Every finding on record at Troy Hills Center

REPEAT DEFICIENCYBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following:On 4/2/26 at 10:09 AM, the surveyor entered the main kitchen for the initial tour. The surveyor, in the presence of the Food Service Director (FSD), observed the following:-Stand-up walk-in freezer: observed an open box of mixed vegetables and an open box of orange sherbets both undated, no date when the boxes were opened. The FSD confirmed that the boxes should have been dated when they were opened.-Drying racks: Observed pans and trays on dry racks with buildup of brownish/blackish substance; three baking muffin trays with hardened substance buildup on back of pans, lifted with the point of a pen, black, dried chunks loosened. The FSD confirmed and stated that the pans needed to be de-greased more.- Double ovens and grill: observed double ovens/stoves and grill in between ovens, brownish/black, dry hardened grease-substance buildup on the sides of ovens and thick accumulation to the floor.-Six steam tables: observed brownish and yellow residue inside the bottom and sides of pans. Observed one steam pan with water and yellow loose residue swimming on top of the water. The FSD confirmed there should be no residue on top and no stains in the steam pans.Dry Storage Room: - Observed the freezer with frozen vegetables and no thermometer in the freezer. The FSD looked for the thermometer and no thermometer was found.-Observed racks of canned items: two cans of vanilla pudding with one inch dent on the lip of the cans. FSD stated she and the supervisors were responsible for checking the cans every morning. The FSD confirmed that the two dented cans should have been removed.Emergency Supply Room:-Observed the dark room with one lightbulb. The FSD confirmed that the lighting was too dark in the room.-Observed six boxes of disposable lids, close to the ceiling tiles, less than six inches (regulation-18 inches). The FSD confirmed that the boxes were too close to the ceiling.On 4/6/26 at 10:54 AM, on the second kitchen tour with the FSD and the Regional [NAME] President of Dietary Operations (RVPDO), the surveyor observed:The Emergency Supply Room:-Observed the room in total darkness, no light in the room. The surveyor asked what would happen if there was an emergency that day. The RVPDO obtained a flashlight and confirmed that needed to be fixed right away.-Observed all the boxes of supplies and items stored less than four inches from the floor. The RVPDO confirmed it should be six inches off the floor as per regulation.On 4/7/26 at 10:06 AM, the surveyor checked the Nursing Units for the Resident Nutritional Refrigerators for compliance. The surveyor observed in the presence of the License Practical Nurse (LPN), Unit 4 Resident Nutritional Refrigerator, the freezer was missing a thermometer and observed heavy accumulation of ice. The LPN confirmed that there should be no ice buildup and would find out who was responsible for cleaning the refrigerator. The LPN also confirmed that the freezer should have a thermometer.On 4/7/26 at 10:14 AM, the surveyor observed the Unit 2 Resident Nutrition Refrigerator, in the presence of the Registered Nurse (RN), the refrigerator temperature (temp) was 48 degrees. Observed residents' food and items in the refrigerator. The RN confirmed the temp was too high. The surveyor observed the freezer with seven ice packs and revealed heavy ice buildup. The RN removed all items and stated that the freezer needed to be cleaned. The surveyor asked the Director of Nursing (DON) who was responsible for checking the Residents' Nutritional Refrigerators in the Nursing Units and she stated that nursing was responsible for cleaning them at night.On 4/7/26 at 10:20 AM, the surveyor observed the Resident Nutrition Refrigerator in Unit 1, the refrigerator was open, with heavy ice buildup in the freezer and actively being cleaned by nursing staff.On 4/8/26 at 10:16 AM, the survey team met with the License Nursing Home Administrator (LNHA) and the DON and the surveyor notified them of the concerns found during the kitchen tour.On 4/8/26 at 1:37 PM, the survey team met with the DON and the LNHA provided pictures of new pans purchased, clean dual ovens, a thermometer in the freezer, boxes in the emergency storage room with appropriate distance from the ceiling and floor, lighting in the room, undented cans, and in-services for cleaning Resident Nutritional refrigerators. The LNHA confirmed all responses that were provided were after surveyor's inquiry.A review of the facility's Kitchen and Sanitation Policy, dated 5/25/25, revealed under Policy Statement, All kitchen areas, equipment, and workstations must be cleaned and sanitized routinely to prevent contamination and ensure safe food handling practices . Under Procedures: #2 Weekly Deep Cleaning, Deep cleaning includes: Cleaning and sanitizing all kitchen equipment (ovens, stoves, refrigerators, etc.) .A review of the undated facility's Food Receiving and Storage Policy, revealed under Dry Food Storage #3, Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use . #5 Food in designated dry storage areas are kept at least 6 inches off the floor.and clear of sprinkler heads.Under Refrigerated/Frozen Storage #1 revealed, All foods stored in . freezer are covered, labeled and dated.Under Foods and Snacks Kept on Nursing Units #3 revealed,. must have working thermometers and are monitored for temperature according to state-specific guidelines .A review of the undated facility's Refrigerators and Freezers Policy revealed under Policy Interpretation and Implementation #7 All food is appropriately dated to ensure proper rotation. #10 Supervisors inspect refrigerators and freezers.for. excess condensation. or maintenance needs .A review of the facility's Food Storage Labeling, Storage, and Use Policy (Dented Cans), dated 5/24/25, revealed under Procedure #1 Upon receiving (Unopened Cans), check all cans for: Integrity (no dents, swelling, or damage) . A review of the facility's Safe Environment Policy dated 5/1/25, revealed under Procedure #12 The facility will maintain adequate lighting levels in all areas suitable to tasks. the facility staff must perform .NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 18 residents reviewed for accommodation of needs (Resident #4), and was evidenced by the following:On 4/2/26 at 11:25 AM, the surveyor observed Resident #4 seated in a wheelchair (w/c) in the atrium. On 4/7/26 at 11:30 AM, the surveyor observed Resident #4 seated in a w/c in their room watching television. The surveyor observed the resident's call bell (used to summon staff assistance) on the floor, behind the bed, not within the Resident's reach. The surveyor asked Resident #4 how they would call for staff assistance if needed. Resident #4 replied that they needed the call thing and would not be able to call for help without it. At that time, the surveyor observed Resident #4 reach their left hand to feel around the bed for their call bell and replied, See, I don't have it. The surveyor reviewed the Medical Record for Resident #4. A review of the admission Record or face sheet (an admission summary) reflected that Resident #4 was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus (a chronic metabolic disorder characterized by consistently high blood sugar levels), hemiplegia(paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, and aphasia (a language disorder that usually results from a brain injury) A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 2/3/26, reflected that the resident was dependent on staff for activities of daily living (ADL) care. A review of Resident #4's care plan report reflected a focus area that included the resident was at risk for falls related to right hemiplegia, unsteady balance, seizures, and muscle spasm relaxant in use with interventions that included but were not limited to; Place call light within reach while in bed or close proximity to the bed. On 4/8/26 at 10:12 AM, the survey team met with the Director of Nursing and Licensed Nursing Home Administrator (LNHA) to discuss the above observations and concerns. A review of the facility's Call Bells policy dated 5/1/25, reflected that the purpose of the policy was to.Ensure residents can reliably request assistance via call bells, promoting safety, dignity, and timely care.Call bells must be beside every resident's bed, within arm's reach. On 4/9/26 at 1:07 PM, no further information was provided by the LNHA. NJAC 8:39-27.1 (a); 31.8 (c) (9)

Based on observation, interview, and review of other pertinent record, it was determined that the facility failed to post the required prior years' State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public.The deficient practice was evidenced by the following: On 4/7/26 at 3:09 PM, the surveyor located the State of New Jersey inspection results binder near front entrance of the building. The surveyor reviewed the contents of the binder which revealed the following: The State of New Jersey inspection results binder contained the results for the survey dated 11/25/24, and did not contain any other results for any other surveys in the past three years. On 4/8/26 at 10:12 AM, the survey team met with the Licensed Nursing home Administrator (LNHA) and Director of Nursing (DON) to discuss the above concerns. The surveyor asked the LNHA who was responsible for keeping the State of New Jersey inspection results binder up to date. The LNHA responded that they were responsible, or they would delegate the receptionist to do it. The surveyor asked if they were of the regulations and that the binder was incomplete. The LNHA admitted to the surveyor that they noticed that it was incomplete and were going to update it. On 4/8/26 at 1:37 PM, the survey team met with the DON and the LNHA stated that the inspection binder was updated with past three years and any complaint survey results. The LNHA did not provide any further information. NJAC 8:39-9.4(b)(c)

Based on interview, record review, and review of facility documents, the facility failed to follow the physician order with regard to monitoring side effects and behaviors in accordance with professional standards of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #96). This deficient practice was evidenced by the following: On 4/7/26 at 11:43 AM, the surveyor observed Resident #96 seated in a chair in the resident's room watching television and using a smart phone. The resident did not express any concerns. A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; anxiety disorder, bipolar disorder, opioid abuse, alcohol abuse, chronic obstructive pulmonary disease, and diabetes mellitus. A review of the admission Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date of 4/2/26, indicated Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the physician orders (PO) included:-A PO dated 4/1/26, clonazepam 1 milligram every 12 hours as needed (PRN) for anxiety. -A PO dated 3/26/26, psychotropic medication (med) monitoring, including observation for side effects (s/e) every shift with documentation of Y if present and N if none observed. -A PO dated 3/27/26, behavior monitoring every shift with required documentation of frequency and intensity using a coded system (0, 1, or 2). A review of the care plan (CP) dated 3/26/26, indicated the resident received anti-anxiety medications (meds) and required monitoring for effectiveness and s/e every shift, as well as documentation of target behaviors per facility protocol. On 4/7/26 at 12:37 PM, the surveyor reviewed the electronic Medication Administration Record (eMAR) and behavior monitoring documentation and revealed that the s/e monitoring was not documented in accordance with the PO. Staff documented check marks above initials instead of documenting Y or N as required. Further review revealed that behavior monitoring was not documented in accordance with PO. Staff documented yes or no instead of using the required coding system (0, 1, or 2), which did not allow for accurate assessment of frequency or intensity of behaviors. On 4/7/26 at 12:43 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that s/e monitoring and behavior monitoring were not documented according to the facility's required coding system. On 4/7/26 at 1:04 PM, the surveyor reviewed the progress notes (PN) and revealed that the resident frequently requested clonazepam for anxiety and staff documented the med as effective. However, there was no corresponding accurate behavior monitoring or s/e monitoring documentation to support evaluation of med effectiveness or potential adverse effects. A review of the facility's Psychotropic Medication and Behavior Monitoring Policy, dated 5/1/25, indicated staff were required to monitor and document behaviors using defined coding for frequency and intensity, and monitor and document s/e every shift using 'Y' or 'N' designations . No further information was provided by the DON. NJAC 8:39-29.3

Complaint #182228Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 5 residents (Residents #12 and #80) observed for incontinence care on 1 of 2 Nursing units (Wing 2).This deficient practice was evidenced by the following: On 4/6/26 at 7:15 AM, the surveyor conducted an incontinence tour on Wing 2 Nursing Unit and observed the following: On 4/6/26 at 7:25 AM, the surveyor, accompanied by the Certified Nursing Assistant #1 (CNA #1), observed Resident #80 in bed. CNA #1 exposed Resident #80's incontinence brief and observed a second incontinence brief in place, both were saturated with urine. CNA #1 confirmed that the two briefs were saturated and that the resident should not have had two briefs on. At that same time, Resident #80 stated that they had not been changed since last night and had not requested to have two briefs. The surveyor reviewed the medical record for Resident #80. A review of the admission Record (AR) or face sheet (an admission summary) reflected that Resident #80 was admitted to the facility with diagnoses that included but were not limited to, pressure ulcer of the sacral region (lower back) stage 3 (full-thickness skin loss) and malignant neoplasm of the breast. A review of the Annual Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. The MDS further assessed that Resident #80 was always incontinent of bowel and bladder and required staff assistance for personal hygiene. A review of Resident #80's Care Plan (CP) had a focus area which indicated that the resident was incontinent of urine and stool, with interventions that included the following:Encourage the resident to use the toilet upon awakening, after meals, nightly, and when neededMonitor for skin irritation and report as indicatedProvide skin care after each incontinence episode and apply a moisture barrierProvide verbal cues and physical assistance as neededPT/OT (Physical Therapy/Occupational Therapy) as needed. There was no documentation indicating that Resident #80 requested two adult incontinence briefs. 2. On 4/6/26 at 7:30 AM, Resident #12 approached the surveyor and CNA #1 in the hallway on Wing 2 Nursing unit and asked to have their diaper changed. The surveyor observed that the resident's clothing was heavily soiled and disheveled. CNA #1, the surveyor, and Resident #12 entered the resident's room. CNA #1 exposed Resident 12's incontinence brief, which was down by their knees and heavily soiled with copious amounts of dried and wet feces. The surveyor observed that the resident had a urinary catheter in place. The resident told CNA #1 that they had not had their brief or clothing changed since Saturday. The CNA confirmed that the brief was heavily soiled with feces and that it did not appear the resident had received care recently. The surveyor reviewed the medical record for Resident #12. A review of the AR reflected that Resident #12 was admitted to the facility with diagnoses that included but were not limited to, bipolar disorder, neuromuscular dysfunction of bladder (nerve damage causing urinary urgency or urinary retention) and the need for assistance with personal care. A review of the Quarterly MDS, with an assessment reference date of 3/3/26, reflected that Resident #12 had a BIMS score of 14 out of 15, indicating the resident's cognition was intact. Further review of the MDS indicated that the resident had no behaviors of rejecting assistance with care, had an indwelling urinary catheter, and was frequently incontinent of their bowels. A review of Resident #12's CP had a focus area which included that the resident was incontinent of their bowels with interventions that included but were not limited to assist the resident with perineal care as needed. On 4/6/26 at 8:10 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) for Nursing Units Wing 1 and Wing 2 confirmed that staff should provide incontinence care every two hours on all shifts and that if a resident refused incontinence care, the CNA should inform the nurse. The LPN/UM confirmed that she had not been informed that Resident #12 had refused care. On 4/6/26 at 11:00 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that incontinence care should be provided every two hours on every shift and that if Resident #12 had refused incontinence care, the 11-7 CNA should have informed the nurse. On 4/8/26 at 10:12 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. On 4/9/26 at 7:56 AM, the surveyor attempted a phone interview with the 11:00 PM-7:00 AM Certified Nursing Aide #2 (CNA #2). CNA #2 did not return the surveyor's call. On 4/9/26 at 8:10 AM, during an interview with the surveyor, CNA #1 stated that Resident #12 never refused care and always allowed her to assist them with incontinence care. A review of the facility's Activities of Daily Living (ADLs), Supporting reflected .Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs .Residents who are unable to carry out ADLs independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate. On 4/9/26 at 1:06 PM, no further information was provided by the LNHA. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, review of medical records, and other pertinent documentation, it was determined that the facility failed to ensure that the resident received care consistent with professional standards of practice to prevent pressure ulcers and promote healing by failing to, a.) ensure that the pressure reducing low air loss mattress was set according to resident's body weight for 1 of 3 residents (Resident #5) and b.) administer treatment according to physician order and document for 1 of 3 residents (Resident #49). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 4/2/26 at 11:30 AM and 4/8/26 at 8:20 AM, Surveyor #1 (S #1) observed Resident #5 in bed with a specialty mattress in place. The resident's air mattress pump was set to a weight of 220 pounds (lbs). The surveyor reviewed the electronic medical record (EMR) for Resident #5. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #5 reflected the resident was admitted with diagnoses that included but were not limited to, fracture of the right femur (break in the thigh bone) and dementia ( a progressive decline in mental ability, such as memory and reasoning). A review of the admission Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/27/26, indicated that Resident #5 had a brief interview for mental status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the resident weighed 100 lbs, was at risk for developing a pressure ulcer, and had a pressure-reducing device on their bed. A review of the resident's most recent weight on 4/7/26 was 100.7 lbs. A review of the current Order Summary Report (OSR) reflected a physician's order (PO) for a low-air-loss mattress, with the function to be checked every shift. A review of the current electronic Treatment Administration Record (eTAR) included documentation indicating that the specialty mattress was monitored for function by nurses every shift. A review of Resident #5's Care Plan (CP) indicated the resident was at risk for alteration in skin integrity with interventions that included but were not limited to preventative skin measures as ordered. The above CP interventions did not include a low-air-loss mattress. On 4/9/26 at 10:20 AM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON confirmed that the specialty mattresses were ordered for residents with pressure ulcers or at high risk of skin breakdown, and that it was the nurses' and CNAs' (Certified Nursing Aide's) responsibility to ensure the mattress pumps were set to the appropriate weights. A review of the facility's Air Mattress (Pressure Redistribution Surface Policy, dated 5/1/25, reflected .Compliance with New Jersey and federal regulations by providing appropriate use, monitoring, and management of air mattresses (pressure redistribution surfaces) to prevent and treat pressure injuries in nursing homes.Set mattress according to the resident's weight per manufacturer guidelines.Verify mattress function and settings at least once per shift.Responsibility of licensed nurses: assessment, care planning, monitoring, and documentation. On 4/9/26 at 1:06 PM, no further information was provided by the LNHA. 2. On 4/6/26 at 10:25 AM, Surveyor #2 (S #2) interviewed Resident #49 in the resident's room while the resident was lying in bed. The resident reported no concerns with skin breakdown and stated the resident had been in the facility for three years. A review of the AR indicated that the resident had diagnoses which included, but were not limited to; congestive heart failure, atrial fibrillation, morbid obesity, chronic obstructive pulmonary disease, and muscle weakness. A review of the quarterly MDS, with an ARD of 3/26/26, indicated Resident #49 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of the wound care consult note dated 11/24/25, which indicated the resident had a right lower leg wound (skin tear), full thickness, with moderate drainage, and required treatment including cleansing with normal saline, application of collagen powder, and covering with bordered foam dressing, to be completed three times weekly and as needed (PRN). A review of the eTAR for November 2025 revealed that from 11/25/25 through 11/30/25 (six consecutive days), there were no nurse signatures documenting completion of ordered wound care treatment for the right lower leg skin tear. The PO, initiated 11/25/25, included: cleanse with normal saline, apply collagen powder, and cover with bordered gauze daily and PRN for wound care. A review of the CP, which included wound care interventions during this time period. On 4/6/26 at 11:24 AM, S #2 interviewed the DON who stated the DON was not present at the time of the incident and would review the record to determine if the missing documentation had been addressed. On 4/6/26 at 12:10 PM, the DON stated there was no documentation to support that the ordered wound care treatment was completed during the six consecutive days. A review of the facility's Wound Care Treatment Policy, dated 5/1/25, indicated that wound care treatments were to be completed as ordered and documented on the Treatment Administration Record to ensure continuity of care and promote healing . No additional information was received from the DON. 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 the physician order with regard to medication with parameter for 1 of 5 residents (Resident #75) reviewed, and was evidenced by the following: On 4/6/26 at 11:10 AM, the surveyor interviewed Resident #75, who was seated on the bed in the resident's room, and voiced out no concern. A review of the medical record for Resident #75, revealed an admission Record or face sheet (an admission summary) indicated diagnoses which included, but were not limited to; congestive heart failure, major depressive disorder with psychotic features, dementia, diabetes mellitus, chronic kidney disease, and hypertension. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 3/10/26, indicated Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the Order Summary Report (OSR) included a physician order (PO) for hydralazine HCl (hydrochloride) 10 milligrams, to be administered three times daily for hypertension (HTN), with instructions to hold for systolic blood pressure (SBP) less than 110. On 4/8/26 at 8:57 AM, the surveyor interviewed the Registered Nurse (RN) on the unit, who described the process for monitoring residents and documenting care, including notifying changes and documenting interventions. On 4/8/26 at 11:34 AM, the surveyor reviewed the electronic Medication Administration Record (eMAR) for documentation of hydralazine parameters documentation as ordered by the physician for January and February 2026, and revealed the following missing nurse signatures for administration of hydralazine on the following dates and shifts:1/13/26 (day shift)1/20/26 (day shift)2/11/26 (day shift)2/16/26 (evening shift) Further review of the medical records revealed there was no documentation in the progress notes (PN) to indicate the medication was administered, held, refused, or otherwise addressed on the above dates. On 4/9/26 at 10:34 AM, the surveyor interviewed the Director of Nursing (DON), who acknowledged awareness of missing signatures on the eMARs and stated that agency nurses had been utilized and that the issue was being addressed with nursing staff. A review of the facility's Medication Administration Policy, dated 5/1/25, reflected that medications must be administered as ordered and documented at the time of administration to ensure accurate tracking and continuity of care . No additional information was provided by the DON. NJAC 8:39-29.3

Based on interview, record review, and review of facility documents, it was determined that the facility failed to, a.) ensure that the Consultant Pharmacist (CP) identified irregularities during the medication regimen review (MRR) recommendations were acted upon and b.) ensure that the attending physician reviewed and documented the clinical rationale when declining a CP's recommendation. This deficient was identified for 1 of 21 residents (Resident #75) reviewed.This deficient practice was evidenced by the following: On 4/6/26 at 11:10 AM, the surveyor interviewed Resident #75, who reported no concerns with care. A review of Resident #75's admission Record or face sheet (an admission summary) revealed that the resident had diagnoses which included, but were not limited to; major depressive disorder with psychotic features, dementia, diabetes mellitus, chronic kidney disease, and hypertension. A review of the quarterly Minimum Data Set(MDS), an assessment tool, with an Assessment Reference Date of 3/10/26, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of physician orders (PO) revealed an order for fingerstick blood glucose monitoring twice daily. Further review of the PO revealed absence of active diabetic medication (med) management requiring such frequency. A review of the CP's Drug Regimen Review (DRR) (also known as the MRR) documentation, dated 12/15/25, included a recommendation stating, Please evaluate the continued need for twice daily fingersticks without coverage since 7/2025 without any current diabetic med. The recommendation was marked as Not Accepted by the physician; however, there was no documented rationale in the medical record to support the decision. Further review of the medical record revealed: No physician progress note (PN) addressing the CP's recommendation, and no documentation explaining the clinical reasoning for continuing twice daily fingerstick monitoring. On 4/8/26 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON), who stated, there should be a rationale if the recommendation is not followed, and acknowledged that this was a quality of life concern. On 4/9/26 at 10:31 AM, the DON stated that after discussion with the physician, the order for twice daily fingersticks was discontinued. No additional information was provided by the DON. NJAC 8:39-29.3

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 4 residents. There were 28 opportunities for error, 3 errors were observed which calculated to a med administration error rate of 10.7%. This deficient practice was identified for 3 of 4 residents, (Resident #46, Resident #63, and Resident #84), that was administered meds by 2 of 3 nurses that were observed.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 4/6/26 at 9:22 AM, the surveyor observed the Licensed Practical Nurse #1 (LPN#1) prepare meds for Resident #84. The meds included an active physician's order (PO) for vitamin D3 oral tablet (tab) 50 mcg (microgram), give 1 tab by mouth one time a day for supplement. The surveyor observed LPN #1 looking for the Vitamin D3 oral tab 50 mcg in the med cart. LPN#1 stated that they did not see it, but it should be a stock med. The surveyor then observed LPN#1 prepare Vitamin D3 oral tab 25 mcg, two tablets (tabs) and administer to the resident with other due meds. The surveyor asked LPN#1 if they had the other med available. LPN#1 stated that they would have to change the order. On 4/6/26 at 9:38 AM, the surveyor observed Licensed Practical Nurse #2 (LPN #2) prepare meds for Resident #46. The meds included an active PO for tecfidera capsule (cap) delayed release (DR) 240 mg (milligram), give 1 cap by mouth two times a day for multiple sclerosis DO NOT CRUSH MEDICATION. The surveyor observed LPN #2 remove the med bottle from a plastic bag that had a pharmacy label attached with an additional information label that reflected, do not crush or open. The surveyor observed LPN #2 remove a cap, open it and sprinkle over applesauce for administration to the resident. The surveyor observed LPN #2 administer due meds to the resident. On 4/6/26 at 9:47 AM, the surveyor observed LPN #2 prepare meds for Resident #63. The meds included an active PO for voltaren gel 1% (Diclofenac Sodium) apply to both knees topically two times a day for chronic pain 4 gram dose. The surveyor observed LPN #2 take the tube of med and squeeze out an undetermined amount into a plastic dosage cup. The surveyor observed LPN #2 bring the cup to the resident with the other due meds. The resident stated that they did not want the voltaren. The surveyor observed that LPN #2 did not administer the voltaren and disposed of it. The surveyor concluded the observation. The surveyor reviewed Resident #84's electronic medical record (eMR). The eMR revealed an Order Summary Report (OSR) that reflected that the resident had an active order for vitamin D3 oral tab 50 mcg, give 1 tab by mouth one time a day for supplement. The eMR also revealed an electronic medication administration record (eMAR) that reflected the same order. The surveyor reviewed Resident #46's eMR. The eMR revealed an OSR that reflected that the resident had an active order for tecfidera caps DR 240 mg, give 1 cap by mouth two times a day for multiple sclerosis DO NOT CRUSH MEDICATION. The eMR also revealed an eMAR that reflected the same order. The surveyor reviewed Resident #63's eMR. The eMR revealed an OSR that reflected that the resident had an active order for voltaren gel 1% (Diclofenac Sodium) apply to both knees topically two times a day for chronic pain 4 gram dose. The eMR also revealed an eMAR that reflected the same order. The surveyor accessed and reviewed the manufacturer prescribing information (PI) for tecfidera. The PI reflected, under dosing Information for tecfidera should be swallowed whole and intact. Tecfidera should not be crushed or chewed, and the cap contents should not be sprinkled on food. On 4/8/26 at 10:12 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns. The surveyor notified the LNHA and DON of the med pass results and the errors. The surveyor asked the DON if staff should follow PO as written, and the DON stated yes. The surveyor asked the DON if it was possible to accurately measure voltaren gel in a plastic dose cup. The DON stated no, the nurse should have used the proper measuring device. The surveyor asked the DON if the staff should follow any cautions and labels on meds or eMAR, and the DON stated yes, the nurse should read and understand all labels and ask if there was a question. On 4/8/26 at 1:37 PM, the survey team met with the LNHA and the DON stated that education was performed to appropriate staff for the concerns found during med pass, and that they reached out to the pharmacy for additional education. A review of the facility's Medication Administration Policy, dated 5/1/25, reflected, under E. a. Long acting or enteric coated dosage forms should generally not be crushed. f. The need for crushing meds is indicated on the resident's chart so that all personnel administering us aware.and the consultant pharmacist can advise on safety alternatives. B. Meds are administered in accordance with written orders of the attending physician. The LNHA did not provide any further pertinent information. N.J.A.C 8:39-29.2 (d)

COMPLAINT NJ#381557REPEAT DEFICIENCYBased on observation, interview, and record review, it was determined that the facility failed to ensure the safe and appetizing temperatures of food were appropriately served to the residents. This deficient practice was identified for 5 of 18 residents residing on 3 of 4 Nursing Units, including during the 4/7/26 Resident Council group meeting, and confirmed during the lunchtime meal service on 4/6/26 on a test tray tested for food temperatures (common room).This deficient practice was evidenced by the following:On 4/6/26 at 11:25 AM, Surveyor #1 (S #1) observed the meal prep, tray line in the main kitchen, in the presence of the Food Service Director (FSD) and the Regional [NAME] President of Dietary Operations (RVPDO) for food temperatures. The FSD calibrated the thermometer in ice to 41 degrees Fahrenheit (F), and she stated that it should be 41 degrees F. S #1 asked what the regulation was, and the RVPDO responded that the thermometer in ice should be calibrated to 0 degrees F. The RVPDO then stepped away and came back with another thermometer and stated that the calibration should be 32 degrees F. The surveyor requested for a test tray to be on the first cart (common room) and prepared last so that food temperature (temp) could be checked.On 4/6/26 at 11:53 AM, S #1 in the presence of the FSD followed the 1st tray cart delivered to residents in the common area. On 4/6/26 at 12:06 PM, S #1 observed all the trays passed to all the residents in the common room (13 minutes). S #1 conducted a temp test on the last test tray on the 1st cart and found the following: Regular Tray:-meatloaf 128 degrees F-vegetables 104 degrees FThe RVPDO confirmed the temperatures taken by the FSD, and stated, the temperatures were off, and the food should be hotter than that. He then stated that they were trying to figure out with the nursing department the best way to deliver the meal trays so that they hold hot.On 4/7/26 at 9:19 AM, S #1 reviewed the grievances from 1/2025-3/2026, which revealed an anonymous grievance dated 1/8/25 regarding a meal was cold and was reported to the Administrator and resolved by temp taken at start of meal tray line and audits were done randomly. A grievance by an unknown resident dated 9/25/25, with complaint of cold food and the resolution was extra plate warmers were ordered and to have available staff during meals to pass trays out timely. On 4/7/26 at 9:19 AM, Surveyor #2 (S #2) reviewed the previous three months of Resident Council Minutes which revealed on 1/7/26, prior concerns were dietary with meal trays, food arriving cold.On 4/7/26 at 10:00 AM, S #2 conducted Resident Council Meeting with five unsampled residents who were alert and oriented (Residents # 30, #44, #50, #56, and #66) chosen by the facility to attend. 4 of 5 residents stated food was still arriving cold and one stated food was lukewarm and not hot; for breakfast, the food was always cold and had not improved; other meals if they ate in their rooms were cold; coffee was ice cold, oatmeal cold; 5 out of 5 residents stated they observed that food sits on the units for sometimes up to forty-five minutes before it was delivered to the residents.On 4/8/26 at 10:18 AM, the survey team met with the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON) regarding the temp of the food on the test tray and the residents in the Resident Council meeting stating cold breakfast and cold food.On 4/8/26 at 1:37 PM, the team met with the DON and the LNHA provided pictures of food temp taken on a test tray of pureed foods in the Unit 4 lunch meal; provided temp logs of a meal prep tray line for February and March 2026. S #1 notified the LNHA that the out of compliance test tray was observed and confirmed when temp were taken in the common room area. No additional information was provided by the LNHA. A review of the undated facility's Food Preparation and Service Policy revealed under Policy Interpretation and Implementation #1, Danger Zone means temp.below 135 degrees F that allow the rapid growth of pathogenic microorganisms that cause foodborne illness . Under Food Preparation, Cooking and Holding Time/Temperatures #5 revealed, Food thermometers used to check food temperatures are . calibrated for accuracy .NJAC 8:39-4.1,17.4(a)2

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 facility 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 4/2/26 at 8:50 AM, upon arrival at the facility, the surveyor observed a sign outside the facility which reflected a different name of facility that was registered in the CMS profile of the facility. On 4/2/26 at 9:30 AM the surveyor asked the Interim Licensed Nursing Home Administrator (ILNHA) for any documents associated with the facility name change. On that same date at 11:00 AM, the ILNHA stated that they could not provide any of the requested documents because only the owners had access, and they were not available. The ILNHA further stated that they did not have a business card to provide, but the Director of Nursing (DON) was able to provide one. The DON's business card revealed that the facility name on the card was listed was not according to the facility's registered name. A review of the DON provided Daily Acuity Tracking Form that reflected the unregistered facility name on the cover page. A review of the ILNHA provided Resident Trust Fund Surety Bond document reflected the unregistered facility name as principal with a date of 12/8/25. On 4/6/26 at 10:29 AM, the surveyor met with the [NAME] President of Operations (VPO). The surveyor asked for any documentation associated with the facility name change and when the facility was acquired by the new company. The VPO stated that the building was acquired 12/8/25. On that same date at 11:41 AM, the VPO provided copies of emails that reflected communication to the Department of Health (DOH) regarding application for a Transfer of Ownership for a long-term care facility. The emails also revealed a date of 12/26/25 for the initial application. The surveyor asked the VPO if there were any further documents notifying CMS about the name change. The VPO stated there were no further documents. NJAC 8:39-5.1 (a)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and follow appropriate infection control practices, for 1 of 3 nurses observed during the medication administration observation in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy.The deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: . Immediately after glove removal. On 4/6/26, the surveyor observed the Licensed Practical Nurse (LPN) assigned to Resident #46 and Resident #63 during the medication administration observation (med pass). At 9:38 AM, the surveyor observed the LPN prepare to administer due medications (meds) to Resident #46. The surveyor observed that the resident was going to receive an eye drop medication (med) as part of the due meds. The surveyor observed the LPN don (apply) gloves but did not observe any hand hygiene procedures with use of alcohol base hand rub (ABHR) or handwashing. The surveyor observed the LPN dropped a tablet (tab) on the ground, removed gloves, don a new set, picked up the tab with the old set and dispose of the tab, then dispose of both sets of gloves. The LPN then donned gloves a third time. The surveyor then observed the LPN entered the resident's room and administer due meds including the eye drops. The surveyor observed the LPN use the same tissue to pat the area under the resident's eyes after eye drop administration. After med administration, the surveyor observed the LPN moved the resident's over bed table by the resident's request. The LPN did not change or remove gloves. The LPN then exited the room, returned to the med cart, removed and disposed gloves. The LPN then moved on to the next resident. The surveyor did not observe any hand hygiene performed. On 4/6/26 at 9:47 AM, the surveyor observed the LPN prepare to administer due med to Resident #63. The surveyor observed that the resident was going to receive an eye drop med as part of the due meds. The surveyor observed the LPN don gloves but did not perform any hand hygiene. The surveyor observed the LPN administered eye drops to the resident. The LPN did not have a tissue for the resident. The surveyor observed the LPN removed a brown paper towel from the bathroom dispenser and hand it to the resident. The LPN returned to the med cart, removed and disposed of the gloves. The surveyor did not observe any hand hygiene performed. The surveyor reviewed the electronic medical record (eMR) for Resident #46. The eMR revealed the following: A review of the admission record (AR) or face sheet (an admission summary), which reflected that the resident was admitted to the facility with diagnoses including but not limited to, multiple sclerosis (a chronic autoimmune disease of the central nervous system) and dysphagia (difficulty swallowing). A review of the quarterly minimum data set (QMDS) (an assessment tool), with an assessment reference date (ARD) of 2/5/26, Section C-Cognitive Patterns had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated that the resident had moderate cognitive impairment. A review of the Order Summary Report (OSR) that reflected that the resident had an active order for loteprednol eye drops scheduled for 9:00 AM (9 AM) administration period. The surveyor reviewed the eMR for Resident #63. The eMR revealed the following:A review of the AR, which reflected that the resident was admitted to the facility with diagnoses including but not limited to, hypothyroid (underactive thyroid gland) and essential hypertension (high blood pressure). A review of the QMDS with and ARD of 3/5/26, Section C, BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. A review of the OSR that reflected that the resident has an active order for artificial tears eye drops scheduled for 9 AM administration period. On 4/8/26 at 10:12 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns, and the surveyor notified them of the med pass observations regarding hand hygiene and infection control. The surveyor asked the DON if staff should perform hand hygiene before and after gloves. The DON stated yes, the staff should either use sanitizer or wash with soap and water. The surveyor asked DON if the staff should use ABHR before giving eye drops. The DON stated no, the nurse should use soap and water before giving eye drops. The surveyor asked the DON if the staff use a clean tissue for each eye when giving eye drops. The DON stated yes. On 4/8/26 at 1:37 PM, the survey team met with the LNHA and the DON stated that education was performed to appropriate staff for the concerns about hand hygiene and infection control. On 4/9/26 at 9:16 AM, the surveyor interviewed the facility Infection Preventionist (IP). The surveyor asked the IP about the process and procedures for hand hygiene with glove use and when giving eye drops. The IP stated that the staff must wash with soap and water or use ABHR before and after gloves, except when giving eye drops, then it must be hand washing. The staff must wash hands after ABHR was used three times. The surveyor asked the IP if separate tissues should be used for eye drops. The IP stated that separate tissues should always be used if giving drops in both eyes. The surveyor asked if a paper towel was a substitute. The IP stated, no, it is not appropriate and may be too rough. The LNHA did not provide any further pertinent information.A review of the facility's Hand Wash Policy and Procedure, dated 5/1/25, the policy did not reflect any mention of hand hygiene with the use of gloves or when giving eye drops. A review of the facility's Medication Administration Policy, dated 5/1/25, reflected under Administration, G. Hands are washed, or hand sanitizing is used before and after administration of.ophthalmic.meds . NJAC 8:39-19.4(n)

Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia (PNA) vaccination. This deficient practice was identified for 1 of 5 residents, (Resident #68), reviewed for vaccination status and was evidenced by the following:On 4/2/26 at 12:18 PM, the surveyor observed Resident #68 walking around in their room. The resident stated no concerns and that they were admitted from hospital. A review of Resident #68's hybrid medical record (both electronic and paper chart), revealed in the admission Record or face sheet (an admission summary) the following diagnoses that included but were not limited to hypotension (low blood pressure), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 1/30/26 revealed a Brief Interview Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Section O-Special Treatments, Procedures and Programs, indicated pneumonia vaccine not offered. Further review of the hybrid medical record revealed no declination form for PNA vaccine.On 4/6/26 at 10:20 AM, the surveyor requested from the Assistant Director of Nursing/Registered Nurse (ADON/RN), to provide information regarding PNA vaccine for Resident #68. On 4/6/26 at 1:25 PM, in the presence of the survey team, the ADON/RN stated, he did not have the PNA vaccine information and would call the Resident Representative (RR) to get information. The surveyor asked, if all residents admitted including current residents should have vaccine information, and what the facility process for vaccines was. The ADON/RN stated, We should be asking the RR or resident for information and offering the vaccines.On 4/7/26 at 12:23 PM, the Director of Nursing (DON) stated that the RR did not have any information on the PNA vaccine and when it was offered, the RR was undecided. The surveyor asked if all residents should have vaccine information or offered and DON confirmed, Yes, they should have a history or some information in their medical records. On 4/8/26 at 10:45 AM, the survey team met with the License Nursing Home Administrator (LNHA) and DON regarding the concern with PNA vaccine not being offered.On 4/8/26 at 12:03 PM, the DON provided PNA vaccine declination form, and stated it was done after surveyor's inquiry. The DON confirmed there was no previous documentation in the medical records regarding refusal of PNA vaccines. A review of the facility's Infection Control Pneumococcal Immunizations for Residents Policy, dated 5/1/25, revealed under Intent, it is the policy of the facility to ensure that the resident receives . Pneumococcal immunizations, in accordance with State and Federal Regulations, and national guidelines . Under Procedure: Pneumococcal Immunization #2 revealed Each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated.NJAC 8:39-19.4 (i)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #81).The deficient practice was evidenced by the following:On 4/2/26 at 12:28 PM, the surveyor observed Resident #81 in the common room area with a Certified Nursing Assistant (CNA) reading the chronicle to the resident.On 4/6/26 at 10:08 AM, the surveyor reviewed Resident #81's hybrid (paper and electronic) medical records which revealed the following information: A review of the resident's admission Record or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; unspecified dementia, severe, with other behavioral disturbance; mild neurocognitive disorder due to known physiological condition with behavioral disturbance; and Alzheimer's disease. A review of the Annual Minimum Data Set (MDS), an assessment used to facilitate the plan of care, with an assessment reference date (ARD) of 1/21/26, revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment; and COVID-19 vaccination status showed resident was not up to date.A review of the care plan (CP) revealed a focus that the resident had impaired cognitive function related to a condition other than delirium: dementia, date initiated, 12/29/23.Further review of the hybrid medical records revealed there was no documented evidence that the resident had refused COVID-19 and the resident or Resident Representative (RR) had an an opportunity to receive education and decline the COVID-19 vaccine. On 4/6/26 at 10:20 AM, the surveyor requested from the Assistant Director of Nursing/Registered Nurse (ADON/RN) to provide information regarding COVID-19 vaccine for Resident #81. On 4/6/26 at 1:25 PM, in the presence of the survey team, the ADON/RN stated, he did not have the COVID-19 vaccine information and would call the RR to get the information. The surveyor asked, if all residents admitted including current residents should have vaccine information, and what was the facility's process for vaccines. The ADON/RN stated, We should be asking the RR or resident for information and offering the vaccines.On 4/7/26 at 12:23 PM, the Director of Nursing (DON) stated that the office of legal guardian who was covering was not aware of the resident's COVID-19 vaccine status for 2025, or if it was offered but would give consent for it to be administered today. The surveyor asked if all residents should have vaccine information or should be offered and the DON confirmed, Yes, they should have a history or some information in their medical records. On 4/8/26 at 10:45 AM, the survey team met with the License Nursing Home Administrator (LNHA) and DON regarding the concern with COVID-19 vaccine not being offered.On 4/8/26 at 1:37 PM, the survey team met with the LNHA and the DON stated that the legal guardian signed the consent for the vaccine and would be given tomorrow. The DON confirmed that the consent was obtained after surveyor's inquiry.A review of the facility's Covid Vaccination-Residents Policy, dated 5/1/25, revealed under Policy, Residents will be offered the COVID-19 vaccination Ensuring Long Term Care (LTC) residents receive COVID-19 vaccinations will help protect those who are most at risk of severe infection or death from COVID-19. Residents and/or RR will be educated regarding the benefits and potential side effects associated with the COVID-19 vaccine .Under Procedure, Offering Vaccination #1 Residents will be offered vaccination against COVID-19 NJAC 8:39-19.4(a)

Based on observation, interview, and review of pertinent documents, it was determined the facility failed to maintain a clean, safe, and sanitary environment in 2 of 4 Nursing units (Wing 1 and Wing 2), and was evidenced by the following: 1. On 4/2/26 at 11:40 AM, during environmental rounds on Wing 1 nursing unit, Surveyor (S #1) observed a strong malodorous urine smell in room [ROOM NUMBER]. S #1 observed that the bathroom floor and shower area were heavily soiled with a yellow-brown substance. The floor tiles by the room's entrance were stained and broken. On 4/6/26 at 7:40 AM, S #1 and the Licensed Practical Nurse/Unit Manager (LPN/UM) entered room [ROOM NUMBER]. The LPN/UM confirmed a strong malodorous urine odor upon entering. On 4/7/26 at 10:00 AM, during the Resident Council Meeting, an unsampled Resident who resided in room [ROOM NUMBER] stated that their roommate was discharged last week and that all of their personal items, including used towels and toiletries, were still in the bathroom. On 4/7/26 at 12:00 PM, S #1 entered room [ROOM NUMBER] and observed that the shower chair, shower area, and bathroom floor were heavily soiled, and the bathroom ceiling tiles were cracked and in disrepair. S #1 observed two towels hanging in the bathroom and two basins full of used toiletries in the bathroom. The resident confirmed that those items belonged to their former roommate. On 4/7/26 at 12:05 PM, S #1 showed Certified Nursing Assistant #1 (CNA #1) the towels and basins filled with used personal items. CNA #1 confirmed that the resident's roommate had been discharged sometime last week and that the CNA should have removed and discarded the roommate's belongings. On 4/7/26 at 12:20 PM, S #1 presented the above concerns to the Director of Housekeeping (DHK). The DHK stated that the rooms were cleaned daily and that they appeared to need a deep cleaning, which should be done every 2-3 weeks. On 4/7/26 at 12:40 PM, during an interview with S #1, the Director of Maintenance stated that the facility staff informs him of areas that need repair using the computerized system. His maintenance staff makes daily rounds in the resident rooms, but he expected them to enter concerns identified as needing repair in the computerized system. On 4/8/26 at 1:38 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The LNHA confirmed that the above observations did not provide a homelike environment and that the facility was working to clean and renovate the resident rooms. A review of the facility's Safe Environment Policy reflected, it is the policy of the facility to provide a safe and clean environment in accordance to State and Federal regulations .The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . On 4/9/26 at 1:07 PM, no further information was provided by the LNHA. 2. On 4/7/26 at 11:35 AM, Surveyor #2 (S #2) observed Resident #10's room, the bedside table, cabinet door out of alignment, falling off; observed the wall behind the chair, the wallpaper was ripped and exposed sheet rock. S #2 interviewed Certified Nursing Assistant #2 (CNA #2) who was in the room, stated that the cabinet door had been like that for a couple weeks. CNA #2 added that the door was not falling off but just not leveled. CNA #2 confirmed that the wallpaper was ripped and sheet rock exposed and stated that she did not pay attention to it because it was not a danger to the resident. On 4/7/26 at 12:12 PM, S #2 observed Unit 2 nursing station entrance to the nursing station, the wallpaper was peeled and ripped. Observed in front of room [ROOM NUMBER], the hallway carpet was stained with brownish substance and ripped. S #2 also observed the double fire doors near rooms [ROOM NUMBERS], the side edges of the wood chipped/splintered. At that same time, S #2 interviewed the Registered Nurse (RN) who was assigned to Unit 2 and showed her the findings above and she confirmed she did not know how long the cabinet door, wall, carpet, wallpapers and door had been like that. On 4/7/26 at 1:01 PM, S #2 interviewed the Maintenance Director, he stated they made rounds daily and they had their own assignments. S #2 and Maintenance Director toured Unit 2 and the areas of concerns and he confirmed he did not know how long it had been like that and should be fixed. On 4/8/26 at 10:35 AM, the survey team met with the LNHA and the DON, and S #2 notified them of the above concerns. On 4/8/26 at 1:37 PM, the survey team met with the DON and the LNHA who stated that the Maintenance Director spackled the wall in room [ROOM NUMBER], fixed the end table, housekeeping looked at the carpet, and maintenance looked at the door and wallpaper on Unit 2 nursing station. A review of the facility's Safe Environment Policy, dated 5/1/25, revealed under Procedure #5 The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public . NJAC 8:39-31.2(e),31.4(a)(e)(f)

REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/18/24 at 10:04 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. On the bottom shelf of a food prep table, next to the dry food storage area, there was a metal tray with 10 bowls of cereal resting on top of boxes of napkin and other utensil supplies. On 1 of the 10 cereals' plastic lid was a clear liquid substance. The surveyor asked the FSD about the observation. The FSD pulled out the metal tray and confirmed the observation. The FSD could not speak to where the liquid came from, and no other areas were wet. 2. On a food prep table across from the walk-in refrigerators, the right side of the table was noted with a small, dried, food debris substance, beige-brown in color. There was no one in area preparing food. The Regional Director of Operations (RDO) who was present at the time acknowledged and stated the staff would clean the table. On the same food prep table on left side of the sink, the surveyor observed a chef knife soiled with white food debris in a metal quarter size pan. There was no one in the food prep area. The RDO called the cook to ask about it, he was not using it for food preparation and took both items to be washed. 3. In the dry rack storage area, the surveyor observed two stacked cooking pots. The manager in training picked up the cooking pots for the surveyor to check. The surveyor observed inside the cooking pot on top of the stack had dry food debris. The manager in training and FSD confirmed that it was soiled and needed to be re-washed. The pot was taken to the dish washing area. On 11/21/24 at 10:25 AM, the surveyor, in the presence of the FSD, toured the kitchen and observed the following: 4. The surveyor observed 4 of the steam table trays uncovered. There was clear water in the compartments and the metals were noted soiled with debris. The surveyor asked the FSD to lift the covers of the last 2 steam table trays. The two compartments also had clear water with the metals noted soiled with debris. The RDO joined the surveyor and FSD, acknowledged they were soiled and that she had just told the staff to clean upon seeing them. The surveyor asked how often the steam table trays were cleaned. The RDO stated they were drained every day and were expected to be cleaned once a week and as needed. On 11/21/24 at 12:47 PM, the surveyor informed the Market President Special Projects (MPSP), the Assistant Director of Nursing (ADON), the Licensed Nursing Home Administrator (LNHA), and the Regional Compliance Advisor (RCA) of the above concerns observed in the kitchen. On 11/22/24 at 02:24 PM, the LNHA, ADON, MPSP, and the RCA met with the survey team. The MPSP stated the observed concerns were cleaned after surveyor observation and education provided to the dietary staff. The area where prepped cereal was stored was moved to a dry storage area to prevent reoccurrence. A review of the facility's policy titled, Warewashing with a last revised date of 9/2017, under Policy Statement indicated: All dishware, serviceware, and utensils will be cleaned and sanitized after each use. A review of the facility's undated policy titled, Equipment, under Policy Statement indicated, All foodservice equipment will be clean, sanitary, and in proper working order. Under Procedures further indicated, .3. All food contact equipment will be cleaned and sanitized after every use .4. All non-food contact equipment will be clean and free of debris . NJAC 8:39-17.2(g)

Based on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 97 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 11/18/24 at 10:04 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). The LNHA stated that the facility's census (the number of residents currently under the care of a specific facility) was 97. A review of the facility's Facility assessment dated [DATE] did not include information about the facility's contingency plan for staffing. A review of the Nurse Staffing Report For the week of Complaint staffing from 9/10/2023 to 9/16/2023, the facility was deficient in CNA (Certified Nursing Aide) staffing for residents on 7 of 7 day shifts. Further review of the Nurse Staffing Report for 2 weeks of staffing prior to survey from 11/03/2024 to 11/16/2024, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts. On 11/20/24 at 10:32 AM, all five residents informed the surveyor during the Resident Council meeting that there were concerns with short staff. All residents stated that the concerns with short staff were previously discussed in other Resident Council meetings and the facility management was aware of it. A review of the 10/21/24 Resident Council Meeting minutes revealed that the Assistant Director of Nursing (ADON) discussed the industry-wide nursing shortages. On 11/25/24 at 9:16 AM, the surveyor interviewed the LNHA regarding FA. The LNHA informed the surveyor that she was unaware of the updates and new memo from CMS (Centers for Medicare and Medicaid Services) about the FA, effective 8/08/24. She further stated that the facility followed the New Jersey (NJ) Mandated law for staffing, and that should be in their FA. The LNHA acknowledged that the FA should address the needs of the residents in the facility. On that same date and time, the surveyor asked the LNHA if she was aware of the short staffing in the facility, and the LNHA responded Yes, and that the facility was not meeting the state-mandated law for staffing which the CNA ratio for 1st shift 1:8, 2nd shift 1:10, and 3rd shift 1:14, and was not meeting the requirements both weekdays and weekends. The surveyor asked the LNHA do they knew how long the facility had not been able to meet the NJ-mandated law, and the LNHA responded Since I started in July 2024. The surveyor asked the LNHA for the following attachments that were not in the provided FA and she said she would get back to the surveyor: -page 43 of 44. Additional Supporting Documents: CMS Facility Assessment-Staff.pdf (date uploaded 8/03/24) -page 44 of 44. Staffing Plan Template (date uploaded 8/15/24) At that time, the surveyor notified the LNHA of the concern that the previously submitted FA did not include information about the contingency plan for staffing. On 11/25/24 at 10:45 AM, the LNHA provided a copy of the Staffing & Personnel and stated that was page 44 of 44 Staffing Plan Template (SPT) and revealed: Nursing: Direct Care License Nurses (Registered Nurses and Licensed Practical Nurses); total # needed, average range, or ratio 20 [Day shift: 5, Evening shift: 6, Night shift: 5] Nurse Aides (CNA); total needed, average range, or ratio 27 [Day shift: 13, Evening shift: 8, Night Shift: 7] The above SPT was based on the FA's census of 97 according to the 9/05/24 records. Further review of the above SPT revealed it did not meet the NJ mandated staffing ratio for CNAs of the Evening shift: 1:10 and revealed: Census: 97 Evening shift 8 CNAs=1:12 (it should be 1:10) On 11/25/24 at 11:25 AM, the surveyor followed up on the attachments for page 43 of 44. A review of the facility's Facility Assessment Policy with review and revised date of 8/15/23 that was provided by the LNHA revealed: Policy: The Center will review and update the assessment annually and whenever there is, or the Center Plans, for any change that would require a substantial modification to any part of the assessment. If there are substantive changes that occur in the Center prior to the annual assessment, the update will occur earlier. On 11/25/24 at 02:46 PM, the survey team met with the LNHA, Director of Nursing, ADON, Market Clinical Advisor, and the RCA for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-5.1(a)

Complaint #: NJ#171636 Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 4 units, (Unit 1 and Unit 3), and 2 of the common areas, (lobby and Unit 3 tub room). This deficient practice was evidenced by the following: 1. During the initial tour of Unit 1 on 11/18/2024 at 11:18 AM, the surveyor observed Resident #80's room with a posted sign of EBP (Enhanced Barrier Precautions; an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). There was a strong smell of urine in front of the resident's door. Inside the room, the surveyor observed the resident lying on a specialized air mattress, with an indwelling catheter covered with a privacy bag, and the resident was dry and clean. The resident informed the surveyor that they were not wet and were changed by an aide today. On that same date and time, the surveyor observed the resident's nightstand table with dried whitish substances on top next to the nebulizer machine, the side of the table with dried whitish substances, and the floor with an accumulation of dust and dried brownish substances. Inside the toilet room, the air vent with accumulation of dust and was grayish to blackish. The windows with accumulation of dust inside and outside and with cobwebs. On 11/19/24 at 8:48 AM, the surveyor asked the Assistant Director of Nursing (ADON) and the Regulatory Compliance Advisor (RCA) to go with the surveyor inside the resident's room. Inside the resident's room, there was a strong smell of urine. The surveyor observed the nightstand table, ceiling tiles, and floor the same as it was observed on 11/18/24. The RCA with gloves brushed off the light on top of the resident's bed and there were reddish stains on RCA's gloves and some dust. The toilet room vent was the same with an accumulation of dust. Later, the Director of Maintenance (DM) came and was notified by the ADON and RCA of the concerns with ceiling tiles. The DM stated that the brownish stains on the ceiling tiles were water drip and should have been changed. Outside the resident's room, the surveyor interviewed the RCA and the ADON. The surveyor asked what the strong smell in the resident's room was, the RCA responded that it was an old urine smell. The ADON stated it was urine. The surveyor also asked why the resident's room had multiple brownish stains on the ceiling tiles, there was an accumulation of dust in the night lights, and floors, stains on the nightstand table and toilet room, and the resident's room stains, and both RCA and ADON had no answer. On 11/20/24 at 12:08 PM, the surveyor interviewed Housekeeper #1 (HK#1), who informed the surveyor that he was aware of the concerns about room [ROOM NUMBER] environment and cleanliness. HK#1 further stated that room [ROOM NUMBER] was cleaned yesterday (11/19/24) after the surveyor's inquiry. On that same date and time, both the surveyor and HK#1 went to room [ROOM NUMBER]. The surveyor and HK#1 observed the floor was clean and with no odor. Inside the toilet room, the air vent was the same when it was observed from day 1 and day 2. The surveyor asked HK#1 how often the vent was being cleaned, and HK#1 responded that usually it was being cleaned by the housekeeper once a week. The windows were not cleaned, it was the same as it was observed from day 1 and day 2. HK#1 stated he would ask the housekeeper to clean it and he acknowledged that if the room was cleaned yesterday, the windows should have also been cleaned. At that same time, the surveyor observed the resident on 113 bed B (near the window) with gauze used as a light string. Outside the room, the surveyor asked HK#1 if it was appropriate for the gauze to be used as a string for the light, and HK#1 did not respond. On 11/21/24 at 12:44 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), ADON, RCA, and Market President Special Project (MPSP). The surveyor notified the facility management of the above concerns about the environment tour from day 1 to 3rd day for room [ROOM NUMBER] where Resident#80 resided. 2. On 11/19/24 at 8:43 AM, the surveyor observed Resident #57 in the atrium during breakfast seated in a wheelchair (w/c). Resident # 57's bilateral w/c armrests with cracks and some areas were covered with white tape. 3. On 11/19/24 at 11:07 AM, the surveyor toured the lobby area (reception area) and the Receptionist was at the desk, there were scattered 20 ceiling tiles with dried brownish discoloration and some with fading brownish colors. The Receptionist stated that the facility was an old facility and Bear with us, we are in the process of painting the walls. The surveyor then asked the DM to meet the surveyors in the lobby area for some inquiries. Later on, the DM came, and the surveyor asked the DM what were those dried brownish and fading brownish discoloration on the ceiling tiles. The DM informed the surveyors that those were from the water leak and that some fading colors were from the spray paint that he used to cover the leak. The surveyor then asked the DM why it was being painted instead of correcting the main problem which was the leak considering the 20 ceiling tiles in the lobby area. The surveyor also notified the concern about room [ROOM NUMBER]'s ceiling tiles. The DM stated that the leak was serviced. 4. On 11/19/24 at 01:39 PM, the surveyor reviewed the last three months' resident council meeting minutes that were provided by the LNHA and revealed: -8/15/24: Housekeeping: fruit flies in room [ROOM NUMBER] -9/16/24: residents would like to know who was responsible for cleaning the outside of the windows and when will it be started. -10/21/24: residents voiced concerns with cleaning outside of residents' windows. On 11/20/24 at 10:32 AM, the surveyor met with five residents for the resident council meeting. Five out of five residents stated that the windows were not cleaned and acknowledged that it was reported in previous meetings. 5. On 11/20/24 at 11:50 AM, the surveyor and Licensed Practical Nurse (LPN) from unit 3 observed room [ROOM NUMBER] for an environment tour. The residents were not inside the room. Both the surveyor and the LPN observed the windows. The LPN informed the surveyor that the windows with accumulation of dust and some cobwebs. Both the surveyor and the LPN observed the blinds in the windows were blackish due to accumulation of dust and the LPN stated that they should have been cleaned. The surveyor then asked the LPN to check the overhead light and the LPN asked why she had to check it if the windows were dirty and acknowledged that the light fixture would also be dirty. Inside toilet room [ROOM NUMBER], both the surveyor and the LPN observed one missing tile and one broken tile, and the LPN stated that she would report it to the DM. The surveyor asked why there was no toilet paper inside the room, and the LPN responded that she would ask the housekeeper. On 11/20/24 at 11:56 AM, the surveyor and the LPN went to room [ROOM NUMBER]. The residents were not inside the room. The LPN confirmed the five ceiling tiles with dried brownish discoloration and the LPN stated that she was unsure what the discoloration on the ceiling tiles was. The LPN observed grayish and blackish substances in the windows and the LPN stated and acknowledged those were dust and cobwebs. The LPN further stated that should have been cleaned. The surveyor also asked the LPN why there was no privacy curtain in bed A and the LPN had no answer. The surveyor and the LPN exited the room, and both observed brownish stains on the floor and the carpet near the door of room [ROOM NUMBER]. The LPN stated that she was unsure what was the stain between the door and the carpet. 6. On 11/20/24 at 12:14 PM, the surveyor asked HK#1 if the facility had a common shower room. HK#1 immediately accompanied the surveyor to Unit 3 tub room. The surveyor observed the tub room (also known as the shower room) dark and not well-lit, and the air vent above the sink had an accumulation of blackish-grayish substances. The surveyor asked HK#1 to please open the light and he responded that the lights were on already and the reason it was a little dark was because the light on top of the sink was broken. The surveyor asked HK#1 what those blackish-grayish substances on the vent and he were would not respond. On 11/20/24 at 12:27 PM, the surveyor interviewed the LNHA about the room cleaning and environment of the residents in the facility. The LNHA informed the surveyor that the protocol and practice was to clean daily and schedule for deep cleaning and the schedule was posted in the nursing station. The LNHA further stated that my expectation was that the contracted housekeeping company would provide services and maintain the clean environment of the facility. She stated the ceiling tiles should have been replaced. On that same date and time, the surveyor notified the LNHA of the concern regarding the continuation of the environment tour from day 1 (11/18/24), day 2 (11/19/24) surveyor with the RCA and ADON in room [ROOM NUMBER], and today (11/20/24) with the LPN from unit 3. The surveyor asked the LNHA if it was appropriate to use the gauze in replacement of the light string for Resident #49 in room [ROOM NUMBER], and the LNHA responded that it should be replaced with the better one. The surveyor asked who was responsible for windows inside and outside the room about cleaning, the LNHA responded that it was the responsibility of the contracted housekeeping department as part of their contracts with the facility and that they should be aware of it. The surveyor notified the LNHA of the concern that during the environment tour, HK#1 and HK#2 both stated that it was the housekeeper's responsibility to clean the windows from the inside and that it was the outside vendor's responsibility to clean the outside windows. The surveyor notified the LNHA of the above findings, observations, and concerns in rooms 113, 304, 314, Unit 3 hallway, lobby, and Unit 3 tub room. The LNHA stated that it should not be like that, it should be replaced and repaired. The surveyor showed the picture of the unit 3 tub room, the LNHA confirmed that the tub room vent was not clean and acknowledged that there was an accumulation of dust a grayish substance. On 11/22/24 at 02:24 PM, the survey team met with the LNHA, ADON, RCA, and MPSP. The LNHA stated that the concerns of the surveyor with room [ROOM NUMBER] were corrected and were resolved after the surveyor's inquiry. The MPSP stated that we had scheduled duct cleaning, and we would give you copies of all the documents we explained today including work orders for duct cleaning. The MPSP stated that it should be the contracted housekeeping company's responsibility to clean the windows of residents in the facility both inside and outside. She further stated that as far as the facility knew it was done in August 2024 the window cleaning, but the facility should have checked when it was cleaned. A review of the facility's Resident Rights Under Federal Law Policy with a revision date of 02/01/23 that was provided by the LNHA revealed: Purpose: To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth A review of Resident Rights Under Federal Law dated 11/28/16 that was provided by the LNHA included that on #9 Safe Environment: The resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The facility must provide: 9.1. A safe, clean, comfortable, and homelike environment, allowing the resident to use their personal belongings to the extent possible . 9.2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 9.3. Clean bed and bath linens that are in good condition . 9.5. Adequate and comfortable lighting levels in all areas . A review of the facility's Detail Cleaning Policy with a revision date of 3/01/24 that was provided by the LNHA revealed: Purpose: To ensure an optimal level of cleanliness of patient rooms and to enhance the overall appearance of their environment . A review of the Patient/Resident Transport Wheelchair Cleaning Policy with an effective date of 3/01/24 that was provided by the LNHA included Process: #4. Perform an inspection of the transport wheelchair for any loose, broken, or damaged areas. Remove damaged wheelchairs from service until repairs are completed. Inspect the following: 4.3. side supports and armrests . On 11/25/24 at 02:46 PM, the survey team met with the LNHA, Director of Nursing, ADON, Market Clinical Advisor and the RCA for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-31.4(a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to follow its Grievance/Concern policy and procedure by failing to a.) conduct a formal investigation of a grievance filed by a resident, (Resident #42) and followed through, b.) persisted for 4 of 4 resident council meetings regarding laundry services of the facility, and c.) conduct a formal investigation of a grievance filed by a resident to another resident to determine if abuse had occurred for 1 of 1 resident (Resident #45). This deficient practice was evidenced by the following: On 11/18/24 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) for an Entrance Conference. The LNHA informed the surveyor that the facility's census (total number of residents) was 97. 1. On 11/19/24 at 01:39 PM, the surveyor reviewed the last three months resident council minutes that were provided by the LNHA and revealed: -8/15/24: Council Members in Attendance: 10 Compliments/Ideas/Preferences/Concerns/Suggestions: Laundry: residents wanted to know who to contact with missing clothes. The Infection Preventionist Nurse (IPN) checked with the LNHA and told the residents if items were missing, inform any staff member and they will fill out a grievance form, be sure to list the specifics of each item missing. -9/16/24: Council Members in Attendance: 7 Discussion of Old/Unfinished Business (include resolution of previous concerns) *There was no response for the last month 8/15/24 concerning laundry issues. Reviewed laundry details and what shift was assigned to take the dirty laundry out of the room and what shift was assigned to bring in clean clothes. -10/21/24: Council Members in Attendance: 11 Discussion of Old/Unfinished Business (include resolution of previous concerns) -The missing baseball hat was not located but the resident purchased a new one. Compliments/Ideas/Preferences/Concerns/Suggestions: -no one assumes responsibility for laundry concerns and passes it off to other depts (departments). -The resident council voted to write a petition to the corporate office to reinstate laundry in the building due to the many unresolved issues and concerns they have and the cleanliness of their clothes. -The new Grievance Officer (GO) reiterated that a resident can ask any staff member to assist in completing a grievance, it was not just filled out by the GO. -The 11:00 PM-7:00 AM (11-7) shift was still not taking dirty laundry out to the bins. Further review of the above resident council meeting minutes revealed that the typewritten report was not signed by facility representatives or the resident council members. On 11/20/24 at 10:32 AM, the surveyor met with five residents for the resident council meeting. Resident #27 informed the surveyor that the concern with laundry services continued, we were not aware of where to go when there were laundry concerns, and no go-to person. Five out of Five residents confirmed the ongoing laundry services problem with missing clothes, not receiving their own clothing, mixed matches, and dirty clothes. All residents stated that the residents in the facility had sent out a petition to the corporate office to have the in-house laundry back due to continued problems with laundry services. Resident #54 stated that they had the same problem before, although right now had no issues because they were currently at Skilled Occupational Therapy (OT) wherein their laundry was being done in therapy as part of their treatment. Resident #54 acknowledged that after the OT sessions, they would not be able to do laundry in the therapy room anymore and would go back to offsite laundry services. Resident#52 stated that a couple of times reported that they were missing clothes and Resident #60 reported two pairs of socks a few months back and the facility did not respond to resident updates on missing items. On that same date and time, Resident#42 stated a month ago no clothes to put on, and the 7:00 AM to 3:00 PM (7-3) nurse in Unit 3 was notified of the concerns and helped the resident to find clothes to wear to be able to get up of bed. Residents #52 and Resident #27 confirmed the allegation that Resident #42 had no clothes to put on due to laundry concerns and the nurse at that time was upset and had to find Resident #42 pants to wear. On 11/21/24 at 8:37 AM, the surveyor interviewed the LNHA. The surveyor notified the LNHA of the concerns with laundry services. The LNHA informed the surveyor that she recently received the petitions and had sent them to the corporate office and waiting for a response. The LNHA also stated that probably there was a 5-year contract with an outside vendor that corporate was involved with before LNHA came and assumed the role as LNHA of the facility. The surveyor asked LNHA for a copy of the contract. The LNHA stated the legality of the equipment and putting back the machines and people. The surveyor asked the LNHA if she was aware of the missing clothes, and some residents had to wear other clothes because the residents had no clothes to wear. The LNHA stated she was aware of missing clothes but unsure about the resident having to wear other clothes. The LNHA stated that she would provide the surveyor with a copy of the nurse on the 7-3 shift in Unit 3 and the phone number. Furthermore, the LNHA stated that the problem was that some clothes were swapped when it was returned. She stated also that it was the responsibility of the Certified Nursing Aides (CNA) to distribute the clothes to respective residents, to read the names, and put them in the drawer or closet of the same resident, sometimes it was not done the right way. The LNHA stated that the process was for the outside laundry company to bring back clothes in big bins, then bins taken on each wing and then distributed each wing for Units 1, 2, 3, and 4, it was a known practice with CNA, and I had a meeting with union rep (representative) and CNA about this. The surveyor asked for a copy. On 11/21/24 at 9:42 AM, the surveyor called the Registered Nurse (RN) who was assigned to Resident #42 when the resident did not have clothes to wear and left a message to call back. On 11/21/24 at 10:03 AM, the surveyor interviewed the RN via a phone conference. The RN informed the surveyor that she was a per diem nurse for 20 plus years in the facility. The surveyor asked the RN if she remembered Resident #42, and she stated Yes, it was one Saturday morning, the resident was concerned that the resident was unable to get out of bed because the resident did not have any pair of pants to wear. The RN further stated that she tried to help the resident and looked for some clothes in the therapy department that did not belong to anyone else, I found something that fit the resident and then the resident was happy. The RN informed the surveyor that there was a new service for the laundry, it was an outsourced, problem working on trying to get it in a timely passion, you know when working on something new as the outside vendor contracted the company to do laundry, things happened, the incident with the resident for not having clothes was very recent unable to state the exact date probably within a month or less than a month. 2. On 11/19/24 at 01:39 PM, the surveyor reviewed the last three months resident council minutes that were provided by the LNHA and revealed: -8/15/24: Council Members in Attendance: 10 Compliments/Ideas/Preferences/Concerns/Suggestions: Nursing: A resident awoke another resident and tried to get into their bed. The complainant resident asked the other resident to leave and would not. The complainant's roommate stayed with the complainant until nursing came, and not the first time the resident visited the complainant's room. Further review of the facility-provided resident council meeting minutes revealed that there was no resolution or follow-through with the above concerns on the 8/15/24 grievance voiced by the complainant. On 11/19/24 at 01:54 PM, the surveyor asked the LNHA about the 8/15/24 Resident Council Minutes that reported to Nursing about the complainant's concerns. The surveyor asked if the grievance was filed and the incident was investigated, and the LNHA stated that she would get back to the surveyor. On 11/20/24 at 8:32 AM, the LNHA stated that the incident on 8/15/24 about the complainant was not a thorough investigation and was not resolved. The LNHA stated that still in the process of investigation after the surveyor's inquiry. The LNHA stated that the residents in the concerns were Resident # 45 (the complainant), Resident # 52 (roommate), and Resident #150. The surveyor asked what the facility's policy and process for grievance was. The LNHA stated that she had to check their policy. The LNHA stated that as the standard of practice if it was a questionable abuse, it should be investigated immediately. On 11/21/24 at 12:44 PM, the survey team met with the LNHA, Assistant Director of Nursing (ADON), Regional Compliance Advisor (RCA), and Market President Special Project (MPSP). The surveyor notified the facility management of the above findings about Resident Council Meeting concerns with laundry, missing clothes, and the complainant's concerns. The surveyor asked if there should be a grievance for Resident#54 about clothes, and the LNHA and RCA stated that there should be a grievance. The surveyor notified them that when the surveyor reviewed the provided Grievance binder from January through November 2024, there was no grievance filed when Resident #54 and Resident #45 voiced concerns. On 11/22/24 at 02:24 PM, the survey team met with the LNHA, ADON, RCA, and the MPSP. The LNHA stated that the grievances of five residents' concerns with no resolutions, we had an emergency resident council meeting today with the presence of the contracted laundry company representative and discussed the concerns. At that same time, the RCA informed the surveyor that the facility conducted the facility wide investigation and interviews of residents and reached out to families as well with regard to the concerns with laundry services and missing clothes. The ADON was unable to identify the exact date of the grievance voiced by Resident #54. The facility management confirmed that there was no grievance initiated by the RN for resident#54 and the RN should have initiated the grievance to further investigate and resolve the concerns. The LNHA stated that education was done to all staff about grievance and reportable events abuse allegation. A review of the facility's Grievance/Concern Policy with a revision date of 10/15/24 that was provided by the LNHA revealed: Policy: All patients and/or their representatives may voice grievances/concerns and recommendations for changes. Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance/concern process. The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient, and coordinating with state and federal agencies, in consultation with the National Law Department, as necessary in light of specific allegations. Purpose: To assure prompt receipt and resolution of patient or representative grievances/concerns. On 11/25/24 at 02:46 PM, the survey team met with the LNHA, Director of Nursing, ADON, Market Clinical Advisor, and the RCA for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-4.1(a)5,11, 12; 13.2(c)

Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 5 of 24 residents, (Residents #14, #45, #68, #79 and #81), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual of October 2023, Section C Cognitive Patterns, Coding Tips o Attempt to conduct the interview with ALL residents. This interview is conducted during the seven-day look-back period (the period over which the resident's condition or status is captured by the MDS assessment) of the Assessment Reference Date (ARD) . The latest version of the CMS - RAI 3.0 Manual (updated October 2023), Chapter 3-page C-2, under C0100 Coding Instructions read: .Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available . Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. 1. The surveyor reviewed the medical records of Resident #14 which revealed the following: The resident's Admission Record (AR; a summary of important information about the resident) revealed that Resident #14 had diagnoses that included, but were not limited to, chronic kidney disease, dementia, schizophrenia, and bell's palsy (sudden weakness in the muscles on one side of the face). A comprehensive Minimum Data Set (cMDS) with ARD of 10/07/24, under section B, B0700, Makes Self Understood and B0800, Ability to Understand Others it was coded that the resident 1. Usually understands. Under Section C- Cognitive Patterns, C0100, Should Brief Interview for Mental Status [BIMS] (C0200-C0500) be Conducted? it was coded 0. No (resident is rarely/never understood). A BIMS evaluation note written by a Licensed Practical Nurse (LPN) dated 10/07/24, indicated a BIMS was conducted with the resident. On 7/10/24 at 12:15 PM, the surveyor interviewed the Reimbursement Clinical Coordinator (RCC) about completing MDS assessments' section B and section C. The RCC stated that if a resident was coded as being able to sometimes understand in Section B, a BIMS should be attempted for a resident in Section C. The surveyor reviewed with the RCC Resident #138's MDS assessments. The surveyor discussed the concern of hospice care not being coded for the resident and the inconsistency of section B and section C coding for the resident. The RCC stated she would review and provide further information. On 11/22/24 at 01:03 PM, the surveyor interviewed the RCC about completing MDS assessments' section B and section C. The surveyor asked the RCC if for a resident that was usually understood should a BIMS test be attempted. The RCC replied, yes. The surveyor discussed the concern for the inconsistency of section B and section C for the resident. On 11/22/24 at 02:24 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Assistant Director of Nursing (ADON), the Market President of Special Projects (MPSP), and the Regional Compliance Advisor (RCA) about the concern the coding of sections B and C of the MDS. On 11/25/24 at 01:12 PM, the LNHA, the Director of Nursing (DON), the ADON, and the RCA met with the survey team. The RCA stated the Regional MDS Coordinator provided education to staff. There was no additional information provided by the facility. 38327 2. The surveyor reviewed the medical records of Resident #45 and revealed: The AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to, unsteadiness of the feet, need for assistance with personal care, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with dyskinesia ( involuntary, erratic, writhing movements of the face, arms, legs or trunk), with fluctuations. The most recent quarterly Minimum Data Set (qMDS) with an ARD of 6/07/24 revealed that Section C for cognition was not assessed or attempted. Section C was electronically signed (was done) by the RCC on 6/21/24 at 10:41 PM, 14 days after the ARD. The most recent cMDS with an ARD of 9/07/24 revealed that Section C was not attempted, the RCC electronically signed on 9/18/24 at 10:44 AM, 11 days after the ARD. A Review of the Progress Notes (PN), documented as a Late Entry Care Plan Meeting (CPM) with an effective date of 6/20/24 was created on 6/24/24 by Social Services (SS) revealed that Resident #45 was alert and oriented with confusion, however, the resident was able to verbalize her needs and concerns. On 11/20/24 at 12:59 PM, the surveyor met with RCC. The RCC informed the surveyor that she was not responsible for answering Section C of the MDS, it was the responsibility of the Director of Social Services (DSS). The RSS stated that if the DSS was unavailable and the MDS was due for transmission, as an MDS Coordinator, she would sign Section C, and that was why her name was reflected in Section C. She further stated that the UDA (User Define Assessment) that was done in the electronic medical records of the resident would auto-populate to the MDS and that she would not verify the accuracy of the response in Section C, that would be the responsibility of who entered the information in UDA that auto-populated in the MDS that the RCC signed off in the absence of the DSS. The RCC acknowledged that a Section C interview should be attempted, and the interview done within the lookback period. She further stated that the facility had no separate policy for MDS and the facility followed the RAI Manual. On 11/20/24 at 01:14 PM, the surveyor interviewed the DSS, who informed the surveyor that she was responsible for answering the Sections C, D, E, Q, and Section V that populated in the CAA (Care Area Assessment) of the MDS. The surveyor asked about Resident #45 and the DSS responded that the resident was alert with confusion and able to verbalize needs. The surveyor asked the DSS why the MDS on 6/07/24 and 9/07/24 were coded as not assessed on Section C and were done after the ARD look-back period. The DSS stated that Section C should be attempted and not to code not assessed. The DSS stated she was unsure why it was coded as not assessed but it should be assessed. The DSS also stated that the UDA should have been done within the ARD lookback period and not after the ARD, which will auto-populate to the MDS. On 11/21/24 at 12:44 PM, the survey team met with the LNHA, ADON, RCA, and the MPSP. The surveyor notified the facility management of the above findings that Resident #45's MDS was done after the ARD and was coded not assessed in Section C. On 11/25/24 at 02:46 PM, the survey team met with the LNHA, Director of Nursing, ADON, Market Clinical Advisor (MCA), and the RCA for an exit conference. The facility management did not provide additional information and did not refute the findings. 48423 3. On 11/18/24 at 10:30 AM, the surveyor observed Resident #68 awake while resting in their bed. The resident was watching television. The surveyor reviewed the medical records of Resident #68 and revealed: The AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to insomnia, need for assistance with personal care, and muscle weakness. A review of qMDS with an ARD of 8/08/24, under Section B0700. Makes Self Understood- Ability to express ideas and wants, consider both verbal and non-verbal expression- reflected Code 0 which indicated: 0.) Understood. Review of Section C - Cognitive Pattern did not reflect Resident #68's BIMS score. Further review of MDS question C0100: Should BIMS (C0200-C0500) be conducted? Reflected Code 0 which indicated No (resident is rarely/never understood) 'Skip to and complete C0700-C1000, Staff Assessment for Mental Status. Section C interview was not attempted and BIMS was not done. Further review of qMDS revealed that Section C was electronically signed by the SS on 8/21/24, 13 days after the ARD. A review of the PN titles as CPM dated 8/22/24, created by SS revealed that Resident #68 was alert and oriented. The Resident tried to verbalize their needs and concerns. The Resident sometimes understood and they understands. 4. On 11/18/24 at 10:43 AM, the surveyor observed Resident #79 resting in their bed. The surveyor greeted the resident, and the resident elevated their head of bed with the controller. The resident was not able to speak much at the time of observation. The surveyor reviewed the medical records of Resident #79 and revealed: The AR revealed that Resident #79 was admitted to the facility with diagnoses that included but were not limited to, hemiplegia (paralysis on one side of the body), hypertension (high blood pressure), and type 2 diabetes mellitus. A review of qMDS with an ARD of 10/11/24, under Section B0700. Makes Self Understood- Ability to express ideas and wants, consider both verbal and non-verbal expression- reflected Code 0 which indicated: 1.) Usually Understood- difficulty, communicating some words or finishing thoughts but is able to if prompted or given time. Review of Section C - Cognitive Pattern did not reflect Resident #79's BIMS score. Further review of qMDS question C0100: Should BIMS (C0200-C0500) be conducted? Reflected Code 0 which indicated No (resident is rarely/never understood) 'Skip to and complete C0700-C1000, Staff Assessment for Mental Status. Section C was not attempted and that BIMS interview was not conducted. Further review of MDS revealed that Section C was electronically signed (was done) by the SS on 10/24/24, 13 days after the ARD. A review of PN documented as a Late Entry N Adv- BIMS Evaluation with an effective date of 10/11/24 was created on 10/29/24 by SS revealed that BIMS should not be conducted. (Resident is rarely/never understood). Complete staff assessment for mental status. Resident was unable to complete BIMS. Seems or appears to recall after 5 minutes: Memory problems. Seems or appears to recall long past: Memory problem. None of the above recalled. 5. On 11/18/24 at 10:27 AM, the surveyor observed that Resident #81 was not in their. The Resident's bed was made. The surveyor reviewed the medical records of Resident #81 and revealed: The AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to, schizophrenia (a serious mental disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder, muscle weakness and hypertension (high blood pressure). A review of cMDS with an ARD of 10/22/24, under Section B0700. Makes Self Understood- Ability to express ideas and wants, consider both verbal and non-verbal expression- reflected Code 1 which indicated: 1.) Usually Understood- difficulty, communicating some words or finishing thoughts but is able to if prompted or given time. Review of Section C - Cognitive Pattern did not reflect Resident #81's BIMS score. Further review of qMDS question C0100: Should BIMS (C0200-C0500) be conducted? Reflected Code 0 which indicated No (resident is rarely/never understood) 'Skip to and complete C0700-C1000, Staff Assessment for Mental Status. Further review of MDS revealed that Section C was electronically signed by the RCC on 10/31/24, 9 days after the ARD. A review of PN documented as a Late Entry N Adv- BIMS Evaluation with an effective date of 10/16/24 was created on 10/20/24 by SS revealed that BIMS should not be conducted. (Resident is rarely/never understood). Complete staff assessment for mental status. Resident was able to complete BIMS. On 11/22/24 at 10:57 AM, during an interview with the surveyor, the RCC stated, Yes, BIMS would be attempted for everyone except if a resident is in coma. The surveyor discussed the concern for the inconsistency of section B and section C for Residents #68, #79, and #81 mentioned above. On 11/25/24 at 01:12 PM, the survey team met with LNHA, DON, ADON, RCA and MCL. The surveyor notified the facility management of the above findings for Resident #68, Resident #79, and Resident #81's MDS were done after the ARD and inaccuracy between Section B and C and Section C was not attempted. On 11/25/24 at 02:46 PM, the survey team met with the LNHA, DON, ADON, MCA and the RCA for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-11.1; 33.2 (d)

Based on observations, interview, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that policies and procedures were developed and implemented to mitigate the spread of infections, and b.) documented on-going staff education and in-services were completed to combat breaks in infection control practices. The multiple observed breaches in infection control practices by multiple facility disciplines, were identified on 02/08/23, 02/09/23, and 02/10/23 on 4 of 4 resident care Wings. This posed a serious and immediate threat to the health, safety and well-being of all residents who resided at the facility due to the lack of infection control oversight provided by the LNHA, which resulted in an Immediate Jeopardy (IJ) that began on 02/08/23 and was identified on 02/10/23 at 4:07 PM. The LNHA was notified of the IJ situation on 02/10/23 at 4:08 PM. The failure of the LNHA to ensure the facility operated in a manner that ensured residents were cared for and an environment that enabled residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being posed a serious and immediate threat to the health, safety, and welfare of staff and all residents who resided at the facility in compliance with federal, state and local requirements as outlined in the Center Executive Director Job Description,. A removal plan was accepted on 02/13/23 at 10:17 AM. The survey team verified the removal plan on 02/13/23 at 12:33 PM. A review of the facility's Center Executive Director Job Description provided on 02/10/23, included but was not limited to the following; Position Summary: The Center Executive Director is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Center Executive Director administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. Works in close collaboration with the Center Nurse Executive to assure high quality clinical outcomes. Ensures staff participate in orientation and training programs .relative policies and procedures, and that such training is properly documented. Refer to: F880, F886 Findings include: On 02/08/23 at 11:12 AM during entrance conference, the LNHA stated the facility was currently in a COVID-19 outbreak. The outbreak began 10/23/22, and the facility currently had 27 COVID-19 residents on four of the four resident care Wings. The survey team requested multiple documents, one of which was the facility staff in-service and education information. On 02/08/23, during tour of the facility, the survey team observed isolation transmission-based precaution (TBP) resident rooms on 4 of the 4 resident care Wings. The surveyor observed Resident #31's room on the 2nd wing. Resident #31's room did not have any TBP signage affixed to the resident's door, or Personal Protective Equipment (PPE) containers outside the room and readily available. The surveyor observed Resident #88's room on the 1st wing. Resident #88's room did not have any TBP signage affixed to the resident's door, or PPE containers outside the room and readily available. The surveyor conducted medical record reviews which included, but were not limited to, Resident #31 had a physician's order dated 12/08/22 to be placed on contact precautions (procedures that reduce the risk of the spread of infections through direct or indirect contact) for Extended spectrum beta-lactamases (ESBL - an organism which is among those responsible for antibiotic resistant strains) of the urine every shift. Resident #88 had a physician's order dated 01/04/23 to be placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA - a cause of staph infection that is difficult to treat because of resistance to some antibiotics) of the sacral wound every shift. On 02/08/23 at 10:58 AM on the 1st wing, Surveyor #1 and #2 observed a laundry aide walking down the hall wearing a PPE gown which was not secured in the back, an N95 mask and eye protection. The laundry aide entered a COVID-19 positive resident room and through an open door, the surveyors observed her touched multiple environmental surfaces, including the furniture. The laundry aide exited the room without first removing her gloves and perform hand hygiene. On 02/10/23 at 9:28 AM in the presence of three surveyors, the LNHA, Director of Nursing (DON), and Assistant Director of Nursing Infection Preventionist (ADON IP) were interviewed and made aware of the situation concerning the two residents who had not been placed on TBP as per physician's orders. The LNHA, DON, and ADON IP acknowledged they were not aware of the two residents being on TBP and that there was no signage affixed to the resident's room doors to alert staff of the required PPE to wear to protect themselves and other residents. The ADON IP stated the facility kept an antibiotic listing but, infections were not tracked for every patient unless an antibiotic was ordered. The LNHA was not aware of no documented tracking of residents on TBP despite an ordered antibiotic. On 02/10/23 at 12:58 PM, the survey team asked the LNHA a second time for the staff education book. The LNHA stated, I thought I told you I gave you all the education I had to give. When asked if the few in-services she gave encompassed the entire staff, the LNHA stated she was not sure and I guess I can have nursing give you the book to see. On 02/10/23 at 1:23 PM, the ADON IP and Registered Nurse (RN) in training for IP, were being interviewed. The ADON IP stated in-services and education for the staff on Infection Control was done, on and off and whenever I get a chance. She further stated that there were not always sign in sheets kept to document who attended or the content of education or in-services. The LNHA was not aware of the lack of completed, documented education, in-services, and competencies for the facility staff. On 02/10/2023 at 10:49 AM on Wing 4 of the facility, a surveyor observed a housekeeper wearing an N95 mask and a face shield. The housekeeper was observed in the doorway of a COVID-19 positive resident room which had signage on the door to indicate what the TBP was and what PPE was required. The housekeeper had not donned a PPE gown or gloves. The housekeeper was using his bare hands to tie a plastic bag that contained used, soiled PPE gowns. The housekeeper then brought the plastic bag filled with soiled PPE gowns out into the hallway and placed the bag on top of the housekeeping cart. The surveyor asked the housekeeper what the process was for collecting soiled gowns in resident rooms that were on droplet precautions or any transmission-based precautions (TBP)? The housekeeper stated that he followed directions from his administrator (LNHA). On 02/10/23 at 2:27 PM, the LNHA and DON were being interviewed. The surveyor asked who was responsible for overseeing the Infection Control program? The DON stated she and the LNHA were responsible. The LNHA was present and agreed. On 02/22/23 at 10:00 AM the LNHA was interviewed in the presence of the survey team. regarding her job decription. The surveyor asked if the LNHA was responsible for everyong in the facility and she stated, ultimately yes and the surveyor inquried if that included infection control and the LNHA stated yes. The surveyor asked what her role in infection control was, the LNHA stated to make sure we have an infection preventionist. On 02/22/23 at 10:04 AM, the surveyor asked if the LNHA was aware that there was no one assuming the ADON IP's role when she had been out. The LNHA sated it would have then deferred to the DON. When asked if the LNHA was aware that all COVID-19 testing was not completed as indicated. The LNHA stated honestly, not. The surveyor asked the LNHA if she should have been made aware and she staetd absolutely, things should have been communicated to me so I could have strategized. A review of the facility provided, Outbreak Investigation / Management policy and process revised 02/01/23, included, but was not limited to 6. Notify: 6.1. Administrator 7. Implement control measures based on signs, symptoms, diagnosis, mode of transmission, and location in the Center. 8. Conduct staff education/competencies as needed regarding disease outbreak and mode of transmission. 10. Monitor for effectiveness of investigation and control measures until cases cease to occur or return to usual levels. The LNHA failed to ensure these directives were being followed. A review of the facility provided, Infection Control Policies and Procedures for COVID-19, effective 03/27/20 and revised 12/07/22. The Policy revealed: General Standard Precautions: 9. Follow CDC published guidance related to the use of facemasks, respirators, gowns, gloves, and eye protection. Education: 31. Provide COVID-19 education as indicated to employees, patients, and visitors. The LNHA failed to ensure these directives were being followed. NJAC 8:39- 19.1(a); 19.2(a)(c)

Part A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility, who has been in an active COVID-19 outbreak status since 10/23/22, failed to ensure: a.) a system was in place and followed to prevent the spread of multidrug resistant infections (organisms resistant to multiple antibiotic treatments including Methicillin Resistant Staph Aureus [MRSA], extended spectrum beta-lactamase [ESBL], vancomycin resistant enterococcus [VRE]) and COVID-19 (a deadly virus), and b.) facility policies and current infection control guidance was followed to limit the spread of infection. The breaches in infection control practices were observed by the survey team on 02/08/23, 02/09/23, and 02/10/23, for 4 of 4 Resident Wings and was evidenced by the following: Reference: Centers for Medicare and Medicaid Services Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH DATE: August 26, 2020 REVISED 09/23/2022. Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022. The facility's system wide failure to ensure that infection control practices were implemented to mitigate the spread of MRSA, ESBL, VRE, and COVID-19 posed a serious and immediate risk to the health, safety and well-being of all residents who resided at the facility. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that began on 02/08/23 and was identified by the survey team on 02/10/23 at 4:07 PM. The Administrator was notified of the IJ on 02/10/23 at 4:08 PM A removal plan was accepted on 02/13/23 at 10:17 AM. The survey team verified the removal plan on 02/13/23 at 12:33 PM. On 02/08/23 at 9:08 AM during tour of the facility, surveyor #1 observed Resident #31's room on the 2nd Wing. Resident #31's room did not have any transmission-based precaution (TBP) signage, or PPE (personal protective equipment, including gowns, gloves, etc.) containers outside of the room and readily available. Surveyor #1, entered the room and attempted to interview Resident #31 at that time and the resident was confused and unable to be interviewed. On 02/02/23 at 10:00 AM, surveyor #1 returned to Resident #31's with a Certified Nursing Assistant (CNA) to perform an incontinence check. There was no PPE signage, or PPE available at the resident's room at that time. The surveyor entered the room with the CNA. The CNA was wearing an N95 respirator mask (filters out 95% of airborne particles), eye protection and gloves, and proceeded to re-position the resident, who was awake, and then check the resident's incontinence brief (disposable brief designed to collect urine and feces). The CNA completed the entire task without wearing a PPE gown. Surveyor #1 reviewed the medical record for Resident #31. Resident #31 was admitted to the facility with diagnoses which included but were not limited; to urinary tract infection and sepsis. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 11/21/22, revealed Resident #31 required extensive assistance of at least one staff for toileting; was always incontinent of bladder and bowel and did not have any urinary or bowel appliances. A review of a physician's order dated 12/08/22, revealed the resident was ordered to be placed on contact precautions (procedures that reduce the risk of spread of infections through direct or indirect contact) for ESBL of the urine every shift. A review of the facility provided urinalysis with a culture and sensitivity test, Lab Results reported 12/02/22, revealed organism identification to include ESBL. A review of the Medication Administration Report (MAR) for December 2022 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered / completed from 12/08/22 through 12/31/22. A review of the MAR for January 2023 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered/completed from 01/01/23 through 01/31/23. A review of the MAR for February 2023 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered/completed from 02/01/23 through 02/10/23, when the MAR was printed. A review of the on-going resident Care Plan (CP) including resolved areas, revealed no focus area, goal or interventions for or related to contact precautions and/or ESBL of the urine. On 02/08/23 during tour of the facility, Surveyor #1, #2, and #3 observed Resident #88's room which was located on the 1st Wing. Resident #88 did not have TBP signage or PPE readily available outside the resident's room. A review of Resident #88's medical record revealed a physician's order dated 01/04/23 to be placed on contact precautions for Methicillin-resistant Staphylococcus Aureus (MRSA - a cause of staph infection that is difficult to treat because of resistance to some antibiotics) of the sacral wound every shift. On 02/08/23 at 8:40 AM on the 4th Wing, Surveyor #3 observed a Registered Nurse (RN) entering a COVID-19 positive resident room. The RN was wearing only an N95 (a respirator mask that filters 95% of airborne particles) mask and eye protection. The COVID-19 positive room had signage posted on the door which indicated what the TBP were and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included, but was not limited to, performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The RN failed to follow the posted guidance and don (put on) a PPE gown or gloves. On 02/08/23 at 9:15 AM on the 2nd Wing, Surveyor #1 observed CNA #1 who was wearing an N95 mask and eye protection. CNA #1 donned a PPE gown, but failed to secure the back of the gown, and failed to don gloves. CNA #1 proceeded to pick up a meal tray and then entered a COVID-19 positive resident room. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE needed to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. Surveyor #1 also observed CNA #2 wearing an N95 mask and eye protection. CNA #2 picked up a PPE gown and entered the same COVID-19 resident positive room without first donning the PPE gown as indicated by signage. On 02/08/23 at 9:20 AM, Surveyor #1 observed the Director of Nursing (DON) on the 2nd Wing. During an interview at the time, the DON stated the staff should put all the required PPE on before entering a room. She stated the PPE gown needed to be secured in the back to keep the person protected, and that once someone entered a TBP room, they would be considered dirty. The DON stated she would send the Assistant Director of Nursing Infection Preventionist (ADON IP) over. On 02/08/23 at 9:28 AM, the ADON IP and the RN in training for IP arrived on the 2nd Wing. Both were made aware of the surveyor's observations. The surveyor observed both were wearing N95 masks and eye protection. The ADON IP stated staff must put the required PPE on outside of the TBP room and then tie the PPE gown in the back for protection. At that time, Surveyor #1 observed the ADON IP enter the same COVID-19 positive resident room without wearing a PPE gown or gloves. The COVID-19 positive room had signage affixed to the door which indicated what the TBP was and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. On 02/08/23 at 9:37 AM, CNA #2 exited the 2nd Wing COVID-19 positive resident room and was interviewed by Surveyor #1 at that time. CNA #2 stated she had worked at the facility for [AGE] years and had been educated on PPE. CNA #2 stated she thought she was in the way, so she stepped inside the room to don her PPE gown. CNA #2 stated should not have entered the room without first putting on the PPE in order to protect herself and the residents. On 02/08/23 at 9:39 AM, CNA #1 exited the 2nd Wing COVID-19 positive resident room and was interviewed by Surveyor #1. CNA #1 stated she had worked at the facility for [AGE] years and had received training on PPE. CNA #1 stated she should have been wearing gloves, and that the PPE gown should have been tied in the back, but sometimes the ties become loose. Surveyor #1 asked what the process would be in the PPE gown became loose while in a TBP room. CNA #1 stated she should put her PPE gown in the hamper and then get a new one. On 02/08/23 at 9:50 AM on the 3rd Wing, Surveyor #3 observed the RN training for IP in the hallway. The RN donned gloves to pick up trash from the floor and then disposed of the trash. She then removed the gloves and touched a resident meal tray and had not performed hand hygiene or changed gloves. Surveyor #3 approached the RN training for IP and interviewed her. The RN stated, I probably should not have touched his/her tray. The RN then used the ABHR located in the hallway to sanitize her hands. On 02/08/23 at 10:28 AM on the 1st Wing, Surveyor #2 observed CNA #3 exit a COVID-19 positive room wearing gloves and an N95 mask which had been positioned down on her face not and was not fully covering her nose. The COVID-19 positive resident room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. CNA #3 was carrying a meal tray that was not bagged and proceeded to place the meal tray directly on top of the shredder bin that was located in front of the nurse's station in the common area accessible to all nursing wings, and where residents were gathered. CNA #3 was observed moving the N95 mask up on her face multiple times. During an interview at that time, CNA #3 stated to the surveyor that normally she would have taken off her gloves, and that she had been fit tested for her N95 mask, but that it kept sliding down on her face. CNA #3 further stated there were no meal tray trucks, so she placed the meal tray on the shredder box. At 10:33 AM, Surveyor #2 observed CNA #3 enter the staff bathroom to wash her hands. CNA #3 turned on the water, applied soap and lathered her hands for 10 seconds with her hands under the running water. During an interview at that time, CNA #3 stated to the surveyor that the process was to lather her hands for 20 seconds. On 02/08/23 at 10:58 AM on the 1st wing, Surveyor #1 and #2 observed a laundry aide while she was walking down the hall and wearing a PPE gown which was not secured in the back, an N95 mask and eye protection. The laundry aide then entered a COVID-19 positive resident room and through an open door, the surveyors observed her touch multiple environmental surfaces including a dresser, and folded clothes, and proceeded to go to the other side of the room and touch other surfaces, including the furniture. She exited the room without first removing gloves, and performing hand hygiene. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The laundry aide did not perform hand hygiene upon exiting the room and proceeded to continue to wear the same gloves as she walked to the hallway of Wing #1. During an interview at that time, the laundry aide stated she had worked at the facility for [AGE] years and had been educated on PPE. The laundry aide confirmed it was her practice to wear the PPE gown through the hallway and stated the PPE gown should be tied in the back for protection. The laundry aide stated, Sorry I forgot when asked about if she should have been wearing gloves through the hallway. On 02/08/23 at 11:12 AM, during the entrance conference conducted with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the survey team was informed that the facility was currently experiencing a COVID-19 outbreak and there were 27 COVID-19 positive residents. The facility provided line list verified the COVID-19 outbreak began on 10/23/22. On 02/08/23 at 12:25 PM on the 2nd wing, Surveyor #1 observed a recreation aide wearing an N95 mask, eye protection and a PPE gown. The recreation aide entered a COVID-19 positive resident room (Resident #95) without wearing gloves and was carrying a lunch meal tray. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The recreation aide placed the meal tray on the resident's over bed table and then moved the over bed table towards the resident with her bare hands. At 1:08 PM, the recreation aide exited the room and was interviewed by Surveyor #1. She stated she had worked at the facility for [AGE] years and had been educated on PPE and COVID-19. She further stated, I didn't see gloves. It was my mistake, sorry. On 02/09/23 at 9:08 AM, Surveyor #1 observed Resident #31's room and there was no TBP signage or PPE readily available. At that time the surveyor reviewed the medical record for Resident #31 which revealed an order dated 12/08/22 for contact precaution for ESBL of the urine. On 02/09/23 at 9:13 AM on the 3rd Wing, Surveyor #3 observed RN #2 wearing an N95 mask and eye protection. RN #2 donned a PPE gown and gloves and entered a COVID-19 positive resident room. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. RN #2 then exited the COVID-19 positive resident room wearing the same PPE gown which was not removed prior to exiting the room. On 02/09/23 at 11:39 AM, during an interview with Surveyor #1 and #2, the DON, in the presence of the LNHA, stated the facility had completed infection control audits and staff was educated to mitigate the spread of infection. The surveyors inquired to the DON for any documentation regarding the audits and education. The DON was unable to provide documentation and stated that the facility recently implemented a form that was used for audits, and the DON stated I don't know if they are always using it [form]. On 02/09/23 at 11:43 AM, the ADON IP stated she had been in contact with the Local Health Department (LHD) either, today, yesterday or the other day. She stated that the LHD had provided her with the Communicable Disease Services (CDS), COVID-19 Patient/Resident Management in Post-acute Care Settings guidance dated 01/23/23. On 02/09/23 at 12:30 PM, Surveyor #3 observed a resident who had tested positive for COVID-19 and was seated in the facility Atrium at a table. The surveyor went to the 3rd Wing to verify that resident was the COVID-19 positive resident who was on TBP. The resident's room door was observed open. Staff were not aware that the resident had left the room and was seated in the Atrium waiting for the lunch tray. The RN in training for IP observed the resident in the Atrium and then escorted the resident back to the unit. While being escorted to his/her room, Surveyor #3 heard the resident coughing. The staff confirmed that the resident was symptomatic and had been complaining of a headache also. During a subsequent surveyor interview, the RN in training for IP did not know or was not aware that the table the COVID-19 positive resident was sitting at, needed to be disinfected. On 02/10/23 at 7:43 A.M. to through 8:22 A.M. on the 2nd Wing, Surveyor #1 observed a Registered Nurse (RN) #1 during a medication administration and observed the following: RN #1 walked up and down the 2nd Wing, administered medications to five residents and was within arm's length of the residents. The RN wore her eye protection on the top of her head offering no eye or face coverage or protection during her medication administration. At 8:22 AM, during an interview with Surveyor #1, RN #1 stated eye protection should be worn down over the eyes for protection. On 02/10/23 at 8:36 AM, RN #1 entered Resident #31's room. RN #1 was wearing an N95 mask and eye protection. RN #1 then picked up a pillow from floor with gloves on, helped the resident take a sip of their protein drink by touching the resident's head and environment, and then administered medications. RN #1 was not wearing a PPE gown and there was no TBP signage on the door. Surveyor #1 had conducted a medical record review on 02/09/23, for Resident #31 and there was a physician's order for contact precautions to be observed. On 02/10/23 at 9:28 AM in the presence of three surveyors, the LNHA, DON, and ADON IP were interviewed in the conference room. The DON stated there were no TBP residents other than COVID-19 positive on the 1st wing, 2nd wing, or 3rd wing. The DON stated there were only two residents located on the 4th wing with TBP other than COVID-19. The DON further stated that someone would let her know if there was an abnormal test result requiring TBP that she was not aware of. The DON stated that the staff would talk in clinical meeting and the physician would decide what TBP to order. After that, it would be the ADON IP's responsibility to put the signage up or have the nurse on the unit place the signage on the door. The DON stated the information would be communicated in the shift to shift report. The ADON IP stated nurses give report to other nurses and CNAs and that would be how the staff would know about TBP. The DON stated that contact precaution would require a PPE gown, gloves, N95 mask and eye protection; and that enhanced barrier and droplet precautions required everything PPE. The ADON IP stated the facility kept an antibiotic listing but, infections were not tracked for every patient unless an antibiotic was ordered. A review of the facility provided list, Resident's on precaution other than COVID-19 undated, but provided on 02/10/23, revealed two residents and their room numbers. The surveyor team identified that the first resident noted was on contact precautions for clostridium difficile (C diff - a contagious bacterium), and the second resident noted was on contact precautions for C diff, and VRE. Resident #31 and Resident #88 were not included on the facility provided list as the DON, ADON IIP, and LNHA were not aware of the physician ordered contact precautions for MRSA and ESBL. On 02/10/23 at 9:58 AM, Surveyor #1 interviewed RN #1 who stated there were no residents that required contact precautions on the 2nd Wing. RN #1 stated she would know that information because there would be signs posted on the door and the ADON IP would have put up the signs. On 02/10/23 at 9:59 AM, CNA #5 stated to the surveyor that there were no other residents on TBP besides COVID-19 on the 2nd wing. She further stated that if there were any other residents requiring TBP, the nurse would let the CNAs know during report and there would be a sign on the door also. On 02/10/2023 at 10:49 AM on Wing 4 of the facility, Surveyor #4 observed a housekeeper wearing an N95 mask and a face shield. The housekeeper was observed to don a PPE gown and gloves, enter a resident room, picking up soiled gowns and collecting soiled gowns in a see-through plastic bag. The housekeeper doffed (removed) his PPE gown and gloves inside the resident room, brought the bag with soiled PPE out into a cart in the hall and next sanitized his hands. The housekeeper was next observed in the doorway of a COVID-19 positive resident room wearing an N95 mask and face shield. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The housekeeper had not donned a PPE gown or gloves. The housekeeper was using his bare hands to tie a plastic bag that contained used, soiled PPE gowns. The housekeeper then brought the plastic bag filled with soiled PPE gowns out into the hallway and placed the bag on top of the housekeeping cart. Surveyor #4 asked the housekeeper what the process was for collecting soiled gowns in resident rooms for residents were on droplet precautions or any transmission-based precautions (TBP)? The housekeeper stated that he followed directions from his administrator. The housekeeper was unwilling to answer any additional questions from the surveyor and stated, please let me get back to work and do my job. On 02/10/23 at 11:30 AM, Surveyor #3 observed CNA #4 in the 3rd Wing hallway. CNA #4 reached inside a TBP room and picked up the breakfast meal tray without donning gloves. On 02/10/23 at 11:35 AM, Surveyor #3 observed a breakfast meal tray bagged and placed on the 4th Wing hallway shredder. Surveyor #3 read the name and verified the tray came from an isolation TBP resident room. On 02/10/23 at 12:02 PM, Surveyor #4 asked the LNHA what the process was for collecting used or soiled gowns from COVID-19 positive resident rooms and other TBP resident rooms. The LNHA stated that she would have to check what the process was and would provide the surveyor with the policy. On 02/10/23 at 2:00 PM, the LNHA provided the surveyor with a policy on the laundry process for collecting biohazard laundry. A review of the policy titled, The Laundry Process dated 01/01/2000, indicated that the Laundry Department was responsible for the safe and proper collection, cleaning, and distribution of linens within the nursing home. At designated times, laundry workers using a large bin with lid, marked For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linen. The policy did not indicate for housekeeping to collect soiled gowns from COVID-19 positive resident rooms or other TBP resident rooms. On 02/10/23 at 12:58 PM, the survey team again requested from the LNHA staff education on infection control. The LNHA stated, I thought I told you I gave you all the education I had to give. Surveyor #1 asked if the few in services she provided encompassed the entire facility staff. The LNHA stated she was not sure and, I guess I can have nursing give you the book to see. At 1:23 PM, the ADON IP and RN in training for IP were in the conference room with three surveyors. The ADON IP stated in services and education for staff regarding infection control was on and off and whenever I get a chance. The ADON IP stated there was not always a sign in sheets to identify who received education or what the education was provided. At 1:25 PM, Surveyor #3 inquired if a resident tested COVID-19 positive and had a room mate, what would the process be. The ADON IP stated the facility would remove the roommate without COVID-19 and place them into another room. She stated if the roommate was unvaccinated, they would, test them, move them, monitor them, and place them on empiric TBP which means if they become symptomatic, they would be put on isolation until the facility could be sure they were not COVID-19 positive. The ADON IP stated the staff were educated to care for the well resident first unless, something comes up. She stated that trying to have dedicated COVID-19 staff was, challenging, which means very difficult. We (facility) don't have enough staff sometimes. The RN in training for IP stated that as long as the staff followed the TBP, they should be ok. At 1:38 PM, the ADON IP stated the COVID-19 outbreak started the end of October (2022) and, we are not in the big numbers of COVID. When asked what she had implemented since the start of the outbreak, the ADON IP stated, we have a form of auditing. She stated supervisors also do education and, I think there are in services on the nursing units. On 02/10/23 at 2:12 PM in the presence of three surveyors, the DON stated that since the facility outbreak, the facility had tried to have dedicated COVID-19 staff but were unable to. The DON acknowledged that all four wings had both well and ill residents. The LNHA was also present and stated that the facility did not have enough equipment to provide dedicated equipment to residents on TBP. On 02/14/2023 at 11:03 AM during an interview with Surveyor #4, the Director of Housekeeping stated that housekeeping was responsible for picking up soiled gowns from COVID-19 positive resident rooms. He stated the process was to don a PPE gown, gloves, N95 mask, and face shield to enter the room. The resident's bin for disposal of soiled PPE gowns had a plastic bag. The housekeeper would tie the dirty bag and hand the bag to a second person outside the room. The second staff would be holding a clean plastic bag for the housekeeper to drop the tied bag of soiled gowns into so it would be double bagged. The second person standing outside the room would then dispose of the double bagged linen into the linen bin in the hallway. The Director of Housekeeping demonstrated the process and showed the surveyor the different bins in the hallway of Wing 1. One bin for trash, two bins for soiled gowns and/or linen, and a third bin for resident's personal clothes. A review of the facility provided, Outbreak Response Plan, undated, included but was not limited to 1.b. Control Measures .frequent COVID-19 in-services and handwashing as well as PPE education and competencies. A review of the facility provided, Outbreak Investigation/Management policy and procedure revised 02/01/23, included but was not limited to Purpose to manage and contain disease/condition outbreak when identified. Case definitions included MDROs and COVID-19. 7. Implement control measures based on signs, mode of transmission. Measures may include standard and transmission-based precautions. 8. Conduct station education/competencies include hand hygiene, donning and doffing PPE, transmission precautions, MDRO. A review of the facility provided, Modified Enhanced Barrier Precautions revised 11/15/21, included but was not limited to Policy: In addition to standard precautions, modified enhanced barrier precautions and contact precautions will be used for MDROs. 5. post the appropriate enhanced barrier precautions or contact precautions sign on the patient's room door. Contact Precautions: required PPE: gloves and gown (don before room entry, doff before room exit; change before caring for another patient) face protection may also be needed if performing activity with risk of splash or spray. 9. Before exiting room, remove and place PPE in trash and perform hand hygiene upon exiting room. 16. Document: type of precautions in care plan. Specific MDRO identification in special instructions section of [redacted] (electronic medical record). Review of the CDS, COVID-19 Patient/Resident Management in Post-acute Care Settings guidance dated 01/23/23, provided to the ADON IP by the LHD, included but was not limited to, When resources permit, facilities should dedicate equipment to individual cohorts. Equipment should not be shared between individuals on TBP and those cared for with standard precautions. If this is not possible, equipment should be used by rounding in a well to ill flow to minimize the risk of cross-contamination. A review of the facility provided, COVID-19 policy and procedure revised 12/07/22, included but was not limited to Policy: in addition to standard precautions, special droplet and contact precautions will be implemented for patients suspected or confirmed with COVID-19. Special droplet and contact precautions requires wearing a N95 respirator upon entry .in addition to the recommended PPE. Definition: all recommended PPE (gown, gloves, eye protection, respirator) while present in the room. Infection Surveillance: 6.2 during an outbreak, the COVID-19 screen will be completed each shift. 31654 27193 Part B The non-compliance remained on 02/27/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Based on observation, interview, record review and document review it was determined that the facility failed to ensure the faciliy policy for infection surveillance during an outbreak was followed by completing a COVID-19 resident screening each shift (for 4 of 4 Wings), and ensure staff performed hand hygiene as indicated on 1 of 4 Wings. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH DATE: August 26, 2020 REVISED 09/23/2022. Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022. On 02/08/23 at 11:22 AM, during the entrance conference held with the facility Administrator (LNHA) and Director of Nursing (DON), the LNHA informed Surveyor #2 that the facility was currently experiencing an outbreak that began on 10/24/22. The DON informed the surveyor that there were currently twenty-seven COVID positive residents. Surveyor #2 inquired about any COVID-19 testing in progress and the DON stated that per facility policy employees and residents were tested twice per week on Tuesday and Thursday, and only employees would be tested for a COVID-19 exposure. On 02/09/23 at 11:33 AM, the LNHA provided the survey team with a copy of the current Infection Control Policies and Procedures for COVID-19, Effective 03/27/20 and Revised 12/07/22. The Policy revealed: the facility follows the CDC published guidance for patient and/or healthcare personnel (HCP) with suspected COVID-19. Infection Surveillance: 6. Complete the COVID 19 Screen UDA in the electronic medical [TRUNCATED]

Based on interview and document review, it was determined that the facility, who was experiencing an outbreak of COVID-19 (a potentially deadly virus) failed to take immediate action to prevent the spread of COVID-19 by failing to: a.) follow facility policy and pertinent guidance to conduct immediate COVID-19 testing for residents by either, a broad-based or contact tracing approach when two Certified Nurse Aide's (CNA #1) who was symptomatic with a cough and fatigue worked on Wing 2, tested COVID-19 positive on 02/05/23 and worked on 02/03/23 and 02/04/23, and CNA #2, who was symptomatic with a cough and congestion tested COVID-19 positive on 02/03/23 and worked on Wing 1 on 02/01/23, b.) conduct immediate resident broad-based testing per facility policy on 02/08/23, 02/11/23 and 02/13/23, in response to a COVID-19 positive resident on Wing 2 (Resident #84), who tested positive for COVID-19 on 02/07/23, and conduct resident broad based testing on 02/13/23 in response to Resident #86 who tested positive for COVID-19 on 02/12/23, and c.) ensure a process was followed to ensure all close contacts of a dietary department employee (Employee #3), who was symptomatic and tested positive for COVID-19 on 02/16/23, were identified and tested immediately (a [NAME] worked on 02/16/23) and failed to receive a COVID-19 test on 02/16/23 during routine facility testing and then proceeded to work on 02/17/23, without first being tested for COVID-19). This deficient practice occurred for 3 of 3 employees (CNA #1, CNA #2 and Employee #3) and 2 of 5 residents reviewed for COVID-19 testing (Resident #84 & #86) and was evidence by the following: Reference: Centers for Medicare and Medicaid Services Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH DATE: August 26, 2020 REVISED 09/23/2022. Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022. Refer to F880 The failure to conduct immediate resident and staff testing upon utilizing either a broad- based approach or contact tracing approach, upon the identification of a single COVID-19 positive staff or resident result resulted in an Immediate Jeopardy (IJ) situation which began on 02/03/23 when the facility failed to conduct either immediate broad based testing, or contact tracing testing in response to CNA #1, who was symptomatic and also tested COVID-19 positive on 02/03/23 and worked on 02/01/23. The facility was notified of the IJ situation on 02/17/23 at 1:42 PM. The removal plan was received on 02/17/23 at 8:52 PM, and accepted on 02/21/23 at 9:07 AM. The removal plan was verified as implemented by the survey team on 02/21/23 at 1:08 PM. On 02/08/23 at 11:22 AM, during the entrance conference held with the facility Administrator (LNHA) and Director of Nursing (DON), the LNHA informed the surveyor that the facility was currently experiencing an outbreak that began on 10/24/22. The DON informed the surveyor that there were currently twenty-seven COVID-19 positive residents. The surveyor inquired about any COVID-19 testing in progress and the DON stated that employees and residents were tested twice per week on Tuesday and Thursday, and only employees would be tested for a COVID-19 exposure. On 02/09/23 at 11:43 AM, the Assistant Director of Nursing, Infection Preventionist (ADON IP) stated she had been in contact with the Local Health Department (LHD) either, today, yesterday, or the other day. She stated that the LHD had provided her with the Communicable Disease Services (CDS), COVID-19 Patient/Resident Management in Post-acute Care Settings guidance dated 01/23/23. On 02/13/23 at 1:15 PM, the LNHA provided the survey team with a copy of the Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022, which she stated was their reference for COVID-19 policies. The document revealed Perform SARS-CoV-2 Viral Testing; Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible.; Asymptomatic patients with close contact with someone with SARS-CoV-2 should have a series of three viral tests for SARS-CoV-2 infection. Testing recommended immediately (but not earlier than 24 hours after the exposure), and if negative, again 48 hours after the first negative test and, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0, day 3, and day 5. Create a Process to Respond to SARS-CoV-2 Exposures Among HCP (Health Care Personnel) and Others; Healthcare Facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. On 02/14/23 at 12:56 PM, the surveyor asked the facility Assistant Director of Nursing Infection Preventionist (ADON IP) what the purpose was for identifying a close contact. The ADON IP stated, to make sure the close contact will be aware and make sure they do not get sick and we test the close contacts for COVID-19. On 02/14/23 at 1:56 PM, a surveyor conducted a telephone interview with the Registered Nurse from the Local Health Department (LHDRN). The LHDRN stated that she informed the facility to follow all Communicable Disease Services of the Department of Health guidance regarding the outbreak. The LHDRN stated she informed the facility ADON IP to follow contact tracing guidance and recommended if the facility was unable to perform contact tracing, they should have tested the whole floor or unit and/or the whole facility. She stated she informed the facility that COVID-19 testing should be completed on day 1, 5, and day 7. On 02/14/23 at 2:06 PM, the DON provided the surveyor with the facility undated Performing Contact Tracing document. The document revealed contact tracing slows the spread of COVID-19 by: Letting people know they may have been exposed to COVID-19 and should monitor their health for signs and symptoms of COVID-19, Helping people who may have been exposed to COVID-19 get tested .A close contact is defined as. 1) someone who was within 6 feet of an infected person for a total of 15 minutes or more, and 2) laboratory confirmed or probable COVID-19 patients. This is regardless of wearing cloth face coverings and PPE. Testing is recommended for all close contacts of confirmed or probable COVID-19 patients .Contact Tracing Workflow for COVID-19, 1. Infected/suspected person interviewed; a. Include status 48 hours prior to exposure; b. Questions to ask regarding exposure: 1. Was the individual tested , 4. When eating (on breaks, etc.) were employees socially distanced, on per table (if appropriate) and facing the same direction .For more detailed information, see Key Information to Collect During a Case Interview from the CDC; 4. Fill out contact tracing log; a. Update information as soon as possible,; b. Infection Preventionist/Center leadership to maintain on Center Share Drive. On 02/15/23 at 9:54 AM, a surveyor interviewed the DON and ADON IP in the presence of the survey team. The surveyor inquired what the contact tracing process entailed. The ADON IP stated if a resident tested positive for COVID-19 that they would find out who the contacts were, who took care of the resident, and if there had been visitors. The ADON IP stated that they would go back and look for a forty-eight-hour period to determine the contacts. The ADON IP stated that when they determined the contacts, they would be tested for COVID-19 the day after the exposure, and then the third and fifth day after exposure. On 02/17/23 at 8:56 AM, the DON provided the facility line listing (LL) to the survey team. The surveyor reviewed the LL which revealed that the initial Onset Date for the first listed Resident on the LL was 10/23/2022, not 10/24/2022 as indicated by the LNHA during the entrance conference, and listed four additional COVID positive staff which included a dietary staff (Employee #3) who was symptomatic with myalgia (muscle pain) and a headache, and tested COVID-19 positive on 02/16/23. The surveyor asked who was completing the contact tracing (a process to determine who came into contact with someone who had an infectious illness) and the DON stated the ADON IP was responsible for all the contact tracing. On 02/17/23 at 9:18 AM, the surveyor interviewed the Food Service Director (FSD), regarding when he had been tested for COVID-19. The FSD stated yesterday (02/16/23) he was tested since it was Tuesday and was the routine testing day. The surveyor asked if he had been aware that Employee #3 was symptomatic, and stated he was not aware. The surveyor asked the FSD if the DON or ADON IP had asked any questions regarding Employee #3 which may have included who Employee #3 had come into contact with, and what her job functions consisted of. The FSD stated no, that he had been informed that the Employee #3 tested positive for COVID-19, and that she needed to go home to quarantine. The surveyor asked what jobs Employee #3 was responsible for, in addition to the observations made by the surveyor on 02/15/23 from 11:37 AM to 12:08 PM when the surveyor observed Employee #3 who had been preparing resident meal trays on the tray-line and was also observed positioned opposite of the cook. The FSD stated that Employee #3 had also been responsible for serving meals to residents in the dining room and when asked what type of mask Employee #3 had worn, he stated a surgical mask. On 02/17/23 at 9:23 AM, in the kitchen, the surveyor observed the cook, prepping food and was wearing a surgical mask that was not fully covering his nose. The surveyor asked the cook if he had been tested on [DATE] for COVID-19. The cook confirmed he had worked on 02/16/23 and stated, no, not yesterday. The cook stated then he was supposed to come in today to get tested , and he went to the testing area and there was no one there to do his test and he started working. On 02/17/23 at 9:25 AM, the surveyor, again, interviewed the FSD. The surveyor asked the FSD if he had been aware that the [NAME] was not tested for COVID-19 on 02/16/23. The FSD stated, no, I was not aware and I was not told. The FSD stated that no one had told him that the [NAME] was not tested for COVID-19 during the routine testing conducted on 02/16/23. On 02/17/23 at 9:35 AM, the surveyor, in the presence of the survey team, interviewed the IP and DON. The surveyor asked the DON if the facility was still in an outbreak, and she stated yes. The surveyor asked what the process was for staff to be tested routinely. The ADON IP stated routine testing doesn't have to be done prior to the employees shift, only if the staff is symptomatic, they will be tested first. If a staff member was exposed, they should be tested the next day. The DON stated if staff were here on the routine testing days, they must be tested . The ADON IP then stated before the employee starts their shift, they must be tested , which was confirmed by the DON. The surveyor asked how they know everyone is tested ; the DON stated they use a staffing sheet. The surveyor asked what the testing policy was for an outbreak. The ADON IP stated, I don't know if there is a policy, there is no specific guidance other than if the person was exposed. The surveyor asked if the cook should have been tested on [DATE]. The ADON IP stated that she didn't have the cook on the schedule and was unaware that he had worked with the DS forty-eight hours back from when she had tested positive for COVID-19 on 02/16/23. The ADON IP stated the cook should have been tested yesterday and today (02/17/23) and stated, I didn't know he wasn't tested . On 02/17/23 at 9:50 AM, the surveyor asked the ADON IP, in the presence of the DON, what was process used to gather information regarding the contact tracing for the close contacts of Employee #3. The ADON IP stated she went to Employee #3 to ask who Employee #3 worked with and stated, I don't really ask many questions to the supervisor, only to the person. The surveyor then asked the ADON IP if Employee #3 had direct contact with any residents, and the ADON IP stated she was unaware and that she had not asked the FSD that question. The surveyor asked if the supervisors should be questioned regarding staff responsibilities during contact tracing. The DON stated yes, absolutely and supervisors should be included in the contact tracing process, and at that time the DON confirmed there was no documented process for completing contact tracing. On 02/17/23 at 10:04 AM, the surveyor interviewed the FSD regarding what time Employee #3 was tested on [DATE]. The FSD stated around 2:30 PM, and then Employee #3 left at 3:00 PM after working her full shift. The FSD stated he tried to get the staff to test earlier and sometimes there would be an overhead intercom announcement. On 02/17/23 at 10:29 AM, the surveyor reviewed the LL which revealed Resident #84, who resided on Wing #2, was symptomatic with congestion and fatigue, tested positive for COVID-19 on 02/02/23. The surveyor asked the DON what testing was completed in response to Resident #84 testing positive for COVID-19. The DON stated all residents were tested , and stated 02/07/23 was day zero, then day one was the next day. The surveyor asked the DON if a contact tracing or broad-based (testing individuals within a particular location, including facility wide, when all contacts who may have been exposed cannot be identified), and all the staff and residents were included. The surveyor asked the DON to confirm the date of testing completed for Resident #84. The DON stated 02/08/23 was the date that all of the COVID-19 testing was completed for Resident #84, and the surveyor asked to see all of the testing information. The DON looked on her computer, and stated, I don't have anything for that date for that unit [Wing 2], I don't see it there, no it was not done. The DON stated she had COVID-19 testing for 02/09/23 (Thursday, a routine testing date), and stated 02/11/23 (Saturday) would be day three of the required outbreak testing for Resident #84. The DON stated, I don't have anything (COVID-19 testing) listed there. The DON confirmed that the next broad-based COVID-19 testing day in response to Resident #84 would be for day five and that would be on 02/13/23 (Monday). The DON stated, I don't have anything listed for the 13th, no, I don't have it, if it was done it should be there, and everything should be entered in here (computer). The surveyor continued to review the LL which revealed, Resident #86, who resided on Wing 3, was asymptomatic and tested positive for COVID-19 on 02/12/23. On 02/17/23 at 10:47 AM, the surveyor requested all testing that was completed regarding Resident #86 testing positive for COVID-19 on 02/12/23. The DON stated that the broad-based testing should have been completed on 02/13/23, which would have been the required day 1 testing. The DON stated, it should have been done, and confirmed it was not completed and the DON stated she does not know why it was not completed, and she will look for it. On 02/17/23 at 10:41 AM, a further review of the LL by the surveyor revealed two Certified Nurse Aide's, (CNA #1) who was symptomatic with cough and fatigue, and who worked on Wing 2, tested COVID-19 positive on 02/05/23 and worked on 02/03/23 & 02/04/23, and CNA #2, who was symptomatic with cough and congestion, tested COVID-19 positive on 02/03/23 and worked on Wing 1 on 02/01/23. The surveyor requested any contact tracing and any COVID-19 testing related to either CNA. The DON stated that there was no contact tracing completed for either CNA. The surveyor asked if there was a file, or anything in writing regarding the contact tracing. The DON stated nothing was written down, there was no file and confirmed that CNA #2 worked on 02/01/23, caring for residents, and on 02/03/23 tested COVID-19 positive. The DON confirmed that contact tracing should have been completed and that there was no contact tracing completed on or testing completed, on 02/04/23. She stated there was nothing, and unfortunately no one was doing it when she (IP) was out. The DON provided CNA #1's time punch logs which confirmed CNA #1 worked on 02/03/23, on 02/02/23; and CNA #2 worked on 02/01/23. On 02/17/23 at 11:31 AM, the DON confirmed the day 1, 3, 5 broad- based testing was not completed in response to Resident #84 who tested COVID-19 positive on 02/07/23 and she did not have documented evidence to support that it was completed. In addition, the DON confirmed that the day 1 testing that should have been completed in response to the 02/12/23 COVID-19 positive test result for Resident #86 had also not been completed, and she was unable to provide documented evidence for completion. On 02/17/23 at 11:43 AM, the DON provided testing documentation to the surveyor for: 02/10/23, Wing 3, and 02/12/23, Unit 3 [Wing 3] Residents and staff secondary to exposure. The DON again, confirmed there was no testing that had been completed on 02/13/23, in response to Resident #86, who resided on Wing 3. At that time, the DON again stated there had been no testing completed on Wing 2, in response to Resident #84's COVID-19 positive test result on 02/07/23. On 02/17/23 at 11:46 AM, LNHA provided time stamp log for the [NAME] which revealed the [NAME] worked on 02/15/23 from 6:07 AM to 6:51 PM; 02/16/23 from 11:11 AM to 7:15 PM; 02/17/23 he punched in at 8:56 AM. The Employee #3 time stamp log revealed that Employee #3 worked on 02/14/23 from 7:03 AM to 1:30 PM; 02/15/23 (three separate time punches) from 6:51 AM to 1:00 PM, from 1:30 PM to 3:04 PM, and from 4:00 PM to 7:30 PM; 02/16/23, 7:02 AM to 12:57 PM, and a second punch log from 1:30 PM to 3:17 PM. Review of the facility COVID-19 Policy, Effective 03/27/20, Revision Date 02/14/23, revealed Definitions: Broad Based Testing requires testing of all individuals within a particular location (unit, wing, floor, facility-wide). Used most often due to the difficulty of ascertaining ALL contacts who may have been exposed to a COVID positive person.; Contact tracing is testing process that requires identifying all of the potential contacts within a patient/person who tests positive for COVID-19 testing.; Contact Tracing is a testing process that requires identifying all of the potential contacts with a patient/person who tests positive for COVID-19 for testing.; Purpose: To prevent the development and transmission of COVID-19.; Practice Standards: 4. Outbreak testing is completed utilizing broad based or contact tracing approach.; 5. Centers will conduct testing and specimen collection in a manner that is consistent with current standards of practice for conducting COVID-19 tests .; 5.2. Completed tests and results will be properly documented and reported as required.; 18. Follow CDC published guidance for patient or HCP with suspected COVID-19.; 20. Perform contact tracing for both suspected and confirmed cases and document on Contact Tracing Log.; 10.1 A broad based approach is utilized to investigate a possible COVID-19 outbreak.: 21. Centers will have a plan based on CDC/CMS/state/local recommendations to prevent transmission, such as having a dedicated space in the facility for cohorting and managing care for patients with COVID-19. Testing for COVID-19: 35. Patients, facility staff, and visitors will be tested according to CMS and state Department of Health requirements and [corporate] guidance.; 35.1 COVID-19 testing results will be documented. NJAC 8:39-5.1(a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a.) ensure the facility policy for Falls Management and Accidents/Incidents policy was followed to determine the causal factor and interventions were updated to prevent recurrent falls, for a cognitively impaired resident (Resident #45), who was identified as high fall risk, had a history of falls with injury which included a fall on 10/08/21 that resulted in a femur fracture that required hospitalization , a subsequent unwitnessed fall on 05/29/22, and a fall requiring hospitalization on [DATE] after sustaining a hematoma to the head, b.) supervision was provided to prevent recurrent falls c.) implement care plan interventions for a resident (Resident #1) identified as requiring two-persons for transfer, was transferred by one staff on 06/06/22, and sustained a fall during transfer which necessitated transfer to the hospital for evaluation, and d.) immediately implement suicide preventions precautions per facility policy and immediately notify the attending physician in response to a resident (Resident #71) who expressed suicidal ideation. This deficient practice occurred for 3 of 5 residents reviewed for accidents and was evidenced by the following: a) During the initial tour of the facility on 02/08/23 at 9:00 AM, Surveyor #1 entered Resident #45's room and observed the resident in bed. At 10:15 AM, surveyor #1 performed a care tour with the Certified Nursing Assistant (CNA). Surveyor #1 observed the resident in bed. The CNA informed the surveyor that Resident #45 was confused and required staff assistance with care. On 02/09/23 at 12:30 PM, surveyor #1 reviewed the medical record for Resident #45. According to the Admission Face sheet, Resident #45 was admitted to the facility with diagnoses that included but were not limited to;major depressive disorder, muscle weakness, unspecified dementia, repeated falls, and unsteadiness on feet. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 01/19/23, revealed Resident #45 was cognitively impaired. Resident #45 received a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of a severely impaired cognition. Resident #45 was totally dependent on staff for care and required extensive assistance of 1 person assist with bed mobility, transfers, and tilting. A review of the Comprehensive Care Plan, initiated 12/21/17, and last revised 11/08/22, revealed a Focus for falls related to: Cognitive loss, lack of safety awareness, preference to be independent. The Care Plan (CP) revealed that Resident #45 sustained falls at the facility on the following dates: 10/08/21, 05/29/22 and 11/06/22. The Goal was to minimize the risk for falls. Interventions to minimize falls, included: Provide verbal cues for safety and sequencing when needed. Initiated 12/21/17; Utilize night light in room/ bathroom. Initiated 08/13/19; Place call light within reach while in bed or close proximity to the bed. Initiated 06/12/20; Remind Resident #45 to use call light when attempting to ambulate or transfer to get in and out of bed. Initiated 06/12/20; Closely monitoring Resident #45, if he/she tired, offer him/her to return to the room for a nap. initiated 02/13/20; Assist out of bed with 1 assist with walker. 10/12/21; Prompted voiding and tilting. Initiated 10/12/21. Encourage to participate in activities that he/she likes. Initiated 10/14/21; Observe for signs and symptoms of abnormal blood pressure including orthostatic blood pressure and promote self-management strategies. Initiated 07/05/22; PT/OT (Physical Therapy / Occupational Therapy) evaluation and treat as needed. Initiated 07/05/22; On 02/15/23 at 8:56 AM, upon entry to the 300's wing, surveyor #1 observed Resident #45 in the resident's room holding onto the wheelchair and was attempting to transfer self to the bed. Resident #45 could not complete the transfer and was very unsteady. The surveyor alerted a staff member who went to the room and assisted Resident #45 into the bed. On 02/16/23, Surveyor #1 requested the falls investigations and a timeline of the falls which included the day, time and location of the falls, and any interventions implemented after each fall. On 02/17/23, the Director of Nursing (DON) provided two fall investigations dated 05/29/22 and 11/06/22. On 02/24/23, the DON provided the fall investigation dated 10/08/21. A summary of the fall incident of 10/08/21, which was dated 10/11/21, revealed that Resident #45 sustained an unwitnessed fall at 1:15 PM in the Atrium. Another resident yelled out that Resident #45 was on the floor. Resident #45 was unable to move their right leg. Resident #45 was transferred to the hospital and admitted with a right femur fracture. Resident #45 was readmitted to the facility on ,d+[DATE]/ 21, with right hip intramedullary rodding. A statement from a staff who was assigned to the 2nd wing revealed that she was on the 2nd wing getting ready for medication administration and heard another resident calling out that Resident #45 was on the floor. A statement from the nurse assigned to the 3rd wing documented, I was in a resident's room and was notified that Resident # 45 was on the floor. A statement from the the CNA assigned to the 3rd wing documented, I was inside assisted with feeding. The nurse called and informed of the fall. Other residents (including Resident #45) were in the Atrium eating lunch, and there was no staff around to monitor the residents. An un-witnessed Incident report (a report the facility fills out to investigate an incident) dated 05/29/22 timed 12:55 PM, included the following: Incident Description: Nursing Description: This writer finds Resident #45 sitting up on his/her buttocks in the hallway between room [ROOM NUMBER] and 315. This writer asks what happened. Resident #45 stated, I don't know.Assisted to chair with 2 staff using mechanical lift. Injury Type: No injuries observed at time of incident. There was no witness to the fall. There were no staff statements that would indicate when Resident #45 was last seen/checked. The causal factor was not identified. According to documentation provided by the DON on 02/27/23 the Interdisciplinary Team met and discussed the fall on 05/31/22. The following was documented, Met and discussed the resident's fall. The resident's plan of care updated to reflect, environmental rounds in resident area for safety, to provide education and redirection within limits. Staff will continue to encourage Resident #45 to use call bell to ask for assistance prior to ambulating. Will refer to PT/OT post incident. An Incident report dated 11/06/22 timed 7:15 PM, included the following information: Incident Description. Nursing Description: Resident #45 was seen at 6:30 PM lying on his/her bed. At 7:15 PM, I was notified by CNA that resident was sitting on the floor by his/her room door. Resident #45 is alert and responsive, denies any pain at this time, ROM [Range of Motion] to upper and lower extremities within normal limit. Assisted back to bed via mechanical lift with 2 assist. Once in bed, hematoma (collection of blood), noted on the left upper eyebrow. Resident Description: Resident unable to give description. Immediate action: Physician notified of incident and reminded that Resident #45 is on Eliquis (anticoagulant medication). Order received to send Resident #45 to the hospital for evaluation. An attached note dated 11/06/22 timed 19:15 [7:15 PM] revealed that the resident was admitted to the hospital and was diagnosed with Urinary Tract Infection. On 02/13/23 at 9:55 AM, surveyor #1 interviewed the DON regarding the falls. She stated that she could not locate any fall investigation related to the fall of 10/08/21. The DON stated that she was not working at the facility at that time and could not locate the investigations. When asked about how residents needs were communicated to the staff, she stated that the supervisors were responsible to communicate to direct care staff any change in condition and then update the care plan with any changes. On 02/13/23 at 1:25 PM, the surveyor interviewed a CNA regarding using the residents care plans. The CNA stated that the CNAs did not have access to resident care plans and received report from the nurses and other CNAs. When asked about a CNA care card, the direct care staff was not aware of the care card. On 02/23/23 at 10:30 AM, Surveyor #1 reviewed the electronic progress notes and could not locate any documentation regarding the fall that occurred on 10/08/21. On 02/24/23 at 11:30 AM, the DON provided the reportable (a report required to be sent to the state department of health) dated 10/08/21, that the fall had been reported to the state, and she could not locate the incident report. The DON indicated she called some staff and was able to get some statements. Statements from residents who could have possibly witnessed the fall were collected on 02/25/23. b) On 02/08/23 at 11:46 AM, Surveyor #1 observed Resident #1 seated in a wheelchair inside the room. The resident requested to speak to the surveyor. Resident #1 stated that he/she had been residing at the facility for 8 years and had noticed a lot of changes. He/she requested to go to bed by 9:00 PM and requested that this information be communicated to staff. Resident #1 informed the surveyor that the above information was on the care plan and had been discussed during the quarterly meeting. The resident also stated that he/she needed assistance with transfer for using the bathroom, and that staff would say they cannot accommodate his/her request because they were shorthanded. The resident stated that he/she fell and was on the floor for 20 minutes before staff answered the call light. On 02/10/23 at 1:19 PM, the surveyor reviewed Resident #1's medical record which revealed: Resident #1 was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, muscle weakness, unspecified lack of coordination and need for assistance with personal care. The Quarterly MDS dated [DATE], revealed that Resident #1 was awake and alert and able to make his/her needs know. Resident #1 scored 15/15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The Comprehensive Care Plan initiated 02/08/22, with a revision date of 06/06/22, had a focus for falls related to cardiovascular accident (damage to the brain from interruption of its blood flow), and impaired mobility. The interventions were: Assist Resident #1 with 2 staff assistance while transferring from bed to Wheelchair and from wheelchair to bed. Date Initiated: 02/26/18, and revised 12/11/20, Educate staff to ask for help when assisting Resident #1 during transfers since he/she is a two person assist wheelchair to bed. On 02/23/23 the surveyor requested the investigation report for review. The DON provided 2 incidents reports dated 06/06/22 and 02/14/23. The investigation report dated 06/06/22 contained the following information: Incident Description: Nursing Description. This writer informed by CNA of resident slipped and fell during transfer from bed to the electric chair. Slip was witnessed by CNA. Resident #1 slipped and fell to floor landing on his/her back. No loss of consciousness reported. No complaint of pain. Resident #1 assisted to wheelchair using mechanical lift with 3 staff. Resident Description: I slipped and fell when transferring. Immediate action: Taken to hospital. The CNA who was present in the room during the transfer, documented the following: While doing a routine care with the resident. While transferring the resident from the bed to the chair, suddenly the resident lost balance landed on the floor. Immediately I called the nurse. My coworker used the [brand name mechanical lift], to lift the resident assisted to the wheelchair. (The causal factor for the fall was not identified and the Falls Management policy was not followed post fall. The CNA executed the transfer alone and the care plan interventions for Resident #1, who required a 2 person assist for transfer from the bed to the chair and from the chair to the bed, had not been implemented when the fall occurred.) On 02/24/23 at 1:35 PM, the surveyor conducted an interview with the CNA who cared for Resident #1 on 06/06/22. The CNA stated, in the presence of the nurse, that she had not been made aware that Resident #1 required 2 persons assist for transfer from the bed to the chair when she had cared for the resident on 06/06/22 and transferred him/her alone. On 02/24/23 at 12:17 PM, the surveyor discussed the fall incident with the DON and requested any additional information. On 02/27/23 at 9:30 AM, the DON provided a typed incident summary with the following statements: The CNA documented that she did not see anything, I just help the nurse to pick the resident up. Another CNA documented: I was working on wing 1 and the other CNA was wing 3. The nurse assigned to the Wing documented: I assisted the staff with moving the resident from room [ROOM NUMBER] to room [ROOM NUMBER]. The resident was able to get into the room. I walked away from my cart for less than 10-minutes, and I was walking back I heard [him/her] start to yell. On 02/27/23 at 10:30 AM, after surveyor inquiry, the DON provide an updated care plan which indicated that Resident #1 was now a one-person transfer. The Surveyor showed the care plan documentation indicating the resident required a two-person transfer to the DON, the DON did not have any comment. No additional information was provided. Another fall incident dated 02/14/23, documented the following: Incident Description: Nursing Description: Resident was noted on the floor in the room in front of the wheelchair. Resident is alert and oriented and denied hitting his/her head. Resident Description: Resident stated he slipped out of the wheelchair. A statement from the nurse assigned to the 3rd wing, revealed that she found the resident on the floor. There was no investigation included with the incident. On 02/08/23 at 11:46 AM, the resident told the surveyor that he/she slipped from the wheelchair and was on the floor for 20 minutes before he/she could get assistance. The resident had a BINS of 15/15 which indicated the resident was cognitively intact. The facility failed to obtain a statement from the resident to identify the causal factor for the fall and implement interventions to prevent further falls. An interview with the resident, revealed that the facility was shorthanded and could not get staff to assist with transfer when needed. A review of the facility provided form titled, Falls Management, dated 09/15/01, and last revised 06/15/22, indicated the following: Policy: Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patient experiencing a fall, will receive appropriate care and post fall interventions will be implemented. Purpose: To identify risk for falls and minimize the risk of recurrence of falls. To evaluate the patient for injury post fall and provide appropriate and timely care. To ensure the patient-centered care plan is reviewed and revised according to the patient's fall risk status. Practice Standards: All patients will be assessed for risk of falls upon admission, with reassessment routinely, post fall to determine ongoing need for fall prevention. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Post Fall management: Document circumstances of the fall, post fall assessment, and patient outcome. A review of the Accidents/Incidents Policy, Effective Date: 06/01/96, Revision Date: 10/24/22 revealed: The Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property involving, allegedly involving, a patient who is receiving services. Incident: defined as any occurrence not consistent with the routine operation of the Center or normal care of a patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security. Purpose: To determine root cause and contributing factors, identify measures to reduce further occurrences and adverse outcomes as part of the Quality Assurance Performance Improvement process. 2.1.4. The physician/APP will be notified of any fall resulting in head injury, suspected head injury, and/or has an unwitnessed fall .2.1.6.2. Document the accident/incident in the patient's chart; Documentation will include all pertinent information, date, time, place, notifications, post-accident/incident evaluation, ongoing evaluations. Reporting: 3.1 All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. 3.1.1. Employees witnessing an accident involving a patient will communicate a factual description of his/her findings to the supervisor or the nurse responsible on the unit. 4. Follow-up/Investigation: 4.1. The Administrator or designee will coordinate all investigations. 4.2. The Administrator, DON, or designee will review all accidents/incidents to determine if: 4.2.2. Required documentation has been completed; 4.2.3. Accident/incident has been investigated; 4.2.4. Interventions to eliminate if possible and, if not, reduce the risk of the accident/incident have been identified and implemented. 4.4. When conducting an investigation, the Administrator, DON, or designee will: 4.4.1. Make every effort to ascertain the cause of the accident/incident; 4.4.2. Initiate a timeline chronology; 4.4.4. Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident; 4.4.5. Document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident . 38079 c) On 02/09/23 at 8:21 AM, Surveyor #2 observed Resident #71 sitting on the side of the bed reading a newspaper. The Registered Nurse (RN) who was caring for the resident, was standing with the surveyor in the hall. At that time, the RN stated Resident #71 had behaviors. A review of the medical record revealed Resident #71 was admitted to the facility with diagnoses which included but were not limited to; paranoid schizophrenia, bipolar disorder, major depressive disorder, and unspecified intellectual disabilities. A review of the on-going Care Plan (CP), revealed a focus area initiated 09/09/21, and revised on 02/09/23, at risk for complications related to; the use of psychotropic drugs, paranoia thoughts, gets excited and agitated easily, and cries easily. Interventions included but were not limited to; monitor for changes in mental status and functional level and report to MD (physician). A focus area impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Intellectual/developmental disability. Interventions included but were not limited to observe and evaluate types of changes .decision making ability, ability to express self .impulsivity, mental status and notify physician as needed. A review of the, Therapy Note, dated 12/15/22, documented by a Social Worker (SW) therapist who was not on staff at the facility, included but was not limited to: Diagnosis major depressive disorder and paranoid schizophrenia. Reports history of depression, paranoia, racing thoughts. Past history included psychiatric hospital admission. Patient disclosed suicidal ideation. A review of a Risk Assessment form dated 12/15/22, included but was not limited to: Yesterday I had a moment where I wanted to commit suicide. Risk Factor: Hx (history) of suicidal behaviors, severity of psychiatric symptoms. Pt (patient) verbally agrees to notifying staff immediately if any thoughts, plans, or intentions should arise again. Identify who at the facility was informed that patient is currently a danger to self: SW (Social Worker) [name redacted]. The form was completed by a SW therapist who was not on staff at the facility. A review of the facility provided Progress Notes (PN) ranging from 12/14/22 through 12/25/22, revealed all staff disciplines failed to document Resident #71's suicidal ideation on 12/14/22 that was reported to the facility on [DATE]. The PN failed to document the resident's physician being contacted, any interventions implemented to ensure the residents safety, and any aspect of the facility, Suicide Precautions policy being implemented. A PN dated 12/16/22, documented by the facility SW, failed to address the resident's suicidal ideation that had been reported to her on 12/15/22, per the SW therapist's documentation. However, the note revealed Resident #71 had been missing his/her roommate. The quarterly Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. A review of the facility provided, Behavior Monitoring and Interventions Report, ranging from 11/01/22 through 02/22/23, revealed an entry dated 12/13/22, no behaviors observed. The next entry was dated 12/15/22, no behaviors observed. The facility failed to document if any behaviors were present on 12/14/22 when the resident had his/her suicidal ideation. A review of Resident #71's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/01/22 through 12/31/22, revealed the facility failed to document any interventions or monitoring of Resident #71 regarding the suicidal ideation. On 02/22/23 at 9:49 AM, during an interview with Surveyor #2, a CNA who was familiar with Resident #71, stated that the resident has not had any behaviors lately that she had been aware of. On 02/22/23 at 10:00 AM, during an interview with Surveyor #2, a second CNA who was familiar with Resident #71, stated that the resident could be agitated and that she would report any behaviors to the nurses. She further stated she was not aware of any concerns in December 2022. On 02/22/23 at 10:08 AM, during an interview with Surveyor #2, the LPN caring for the resident stated the resident could be nasty and wants things done immediately. The LPN showed the surveyor where behaviors would be documented in the electronic medical record. The LPN further stated she was not aware of any concerns regarding Resident #71 in December 2022. On 02/22/23 at 10:43 AM, during an interview with Surveyor #2, the DON stated a resident's care plan would be so the entire staff would be aware of the resident's care needs. On 02/22/23 at 11:02 AM, the facility Social Worker (SW) and DON were interviewed by the survey team. Surveyor #2 requested the SW show the documentation from where she had been contacted by the therapist SW. The SW was unable to locate any documentation and stated maybe the therapist SW did not inform her. Surveyor #2 showed the SW the note from the therapist SW the documentation that she had been made aware of the notation identify who at facility was informed that patient is currently a danger to self: SW [name redacted] which indicated the facility SW. The DON stated that the suicidal ideation should have been documented to ensure the nurses were monitoring the resident. The DON stated the resident would have been on 15-minute checks. The DON further stated the CP should have been updated, even if the resident stated he/she was not going to do anything, they would still need to be on watch until seen by the psychologist, and that the physician should have been notified. On 02/22/23 at 12:26 PM, during an interview with Surveyor #2, the Nurse Practitioner for the resident's psychiatric medical group, stated she could not remember what happened in December 2022 and was unable to continue to speak to the surveyor. On 02/23/23 at 8:50 AM, during an interview with the survey team, the DON stated that the staff were able to locate a handwritten piece in a drawer at the nurse's station, of paper with 15-minute checks for the resident. A review of the provided paper revealed the resident's name, room number, 12/15 (no year), and staff initials. The paper did not reveal what the resident was being monitored for any behaviors. The DON stated that the 15-minute checks should have been documented in the resident's medical record. The DON further stated, I can't see a note that attending physician was notified. The DON stated that the physicians had remote access to medical records. The survey team reviewed the facility provided, Suicide Precautions procedure revision date 06/01/21, which included but was not limited to: 2. Immediately report behavior/wishes to supervisor and attending physician. 3.1. initiate suicide precautions which included but were not limited to: one-on-one 24-hour supervision; limit/restrict mobility throughout center; remove hazardous items. The DON stated there was no 24-hour supervision initiated; no limited or restricted mobility through the center; and she could not say if any hazardous items were removed. The DON stated that the facility policy should have been followed and that there should have been documentation to ensure the resident was kept safe and what the staff should have been doing. The DON acknowledged the suicidal ideation was not on the 24-hour report to inform the next shift staff. The DON further stated there were no directives or orders provided by the physician because he was not notified. The DON stated there was no investigation completed, but that the SW therapist stated the resident was, ok. When asked if the SW therapist was a practitioner and able to make the decision to order interventions, the DON stated, I don't know. On 02/23/22 at 10:05 AM, during a telephone interview with Surveyor #2, Resident #71's attending physician (MD) stated he was not made aware of the resident's suicidal ideation in December 2022. The MD stated that he would have ordered the nurses to do either 15-minute checks or as needed for the resident who was very independent. The MD stated he would have ordered a psychiatric evaluation and possibly may have sent the resident out for a psychiatric evaluation as he has had to do before. On 02/23/23 at 10:22 AM, during an interview with the surveyor, the DON stated that the SW therapists note dated 12/15/22, revealed low risk. The DON acknowledged that any risk of suicidal ideation should be taken seriously and does not negate that the procedure was not followed. A review of the facility provided, Behaviors: Management of Symptoms, revision date 10/24/22, included but was not limited to: 7. if behavior escalates to the point of being dangerous to self or others, take immediate measures to protect the safety of all patients and staff. 8. Document: 8.1. behavior goals, interventions, evaluation within the comprehensive patient-centered care plan; 8.2. behavior monitoring and interventions in electronic Medication Administration Record. 8.4. notification of physician. NJAC 8:39-27.1 (a)

Complaint Intake: NJ 3 Based on interview and record review, it was determined that the facility failed to ensure a resident was free from significant medication errors for 1 (Resident #1) of 3 residents reviewed for medication administration. Resident #1 received four medications in error, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], that were not prescribed to be administered to the resident. This resulted in Resident #1 experiencing a drop in vital signs and the resident had to be transferred to the hospital and admitted to the critical care unit (CCU). Findings included: 1. Resident #1 was initially admitted to the facility on [DATE], discharged to hospital on [DATE], and readmitted to the facility on hospice on [DATE]. The resident expired at the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], indicated the resident scored 03 out of 15 on a Brief Interview for Mental Status (BIMS), indicating a severely impaired cognition. Resident #1 required limited assistance for bed mobility, transfer, toileting, dressing, and activities of daily living (ADLs) and required physical help with bathing. According to a nurse's progress note on [DATE] at 5:30 PM, late entry from 9:30 AM by Licensed Practical Nurse (LPN) #4, and the reportable to the New Jersey Department of Health (NJDOH) of the incident on [DATE] at 9:30 AM, Resident #1 was given [MEDICATION(S)] 1000mg (milligrams) (a medication for lowering blood sugar), [MEDICATION(S)] 10mg (a medication for lowering blood sugar), [MEDICATION(S)] 25mg (used to treat hypertension and heart failure), and [MEDICATION(S)] 20meq (milliequivalents) (a medication for low potassium), which was ordered for a different resident. LPN #4 was preparing medications for a resident when Resident #1 called out for help. LPN #4 went to Resident #1's room, with the medications in hand, assisted Resident #1 to the bathroom, and LPN #4 then administered those medications to Resident #1. A progress note dated [DATE] at 7:00 PM indicated the resident had episodes of [CONDITION(S)] (low blood pressure) and a low heart rate throughout the day. According to a progress note on [DATE] at 9:35 PM, Resident #1 had a blood pressure of ,d+[DATE] and a heart rate of 33. The physician was notified by LPN #4 and orders were noted for the resident be sent to the hospital. Hospital records revealed the resident's vital signs on arrival were blood pressure ,d+[DATE], heart rate 33, and blood sugar 50. The resident was given [MEDICATION(S)] to stabilize the resident's blood sugar, and over the next four days the resident remained in the CCU. The resident's blood sugars fluctuated, dropping to the 40 and 50's with [MEDICATION(S)] administered each time. By the second day, the blood sugars stabilized according to the progress notes from the hospital. The resident remained in the hospital for fourteen days. According to hospital records, the resident was not a candidate for [CONDITION(S)]. While hospitalized , the resident was diagnosed with acute renal failure and polypharmacy (the simultaneous use of multiple drugs to treat a single ailment or condition) overdose. Resident #1 returned to the facility on [DATE] under hospice care and subsequently expired on [DATE]. A review of the death certificate revealed Resident #1 succumbed to acute renal failure and polypharmacy overdose. On [DATE] at 2:00 PM, the Director of Nursing (DON) stated there was no incident and accident report for this resident. The DON stated the reason they turned this incident into a reportable was because the nurse who made the mistake was not honest about what happened. A medication error is not a reportable event. The nurse only reported giving the [MEDICATION(S)] at first, and a couple of hours later, she reported all the medications she had given in error to Resident #1. The DON told the surveyor of the interventions put in place to prevent this from occurring again. The DON stated she in-serviced all nursing staff on neglect/abuse, medication administration, medication errors, and the transfer to hospital checklist. All nurses had to pass two medication passes with the pharmacist and a supervisor. The DON started these in-services on [DATE]. The nurse involved in the medication error was terminated for being dishonest and was reported to the state board of nursing. The supervisor that was responsible for that unit was also terminated for not following up after being notified of the error. New Jersey Administrative Code § 8:,d+[DATE].2 (d)