (PNs), the doctor is expected to be called if the medication is refused and [it] would be documented only in the PNs. During an interview on 5/24/2023 at 1:55 p.m., the Regional Director of Nursing (RDON), in the presence of the Administrator, stated, . there's no specific Physician Notification Policy. She continued to say, If a resident consistently refuses [medication], we educate the patient [resident], tell [the] NP (Nurse Practitioner), and if the NP was notified, there could be a note. During an interview on 5/24/2023 at 2:29 p.m., the Registered Nurse (RN) assigned to Residents #1 & #2 stated, [the] doctor [physician] is notified by the Unit Manager (UM), Clinical Director or the nurse assigned to the resident when a medication is refused. She continued that whenever the nurse calls the doctor, [the nurse] documents in the PNs. The RN stated, . if it's not documented, it's not done. At the time of the survey, the nurses who did not administer the medications were unavailable. A review of the facility policy titled Documentation in Medical Records, last date revised 1/18/2023, revealed the following: Under Policy: included Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Under Policy Explanation and Compliance Guidelines: included: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the Resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but not limited to: .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the Resident's care and/or responses to care. c. Documentation shall be timely and in chronological order . N.J.A.C. 8.39-13.1 (d)

Complaint #NJ164303 Based on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to provide evidence that an Intravenous medication was administered according to the Physician's Order and failed to follow its policies titled Medication Administration, and Intermittent Infusion Administration. This deficient practice was identified for 1 of 4 residents (Resident #3) reviewed for medication administration and was evidenced by the following: Review of the Medical Record (MR) was as follows: According to Resident #3, Face Sheet, the resident was admitted to the facility with diagnoses which included but were not limited to Bacteremia (a bloodstream infection), sepsis (blood poisoning), and Endocarditis (an infection of the heart involving heart valves). A review of the initial Minimum Data Set (MDS), an assessment tool dated 4/25/23, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. This MDS also showed the resident required Intravenous (IV) medications. A review of Resident #3's Care Plan (CP) dated 4/19/23 addressed the potential for complications related to antibiotic therapy, which included interventions as follows: Administer Antibiotic medications as ordered by a physician. Monitor/document side effects and effectiveness. A review of the Physician's Order Summary (POS) dated 4/19/23 included an order for Ceftriazone Sodium Intravenous Solution Reconstituted 2grams, use 2grams intravenously every 12 hrs for Bacteremia/Encarditis to be administered to Resident #3. A review of the Medication Administration Record (MAR) on 5/24/23 at 1:28 PM revealed there was no documented evidence that Resident #3 received the scheduled IV medication of Ceftriaxone Sodium 2gm every 12 hours on 5/10/23 and 5/19/23 at 6:00 PM since both spaces were left blank. During an interview conducted by the surveyor on 5/24/23 at 2:29 PM with the Director of Nursing (DON), the DON stated she made a telephone call to the Licensed Practical Nurse (LPN) who was on duty for the evening shift. The LPN stated to the DON that she gave the medication but probably forgot to save it in the computer. The DON further stated her expectation was the LPN should have documented the medication after it was administered to Resident #3 . During an interview conducted by the surveyor with the DON on 5/24/23 at 3:00 PM, the surveyor reviewed Resident #3's MAR. The DON acknowledged that no documentation would most likely mean the medication wasn't given. A review of the facility's policy titled Medication Administration, dated 7/20/20, and revised 1/18/23, included, Policy: Medications are to be administered by licensed nurse, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Also included in the policy under 10. Review MAR to identify medication to be administered; 17., Sign MAR after administered; and 20. Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift. A review of the facility policy titled Intermittent Infusion Administration, dated 4/18/2018, included under S., Document the dose given on the medication administration record as well as any IV site complications/concerns and resident's tolerance of procedure in the nurse's notes. The IV flow sheet is to be completed per facility policy. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice during medication administration for 1 of 4 residents (Resident #23) observed for medication pass. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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 a medical regimen 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 state: 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 08/19/2021 at 8:45 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #23. The LPN dispensed 13 medications, including a [MEDICATION(S)] Patch 4%. The LPN removed the patch from the packaging and labeled the patch with the date, time and her own initials. Upon entering the resident's room with the medication, the LPN explained to the resident that she was going to apply the [MEDICATION(S)] Patch and exposed the resident's back. At that time, the surveyor stopped the LPN and asked to return to the medication cart. The LPN removed the [MEDICATION(S)] Patch box from the medication cart and verified the strength was 4%. The LPN then reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN then stated that the physician had to be notified to clarify the order. Review of Resident #23's Order Summary Report included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 08/19/2021 at 9:10 AM, the LPN stated she performed three checks prior to administering medications, to ensure the right resident receives the right medication and dose. When asked if the LPN performed the three checks prior to administering the [MEDICATION(S)] Patch, the LPN stated, I didn't see the 4% on the box. During an interview with the surveyor on 08/19/2021 at 10:07 AM, the Care Manager stated that the nurse administering medications should perform three checks by comparing the medication to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 08/19/2021 at 10:25 AM, the Director of Nursing (DON) stated that the nurse administering medications should review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated that the LPN should have performed these checks prior to administering the [MEDICATION(S)] Patch. Review of the facility's Medication Administration: Medication Pass policy, dated 03/2010, included, Open MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] NJAC 8:39-27.1(a)

Based on observation, interview, and document review, it was determined that the facility failed to maintain a.) equipment in a manner to minimize microbial growth and cross contamination, and b.) the proper rinse temperature for the dish machine. This deficient practice was evidenced by the following: On 09/17/19 at 8:57 AM, during the initial tour of the kitchen and accompanied by the Chef, the surveyor observed the dish machine in operation and the Dish Washer (DW) was observed pushing two small containers through the machine to be washed. The rinse temperature was 140 degrees Fahrenheit (F). The DW stated it is stuck, referring to the gauge. At 9:04 AM, the Dietary Director (DD) joined the tour. The DD director was interviewed regarding if the hot water booster was in operation, he stated it was on. The DD confirmed that the rinse temperature of the dish machine was not reaching proper temperature and he stated he will make a service call. The tour continued with the Chef and the following was observed: The can opener blade contained debris. The large blender that was identified as clean, was stored upright and was wet. A rack, identified as containing clean equipment, by the Chef, contained the following: 6-1/3 shallow pans were stacked together and were wet inside 1-1/3 shallow pan was wet with plastic stuck to the bottom interior of the pan 2 large shallow steam table pans were wet inside 2 large shallow steam table pans contained debris inside A large bin of ladles was exposed to air and debris was noted inside the container containing the ladles The meat slicer was covered and identified as clean by the Chef. Debris was observed on the blade and base of the slicer. At 9:20 AM, the surveyor and DD continued the tour and the DW was observed using the dish machine and running through a steam table pan. The rinse temperature was observed, as in previous observation, at 140 degrees F. The surveyor asked the DW what the rinse temperature should be and he stated 180 degrees F. At that time, the Food and Nutrition Services, Machine Warewashing Sanitation Log was reviewed. The Final Rinse Temperature for the 09/16, Noon meal was 157 with the initial of the DM next to the temperature. The DW confirmed he took that temperature and stated he was unaware of the temperature not reaching 180 degrees F. At that time, the DD instructed the DW to stop using the dish machine and a service call was placed. On 09/19/19 at 12:20 PM, the DD provided the surveyor with a copy of a service call for the dish machine, dated 09/17/19 at 9:56 AM. The comments indicated the Booster heater was tripped. Took off panel and hit the reset button. Temp went up to 190 after reset button was pushed. Review of the Food Handling Policy in the Food and Nutrition Services Policies and Procedures manual, revised 08/08/18, revealed that food thermometers are available to all employees who are responsible for checking the internal temperature and holding temperature of the foods. Review of the Machine Warewashing and Sanitizing Policy in the Food and Nutrition Services Policies and Procedures manual, revised 03/16/14, revealed the final rinse temperature is a minimum of 180 degrees F. If temperatures fall below the standard for either wash or final rinse, the Director of Dining Services or Maintenance is notified immediately. Review of the Cleaning Procedure from the Warewashing Manual, dated 12/01/15, revealed to place dishware on drain board, inverted to drain and air dry. NJAC 8:39 17.2.(g)