Every finding on record at United Methodist Communities at the Shores

Based on interview and record review, it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident received a new mental illness diagnosis. This deficient practice was identified in 1 of 1 resident reviewed for PASRR (Resident #4) and was evidenced by the following:On 08/26/2025 at 7:06 PM, during the initial tour of the facility Resident #4 was in the room in bed.On 8/27/25 at 11:26 AM, the surveyor reviewed the medical Record for Resident #4.A review of the admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility with diagnoses which included but not limited to failure to pneumonia, bipolar disorder, muscle weakness, and chronic pain.A review of Resident #4's PASRR level one in the Electronic Medical Record (EMR) dated 11/2022 showed that section one of the PASRR asked if the resident had a mental illness was marked as no. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/29/25, reflected the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of section I of the MDS titled active diagnoses revealed the resident had a diagnosis of bipolar disorder and schizophrenia.On 8/28/25 at 10:15 AM, the surveyor interviewed the Director of Nursing (DON) regarding the PASRR level one being marked as no for mental illness and the DON stated it should be reviewed on admission to the facility. On 8/29/25 at 10:00 AM, the surveyor requested a copy of the PASRR policy from the DON and the DON told the surveyor the facility did not have a PASRR policy.NJAC 8:39-27.1(a)

Based on Interview, record review, and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. The deficient practice was identified for 1 of 1 resident (Resident #45) investigated for Unnecessary Medications and was evidenced by the following: A review of Resident #45's admission Record reveale diagnoses of but not limited to; Cerebral Ischemia (blood flow reduced or blocked to the brain), Atherosclerosis Heart Disease (plaques build up in the arteries), Nonrheumatic Aortic Valve Stenosis, and Myocardial Infarction (heart attack). A review of Resident #45's Physician Orders (PO) dated 8/8/25 included: Eliquis Tablet 2.5 MG (milligrams), give 1 tablet by mouth two times a day for anticoagulated (blood thinner) that prevents blood from clotting, reducing the risk of blood clots forming in the arteries, veins, or heart. A review of Resident #45's Individual Comprehensive Care Plan (ICCP) revealed that there was only one care plan focus since the resident was admitted to the facility. The ICCP focus was dated 8/12/25 and revealed that Resident #45 was at risk for malnutrition. A review of Resident #45's admission 5 Day Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/14/25, included under section N Medications, that Resident #45 was on an Anticoagulant (blood thinner). On 8/28/25 at 10:35 AM, during an interview with the Surveyor, Register Nurse/Unit Manager (RN/UM #1) of the Bay House Unit, replied, that the baseline care plan time frame is within 24 hours and should include interventions related to the diagnosis such as pain, skin issues, and most important things going on. RN/UM #1 agreed that Antibiotics and Anticoagulants should be included in the baseline care plan within the first 24 hours. At that time the RN/UM #1 reviewed the resident's ICCP in the presence of the surveyor and RN/UM #1 stated that she did not see that Resident #45's ICCP included Anticoagulant or blood thinners. RN/UM #1 stated, yes, an anticoagulant should be in the ICCP, I'm going to fix it right now. On 8/28/25 at 12:10 PM, during an interview with Administration in the presence of the survey team, the Regional Registered Nurse stated that the time frame for a baseline care plan is 16 hours with a window of 48 hours and that an anticoagulant should be included. On 8/28/25 at 12:00 PM, the surveyor reviewed the facility's policy titled, Care Plan (RS-1) with a revised date of 8/8/25 that included; The Baseline Care Plan is to be completed upon admission and should include minimal instructions and information needed to provide effective and person-centered care of the resident.After completing the admission nursing evaluation, nursing will use the information available to develop the Baseline Care Plan within 16 hours of admission and will be reviewed with the resident/representative within 48 hours of admission with the Interdisciplinary Team (IDT) Care Conference. 8:39-11.2(d)

Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment care for 1 on 15 residents reviewed for comprehensive care plans related to an indwelling urinary catheter (tube inserted in the bladder to drain urine). (Resident #34.)This deficient practice was evidenced by the following: A review of Resident # 34's admissions record revealed that, Resident # 34 was admitted with but not limited to Retention of Urine (a condition where your bladder doesn't empty all the way or at all when you urinate), and heart failure. A review of the Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter. A review of the current Care Plan (CP) for Resident #34 did not include documentation of a CP focus area or interventions for the care of indwelling catheters. During an interview on 08/28/2025 at 09:13 AM with the surveyor the Registered Nurse (RN) said that care plans are reviewed monthly and updated as need if the residents need change. The RN also said that residents with indwelling urinary catheters should have focus and interventions in place on a care plan. When asked if Resident #34 was care planned for the indwelling catheter, the RN stated No he is not, but he will be.During an interview on 08/25/2025 at 12:12 PM with the surveyor the Director of Nursing said that residents with indwelling urinary catheters should have focus and interventions in place on a care plan. A review of a facility provided policy revised on 08/08/2025 titles, Care Plan revealed under, Procedure that, 13. The interdisciplinary Care Plan Team will develop the care plan in coordination with the attending physicians plan of medical care. The Care plan is individualized and addresses the resident's medical, nutritional, psychological, physical, functional, social, educational and spiritual needs and the severity of the resident's condition . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination for 1 of 2 resident reviewed for a urinary catheter, (Resident #34). The deficient practice was evidenced by the following: During the initial tour of the unit on 08/26/2025 at 06:54 PM, Resident #34 was in bed with a Foley catheter drainage bag in contact with the floor, with privacy bag intact. It was not secured to the bed frame. A review of Resident # 34's admissions record revealed that, Resident # 34 was admitted with but not limited to Retention of Urine (a condition where your bladder doesn't empty all the way or at all when you urinate), and heart failure. A review of the Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter.During an interview on 08/28/2025 at 09:13 AM with the surveyor, the Registered Nurse Mentor (RNM) said, indwelling urinary catheters should be hanging on the side of the bed frame, not touching the floor and in a privacy bag to prevent contamination. During an interview on 08/28/2025 at 01:12 PM with the surveyor, the Director of Nursing (DON) said, indwelling urinary catheters bag should never be on the floor. A review of a facility provided policy revised on 8/8/2025 titled, Foley Catheter Care and Catheter Maintenance Guidelines revealed under, Urinary Catheter Maintenance to, Ensure that the collecting bag is secured below the level of the bladder at all times and not resting on the floor . N.J.A.C. 8:39-19.4(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:19 to 10:05 AM the surveyor, accompanied by the Executive Chef (EC), observed the following in the main kitchen: 1. On an upper shelf in the dry storage room a container of Ground Thyme was dated [DATE]. The surveyor asked the EC if the container of thyme was dated 2022,2023, or 2024. The EC could not tell the surveyor how old the thyme was or when it was placed on the shelf. The EC removed the thyme to the trash. On a lower shelf in a previously opened card board box, a previously opened bag of pasta had no dates. The EC removed the pasta to the trash and agreed that the bag had no dates. In addition, on an upper shelf a previously opened container of Heinz tomato ketchup had dried ketchup covering the lid of the bottle. The EC agreed that it was dirty and could not identify when the bottle was opened or the use by date. Observation of the bottle of ketchup did not reveal a manufacturers use by date. 2. On a middle shelf of the walk-in refrigerator a soup tureen contained beef au jus, as identified by the EC. The plastic wrap covering the au jus was torn and the au jus was exposed. The plastic wrap had a date of ,d+[DATE] and ,d+[DATE]. EC agreed that the au jus was expired and exposed. 3. A mobile 4 wheeled multi-tiered cart in the walk-in refrigerator contained a sheet pan with a vanilla cake on a middle rack. The cake was uncovered and exposed. On a separate cart a sheet pan contained sliced deli meat prepped for the dinner meal and covered with paper. The sheet pan had no dates to indicate when the product was produced or when the product was to be used by. 4. In the walk-in freezer on an upper shelf, (2) packages of individual quiches had been removed from their original container. The quiches had a prep date of ,d+[DATE] and a use by date of ,d+[DATE]. The EC could not tell the surveyor what year they were prepped or how long the freezer storage period would be. The quiches were observed to be covered with frost on the inside of the packages. 5. A stand-up mixer was covered with a plastic bag and was not in current use. The EC stated that the mixer was not in use and that the mixer was cleaned and sanitized. The surveyor had the EC remove the plastic bag to inspect the mixer for cleanliness. Upon removal of the plastic bag the surveyor observed that the electric power cord was placed inside of the cleaned and sanitized mixer bowl where food ingredients are prepared and mixed. The cord was observed to be covered with unidentifiable debris. The EC then removed the contaminated mixer bowl and instructed kitchen staff to clean and re-sanitize the mixer bowl. The EC agreed on interview that the power cord should not be stored within the cleaned and sanitized mixer bowl. On [DATE] from 9:38 to 10:37 AM the surveyor, accompanied by the General Manger (GM), observed the following in the main kitchen: 1. (2) containers of plastic wrap were resting on top of the loading area/prep table. The boxes were opened, and the plastic wrap was exposed. Both containers had cardboard lids attached and opened. On interview the GM stated, They should be closed when not being accessed. 2. The surveyor observed the ice machine maintenance technician in the kitchen during food production. The technician was conducting quarterly maintenance/deep cleaning of the kitchen ice machine, according to the GM. The technician was observed kneeling in front of the ice machine. The technician had no hair net/covering and their hair was exposed. The GM stated that she had previously told the technician that a hair net/covering was required to be worn while in the kitchen. The GM was observed to then tell the technician to donn a hairnet/covering. 3. The surveyor observed dust accumulation on the ceiling tiles/metal channels above the steam table, where resident food is prepped and served. In addition, dust accumulation was observed on the light shield/cover above the food production area/steamtable for the overhead lighting. The surveyor utilized a step stool to gain access to the ceiling and determined that dust accumulation was present after doing a finger swipe on the surface of the light cover. In addition, a grease-like and dust substance was determined to exist on the ceiling panel/tile in the food production area above the range/oven unit. This was determined by a finger swipe by the surveyor. A support column adjacent to the steam table was noted to have an accumulation of a dark, unidentified substance on the upper area of the column and extending down approximately 1 foot from the ceiling. On closer inspection the surveyor was able to determine that the substance was a dark dust-like substance. On interview the GM replied to the surveyor, Ok, when asked by the surveyor if the dust accumulation in the food production area could possibly contaminate food or exposed dishware/equipment in the food production area. The GMs upon further questioning did agree to the surveyor that the dust could be a potential source of contamination and also stated that the ceiling was not currently included on the kitchen cleaning schedule. 4. (3) stacks of bowls in a well on the steam table were not inverted or covered and were exposed to contamination. Active food production was not taken place at the time. On interview, the GM stated, They should be inverted or covered to prevent contamination when not in active use. 5. The surveyors observed a dust-like substance throughout the walk-in refrigerator, The dust-like substance was on the wire cage surrounding the fire sprinkler head on the ceiling, along the conduit covering the electric power supply line along the wall of the refrigerator to the left of the entry door, the ceiling of the walk-in, and dust and what appeared to be a mold- like substance was above the refrigeration unit and on the ceiling in front of the refrigeration unit entry door. The fans were actively running during the observation and the potential existed to have dust and mold contaminate the refrigerated food supply. On interview the EC and GM agreed that the walk-in was full of dust and also had mold on the ceiling. The GM stated to the surveyor that we clean the walk-in but not the walls and ceiling as part of our current cleaning schedule. The surveyor reviewed the facility policy titled Food Safety Product Labeling and Dating Guidelines, Document Code: 1.2.19, and Revision Date: [DATE]. The following was indicated under the heading Purpose and Scope: Assist with the labeling requirements on food products and use-by-dates. Under Receiving/Storing (Dry or Frozen) - Rotation System the following was observed: Date cartons, cases, boxes. etc., with date received. This is not needed - if products remain in master cases already dated by the manufacturer. In order to maintain traceability of food products during a potential recall it is recommended to transfer the lot number and/or the manufacture date of the product to the new container if removing contents from the original packaging for storage. The following was revealed under the heading Date Marking Time Control for Food Safety: [company name/vendor] policy using the 2017 FDA Food Code as guidance specifies ready-to-eat, time/temperature control for safety (TCS) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to be consumed on the premises, sold, or discarded when held at a temperature of 5 C (Celsius) (41 F(Fahrenheit)) or less for a maximum of 7 days. In addition, the following was revealed under the heading Date Marking Non Time Control for Food Safety: The FDA Retail Food Code and [company/vendor name] policy exempts non-time control for food safety from the date marking requirements. However, Joint Commission and CMS may require dating of all opened products for stock rotation purposes. These dates are for quality purposes only and do not pose a food safety risk. Non-TCS if dated should use the manufacturer's use by date or operations can use the [company/vendor name] Product Quality Assurance Shelf Life Guidelines for guidance on dates. Once a product does have a documented use by date, the FDA Food Code and [company name/vendor] Policy requires the product to be consumed or discarded by that date. It is important to date food properly to avoid unnecessary disposal of safe food. The surveyor reviewed the facility provided policy titled Cook's Daily Cleaning Schedule, Utility Dating Cleaning Schedule, and Utility Weekly Cleaning Schedule, undated. Review of the (3) kitchen cleaning schedules revealed that per the Utility Weekly Cleaning Schedule, Walls/Columns were to be cleaned weekly. The (3) facility provided cleaning lists did not address cleaning of the kitchen ceiling and they did not address cleaning of the walk-in refrigerator ceiling or walls. The facility failed to provide a copy of their hair net/covering policy and storage of dishes/utensils when not in use as requested by the surveyor. NJAC 18:,d+[DATE].2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that all medications were administered without error rate of 5% or less. During medication pass observation on 02/14/2024, the surveyor observed one nurse administer medications to five residents. There were 26 opportunities and 2 errors which calculated to a medication administration error rate of 7.69%. This deficient practice was identified for 2 of 5 residents, (Resident #105 and Resident #106) and was evidenced by the following: On 02/14/2024 at 7:18 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare and administer Prednisone (steroid medication) 20 mg (milligrams) po (by mouth) to resident #105. The Prednisone package had a red Cautionary label on the package from the pharmacy to take with food. There was no food observed in Resident #105's room and LPN #1 did not offer the resident any food. At that time the surveyor asked Resident #105 if he/she had eaten breakfast. Resident #105 replied, No. At that time the surveyor requested LPN #1 to read the package cautionary and LPN #1 told the surveyor, Give with food. LPN #1 then explained that the facility practice is they (the nurses) give the medications and then the aides bring the breakfast. LPN #1 again stated, Our system is the resident wakes up, we give the med's (medications) and then they get breakfast. On 02/14/2024 at 08:00 AM, the surveyor observed LPN #1 prepare and administer Metoprolol ER (medication used to treat high blood pressure/extended release) 50 mg po daily with FOOD to Resident #106. A cautionary statement on the Medication Administration Record (MAR) indicated Take with meal or immediately after a meal. LPN #1 did not offer Resident #106 any food at the time of administration At that time the surveyor asked Resident #106 if he/she had eaten breakfast and Resident #106 replied, Soon. At 8:04 AM, LPN #1 said her next step would be to get Resident #106 breakfast. Resident #106's breakfast was delivered at 8:18 AM. A review of Resident #105's Admission Record revealed Resident #105 was admitted with diagnoses including but not limited to: Bacterial Infection. A review of the Order Summary Report revealed a physician order for Prednisone Oral tablet 20 mg Give 1 tablet by mouth one time a day related to Bacterial Infection unspecified. A review of the Admission Record revealed Resident #106 was admitted to the facility with diagnoses including but not limited to: Hypertension. During an interview with the surveyor on 02/16/2024 at 1:01 PM, the acting Director of Nursing was asked wby the surveyor what is your expectation for nurses when they are passing the medications and a medication has a cautionary statement. The acting Director of Nursing replied, I expect the nurses to follow the cautionary statements. The surveyor questioned what is not considered food and the acting DON replied Crackers, milk, and applesauce are not considered food. A review of a facility policy titled Medication Management Program Guidelines (RS-10) with a last approved date of 11/6/2023, revealed under the Procedure section: Cautionary Statements shall appear on the residents record of medication administration and the system shall include provisions for noting additional information, including but not limited to special times or routes of administration and storage conditions. N.J.A.C 8:39-29.2(d)

Based on interviews, and review of other facility documentation, it was determined that the facility failed to consistently offer nighttime snacks to all residents on a nightly basis. This deficient practice was identified for 4 of 5 residents (Residents #11, Resident #35, Resident #39, and Resident #251) during the Resident Council group meeting and was evidenced by the following: On 02/14/2024 at 10:15 AM, the surveyor conducted a group meeting with five residents who were selected by the facility. Four of the five residents stated that they were not offered evening snacks; however, they did state you can ask for anything and they will bring it to you. On 02/14/2024 at 12:33 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that usually the aide will offer snacks to the residents, or the activity aide will do it before they leave for the night. When asked what time the snacks are given, CNA #1 replied she was not sure what time snacks are given. On 02/16/2024 at 01:04 PM, surveyor interviewed the Director of Nursing (DON), who stated that the staff should be offering evening snacks to everyone, not just if the resident asks for one. On 2/20/2024 at 12:21 PM, the surveyor interviewed Licensed Practical Nurse (LPN #3), who stated that the CNAs usually hand snacks out at night and that they ask everybody. LPN #3 was not sure what time this is done. On 2/20/2024 at 12:30 PM, the surveyor interviewed the DON who stated that the CNAs hand snacks out in the evening. She also stated that sometimes the nurses do it. When asked what time snacks are handed out, she stated sometime in the evening, after dinner, before bed. Facility mealtimes as provided by the facility to team on entrance notes that breakfast is at 7:30 AM, Lunch is at 12:00 PM, Supper is at 5:30 PM, and evening snack is at 7:00 PM. A review of a facility policy titled Hydration and Snack, revised 2/14/2024, indicates: Preferred snacks will be stocked and accessible at preferred times. Snacks will always be available on a 24-hour basis in order that all preferences are accommodated. At the specified times that snacks are provided, nursing assistants will offer snacks to residents who choose to remain in their rooms and to those who retire early in the evening. N.J.A.C. 17.4 (b)

Based on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #22, and Resident #43) reviewed for Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 02/14/2024, the Administrator provided the surveyor with a list of residents who were discharged from the facility within the last six months and should have received Beneficiary Notices. The surveyor reviewed two of the residents (Resident #22, and Resident #43) listed who were discharged from a Medicare Part A (helps cover skilled nursing facility care including rehabilitation services) stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. On 02/16/2024 at 10:34 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #22. The SNFBPNR indicated the Resident #22's last covered Medicare day was 01/16/2024 and Resident #22 remained in the facility. The SNFBPNR further revealed that both a SNFABN and a Notice of Medicare Non-Coverage (NOMNC) were provided to the resident or the resident's representative.The facility was unable to provide a signed SNFABN for the date of 01/16/2024. On 02/16/2024 at 10:34 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #43. The SNFBPNR indicated the Resident #43's last covered Medicare day was 12/14/23 and Resident #43 remained in the facility. The SNFBPNR further revealed that both a SNFABN and a Notice of Medicare Non-Coverage (NOMNC) were provided to the resident or the resident's representative. The facility was unable to provide a signed SNFABN for the date of 12/14/23. On 02/16/2024 at 10:40 AM, the surveyor interviewed the Clinical Care Coordinator who stated that she only does an initial SNFABN on long term care and that if they go out to the hospital and return to the facility, she does not get another SNFABN. She further stated that she doesn't have a policy on SNFABN's. NJAC 8:39-4.1a(8)

Based on observation, interview, review of medical records, other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 17 residents reviewed (Resident #29 and Resident #101). This deficient practice was evidenced by the following: 1. On 02/12/2024 at 11:10 AM, the surveyor observed Resident #29 out of bed in a wheelchair. The resident was first seen in the library. The nurse stated that the resident at times wanders to library. Resident was seen coming back into unit from library. Resident #29 was very pleasant and stated they were doing well. The surveyor review of Resident #29's admission record indicated that the resident was admitted with diagnoses that included, but were not limited to; a right hip fracture with surgical repair. A review of Resident #29's medical record indicated that on 11/09/2023, the resident was found on the floor by the window in the room. No injury was noted. A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/12/2023, indicated a Brief Interview of Mental Status (BIMS) was 4, indicating severe cognitive impairment and Section J was coded to indicate no falls had happened since last assessment. On 02/15/2024 at 12:30 PM, the surveyor interviewed the MDS Coordinator, who confirmed that the fall was not coded on that MDS and should have been. 2. The surveyor review of Resident #101's admission record indicated that the resident was admitted with diagnoses that included, but were not limited to; urinary retention and dementia. A review of Resident #101's medical record indicated that on 05/20/2023 the resident was found on the floor near the bathroom. Resident #101 complained of right hip pain, was transferred to acute care, and found to have a right hip fracture. A review of the Discharge MDS dated [DATE], indicated both long- and short-term memory impairment and Section J was coded to indicate one fall with no injury, and one fall with injury except major and one fall with major injury. On 02/16/2024 at 11:15 AM, the surveyor interviewed the MDS Coordinator who stated that only J1900C should've been coded as one fall with major injury and the other two area should've been coded as no fall with no injury and no fall with injury except for major according to the RAI instructions. A review of the RAI User's Manual Version 1.17.1 dated October 2019 revealed . Chapter 3 MDS Items . Section J: Number of falls . Determine the number of falls that occurred since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. A review of a facility policy titled Resident Assessment Instrument (RAI) Completion, revised 4/11/2019, includes, The person who completes each section must sign the MDS to verify accuracy of the sections completed. N.J.A.C 8:39-11.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's skin disorder diagnosis. The deficient practice was identified for 1 of 1 (Resident #21) investigated for positioning and mobility. The deficient practice was evidenced by the following: During the initial tour of the facility on 2/12/2024 at 10:29 AM, the surveyor observed Resident #21 sleeping in his/her geri chair in the unit hallway. Resident #21 was observed wearing bilateral heel protectors. On 2/14/2024 at 12:03 PM, the surveyor observed Resident #21 in the dining area in his/her geri chair waiting for lunch. Resident #21 was observed wearing bilateral heel protectors. According to the Admission Record, Resident #21 was admitted to the facility with the following but not limited to diagnoses: Disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). According to the 12/18/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #21 had short term and long-term memory problem and cognitive skills are severely impaired. Section GG of the MDS revealed Resident #21 uses a wheelchair. Section I revealed Resident #21 had an active diagnosis of disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain Injury (injury that affects how the brain works). A review of Resident #21's Care Plan date initiated 2/3/2023, revised on 11/28/2023, revealed that it did not address the bilateral heel protectors as an intervention for skin integrity. On 2/15/2024 at 9:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2). LPN #2 stated, The aid applies the bilateral heel protectors when he/she gets out of bed to go into the geri chair. I do not apply them unless they are on the Treatment Administration Record (TAR) for me to apply them. The surveyor then asked what the purpose of the bilateral heel protectors served. LPN #2 stated, The resident uses them to off load his/her heels and it helps prevent pressure ulcers. LPN #2 also stated, There should be a physicians order for them, and it should also be listed on his/her care plan. On 2/15/2024 at 10:05 AM, the surveyor conducted an interview with the Certified Nursing Assistant (CNA #1). CNA #1 stated, The CNAs apply the resident's bilateral heel protectors. Resident #21 always wears them except when completing hygiene care. He/she needs them to prevent redness to the heels and pressure ulcers. The surveyor then asked who was responsible for ordering the heel protectors. CNA #1 said she wasn't sure who orders them. If they are ordered the nurse will relay the information to the CNA's. She also stated, It will be added to our task page that we sign off and it should be added to their care plan. On 2/16/2024 at 1:08 PM during an interview with the surveyors, the surveyor asked how you identify a resident at risk for pressure ulcers (PU) or pressure injuries (PI). The Director of Nursing (DON) stated, We complete the Braden scale on admission and quarterly. If a resident is at risk for PU/PI to the heels, we would either offload the heels with pillows or use the blue Prevalon heel boots. There would be a physicians order for the Prevalon heel boots, and the nursing department will provide them. The surveyor then asked, should the intervention in place be included on the resident's care plan. The DON stated, Yes, if they are using the Prevalon heel boots it should be included on the care plan. The surveyor reviewed the facility policy titled: Care Plan, revised 11/9/2023. The following was revealed under Procedure: 9. The care plan shall identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan shall be complete, current, realistic, time specific and appropriate to the individual needs for each resident. 32. When there are changes in the resident's condition, the Comprehensive Care Plan is updated as needed to change goals, time frames, or interventions. The surveyor reviewed the facility policy titled: Pressure Injury Prevention & Managing Skin Integrity, revised 7/14/2021. The following was revealed under Policy: Pressure ulcer/injury interventions, based on the resident's Braden assessment, will be implemented by nursing, and documented in the clinical HER. Skin care intervention when appropriated will be documented on the care plan. The surveyor reviewed the facility policy titled: Heel Protectors, revised 2023. The following was revealed under Policy: Residents will be provided with heel protectors when indicated on the Care Plan for preventative skin care, or as ordered by physician or charge nurse. N.J.A.C. 8:39-11.2 (e)2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain professional standards of nursing practice for not obtaining a physician's order. The deficient practice was identified for 1 of 1resident (Resident #21) investigated for positioning and mobility. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During the initial tour of the facility on 2/12/2024 at 10:29 AM, the surveyor observed Resident #21 sleeping in his/her geri chair. Resident #21 was observed wearing bilateral heel protectors. On 2/14/2024 at 12:03 PM, the surveyor observed Resident #21 in the dining area in his/her geri chair waiting for lunch. Resident #21 observed wearing bilateral heel protectors. According to the Admission Record, Resident #21 was admitted to the facility with the following but not limited to diagnoses: disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). According to the 12/18/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #21 had short term and long-term memory problem and cognitive skills were severely impaired. Section GG of the MDS revealed Resident #21 uses a wheelchair. Section I revealed Resident #21 had an active diagnosis of disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). A review of the Physician Order Summary Report (POS) located in the electronic medical record (EMR) revealed that Resident #21 did not have a physician's order for bilateral heel protectors. On 2/15/2024 at 9:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2). LPN #2 stated, The aid applies the bilateral heel protectors when he/she gets out of bed to go into the geri chair. I do not apply them unless they are on the Treatment Administration Record (TAR) for me to apply them. The surveyor then asked what is the purpose of the bilateral heel protectors. LPN #2 stated, The resident uses them to off load his/her heels and it helps prevent pressure ulcers. LPN #2 also stated, There should be physicians order for them, and it should also be listed on his/her care plan. On 2/15/2024 at 10:05 AM, Surveyor conducted an interview with the Certified Nursing Assistant (CNA #1). CNA #1 stated, The CNAs apply the resident's bilateral heel protectors. Resident #21 always wears them except when completing hygiene care. He/she needs them to prevent redness to the heels and pressure ulcers. The Surveyor then asked who orders the bilateral heel protectors. CNA #1 said she wasn't sure who orders them. If they are ordered the nurse will relay the information to the CNA's. She also stated, It will be added to our task page that we sign off and it should be added to their care plan. A review of Resident #21's Task in the EMR revealed that there was no identified task for the bilateral heel protectors. On 2/16/2024 at 1:08 PM during an interview with the surveyors, the surveyor asked how you identify a resident at risk for pressure ulcers (PU) or pressure injuries (PI). The Director of Nursing (DON) stated, We complete the Braden scale on admission and quarterly. If a resident is at risk for PU/PI to the heels, we would either offload the heels with pillows or use the blue prevalon heel boots. There would be a physicians order for the prevalon heel boots, and the nursing department will provide them. The surveyor reviewed the facility policy titled: Heel Protectors, revised 2023. The following revealed under Policy: Residents will be provided with heel protectors when indicated on the Care Plan for preventative skin care, or as ordered by physician or charge nurse. NJAC 8:39-27.1(a)

Based on interview and review of other facility documentation, it was determined that the facility failed to ensure 1 of 5 Certified Nursing Assistants (CNA #3) received 12 hours of required education annually. This deficient practice was evidenced by the following: The surveyor reviewed five (5) random CNA education files for the year 2023. A review of a transcript for CNA#3 titled, SYMPIR LEARNING, revealed the following: CNA #3 completed 10.75 hours. During an interview with the Nursing Staff Educator (NSE) on 02/14/2023 at 12:16 PM, she stated that the CNA was responsible to complete the yearly mandatory 12 hours of education to include both the Abuse training and the Dementia training. The NSE stated that she could not speak to why the CNA training was not completed. During an interview with the Licensed Nursing Home Administrator (LNHA) on 02/15/2024 at 11:43 AM, she stated that they are aware that the staff are not completing their yearly mandatory education and are reviewing their processes. A review of a facility policy titled, Clinical Staff Competency (RS-52) with a revised date of 03/23/2023, revealed under Competency Content; Required in-service training, specific to nurse aides, will include at least 12 hours per year. Topics for education include all in-services required by state agency NJSHSS, CMS, and those determined by the facility assessment. NJAC 8:39-43.17 (b)

C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to file a formal grievance and follow their policy titled Resident Concerns & Grievances, after receiving a family member complaint. This deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for Grievances and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of another part of the head, pain and benign prostate hyperplasia (an enlarged prostate). A review of a clinical note from the former Social Worker (SW) dated 11/2/22 noted that on 10/31/22, the former SW was approached by Resident #1's family member with multiple concerns regarding care over the weekend. The clinical note revealed the former SW and the Nurse Mentor / Registered Nurse (NMRN) met extensively with the resident's family members regarding the family's concerns. During this time, the SW and NMRN assured the family that their concerns would be checked into and addressed. The SW further noted that the complaints were documented via [through] a grievance form. On 5/11/2023 at 12:00 PM, the surveyor requested a list of grievances filed during October and November 2022 from the Director of Nursing (DON). Resident #1's name was missing from the list provided to the surveyor. On 5/12/2023 at 9:56 AM, the surveyor requested the former SW notes regarding Resident #1 from the DON. Further review of the SW notes indicated that she had filed a grievance form about the family member's complaints on 10/31/23. However, during the survey, the facility could not provide any grievance form about Resident #1's family members' complaints. During an interview on 5/12/23 at 11:39 AM regarding Resident #1, the former SW recalled she knew the resident and documented information about the complaint from the family. The former SW didn't remember the specific complaint by the family. She stated, If a complaint was initiated, it would be investigated. The SW did not recall or specify that a grievance form was filed during the interview. During an interview on 5/17/23 at 9:50 AM regarding the grievance form, the DON stated she spoke to the former SW, who told her that she did not file a grievance form on 10/31/22, as indicated in her progress note. The former SW told the DON that because she typed up a narrative in the progress notes with the NMRN, she felt it would be redundant to file a grievance form. According to the DON, the former SW said even though her note said she filed a grievance form; she did not actually do it. The DON stated that her expectation was if the SW said she filled out a grievance form, she should have done it. Review of the facility's policy titled Resident Concerns & Grievances, dated 1/17/23, included the following under: Purpose: To respond to resident complaints related to care, treatment, or services in a manner consistent with the procedures described below Under: Definitions: included Grievance - A grievance is any written or verbal concern by a resident, relative, or any representative related to resident care or the quality of services provided. Prompt effort to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. A complaint is considered a grievance when . The complaint is communicated verbally but cannot be resolved at the time of the complaint by staff present; it requires additional time for investigation or action, or referral to other staff for sufficient resolution. Procedure - All grievances shall, whenever possible, be responded by the designated SW or responsible department manager closest to the cause of the concern/grievance; responses to resident/responsible party shall be made as soon as possible and preferably immediately; and (1) If a concern/grievance of any kind is noted, the Concern/Grievance form is used. NJAC: 8:39-13.2(c)

C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to accurately complete an Admission Assessment to reflect the resident's status and failed to follow their policy titled Healthcare Admission Process, for a newly admitted resident (Resident #1). This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: Subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of other parts of head, pain and benign prostate hyperplasia (an enlarged prostate). A review of the Skilled Nursing Admission Evaluation (SNAE) dated 10/25/22 at 3:38 PM, completed by the Nurse Mentor/Registered Nurse (NMRN) for Resident #1 upon entry to the facility, showed under Urinary Continence that the resident was always continent. Resident #1 was also noted to have an external urinary catheter at the time of admission. Under the section Wound Care, the resident was noted to have no wounds present at the time of admission, even though the resident had lacerations and sutures present from the fall. During an interview on 5/12/23 at 10:02 AM, the NMRN, who completed Resident #1's admission assessment. She stated Resident #1 was continent of urine. The surveyor showed the NMRN the Skilled Nursing Admission Evaluation that noted Resident #1 also had an external urinary catheter at the time of admission. The NMRN stated she doesn't know why Resident #1 would have an external urinary catheter if he was continent. She further stated the resident could have had it from the hospital, but she wasn't sure. During an interview on 5/17/23 at 10:19 AM, the Director of Nursing (DON) stated the NMRN should have measured the wound and noted how many sutures were in the wound on the admission assessment form. The DON further stated the NMRN does admission assessments regularly and was aware of the procedure to complete the forms. When the surveyor asked the DON about the resident's urinary status of being continent but having an external catheter on the admission record, the DON stated, they come from the hospital that way sometimes. During an interview on 5/17/23 at 12:10 PM, regarding the Wound Care section of the admission assessment, which indicated Resident #1 had no wounds at the time of admission to the facility. The surveyor showed the NMRN Resident #1 FS which indicated lacerations from the injury sustained at home. The NMRN stated she should have documented in the Wound Care section the laceration and the number of sutures the resident had at the time of admission. She further stated that she wouldn't have measured the wound. When asked if she should have filled out the top section of the form where it noted wound, type, location, body, head, arm, and leg, the NMRN stated she didn't know if those areas should have been filled out. She continued to say she should have documented in the surgical incision section that Resident #1 had a laceration and the number of sutures where the wound was located. During a second interview on 5/17/23 at 12:40 PM, the surveyor interviewed the DON about the skilled nursing admission evaluation done by the NMRN. The DON stated the NMRN should have documented the laceration on Resident #1's head and the number of sutures present. Review of the Healthcare Admission Process dated 8/12/23, revealed under (D) Nursing Admission Evaluation, A head to toe assessment included the following body systems (7) genitourinary, (8) skin and (I) Wound Assessment: To be completed on the day of admission if the resident is admitted with skin changes (bruises, skin tears, pressure ulcers, etc.) and weekly until the wound is healed. NJAC 8:39-11-2(d)

C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to initiate a comprehensive person center care plan for a resident with lacerations and identified urinary incontinence. The facility also failed to follow its policy titled Care Plan (RS-1), dated 01/17/2023. This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of another part of head, pain and benign prostate hyperplasia (an enlarged prostate). Review of the Skilled Nursing Admission Evaluation (SNAE), dated 10/25/22 at 3:38 PM for Resident #1 completed by the Nurse Mentor/Registered Nurse (NMRN) upon the resident's entry into the facility, showed Resident #1's urinary status as continent but also noted the resident came in with an external urinary catheter (a device used to collect urine). Review of the nursing progress notes (NPNs) for Resident #1 revealed the resident was incontinent of urine on 10/26/22, 10/27/22, and 10/31/22. The Physician's admission note dated 10/26/22 also identified the resident as incontinent of urine. The surveyor reviewed a written statement from the Certified Nursing Assistant (CNA) who cared for Resident #1. The CNA's statement indicated the resident wasn't wearing incontinence briefs when he entered the facility. The CNA wrote that the next day after admission, the resident's bed was soaked. The CNA explained to the resident the need to wear incontinence briefs, and the resident was okay with that. The surveyor reviewed the Licensed Practical Nurse (LPN #1) statement dated 10/28/22 and 10/30/22, which indicated the CNA provided incontinence care due to the resident being incontinent of urine. The surveyor reviewed another statement from a second LPN (LPN #2) dated 10/30/22, which indicated LPN #2 answered the resident's call light, the resident's spouse told LPN #2 the resident needed to use the bathroom and/or be changed. Review of the Care Plan dated 10/26/22 revealed Resident #1 had no care plan in place for incontinence of urine or a laceration after it was identified by the doctor and nursing staff. During an interview on 5/17/23 at 10:19 AM, the Director of Nursing (DON) stated that urinary incontinence should be on the resident's care plan. She looked at the care plan for Resident #1 and indicated that she did not see the resident care plan for urinary incontinence. The DON explained that The resident should have been care planned after he/she was identified as incontinent of urine. She further stated that the Minimum Data Set (MDS) Coordinator would be responsible for making sure the resident was care planned for incontinence of urine. At the time of the survey, the Minimum Data Set (MDS) Coordinator was unavailable for an interview. A review of the facility policy Bladder Incontinence Management, dated 3/8/22, under Skilled Healthcare Procedure, The care plan and the resident's summary will be updated to reflect the resident's individualized toileting needs and the appropriate bladder management program. A review of the policy Care Plan under Purpose - to guide the care and treatment provided to each resident; 16. The RN MDS Coordinator is responsible to ensure that each portion of the care plan is updated; 17. The care plan process is part of a dynamic cycle: evaluation of resident care is followed up by a re-assessment of resident needs to determine whether or not the plan of care requires modification. This process is completed whenever the resident's condition changes; 18. The Care Plan is to reviewed and updated by all staff providing care or services for the resident. NJAC: 8:39-11.2(i)

Complaint#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to provide evidence that incontinence care was consistently provided to Resident #1. The facility also failed to follow its policies titled Bladder Incontinence Management and Activities of Daily Living. This practice was identified for 1 of 5 residents (Resident #1) and evidenced by the following: Review of the medical record is as follows: According to the Face Sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of other part of head, pain and benign prostate hyperplasia (an enlarged prostate). A review of the Skilled Nursing Admission Evaluation (SNAE) completed by the Nurse Mentor/Registered Nurse (NMRN) for Resident #1 on 10/25/22 at 3:38 p.m. indicated Resident #1's urinary status as continent, with an external urinary catheter (a device used to collect urine). According to the nursing progress notes (NPN), documented by the Registered Nurse (RN), dated 10/26/22 at 3:45 p.m., Resident #1 was incontinent of urine. Further review of the NPN revealed other incontinence episodes on 10/27/22 and 10/31/22. The physician admission note dated 10/26/22 also identified Resident #1 as incontinent of urine. A review of the Activities of Daily Living (ADLs) Verification Worksheet from 10/25/23 through 11/1/23 revealed blank spaces, which indicated the task was not documented as being completed as follows: On 10/27/22, on the day (7:00 a.m.-3:00 p.m.) and evening (3:00 p.m.-11:00 p.m.) shift was blank. On 10/28/22, on the night shift (11:00 p.m.-:7:00 a.m.)shift was blank. On 10/29 /22, on the 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 10/30/22, on the 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 10/31/22, 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 11/1/22, on the 7:00 a.m.-3:00 p.m. shift was blank. During an interview on 5/17/23 at 11:25 a.m., the surveyor reviewed the aforementioned blank spaces with the Director of Nursing (DON). The DON acknowledged the blank spaces. She stated, We have a problem with [the] documentation of ADLs. The DON continued that if the resident refused care, there is a column the staff can document the refusal, but none were noted on the form. She further stated the Certified Nursing Assistants (CNAs) didn't document the care given to Resident #1. The CNAs should have documented every time the resident was toileted or changed. During an interview on 5/17/23 at 11:40 a.m., the CNA stated she checked the resident's incontinent briefs and would ask the residents if they needed to be changed at the start of her shift and as needed throughout the shift. The CNA stated she would change all residents, then go into the computer and document after all residents were changed, not after each resident. During a second interview on 5/17/23 at 12:40 p.m., the surveyor interviewed the DON, who presented a timeline of urinary incontinence care that was not provided for Resident #1. The DON stated, on days without documentation, I don't know if care was done. If it's not documented, it's not done. The DON said the CNAs should have provided care and then immediately documented that care was given. Reviewed of the facility's policy titled Bladder Incontinence Management (RS-11), dated 3/8/23, which noted under Purpose - to ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible; and To ensure that each resident who is incontinent of urine is identified, assessed upon admission and is provided appropriate treatment through a systematic person centered approach to assist the resident to regain urinary continence upon recovery from a significant change in functional status; Special Instructions: UMC: a 3-day voiding trial; Definitions of types of urinary incontinceChronic Urinary incontinence - overflow - leakage of small amounts of urine when the bladder has reached maximum capacity; under Skilled Healthcare Procedure: A bladder management program will be implemented based on the resident's - specific reason for incontinence, individual goals, and the schedule for toileting, as well as special concerns. Review of the facility's policy titled Activities of Daily Living, dated 7/22/20, which noted under c. other functional communication systems, A resident who is unable to carry out activities of daily living will receive necessary services to maintain grooming ., The direct care giver is responsible for documentation of the ADLs each shift, whether through paper or electronic documentation .and, The Certified Nursing Assistants (CNAs) are responsible for completing the ADL data in the kiosk or tablets each shift, however, it remains the DON/Nurse Designee and the MDS Coordinator's responsibility to check for accuracy and daily completion of ADLs. NJAC-8:39 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/21/2021 from 9:55 AM to 10:47 AM the surveyors, accompanied by Dining Director (DD) and Executive Director (ED) observed the following in the kitchen: 1. At 10:31am, the surveyor attempted to wash his hands at the designated hand washing sink. Upon turning on the water, the surveyor attempted to apply soap from the wall mounted soap dispenser. The surveyor was unable to obtain soap. The DD opened the soap dispenser, and the dispenser was empty. The DD stated, There are two other sinks available with soap. Surveyor asked if all sinks are to have soap available. The DD responded, Yes. 2. On the second shelf of the 2- Door Refrigerator an opened bag of parmesan cheese was wrapped in plastic wrap. The Parmesan cheese was dated 10/3/21 and 9/27/21. The DD was unable to determine an accurate open date. The DD threw the parmesan cheese in the trash in the presence of the surveyors. 3. The surveyor observed 2 stacks of bread-and-butter plates, 2 stacks of casserole dishes, 3 stacks of plates, 1 stack of square bowls, and one bin of dessert bowls in the wash rack area that were uncovered and not stored in the inverted position. The food contact surfaces were exposed. On interview the DD confirmed that all contents of this area are cleaned and sanitized and should be covered or inverted to prevent contamination. 4. A plastic bin contained cleaned and sanitized dessert bowls in the wash rack area. The bowls were uncovered and not stored in the inverted position with food contact surfaces exposed. On interview the DD confirmed that all contents of this area are cleaned and sanitized and should be covered or inverted when not in use. 5. On the middle shelf of the walk-in refrigerator, a half tray of cooked sausage links was covered with plastic wrap and was dated 10/17/21. The ED stated, That was left over from breakfast I don't know why they saved it. Leftovers are good for 72 hours. I'm throwing it away. In addition, on an upper back left corner shelf, an opened bag of shredded mozzarella cheese was wrapped in plastic wrap. The mozzarella cheese had no dates. The ED threw the cheese in the trash. 6. On a rear lower shelf of the walk-in refrigerator, 5 independently wrapped roast beef cuts had a sticker dated 10/10/21. On interview the surveyor questioned the DD and ED if the sticker indicated the date that the meat was pulled from the freezer to defrost. The ED stated, I think that was the received date. On further interview the ED stated, I'm sure they haven't been in here for 10 days, but I can't prove it. The ED removed the roasts from the refrigerator and threw them in the trash. 7. On the middle shelf of the walk-in freezer, an opened bag of French fries, an unopened bag of peas, and two unopened bags of carrots were removed from its original container and were not labeled or dated. A package of frozen hamburger patties was removed from its original container and the bag was torn, exposing the hamburger patties. The hamburger patties had no dates. The ED removed the patties to the trash. The surveyor reviewed facility policy titled Hand Hygiene (RS-26), last reviewed 4/17/2020. The following was revealed under the heading Procedure: Procedure: Hand hygiene procedure with soap and water: Locate appropriate equipment: liquid soap, warm running water, and paper towels. The surveyor reviewed facility policy titled Section 11: Sanitation & Infection Control Labeling & Dating, dated 1/2016. The following was revealed under the heading Procedure: Procedure: All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. The surveyor reviewed facility policy Handling Service Ware and Utensils, dated 6/2003. The following was revealed under the heading WHY PROPER HANDLING IS IMPORTANT: Flatware/silverware (forks, knives, and spoons) can become easily contaminated if we touch them without bare hands or with soiled gloves, or through other possible sources of contamination. In addition, the following was revealed under the heading HOW TO PROPERLY STACK SERVICEWARE AND UTENSILS DURING AND AFTER DISHWASHING: Stack plates, bowls, cups, and glasses in clean, protected storage racks or other designated storage space. The surveyor reviewed facility policy QUICK REFERENCE LIST FOR SHELF LIFE OF PRODUCTS--PURCHASED, revised 1/2003. The following was revealed under the heading Purchased PRODUCTS WITHOUT MANUFACTURERS EXPIRATION DATE: Raw Frozen Solid Whole Muscle Meats, thawed- Use within 3 to 4 days after freezer for thawing and under refrigeration. The following was revealed under the heading PRODUCTS PREPARED IN UNIT: Hot Foods, left over after meal period- 14 to 48 hours (if acceptable for reheating once only-follow recipe.) The surveyor reviewed facility policy Utilization of Excess Prepared Foods-700.07, Shelf Life of Products, undated: PURPOSE To prevent food-borne illness. To prevent spoilage and deterioration. RESPONSIBILITY Director of Dining Services PROCEDURE 1. Excess prepared foods must be utilized within a 72-hour period from time of preparation unless properly frozen. N.J.A.C. 18:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to detect and remove expired medication in 1 of 1 automated pharmacy dispensing units. This deficient practice was evidenced by the following: On 10/22/21 at 12:15 PM, the surveyor checked the automated pharmacy dispensing unit (APDU, a computerized storage device in which extra medication is stored for use in residents, where such medication is otherwise not available elsewhere). The surveyor observed the following, in the presence of the Registered Nurse (RN) and the Licensed Practical Nurse (LPN): eight capsules of expired [MEDICATION(S)] 50 milligrams (mg) (an antibiotic), all of which expired on 10/01/21; six tablets of [MEDICATION(S)] 250 mg (an antibiotic), all of which expired on 10/01/21; six capsules of [MEDICATION(S)] 100 mg (an anti-[CONDITION(S)] medication), all of which expired on 10/01/21; one bottle of 5 milliliters (ml) of [MEDICATION(S)] 1% (eyedrops used to dilate the eyes or decrease pain and inflammation), which expired 09/21; ten tablets of [MEDICATION(S)] 100 mg (an antibiotic), all of which expired 10/12/21; five tablets of [MEDICATION(S)] Extended-Release 20 milliequivalents (mEq) (a supplement), all of which expired 09/24/21; 16 tablets of [MEDICATION(S)] 1 mg (a blood thinner), all of which expired 10/01/21; nine tablets of [MEDICATION(S)] 3 mg, all of which expired 10/12/21; and ten tablets of [MEDICATION(S)] 4 mg, all of which expired on 10/12/21. During an interview with the surveyor on 10/22/21 at 12:42 PM, the RN and LPN acknowledged the presence of the expired medications. The RN stated that she and the Director of Nursing (DON) are responsible for checking the medication stored in the APDU. The RN also stated she was never asked to check the storage supply and does not know who else would be responsible for checking medication in the APDU. She did not know why expired medications were present or if the pharmacy staff had any responsibility for checking the stock. The LPN stated he thought the back-up supply was checked quarterly, perhaps by a representative from the pharmacy. During an interview with the surveyor on 10/22/21 at 1:08 PM, the DON was in the process of checking the dates and removing expired medications from the APDU. She stated that she checked the expiration dates on the medications a few weeks ago and the process needs to be completed more often. She further stated that she, as the DON, was responsible for checking medication expiration dates and that it needs to be done on a weekly basis. During an interview with the surveyor on 10/22/21 at 2:20 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, the DON confirmed that expired medication should have been removed from stock. The DON stated she was not certain if there was a policy related to expiration dates, specifically related to medications kept in storage, but that she would investigate the matter and provide any additional and relevant policies. No policy, specifically related to stored medications and expiration dates, was supplied to the team on exit. NJAC 8:39-29.1(e)

Based on interview and record review, it was determined that the facility failed to provide written notification, including the reason, to the appropriate entities for the facility-initiated transfer of a resident to an acute care setting. In addition, the facility failed to document the events that led to the transfer. This deficient practice occurred to 1 of 1 resident reviewed (Resident #20) for hospitalization s and was evidenced by: The surveyor reviewed Resident #20's medical record on 12/19/18. According to the Admission Record, Resident #20 was admitted to the facility with medical [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 11/2/18, the resident had severe cognitive impairment. The care plan indicated that Resident #20 was on antipsychotic medication with the goal to not have any changes with mood over the next 90 days. The care plan also reflected that the resident had a history of [REDACTED].#20. When interviewed by the surveyor on 12/18/18 at 11:15 a.m., a Registered Nurse (RN#1) stated that Resident #20 had been hospitalized in the past but did not recall the reason for the hospitalization . On 12/19/18 at 09:24 a.m., the surveyor reviewed the medical record which indicated the resident was hosptalized on [DATE] with a [DIAGNOSES REDACTED].#20's transfer and subsequent admission to the hospital. When interviewed by the surveyor on 12/19/18 at 03:50 p.m., the Director Of Nursing (DON) and the Administrator (LHNA) stated that they were unable to locate documentation in Resident #20's medical record that led up to the resident's transfer to the hospital on [DATE] or that the resident's representative was notified in writing for this transfer/discharge. The DON stated that he/she will follow up on 12/20/18 in reference to the location of the documentation. On 12/20/18 at 09:05 a.m., the DON provided a copy of an In-Service Training Report, dated 12/10/18, addressing the actions that the nurses must take regarding the the emergency transfers of residents from the facility. According to this data, the Office of the Ombudsman must be notified, by fax, at the time of the residents' emergency transfer. In addition, a copy of this notification must be provided to the Social Worker (SW) so that the residents' representative can be notified of the transfer. The DON also provided an exampled copy of the Notice of Emergency Transfer that was to be completed by the nursing staff. During this same interview, the DON provided a copy of the Clinical Notes Report, dated 12/19/18 at 06:49 PM, that was documented by RN #2. This documentation was indicated as a late entry to the assessment of 10/30/18. This late entry clinical note included Resident #20's clinical condition, the order received from the physician and the resident's transfer to the emergency room (ER) with his/her spouse present. The DON stated that the nursing staff was informed that they would have to complete the Notice Of Emergency Transfer form for Resident #20's transfer and hospitalized from [DATE] because one was not on file at the facility. On 12/20/18 at 11:04 a.m., the LNHA provided the surveyor a copy of the Monthly Discharge Notice List to NJ Long Term Care Ombudsman (LTCO). A review of this data revealed that Resident #20 was included on the LTCO list with a transfer date of 10/30/18. The reason for transfer was documented as an Emergency Department evaluation and the date that this notice was faxed to the Office of the Ombudsman was documented as 12/19/18. On 12/20/18 at 11:58 a.m., the LNHA provided a copy of the facility's policy/procedure on Discharge and Transfer to the surveyor. According to this policy/procedure, that had a revision date of 11/8/18, the resident/resident representative and Ombudsman were to be notified of the resident's discharge/transfer from the facility and that a written notice will be provided by nursing or the social worker to the NJ OOIE (New Jersey Office of the Ombudsman for the Institutionalized Elderly) of all emergency leave of absences (LOA)/transfer of residents to an acute care setting on an emergency basis. This policy/procedure also indicated that a copy of the notice must be provided to the resident/resident representative and faxed, emailed, or sent regular mail to the Office of the Ombudsman and that a list of all discharges and leave of absences must be sent to the NJ OOIE office monthly via fax or email by the social worker/designee of each community. NJAC 8:39-4.1(a) 31

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of care of ensuring that the all residents receive the medications as ordered by the physician. This deficient practice occurred with 1 of 2 nurses observed during the medication pass who administered medications to 1 of 5 residents (Resident #44) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/18/18 at 9:40 AM, the surveyor observed the Registered Nurse (RN) administer medication to Resident #44. The RN poured out one tablet of Losartan 50 milligrams (mg) one tablet of [MEDICATION NAME] 10 mg, and two tablets of Peri-[MEDICATION NAME] 8.6-50 mg. The Peri-[MEDICATION NAME] is a combination medication that is intended to treat constipation. During this observation, the surveyor asked the RN how many tablets of the Peri-[MEDICATION NAME] were ordered. The RN stated that two tablets of Peri-[MEDICATION NAME] were ordered for Resident #44, along with the one tablet each, of the other two medications. She then confirmed that a total of four tablets were to be administered. The RN then went into the resident's room and asked the resident to sit up in bed for the medication administration. Resident #44 sat up in bed and extended the palm of a hand. The RN poured the medications into the hand of Resident #44, who was turned away from the RN and facing the surveyor. Upon accepting the medication, Resident #44 dropped one tablet of Peri-[MEDICATION NAME] onto the bed. Resident #44 proceeded to take the medication and asked the RN how many tablets should be present, to which the RN replied, three. Resident #44 then took the three remaining tablets and moved to a lying position. At this time, the tablet on the bed fell to the floor between the bed and the wall. The RN signed the MAR, indicating that all medications were administered as ordered. She went across the hallway to return the Peri-[MEDICATION NAME] to the cabinet. At this time, the surveyor asked her how many tablets were administered to Resident #44, to which she responded with, four. The surveyor advised her about the fallen tablet, which she then acknowledged, collected off the floor, and deposited into the drug buster for disposal. On 12/19/18 at 8:48 AM, the survey team interviewed the Director of Nurses (DON). The DON stated that the incident with the Peri-[MEDICATION NAME] 8.6-50 mg tablets was an error. On the same day at 10:00 AM, the surveyor obtained and reviewed a copy of the physician's orders [REDACTED]. Both documents indicated that Resident #44 had an order for [REDACTED]. On 12/20/18 at 12:10 PM, the surveyor obtained and reviewed the facility's policy related to medication administration from the DON. The policy was titled, Medication Management Program Guidelines (RS-10) and indicated that medication administration was to occur with verification of the prescriber's orders and seeing that the resident takes medication, if prescribed by the oral route. NJAC 8:39-27.1(a) and 8:39-29.2(d)

Based on record review, it was determined that the facility failed to follow established plans of care to prevent falls and injuries. As a result, a resident sustained [REDACTED]. This deficient practice was identified in 1 of 3 residents reviewed for falls, bruises and abrasions (Resident #1) and was evidenced by the following: During review of the electronic medical record (EMR), the surveyor observed that Resident #1 had impaired cognition and was non-ambulatory. The interdisciplinary plan of care identified the resident as being at risk for falls. Interventions on this plan of care included the use of a pummel cushion when out of bed in the wheelchair. The surveyor reviewed nurses notes and corresponding fall investigations which revealed that on 10/7/11 at 10:35 p.m., Resident #1 had an unwitnessed fall from a wheelchair in the resident's room. Resident #1 sustained a laceration to the right forehead that resulted in the resident being transported to the local hospital emergency room to receive 7 staples to close the laceration. The fall investigation revealed the facility's corrective actions of: "Resident shouldn't be left in the (resident's) room alone and should be monitored." When the facility revised Resident #1's care plan on 10/10/11, they failed to include that Resident #1 was to be monitored. According to the EMR, Resident #1 had a second fall from the wheelchair in the rotunda area on 10/22/11 at 7:30 p.m. The resident sustained [REDACTED]. Resident #1 also suffered a skin tear to the right hand required physician-ordered adhesive strips to close the wound. The resident also experienced right hip pain. According to the EMR, there was no documented evidence that the pummel cushion, which was an intervention on the resident's plan of care, was in place at the time of the falls on 10/7/11 and 10/22/11. In addition, there was no documented evidence that Resident #1 was being monitored at the time of the second fall of 10/22/11. Resident #1 also had a history of [REDACTED]. The care plan also indicated that the resident's wheelchair leg rests were to be padded. The handwritten care card located at the nurses station and available for staff use, including the Certified Nursing Assistants (CNA), indicated that the staff were not to use foot rests on the resident's wheelchair but did not identify that any padding was to be used on the leg rests. Resident #1 sustained skin tears on 9/12/11, 10/4/11 and 10/21/11 when these planned interventions were not followed. (Refer to F323) NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of data provided by the facility, it was determined that the facility failed to provide planned interventions to prevent injuries. As a result, a resident sustained [REDACTED]. This deficient practice was identified in 1 of 3 residents, (Resident #1) reviewed for falls, bruises and abrasions. The facility also failed to provide a safe, hazard-free environment for all residents. This deficient practice occurred for 1 of 12 residents (Resident #7), as well as in multiple resident's restrooms. This deficient practice was evidenced by the following: 1.) During the initial tour that was conducted on 12/12/11 at 9:30 a.m., the nurse accompanying the surveyor said that Resident #1 had cognitive impairment and was receiving hospice services for End Stage Dementia. The nurse also said that the resident had a history of [REDACTED]. On 12/12/11 at 12:45 p.m., the surveyor observed Resident #1 seated in a recliner with a lapbuddy restraint attached. The resident was wearing long pants and a long sleeve shirt. The surveyor also observed protective coverings being worn underneath the clothing which were exposed at both wrists and ankles. When interviewed on 12/13/11 at 8 a.m., the resident's hospice aide said that the resident had sustained "multiple" falls from the wheelchair in the past 6 weeks. In addition to a history of falls, Resident #1 also had a history of [REDACTED]. The Resident Assessment Instrument (RAI), dated 10/31/11, identified that Resident #1 had [DIAGNOSES REDACTED]. The RAI also identified that the resident had impaired cognition, was non-ambulatory, required extensive assistance with care and had sustained a fall with major injury in the past 90 days. The care plan, that was developed by the facility for Resident #1, included the use of alarm devices to alert staff if the resident attempted to exit the bed or chair, and the use of a pommel cushion when sitting in the wheelchair (a seat cushion with a mound attached to it, resembling a saddle horn, positioned between the legs. When used on the seat of a wheelchair, the cushion reduced forward movement of the pelvis.) According to the Care Plan History Report dated 2/2/11, Resident #1 had a fall on 12/5/10. At that time, the resident was evaluated by Physical Therapy for positioning and a pummel cushion was added to the care plan as a fall intervention. The surveyor reviewed an Electronic Medical Record (EMR) nurses note, dated 10/7/11 at 6:40 p.m., which indicated Resident #1 had been found on the floor, bleeding from the anterior scalp, by a Certified Nursing Assistant (CNA). The responding nurse called 911 and the resident was transferred to the hospital. In a follow-up note, dated 10/8/11 at 11:17 p.m., the nurse wrote that the resident had returned from the hospital at 5:30 p.m. with 7 staples on the forehead. The corresponding fall investigation (or "Incident Detail Report") and written staff statements identified that Resident #1 had been alone in the resident's room sitting in a wheelchair. The report identified that the alarm device had sounded at the time of the incident. There was no documentation on this fall investigation that a pommel cushion was in place at the time of the resident's fall from the wheelchair. On 10/7/11 at 10:34 p.m., a nurse had documented corrective actions, related to this fall, that included: "Resident shouldn't be left alone in room and should be monitored." The care plan revision, dated 10/10/11, indicated "Do not leave alone in (resident's) room," but did not include the additional monitoring that the nurse had documented on 10/7/11 at 10:34 p.m. as a part of the intervention for falls. The intervention of the pommel cushion remained in place on the plan of care. In a second EMR nurses note, dated 10/22/11 at 11:28 p.m., Resident #1 had experienced another fall from the wheelchair. The nurse wrote that there was significant bleeding from the head, a skin tear on the right hand, and that the resident also complained of pain in the left hip. The note identified that the resident was transferred to the hospital at 7:40 p.m. that evening. In a subsequent nurse's note, dated 10/23/11 at 1:21 a.m., the resident returned to the facility with an undetermined number of sutures on the forehead. The EMR identified that there was no hip fracture and that adhesive strips were ordered by the physician to close the skin tear. The corresponding fall investigation and a written staff statement identified that the alarm device was in use and had sounded at the time of the incident, however, there was no documentation indicating the presence of the pommel cushion on the resident's wheelchair prior to this fall. In addition, there was no documented evidence that Resident #1 was being monitored by staff at the time of the fall. The "Incident Detail Report" section that identified staff or individuals involved in this incident was blank. However, in an employee statement, dated 10/22/11 at 7:30 p.m., the nurse wrote that another resident's family member was beside Resident #1 when the nurse responded. There was no documented statement or interview from that other resident's family member to indicate what had occured. When interviewed by the surveyor on 12/15/11 at 10:10 a.m., the Director of Nursing (DON) stated that she did not know whether or not the family member was a witness to the second fall because that person had never been interviewed. The DON stated that the cause of both falls suffered by Resident #1 had not been thoroughly investigated in order to determine if they were avoidable. 2.) During review of the EMR, the surveyor noted that Resident #1 also had a history of [REDACTED]. The care plan also indicated that the resident's wheelchair leg rests were to be padded. The handwritten care card located at the nurses station and available for staff use, including the Certified Nursing Assistants (CNAs), indicated that the staff were not to use foot rests on the resident's wheelchair but did not identify that any padding was to be used on the leg rests. In a nurses note, dated 9/12/11 at 9:10 a.m., the nurse documented that Resident #1 sustained a skin tear to the left lower extremity which required a physician-ordered treatment. The size of the skin tear had not been documented. The corresponding "Incident Detail Report" also failed to provide documented wound measurements but identified that staff had observed Resident #1 hitting the left leg on the wheelchair footrest. The Director of Nursing (DON) documented on this report that "the resident had footrests removed due to skin tears but states she is now more comfortable with them on the chair." However, there was no documented evidence that the application of footrests had been resumed or assessed as safe as part of the resident's plan of care after being previously determined to be a safety hazard. In another nurses note, dated 10/4/11 at 10:03 p.m., the nurse documented the occurrence of a skin tear of unknown origin on Resident #1's right lower leg. According to this documentation, the skin tear on the resident's right lower leg measured 20 centimeters (cm) by 30 cm. and required a physician-ordered treatment. In the corresponding "Incident Detail Report", the nurse documented that the wound on the resident's right lower leg measured 10 cm by 20 cm and that "..the leg rests on the wheelchair must always be checked in such a way the legs of the resident are sitting on the leg rest and not on the floor so as to prevent skin tears caused by the leg rests." There was no documented evidence that the leg rests were padded as per the plan of care at the time of this injury. In a third nurses note, dated 10/21/11 at 12:24 p.m., the nurse documented that the resident had sustained a skin tear to the left lower leg which required a physician-ordered treatment. The corresponding "Incident Detail Report" indicated that the wound measured 1.5 cm by 0.3 cm. The nurse documented that Resident #1 was observed removing the left foot and leg from the foot rest, and while doing so, hit the left shin on the footrest, causing the skin tear. There was no documented evidence that the application of footrests had been resumed as part of the resident's plan of care after being previously determined to be a safety hazard. When interviewed by the surveyor on 12/15/11 at 10 a.m., the Director of Nursing was unable to provide additional information related to the resident's plan of care at the time of these injuries. According to the facility's "Incident/Accident Report" policy, when an accident or incident occurs, "necessary measures will be taken to address the situation in accordance to accepted standards of practice..." This policy also indicated that the professional staff should "chart the incident in the interdisciplinary progress notes. Include, as applicable: a.) a detailed description of findings, observations, and interventions... b.) the time of physician notification c.) any resident observations or comments". In addition, this policy indicated that "a descriptive statement from the resident, if possible, and from any employee or visitor who may have been involved or witnessed the occurrance" should be obtained. 3. On 12/12/11 at 12:30 p.m., the surveyor observed a crack in the floor tile extending the entire length of Resident #7's room. Sections of the crack created an uneven walking surface, causing a tripping hazard. 2. At 10:34 a.m., the surveyor observed that the 22-feet handrail by resident room 328 was loose on one end and moved when touched. 3. At 10:09 a.m., the surveyor observed that there were two nurse call cords in the restroom of resident room 311. When interviewed at this time, the facility's Maintenance Director stated that they had installed all new nurse call lights in the residents' restrooms of the Healthcare Unit about 4 weeks ago. He further stated that the second cord was from the old call light system. The Maintenance Director stated that although the old call light was still affixed next to the new call light cord system, the old system was disabled at the time. When the surveyor pulled on the cord of the old system, no call light or sound was activated. The Maintenance Director, who was present during this test, stated that if a resident was to fall in their restroom and pulled the old call system cord, nothing would happen until they pulled on the new system cord. The surveyor observed the old nurse call light cords still in place in the restrooms of resident rooms 306, 307, 309, 314, 315, 318, 319, 321, 327, 332 and 328. When interviewed by the surveyor at 10:14 a.m., a facility's maintenance employee stated that all the resident restrooms on the Healthcare Unit still had the old cords hanging in place. The surveyors interviewed alert and oriented residents and staff on the 300 unit at 11:30 a.m.. All residents and staff interviewed stated that they had been inserviced on the new system and knew which was the new cord they were to use if they required assistance. The surveyors also interviewed the unit charge nurse who indicated that all confused residents were assisted to the bathrooms and were supervised in the bathrooms. NJAC 8:39-31.2(e) NJAC 8:39-27.1(a)