**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documentation, 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, for two (2) of 21 residents, (Residents #15 and #114) reviewed for MDS accuracy, and was evidenced by the following: 1.The surveyor observed Resident #15 on 8/22/2025 at 12:00 pm eating lunch in the unit dining room. An observation of the resident’s room on 8/25/25 at 9:35 am revealed signage on the door leading to the room indicating the resident was on Enhanced Barrier Precautions (EBP). A plastic bin was placed at the entrance to the room in the hallway containing personal protective equipment (PPE). A review of the resident’s care plan indicated the resident was on EBP because of a history of multiple drug-resistant organisms (MDRO) in the urine. Additionally, the resident was care planned for a diagnosis of diabetes and the use of insulin therapy. The June 2025 Medication Administration Record (MAR) indicated the resident received Humalog (insulin) during the period of 6/12/25 through 6/19/25. A review of the 6/19/25 quarterly MDS indicated the facility failed to code the resident for having had a history of MDRO (Section I1700) and having had insulin in the past 7-day period of 6/12/25 to 6/19/25 (N0300). 2. On 8/25/2025 at 9:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #114, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #114 was admitted with diagnoses that included, but were not limited to, hypertensive heart disease without heart failure (conditions caused by high blood pressure) and dementia (loss of memory). A review of the admission MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severe impaired cognition. Further review of the A/MDS in Section J – Fall History on Admission/Entry or Reentry B: Did the resident have a fall anytime in the last 2-6 months prior to admission/entry or reentry? 0. No. A review of the baseline Care Plan (CP) dated 10/2/24 under H. Safety Risks 31a. Specify fall during 2-6 months prior to admission revealed “as per daughter had a fall in July 2024.” A review of the “Admission/readmission Evaluation V6-V2” form dated 10/2/24 under “Section B. History of Falls (past 3 months) 2. 1-2 falls in the past 3 months and Section R. Fall Risk” revealed that Resident #114 has a score of 13.0. A review of the CP report with an initiated date of 10/3/2024, with the focus on the resident is at risk for falls/injury related to unsteady gait. On 8/28/25 at 9:15 AM, the surveyor interviewed the Corporate Director of Clinical Reimbursement (CDCR) regarding the concern above, but did not provide further information. NJAC 8:39-33.2 (d)

COMPLAINT # NJ00172263 Based on interview, record review, and review of other pertinent facility documents on 3/25/24, it was determined that the facility failed to consistently complete the dialysis communication form and maintain a residents dialysis communication record. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for dialysis. This deficient practice is evidenced by the following: 1. According to the facility admission RECORD Resident #1 was admitted with diagnosis that included but were not limited to: End Stage Renal Disease. The Minimum Data Set (MDS) an assessment tool dated 9/15/23, Resident #1's cognitions were intact and required assistance during Activities of Daily Living (ADL). The care plan (CP), undated, revealed that Resident #1 had Seizure Disorder and Dysphagia. Interventions included but were not limited to the Resident attend dialysis three times a week on Tuesday, Thursday, and Saturday The surveyor reviewed Resident #1's Dialysis Communication Binder (DCB) on 3/25/24 at 10:31 AM. The DCB reflected forms titled Resident Facility + Dialysis Center Information Exchange (RFDCI), dated 11/2/23, 11/7/23, 11/11/23, 12/2/23, 12/26/23, 1/2/24, 1/6/24, 1/9/24, 1/18/24, 1/23/24, 1/25/24, 1/30/24, 2/1/24, 2/8/24, 2/13/24, 2/20/24, 2/22/24, and 2/27/24. the DCB did not have the following RFDCI for the following dates 11/4/23, 11/9/23, 11/14/23, 11/16/23, 11/18/23, 11/21/23, 11/25/23, 11/28/23, 11/30/23, 12/5/23, 12/9/23, 12/12/23, 12/14/23, 12/16/23, 12/19/23, 12/21/23, 12/23/23, 12/28/23, 12/30/23, 1/4/24, 1/6/24, 1/11/24, 1/13/24, 1/16/24, 1/20/24, 1/27/24, 2/3/24, 2/6/24, 2/10/24, 2/15/24, 2/24/24, and 2/29/24. The facility was unable to provide documentation that Resident's condition on the abovementioned dates were communicated to the Dialysis Center (DC). During the interview with the surveyor on 3/25/24 at 4:16 PM, the Director of Nursing (DON) stated that during the Dialysis days, the nurse had to complete the RFDCI (a communication tool between the facility and the Dialysis Center) to be given to the Transportation driver (TD), the TD gives the DCB to the DC. The DON further stated that when the resident comes back from the DC, the Nurse would review the RFDCI. The DON added, if there are no communication form, the nurses are expected to call the DC and the DC had to fax the form to the facility. The DON was unable to explain the missing RFDCI in Resident #1's DCB. The DON acknowledged that some of the RFDCI were incomplete. A review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, dated 9/2023, indicated under Policy Statement Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .4 .How information will be exchanged between the facilities . A review of the facility policy titled Dialysis Patients - Hemodialysis (outside), undated, indicated Each resident assigned to an HD center will have a binder assigned to go take to dialysis with the dialysis form completed by the nurse (center) .The dialysis center is to complete the lower portion of the form upon return to the center from the HD center. If the form is incomplete from the HD Center, the nurse assigned will reach out to the HD Center to communicate the need to have the information to center . NJAC 8:39-27.1(a)

Complaint# NJ169589 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) ensure written grievance decisions met documentation requirements and b) maintain evidence of the result of all grievances for no less than three (3) years from the date the grievance decision was issued according to facility practice and policy. This deficient practice was identified for one (1) of five (5) residents (Resident #352) reviewed for complaints. This deficient practice was evidenced by the following: On 02/16/24 at 10:34 AM, the surveyor requested for all the reportable and grievances for the last six months for Resident #352 from the Licensed Nursing Home Administrator (LNHA). The surveyor reviewed the facility provided grievance log for November 2023 that included Resident #352. A review of the Complaint #NJ169589 dated 12/08/23, reflected that the complainant had spoken with the Social Worker around 11/13/23, to discuss concerns but conditions had not improved. The surveyor reviewed the closed record for Resident #352. The resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (disease of inadequate control of blood levels of glucose), enterocolitis due to clostridium difficile (inflammation through the intestines due to a highly contagious bacterial infection), difficulty walking, need for assistance with personal care and altered mental status. A review of the resident's most recent admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/30/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. On 02/22/24 at 11:52 AM, during an interview with the surveyor, the Social Services Director (SSD) stated that they do their best to resolve the grievances and typically were investigated/resolved within 10 days. At that time, the SSD stated she had investigated the grievance for Resident #352 with the then Assistant Director of Nursing (ADON). At that time, the surveyor and the SSD discussed the Grievance/Concern Form which also included an allegation that a Certified Nursing Assistant had told the resident If you fall, I am not going to pick you up. The day of the incident was documented on the grievance form to have occurred on a Wednesday or Thursday. At that time, the SSD informed the surveyor that no staff member was identified by the complainant and as a result no staff was identified. The SSD could not speak as to where the statements obtained during the investigation or if any was obtained. The surveyor and the SSD reviewed the findings and summary portion of the grievance investigation which revealed the process for investigation which included the following: -An interview with staff members having contact with the resident during the relevant periods and shift of the alleged incident. -Interviews with the resident's roommate, family members and visitors. The surveyor and the SSD did not observe any of the above documents included in the grievance investigation packet provided. On 02/22/24 at 01:37 PM, during an interview with the surveyor, the LNHA stated the ADON at that time was the nurse on duty and there were no statements on file for the investigation conducted regarding the resident's grievance. On 02/23/24 at 11:39 AM, during an interview with the surveyors, the LNHA confirmed that there no witness statements [to help determine the root cause] on file for Resident #352's grievance. On 02/23/24 at 12:29 PM, during a meeting with the survey team, and the Director of Nursing (DON), the LNHA stated that Quality Assurance Performance for Improvement (QAPI) was initiated for the grievance process and that the Social Worker was the gate keeper of all grievances. The concern regarding the grievance process was communicated by the surveyor to the LNHA. On 02/26/24 at 12:05 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that all staff were given education on the process for grievances and acknowledged that no investigation statements were included with Resident #352's grievance concern. A review of the facility provided policy; Grievance/Complaints, Recording and Investigating dated/revised July 2023 under Policy and Interpretation and Implementation included the following: 4. The investigation and report will include, as applicable: d) the names of any witnesses and their account of the alleged incident f) the employees account of the alleged incident g) accounts of any other individuals involved, (i.e., employees, supervisor, etc.) NJAC 8:39-4.1(a)(35);13.2(c)

Based on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of the 23 residents reviewed, Resident #80. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake, and laying on a low bed with two floormats in use. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: According to the admission Record (admission summary), Resident #80 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), encephalopathy (a broad term for any brain disease that alters brain function or structure), major depressive disorder, mood disorder due to known physiological condition, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance. A review of the resident's Progress Notes (PN) showed the following information: 8/20/23 at 3:59 PM=revealed that Licensed Practical Nurse #1 (LPN#1) documented that at 3:45 PM the housekeeping staff notified LPN#1 that Resident #80 was laying on the floor, the resident was unable to explain what happened and no visible injury noted to the resident. 10/18/23 at 7:58 PM=revealed that LPN#2 documented that the resident was found laying on the bedroom floor and there was no injury noted. 10/28/23 at 11:21 PM=revealed that LPN#1 documented that at 9:50 AM, the housekeeping staff notified LPN#1 that the resident was on the floor. The resident denied pain and noted redness to the left knee. 11/09/23 at 3:12 PM=revealed that LPN#3 documented that she was called into the room of the resident by a staff member. The resident laying on the mattress on the right side of the bed. No apparent injuries upon assessment. 12/18/23 at 4:03 PM=revealed that LPN#1 documented that at 3:55 PM, he was alerted by staff that the resident was laying on the floor mat on the left side of the bed and there was no visible injury noted. 12/18/23 at 9:00 PM=revealed that LPN#4 documented that at 8:30 PM, when LPN#4 walked by the resident's room, the resident lying on the floor mat on the left side of the bed, and there was no injury noted. A review of the resident's comprehensive MDS (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 01/05/24 revealed in Section C Cognitive Status C1000 that the cognitive skills for daily decision-making that resident's cognition was severely impaired. The cMDS in Section J Health Conditions included that the resident had no falls since admission/entry or reentry or the prior assessment (OBRA [Omnibus Budget Reconciliation Act, assessment is due no less frequently than every 92 days] or Scheduled PPS [Prospective payment system, completed when a Medicare Part A stay ends, but the resident remains in the facility]), whichever is more recent. A review of the MDS with an ARD of 11/02/23 showed that in Section J there was one fall that was captured with no injury. Further review of the above MDS showed that the fall incident that happened on 11/09/23 and the two fall incidents that happened on 12/18/23 (at 3:55 PM and 8:30 PM) were not captured in the 01/05/24 cMDS. The MDS with an ARD of 11/02/23 did not capture the fall incident with a minor injury that happened on 10/28/23 that resulted in a redness to the left knee. On 02/20/24 at 9:15 AM, the surveyor in the presence of another surveyor, notified the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) of the above findings regarding the MDS was not accurately done to capture the fall incidents of the resident. On 02/20/24 at 9:32 AM, the surveyor interviewed the MDS Coordinator Assistant/Licensed Practical Nurse (MDSCA/LPN). The MDSCA/LPN informed the surveyor that she was responsible for MDS assessment that included section J for falls. The MDSCA/LPN stated that there was no facility-specific policy for MDS and that the facility follows the RAI (Resident Assessment Instrument) Manual. She further stated that the information she gathered from the electronic medical records, specifically in the Risk Management where fall investigation documentation can be located in answering section J of the MDS. On that same date and time, the surveyor notified the MDSCA/LPN of the above findings and concerns. The MDSCA/LPN then opened her computer and verified the MDS concerns of the surveyor. The MDSCA/LPN confirmed that the MDS with an ARD of 01/05/24 and 11/02/23 were not accurately coded to reflect the falls of the resident. She further stated that she did not know what happened and probably an oversight. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns. On 02/26/24 at 12:04 PM, the survey team met with the LNHA, and the DON, and there was no additional information provided by the facility management. NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/14/24 at 11:26 AM, during the initial tour, the surveyor observed Resident #71 in their room laying in bed. Resident #71 stated he/she was blind in the left eye and requested for the nurses to administer medication on the right side. The resident further stated that the facility lost their glasses. The resident stated that resident informed the Social Worker Director (SWD) that his/her glasses were missing, and had no glasses for four months. On that same date and time, Resident #71 stated that he/she reported to the floor nurse that their glasses were missing. The resident claimed that it was very hard for the resident to see without the eyeglasses as well as feeding self. The surveyor reviewed the hybrid medical records for Resident #71. The Resident's AR reflected that Resident #71 was admitted to the facility with diagnosis which included unspecified cataract (a clouding of the lens of the eye, which is typically clear), hypertensive heart (problems that occur because of high blood pressure that is present over a long time), diabetes mellitus (refers to a group of diseases that affect how the body uses blood sugar (glucose), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The quarterly MDS dated [DATE], reflected the resident's vision was adequate, and that there was adequate light (with glasses or other visual appliances). The assessment indicated that the resident had a BIMS score of 15 out of 15 which reflected that the resident's cognition was intact. A review of the resident's CP revealed that there was no care plan to reflect the care for resident's vision impairment. A review of resident's consultation in the electronic medical record reflected that the resident was seen and examined by the eye doctor with diagnosis which included. 1. Proliferate diabetic Retinopathy (the advanced stage where abnormal new blood vessels grow on the surface of the retina) 2. Cataract OU (Oculus Uterque. It stands for both eyes). A review of the resident's medical records revealed that there was no documentation that reflected resident's missing glasses. A review of Resident #71's Interdisciplinary Progress notes dated 01/18/2024 indicated in the Clinical review note that Resident #71's vision was adequate. On 02/16/24 at 11:35 AM, the surveyor interviewed the SWD and requested a copy of Resident #71's grievance/concern form. A review of Grievance form with SWD, both the surveyor and the SWD noted date of occurrence 01/23/24, there was no follow up noted with eye doctor concerning resident's glasses. The SWD stated that it was a possible that it was an oversight. The SWD further stated that the turn around time for follow up was 7-10 days, and the SWD acknowledged that it was not done. On 02/16/24 at 10:00 AM, the surveyor interviewed LPN#2 on the 3rd floor who was responsible for care planning. The LPN stated he was not good at care planning. The LPN acknowledged Resident #71 should have care planned for impaired vision. At the same time, the surveyor interviewed the MDS Coordinator/LPN (MDSC/LPN) who had acknowledged impaired vision should have been added to care plan. On 02/16/2024 at 10:30 AM, the surveyor interviewed the DON who stated that impaired vision should have been in the care plan. On 02/20/2024 at 11:07 AM, the surveyor reviewed the progress notes which reflected that the resident was seen and examined by an eye doctor, and with recommendation to follow up with an eye specialist. On 02/20/2024 at 11:55 AM, during an interview, Resident #71 stated they were seen by the eye doctor on 02/19/2024. On 02/20/24 at 12:30 PM, the surveyor observed Resident #71 in bed with then eyes closed and their lunch tray on overhead table untouched. On that same date and time, the surveyor interviewed the CNA who delivered the tray. The CNA stated that Resident #71 told her to leave the tray on the table. The CNA informed the surveyor that the resident had no special needs and that she was aware of anything special about the patient needs. On 02/22/2024 at 12:28 PM, the surveyor interviewed the LPN/UM regarding the facility's practice with regard to eye consult. The LPN/UM stated that he goes through all the patient chart monthly to find out who needs or have seen the eye doctor. He further stated that there was no policy or report that being generated. On 02/22/2024 at 12:39 PM, the surveyor interviewed the Unit Clerk (UC). The UC stated that he generate resident roster and sent to the eye doctor via email monthly. A review of the Census (resident's assigned room while at the facility) line provided by administrator included the following: 11/02/23-01/22/24= Resident #71 was in room [ROOM NUMBER]A. 01/22/24- Room moved from 326B to room [ROOM NUMBER]B. 01/23/24- Grievance completed following day after resident moved. 02/22/24-glasses located in 326B where patient was last physically in the room on 01/22/24. On 02/23/24 at 12:45 PM, the surveyor interviewed the contracted Housekeeper Manager (HKM) of the facility. The HKM stated that yesterday, while doing her second check on room [ROOM NUMBER]B for possible admission attempted to open drawer, she was unable to open, and she placed her hands underneath and found the missing glasses. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above findings and concerns regarding Resident #71. The LNHA and DON stated that the HKM found the eyeglasses in the old room yesterday late afternoon. On 02/23/24 at 12:18 PM, the survey team met with the LNHA and DON. LNHA acknowledged that the resident's care plan was updated after surveyor's inquiry. The DON stated that the UM and nurses should properly assess the resident for vision, review the consult, and documents in the progress notes. The DON further stated that she was not sure where was the breakdown of the process why the assessment did not reflect of the vision loss. NJAC 8:39-27.1 (a) Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a) follow the weekly skin assessments schedule and documentation of the weekly skin assessment according to the order and facility policy for one (1) of 20 residents, (Resident #89) reviewed for quality of care and b) ensure appropriate care and services was provided to a resident with regard to vision for one (1) of two (2) residents, Resident #71, reviewed for visual impairment. This deficient practice was evidenced by the following: 1. On 02/14/24 at 11:21 AM, the surveyor observed the resident out of bed (OOB) in a wheelchair with the call bell within reach. The resident was actively watching TV (television) and had no complaints of the food or the staff. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #89 as follows: The admission Record (AR, an admission summary) reflected that that resident was a long-term care resident at the facility and had diagnoses which included but were not limited Amyotrophic Lateral Sclerosis (ALS) (fatal type of motor neuron disease. It is characterized by progressive degeneration of nerve cells in the spinal cord and brain), morbid obesity, and muscle weakness. The resident's comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, dated 11/30/2023 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact. A review of the resident's Care Plan (CP) revealed a focus area that the resident is at risk for malnutrition related to (r/t) hospice care, need for therapeutic and mechanically altered diet, increased risk for wounds, overweight that was initiated on 5/02/23. A review of the resident's CP revealed a focus area that the resident is at risk for pressure ulcer development r/t disease process, decreased mobility, and decrease motility and was initiated 5/16/23 and revised 11/29/23. Further review of the resident's CP revealed a focus area that the resident has bladder incontinence t/t disease process was initiated 5/16/23 and revised 11/29/23. A review of the Braden scale dated 10/12/23 revealed a score of 14 which is moderate. Under the section Moisture degree to which the skin exposed to moisture was #2 very moist. A review of the Weekly skin assessment documentation revealed a weekly skin assessment was completed on 12/07/23. The next weekly skin assessment the surveyor could review was dated 01/11/24. The weekly skin assessments that should have been completed and were missing were for dates 12/14/23, 12/21/23, 12/28/23, and 01/04/24. The resident's treatment administration record (TAR) dated 12/01/23-12/31/23 revealed Weekly Skin assessment: Thursday every Day shift 7a-3p skin assessment. A review of the resident's TAR dated 01/01/24-01/31/24 revealed Weekly Skin assessment: Thursday every Day shift 7a-3p skin assessment. Further review of the TAR revealed that nursing documented completion of the above treatments on the TAR for every day for the dates of 12/14/23, 12/21/23, 12/28/23, and 01/04/24. There was no corresponding Weekly Skin Assessment completed in the assessment part of the electronic medical records to corresponds to the signed TAR for dates 12/14/23, 12/21/23, 12/28/23, and 01/04/24. On 02/26/23 at 11:04 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) who stated, the Certified Nurses aids (CNA) are responsible during washing or changing the resident and they let the nursing staff know of any new issues, then the nursing staff document on the TAR and on the weekly skin assessment. LPN#1 further stated that there was an area to document if skin was intact, it showed on TAR and cross reference so it cannot be missed. We as nurses are responsible to document in both areas on the TAR and the weekly skin assessment form. On 02/23/24 at 10:10 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), she stated, the treatments that are ordered and entered on the TAR for resident #89 are to help prevent pressure ulcers. The nurse was doing the skin check and signing off the TAR, but then needs to go into the skin assessment documentation and document what was observed during the weekly assessment. The staff was supposed to document in both areas, The weekly skin assessment form has a no new area or concern spot for them to check if that is the case. On 02/26/24 at 11:31 AM, the surveyor interviewed the Director of Nursing (DON), who stated, the weekly skin assessment was a document completed on new admissions and ordered weekly. If there are any new areas of concern nursing would fill out the form completely. There was a section to mark if no new areas of concerns are applicable. Once the assessment was done then nursing will sign it off on the TAR. The DON further stated that the weekly skin assessment was reviewed by multiple disciplines in the facility. That was how we communicate about the resident's skin. On 02/27/24 at 11:15 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, for the Exit Conference and there was no additional information provided by the facility. A review of the facility's Prevention of Pressure Injury policy, dated 2001, revised 6/2023 included: Policy: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Section Monitoring: #1) Evaluate, report and document potential changes in the skin. #2) review the intervention and strategies for effectiveness on an ongoing basis.

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that the left elbow splint was consistently applied according to the physician's order. This deficient practice was identified for one (1) of three (3) residents reviewed for the limited range of motion (ROM), Resident #80. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake and laying on a low bed. The resident did not have a splint in use at the time of observation. There was a splint on top of the nightstand table. On 02/15/24 at 01:07 PM, the surveyor and the Licensed Practical Nurse (LPN) went inside the resident's room. The LPN informed the surveyor that Resident #80 was in the activity in the dining area. Then both the surveyor and the LPN went to the dining area and both observed that the resident was seated in a recliner wheelchair with no splint in use. At this time, the LPN informed the surveyor that the resident had limitations to the right arm and that the right elbow splint should been used at that time. Later on, both the surveyor and the LPN went back to the resident's room. The LPN stated that he would try to find the right elbow splint and that the last time he saw it was on top of the nightstand table when he worked yesterday at 3-11 shift. He also confirmed that on 02/14/24 3-11 shift he did not find the resident had it on when he was about to remove it at night as per the physician's order. The LPN looked inside the resident's room for the splint and it was not found. On 02/15/24 at 01:10 PM, the surveyor observed LPN asked the assigned Certified Nursing Aide (CNA) of the resident regarding the right elbow splint, and both went back to the resident's room to look for the splint. At this time, the LPN found the right elbow splint inside the second drawer of the nightstand table. The CNA told the LPN that she did not know that was the one (right elbow splint) that they were looking for. The CNA further stated, I thought you were looking for the sleeves for the arms. The CNA stated that the resident did not refuse the splint and the CNA did not know where the splint was. The CNA further stated that this was not the first time that the resident did not have a splint on because she did not see that the resident was on a splint for a long time (CNA was unable to state specific time period). The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: According to the admission Record (admission summary), Resident #80 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), encephalopathy (a broad term for any brain disease that alters brain function or structure), major depressive disorder, mood disorder due to known physiological condition, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance. The resident's comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 01/05/24 revealed in Section C Cognitive Status C1000 that the cognitive skills for daily decision-making showed that the resident's cognition was severely impaired. The personalized care plan with a focus on the resident's declined strength, generalized weakness, impaired mobility, and balance, difficulty with transfers, and declined self performance s/p (status post) recent hospitalization date initiated on 6/30/22 with an intervention that included RUE (right upper extremity) orthoses: elbow splint and hand roll on in AM (morning) and off in PM (afternoon) as tolerate initiated on 02/03/24. Review of the February 2024 Order Summary Report showed an order date of 11/03/23 for a patient (also known as a resident) to be donned (put on) right elbow splint and right hand roll splint during the day and doff (remove) of night. Please check for skin integrity before each placement one time a day and remove per schedule. The above order for right elbow splint and right hand roll was transcribed to the February 2024 electronic Treatment Administration Record (eTAR) and was signed with a checkmark at 10:00 AM as applied and removed at 9:00 PM from 02/01/24 through 02/22/24. There were two (02/06/24 and 02/10/24) out of 22 days that it was refused (coded as 2). Further review of hybrid medical records revealed that there was no documentation that the right elbow splint and hand roll were refused on 02/14/24 and 02/15/24. On 02/23/24 at 10:42 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The surveyor notified the facility management of the above concerns and findings. On 02/26/24 at 12:04 PM, the survey team met with the LNHA and DON. There was no additional information provided by the facility management. NJAC 8:39-27.1(a); 27.2(m)

Based on observations, interviews, and review of other pertinent facility provided documentation, the facility failed to a) ensure a root cause analysis conclusion was included routinely in a resident's fall investigation/incident report, b) implement the resident's care plan fall intervention, and c) ensure that fall assessments were done according to facility's practice and policy, and standard of practice, for one (1) of three (3) residents reviewed for falls (Resident #80). 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. On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake, laying on a low bed with a scoop mattress (designed with raised edges or contoured sides that 'scoop' upward, creating a barrier to help prevent users from rolling off the bed), and two floormats in use. On 02/15/24 at 8:18 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for the resident's fall investigations for the last six months. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: According to the admission Record (admission summary), Resident #80 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), encephalopathy (a broad term for any brain disease that alters brain function or structure), major depressive disorder, mood disorder due to known physiological condition, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance. The resident's comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 01/05/24 revealed in Section C Cognitive Status C1000 that the cognitive skills for daily decision-making showed that the resident's cognition was severely impaired. The surveyor received from the LNHA a total of six fall investigations. The provided six fall investigations were dated 8/20/23, 10/18/23, 10/28/23, 11/09/23, and two 12/18/23 (3:55 PM and 8:30 PM). All six fall investigations were unwitnessed. The following were the immediate actions taken post fall from the provided fall investigations and care plan status: 8/20/23=assessed for pain/discomfort and scoop mattress to be placed. A scoop mattress was added as an intervention in the care plan with a created date of 8/21/23. 10/18/23=floor mats to be put in place. Floor mats were added as an intervention in the care plan with a created date of 10/19/23. 10/28/23=Neuro (neurological) check initiated will suggest floor mat to the right side of the bed. The care plan did not reflect a neuro check and floormat to the right side of the bed. There was a care plan intervention that was created on 10/30/23 for Psych (Psychiatric) consult for restlessness. There was a Neurological check form that was provided for dates 10/28/23 and 10/29/23. 11/09/23=assessment completed and returned resident to bed. There were no changes to the care plan. 12/18/23 3:55 and 8:30 PM=assessed for pain, discomfort, and injury. OT (occupational therapy) screen for high back w/c (wheelchair) trial to increase time OOB (out of bed) as added as an intervention in the care plan with a created date of 12/20/23. A review of the provided last six months' incidents and accidents (Risk Management) reports by the LNHA showed that there was no root cause analysis documented for fall incidents dated 8/20/23, 10/18/23, 10/28/23, 11/09/23, and 12/18/23. The Progress Notes (PN) showed the following: 1. Late Entry created on 11/02/23, the effective date of 10/30/23, that was electronically signed by Licensed Practical Nurse #1 (LPN#1, also known as the facility's Assistant Director of Nursing or ADON) which included that the IDT (interdisciplinary) team met regarding resident's fall. Fall mat to be placed to side of the bed and psych consult for evaluation of restlessness. 2. Late Entry created on 11/13/23, the effective date of 11/10/23, that was electronically signed by Registered Nurse (also known as the facility's Infection Preventionist Nurse or IPN) which included that The IDCT (interdisciplinary team) met to discuss the residents fall. Resident #80 was noted laying on the fall mat on the right side of the bed. Resident unable to tell staff what happened. No injury noted. Resident has episodes of restlessness and moves about in bed due to the restless. The intervention that is in place is working, plan of care as is to continue. Further review of the resident's electronic medical records showed that there was no documentation of root cause analysis of the resident's fall incidents on 8/20/23, 10/18/23, and 12/18/23 in the PN. A review of the hybrid medical records showed that the last Fall Risk Assessment (FRA) was done was on 6/29/22. On 02/15/24 at 12:47 PM, the surveyor in the presence of another surveyor interviewed LPN#2. LPN#2 stated that he remembered the 10/28/23 fall incident of the resident when the housekeeping staff informed him that the resident was on the floor. LPN#2 stated that there was one floor mat in use at that time on the left side of the bed and there was none on the right side. He further stated that was why he recommended to put a floormat on the right side of the bed as a new intervention. LPN#2 also stated that he remembered that when he recommended to add a floor mat to the right side of the bed, someone had told him that the resident should had two floormats as a previous intervention. On that same day and time, LPN#2 confirmed that there was only one floormat at the time of the incident on 10/28/23 and he did not know why it was not two floormats. He acknowledged that the facility should follow the care plan and previous intervention for floormats. On 02/20/24 at 9:15 AM, the surveyor in the presence of another surveyor interviewed the Director of Nursing (DON), and LNHA. The DON informed the surveyor that fall assessments were done upon admission, quarterly, and when there were significant changes. The DON stated, I don't think we do fall assessments every time there's a fall incident. The DON further stated that fall assessments were done in the electronic medical record. Both the LNHA and the DON were unable to state the facility's policy regarding fall assessment, and both stated that they would get back to the surveyor. At that same time, the surveyor notified the facility management of the above concerns and findings. On 02/20/24 at 9:32 AM, the surveyor interviewed the MDS Coordinator Assistant/Licensed Practical Nurse (MDSCA/LPN). The MDSCA/LPN stated that the fall assessment should be done quarterly corresponding to the MDS schedule and it should be done in the evaluation part of the electronic medical records. The MDSCA/LPN indicated that she was not sure if the facility's practice was to do another fall risk assessment when there was a fall incident that happened. At that same time, the surveyor then notified the MDSCA/LPN of the above concerns. She did not have an answer as to why the last FRA was done on 6/29/22 when it should have been done quarterly. On 02/20/24 at 9:57 AM, the surveyor interviewed LPN#3 regarding fall investigations. The LPN stated that the fall assessment done upon admission and readmission in evaluation part of the electronic medical record. On 02/20/24 at 10:36 AM, the surveyor interviewed LPN#2 regarding the fall assessments. The LPN stated that FRA done quarterly by the Unit Manager (UM) or the MDSCA/LPN in the electronic medical record, in the evaluation section. At this time, the surveyor asked LPN#2 to show the surveyor if the FRA was done quarterly. The surveyor then asked the LPN why the FRA last done was on 6/29/22 and the LPN had no response. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns and findings. A review of the facility's Fall Risk Assessment Policy with a revised date of March 2018 that was provided by the LNHA included that the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Policy interpretation and implementation: upon admission, the nursing staff and the physician will review the resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). On 02/26/24 at 12:04 PM, the survey team met with the LNHA and DON. There was no additional information provided by the facility management. N.J.A.C. 8:39-27.1 (a); 33.1(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to consistently document catheter urinary output according to the physician orders. This deficient practice was identified for one (1) of two (2) residents reviewed for urinary catheters (Resident #13) and was evidenced by the following. On 02/14/24 at 10:45 AM, during the initial tour, the surveyor did not observe the resident in the room. The resident's bed was at a high position and the bedside table was at the foot of the resident's bed. On the side of the bed was an intravenous pump for Vancomycin (antibiotic) that appeared to have been administered completely. At 02:14 PM, the surveyor observed the resident in the rehabilitation room with one of the rehabilitation staff. Resident #13 greeted the surveyor. Resident #13 was seated in front of the Occupational Therapy Director and was assisted by the Occupational Therapy Aid. The surveyor reviewed the medical record for Resident #13. Resident #13's admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to urinary tract infection, site not specified, orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with diabetic neuropathy (disease of inadequate control of blood levels of glucose), hypertensive heart (high blood pressure) and resistance to multiple antimicrobial drugs (resistance to multiple antibiotics). A review of Resident #13's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 01/11/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had an intact cognition. The resident's care plan (CP) initiated on 01/24/24, included a focus that the resident was at risk for infection secondary to suprapubic catheter (SPC); urinary retention (noted in the emergency room was 1000 cubic centimeter (cc; is equal to milliliter; ml) 10/27/22, SPC was inserted for flaccid neuropathic bladder (also known as neurogenic bladder; bladder that does not empty or store urine properly). The CP interventions included monitor urine output for color, consistency, cloudiness, sediment, and odor which was initiated on 8/18/22. A review of the Order Summary Report (OSR) for December 2023 reflected an order to monitor the resident's urine output every shift and document. The December 2023 Treatment Administration Record (TAR) revealed the urinary catheter output was not documented for the following days and shifts: December 2023: 12/01/23 to 12/18/23 all three shifts 12/19/23 not applicable/hospital leave 12/20/23 to 12/31/23 all three shifts The OSR for January 2024 reflected an order to monitor the resident's urine output every shift and document. The January 2024 TAR revealed the urinary catheter output was not documented for the following days and shifts: January 2024: 01/01/24 to 01/11/24 all three shifts 01/12/24 day shift and evening shift 01/13/24 to 01/22/24 01/23/24 day shift and evening shift 01/29/24 night shift 01/30/24 not applicable/hospital leave 01/31/24 all three shifts The OSR for February 5 2024 reflected an order to monitor the resident's urine output every shift and document initiated on 02/05/24. The February 2024 TAR revealed the urinary catheter output was not documented for the following days and shifts: February 2024: 02/01/24 to 02/25/24 all three shifts On 02/26/24 at 10:49 AM, during an interview with two surveyors, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the urine output was documented in the point of care system and reported to the nurse. The nurse records the output into the electronic Medication Administration Record (eMAR). At that time, the LPN/UM confirmed that the output was not recorded in December 2023, January 2024, and February 2024 and that it should have been. In addition, the LPN/UM stated that the resident was hospitalized in December 2023 because of a bleeding from the outside portion of the SPC. The resident received wound care daily and the wound doctor saw the resident once a week who cauterized the bleeding. Furthermore, the LPN/UM stated that monitoring the resident's urinary output was important to help monitor the resident's hydration status, kidney function, catheter patency and preventing urinary tract infection. On 02/26/24 at 12:05 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding missing urinary output documentation for the resident for December 2023, January 2024, and February 2024. At that time, the DON stated the urinary output should have been monitored as per physician's order to ensure that there was no urinary retention, assessment of the urine to indicate hydration and/or urinary tract infection. On 02/27/24 at 10:26 AM, during a follow-up meeting with the surveyors, the DON stated the supplementary documentation for the urinary output was a data entry error which led to the elimination of the area for documentation of the quantity. A review of the provided facility policy, Output, Measuring and Recording dated/revised in October 2010, under Steps in Procedure included section 8. Record the amount noted on the output side if the intake and output record. Record in mls (milliliters) and 9. Record the time the output was measured. A review of the provided facility policy; Emptying a Urinary Collection Bag dated revised in June 2023 under Documentation included: The following information should be recorded in the resident's medical record . 1 The date and time the procedure was performed. 2 The amount of urine emptied from the drainage bag. 4. Character of the urine such as color . NJAC 8:39-27.1(a) 33.2 (c) 5

Based on observations, interviews, records review, and review of other facility documentation, it was determined that the facility failed to: a.) monitor the resident's nutritional supplement intake, b.) implement and monitor weekly weights, and c.) ensure the accuracy of a resident's weight who had a history of weight fluctuation. This deficient practice was identified for one (1) of three (3) residents reviewed for nutrition (Resident #45) and was evidenced by the following: Reference: American Thyroid Association A review of the brochure of Thyroid Function Test included, -A high TSH (thyroid stimulating hormone) level indicates that the thyroid gland is not making enough thyroid hormone (primary hypothyroidism). -TSH level is low, usually indicates that the thyroid is producing too much thyroid hormone (hyperthyroidism). A review of the brochure of The relationship between thyroid and weight included the following: Thyroid hormone regulates metabolism in both animals and humans. Metabolism is determined by measuring the amount of oxygen used by the body over a specific amount of time. If the measurement is made at rest, it is known as the basal metabolic rate (BMR). Patients whose thyroid glands were not working were found to have low BMRs, and those with overactive thyroid glands had high BMRs. Since the BMR in the patient with hypothyroidism (see Hypothyroidism brochure) is decreased, an underactive thyroid is generally associated with some weight gain. The weight gain is often greater in those individuals with more severe hypothyroidism. Since the BMR in patients with hyperthyroidism (see Hyperthyroidism brochure) is elevated, many patients with an overactive thyroid do, indeed, have some weight loss. On 02/14/24 at 10:59 AM, the surveyor observed Resident #45 in their room. The resident stated he/she was tired and verbalized not liking the eggs served for breakfast but did not recall informing anyone of resident's preference. On 02/15/24 at 11:59 AM, the resident stated that breakfast was okay and had no interest in activities that day. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #45. The resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to enterocolitis due to clostridium difficile ( (inflammation through the intestines due to a highly contagious bacterial infection), disorder of the adrenal gland (cause of too much or too little of certain hormones), and hypothyroidism (underactive thyroid; can cause unexplained weight gain). The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 02/08/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Additionally, the MDS revealed that the resident required setup or clean-up assistance for eating. A review of the resident's Care Plan (CP) initiated on 11/11/23, revealed the resident was at risk for malnutrition related to weight changes; need for fortified foods; therapeutic diet .The goal included that the resident would maintain weight with positive or negative range of 5%. Interventions included the following: -4 ounces of health shake (220 kilocalories (kcal); 1 kcal equal to 1 calorie; a nutritional supplement) 6 grams (gr) of protein) initiated on 12/12/23 and discontinued on 1/3/23. The resident's CP included an intervention of weekly weights for four (4) weeks that was initiated on 01/03/24. A review of the resident's Weights and Vital Summary revealed the following: On 02/05/24 the resident weighed 150.0 pounds (lbs) On 01/05/24 the resident weighed 155.5 lbs On 12/11/23 the resident weighed 156.5 lbs This indicated an approximate (-6.3%) significant weight loss in one (1) month, from November 2023 to December 2023. On 12/6/23 the resident weighed 162.5 lbs On 11/16/23 the resident weighed 167.0 lbs On 11/16/23 the resident weighed 167.0 lbs Further review of the weight data reflected, the weight from 11/16/2023, when the resident weighed 167 lbs and the weight on 02/05/2024, when the resident weighed 150 lbs indicated another significant weight loss of approximately 10.18 % in three (3) months. A review of the Dietary Progress Note on 12/11/23 reflected the resident was triggered related to significant weight loss for one month at approximately 6.3% . Recommendations included 4 ounces of health shake daily (200 kilocalorie (kcal; equal to 1 calorie, 6 grams (gr) of protein) to deter further weight changes. A review of the Dietary Progress Note dated 12/31/23, included that the resident triggered for an unplanned/undesired weight significant weight loss for one (1) month. The resident's appetite had increased, and that the resident had requested for the health shake to be discontinued. A recommendation of weekly weights for four (4) weeks was added. The Order Summary Report (OSR) from 12/31/23 to 02/22/24 revealed a weekly weight order, one time a day every 7 days, which was initiated from 01/03/24 to 01/29/24. A review of the electronic Medication Administration Record (eMAR) and electronic Treatment Record (eTAR) for December 2023 did not reflect an order for the health shake. The supplement record revealed an order for the health shake without documentation of administration, refusal or amount consumed from 12/12/23 to 12/31/23. On 02/20/24 at 12:31 PM, during an interview with the surveyor, Certified Nursing Aide #1 (CNA #1) stated that the task of obtaining daily and weekly weights of the residents were assigned to the CNAs through the nurses and that the task of obtaining monthly weights of the residents were assigned to the CNA through the Unit Manager. At that time, the CNA #1 stated that the resident's weights were logged into the roster in the weight book. The weight book was located at the front desk of the nurses' station. CNA #1 also stated that once the weight was obtained and logged into the book, and the CNAs reported to the nurses who documented the weight into the eMR. At that time, CNA #1 stated that the dietician informs nursing who needed weighting and the nurses delegated the weight task to us, the CNAs. On 02/20/23 at 12:38 PM, the surveyor requested for the weight book from the LPN/Unit Manager (LPN/UM). At that time, the LPN/UM could not locate the weight book. At that same time, the LPN/UM stated the daily and weekly weights were documented into the eMAR or the eTAR. The re-weights were documented on the weight book as per the dietician. On 02/23/24 at 9:45 AM, during a follow-up visit with the resident, the surveyor observed the resident lying in bed. The resident stated that he/she had finished his/her cereal that morning and did not like the health shakes given to him/her in the past. The resident stated he/she was aware of his/her weight loss and informed the surveyor that he/she had no feelings towards the unplanned weight loss. On 02/23/24 at 9:50 AM, during an interview with the surveyor, CNA #2 stated the resident had his/her breakfast. On 02/23/24 at 9:52 AM, during an interview with the surveyor CNA #3 stated that the health shakes [nutritional shakes] were given by the nurses assigned to the medication cart. On 02/23/23 at 9:54 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated that if an order was placed into the supplement (meal enhancement portion of the electronic medical record (eMR) the order did not show on the eMAR for the nurses to administer or document on. The surveyor and the LPN reviewed the resident's supplement record together. At that time, the LPN confirmed that there were no documentation of the administration, refusal and/or amount consumed of the health shake from 12/12/24 to 12/31/23, for the Registered Dietician (RD) to monitor, and estimate the resident's estimated nutritional needs in accordance with standard of practice. On 02/23/24 at 10:17 AM, during an interview with the surveyor, the RD stated that there was an issue with the supplement in December wherein the nutritional supplements were given during lunch and the resident was not consuming the health shake. Since then, we adjusted for the health shake to be given in between meals. At that time, the RD confirmed that the consumption was not being recorded. The RD stated she had spoken with the resident who wanted the health shake discontinued. At that time, the RD stated she was unable to ensure the that the nutritional supplement intervention was appropriate without the proper documentation of the consumption of the health shake. In addition, the RD stated that the goal for the resident was to maintain weight. The resident had a Body Mass Index (BMI) of 27.1 and that the BMI was within normal limits. At that time, the RD confirmed that her recommendation and PO were not followed since the weekly weights were only completed once out of the four (4) weeks. Furthermore, the RD stated she should have communicated with the nursing about the missing weekly weights which was discontinued on 01/29/24. The RD also stated that the weekly weights were to ensure the interventions against weight loss were working. The surveyor and the RD reviewed the resident's medical record for the triggered significant weights loss of the resident together as followed: On 11/16/2023, the resident weighed 167 lbs and the weight on 12/11/2023, when the resident weighed 156.5 pounds which indicated a significant weight loss of approximately 6.29 % one (1) month. On 11/16/2023, when the resident weighed 167 lbs and the weight on 02/05/2024, when the resident weighed 150 lbs which indicated another significant weight loss of approximately 10.18 % in three (3) months. At that time, the RD confirmed that she had not asked for reweighs on 12/11/23, 01/5/24, and 02/5/25. At that time, the RD stated that re-weights were necessary to ensure the accuracy of weight loss or weight gain. The RD also stated that a resident's unplanned and undesired weight loss had a negative impact on the resident's overall health. On 02/23/24 at 12:29 PM, during an interview with the surveyor, The Medical Doctor stated he was aware of the resident's weight loss. On that same date and time, during a meeting with the surveyors, Licensed Nursing Health Administrator (LNHA) and Director of Nursing (DON), the surveyor discussed the concerns regarding the missing documentation for the health shake, the incomplete weekly monitoring and the missing reweighs for Resident #45. On 02/23/24 at 12:53 PM, during an interview with the surveyor, the LPN/UM explained the process for weights. The LPN/UM stated that the RD would conduct an assessment for a resident, enter the orders for weights and inform her. All residents newly admitted were weighed weekly for four (4) weeks. Residents that required weekly weight monitoring were entered by the RD herself. At that time, the surveyor and the LPN/UM reviewed the hybrid medical record for the resident's weight monitoring. The physician's order (PO) reflected a weight order, one time a day every 7 days, which was initiated from 01/03/24 to 01/29/24. The hybrid medical record revealed that the resident was weighed once on 01/05/24. The LPN/UM could not explain why the recommendation of the RD and the PO was not followed. The LPN/UM also confirmed there were no documented reweighs on the hybrid medical record. On 02/26/24 at 12:05 PM, during a meeting with the survey team, the DON stated that the order for the health shake was placed in the eMR and confirmed that the amount of consumption or refusal was not documented. A reweigh was done on 02/23/24 and there was no weight change. An education was started, and the glitch in the eMR was fixed regarding documentation of the supplements. On 02/27/24 at 10:08 AM, during a meeting with the survey team, the LNHA and the DON, the Regional Registered Dietician (RRD) stated that the significant weight loss on 12/11/23 was identified by the RD who recommended the addition of the health shake. The health shake was provided by dietary and was given with the meal trays. The RRD provided the meal tickets that reflected the health shake was included with the meal. The RRD also stated the resident's TSH level was drawn on 11/20/23, and the level was at 26 uIU/ml [microunits per milliliter; with a normal range of 0.3 to 4.2 uIU/ml]. The TSH was redrawn on 01/05/24, which resulted in a level of 1.86 uIU/ml and another on 01/29/24, which resulted in 0.21 uIU/ml. The RRD stated that the TSH levels may have contributed to the weight loss. At that time, the RRD confirmed that the calories for the health shake were not documented, the weekly weights should have been obtained and caught during the monthly meeting. Additionally the RRD confirmed the re-weights should have been done for Resident #45 who experienced two significant weight loss. A review of the provided facility policy, Food and Nutritional Services, under Policy Interpretation and Implementation included 7. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems. 7(b) a nurse will evaluate the significance of such information and report it, as indicated to the attending physician and dietitian. A review of the facility provided Clinical Dietician Job Description under Responsibilities and Duties included the following: -Review all monthly and weekly weights, complete assessments and make modification to the nutrition plan of care as clinically indicated. NJAC 8:39-27.1(a),27.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain consistent documentation of accounting of backup controlled substance inventory, b) ensure accurate accounting and reconciliation of backup controlled substances, and c) ensure that the facility management was notified of the identified discrepancies in the backup controlled substances according to the facility's practice, policy, and standard of practice. This deficient practice was identified in one (1) of two (2) medication storage rooms during the medication storage review. 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. On 02/20/24 at 10:14 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) and Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the facility's routine controlled backup medications (meds) monitoring and accounting. Both the ADON and the LPN/UM stated that the routine counting of backup controlled meds was done this morning. The LPN/UM stated that the counting of backup controlled meds is done every shift. The LPN/UM further stated that there was no accountability or log to show that the routine monitoring and counting of controlled backup meds were done, and there was no printed report. On that same date and time, the LPN/UM stated that if there was a discrepancy, it will show in the automated/electronic (a/e) system. The surveyor then asked for a printout of today's count of controlled backup meds from the a/e system and the LPN/UM stated that she would get back to the surveyor. On 02/21/24 at approximately 11:08 AM, during an inspection of the 2nd-floor med room with the use of an a/e system for controlled backup meds, the surveyor observed both the LPN/UM and the ADON on-the-spot count and there was no discrepancy noted. On that same date, during an interview with the surveyor, the LPN/UM in the presence of the ADON stated that on weekends, it was the responsibility of the supervisors to make sure that the daily counting and monitoring of backup controlled meds are done even though there was no accountability and documents that will show that the process was done. At that same time, the surveyor asked the ADON and the LPN/UM if they had encountered or received reports of discrepancy and what the facility's process about discrepancies identified with backup controlled meds in the a/e system. Both the ADON and the LPN/UM stated that it would show in the machine that there is a discrepancy, and it would be them (ADON and LPN/UM) who would fix the discrepancy shown in the monitor of the a/e system. The surveyor then asked the LPN/UM and ADON, how about the weekend, and the days when both of them do not work, who will be responsible for the discrepancy. Both stated that it would be fixed when both of them come back on Monday or the following day when they report to work. Furthermore, the surveyor asked both the ADON and the LPN/UM if they had to notify the Director of Nursing (DON) of the discrepancy that was identified and corrected by both of them and if there was a report that had to be generated to show the investigation done for the discrepancy. The LPN/UM stated that as far as she knew, she did not need to notify the DON of the discrepancy, and no report was done because everything was in the a/e system. Furthermore, the surveyor asked again for the printed report to show that the daily monitoring and counting of backup controlled meds was done. On 02/21/24 at 11:48 AM, the surveyor asked the DON and the Licensed Nursing Home Administrator (LNHA) for the facility's policy regarding controlled meds and the report of any discrepancy for the last six months. On 02/21/24 at 12:52 PM, the LNHA provided a copy of the Discrepancy/User Report for the date range of 9/01/23-02/21/2024 and there were discrepancies in the report. On 02/21/24 at 01:09 PM, the surveyor met with the LNHA and DON. The surveyor asked the facility management about their process of monitoring and accounting for controlled backup meds. Both the LNHA and the DON were unable to state the facility's process and policy. On that same date and time, the surveyor asked the facility management what will be the expectations and standard of practice if there were a backup controlled meds discrepancy. Both the LNHA and the DON stated that the discrepancy should be reported immediately to them (LNHA and DON), fill out a form, and do the investigation. Both the DON and the LNHA acknowledged that they were unaware of the discrepancies that were printed in the report and there was no accountability for routine monitoring and accounting of backup controlled meds until the surveyor's inquiry. At this time, the surveyor also notified the facility management that the provided discrepancy report showed that on 01/04/24 at 7:54 AM there was a discrepancy noted for Alprazolam (an antianxiety med) 0.5 milligram (mg) that was corrected by the ADON and there was no witness. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns and findings. The facility management acknowledged that they were not aware of the discrepancies that happened in the last six months and had no accountability for the routine counting of controlled backup meds in the a/e system. The DON stated that ADON had a super user identification that could open the a/e system backup machine for controlled meds without the presence of another nurse/witness which the facility management found out after the surveyor's inquiry. The DON provided documentation that the Alprazolam was accounted for and the discrepancy was resolved. At that same time, both the LNHA and the DON acknowledged that there should be routine monitoring and accounting for the backup controlled meds and they should be notified of the discrepancies to make sure that proper investigation will be done. A review of the facility's Controlled Substances Policy with a revised date of June 2023 that was provided by the LNHA included that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled meds. Policy interpretation and implementation included that controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Controlled meds are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing Services (DNS) immediately. The DNS investigates all discrepancies in controlled med reconciliation to determine the cause and identify any responsible parties and reports the findings to the Administrator. The DNS consults with the provider pharmacy and the Administrator to determine whether further legal action is indicated. Automated/Electronic (a/e) Systems that includes narcotics-this system maintains a constant inventory as each nurse removes or adds medications. An alert is triggered on the screen when the count does not reconcile. In the event of such an alert (e.g. discrepancy, miss-count), the discrepancy must be reconciled. On 02/26/24 at 12:04 PM, the survey team met with the LNHA and DON. There was no additional information provided by the facility management. NJAC 8:39-29.4(k)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 02/16/23, the two (2) surveyors observed four (4) nurses administer medications to five (5) residents. There were 32 opportunities, and two errors were observed which resulted in a medication error rate of 6.25%. This deficient practice was identified for two (2) of six (6) residents (Resident #22 and #354), that was administered by two (2) of four (4) nurses. This deficient practice was evidenced by the following: A review of the manufacturer's specifications for Cosopt PF under section 17.4 Handing the Single-Use Container included: COSOPT PF is a sterile solution that does not contain a preservative. The solution from one individual unit is to be used immediately after opening for administration to one or both eyes. Since sterility cannot be maintained after the individual unit is opened, the remaining contents should be discarded immediately after administration. A review of the manufacturer's specifications for Cosopt under section 11 Description included: COSOPT is supplied as a sterile, clear, colorless to nearly colorless, isotonic, buffered, slightly viscous, aqueous solution . Benzalkonium chloride 0.0075% is added as a preservative. 1. On 02/16/24 at 8:27 AM, the surveyor observed the Licensed Practical Nurse #1(LPN #1) prepare medications (meds) for Resident #22. The meds included a physician's order of Vitamin D3 25 microgram (mcg equivalent to 1000 International Units (IU); Cholecalciferol), give 1 tablet by mouth one time a day for supplement with an order date of 7/10/21. At that time, the surveyor observed the LPN #1 pour one (1) capsule of Vitamin D3 1,250 mcg equivalent to 50,000 IU (Cholecalciferol) into a med cup for administration to Resident #22. LPN #1 informed the surveyor that the container of Vitamin D3 1,250 mcg was a house stock (facility supply) bottle. At 8:45 AM, LPN #1 confirmed with the surveyor that she was ready to administer the resident's meds and walked toward the resident's room threshold. At 8:46 AM, the surveyor stopped the med pass observation at the resident's room threshold and asked LPN #1 to walk back to the med cart parked at the hallway. At that time, the surveyor and the LPN #1 reviewed the electronic Medication Administration Record (eMAR) against the house stock bottle from which the Vitamin D3 1,250 mcg was poured from. At that time, LPN #1 confirmed she had poured the wrong dose and recognized the physician order was for Vitamin D3 25 mcg as opposed to the poured dose of 1,250 mcg. A review of the pharmacy provider invoice dated 01/29/24 revealed an order for six (6) bottles of Vitamin D3 (25 mcg) 1000 IU was shipped to the facility. A review of LPN #1's most recent competency for Medication Pass dated 02/02/24, conducted by the Assistant Director of Nursing (ADON) reflected that LPN #1 had passed the facility's competency assessment without a concern. 2. On 02/16/23 at 9:09 AM, the surveyor observed LPN #2 prepare meds for Unsampled Resident #354. The meds included a physician order of Cosopt PF (Preservative Free) ophthalmic solution 2-0.5% (Dorzolamide hydrochloride - Timolol maleate), instill one (1) drop in the left eye two times a day for glaucoma (a group of eye conditions that can cause blindness). Wait five (5) minutes between different drops, with an order date of 02/26/24. At that time, the surveyor observed LPN #2 pull an eye drop med from an unlabeled clear plastic bag that contained two (2) different eye drop meds. The first eye drop med had a pharmacy label which indicated it was for Unsampled Resident #354, and the name of the med, Brimonidine. The second eye drop med observed by the surveyor was a Cosopt multidose eye drop bottle that did not have a pharmacy label to indicate for which resident it belonged to, nor did it indicate the name of the med. The surveyor observed the manufacturer's label on the Cosopt eye drop. At 9:18 AM, LPN #2 confirmed with the surveyor that he was ready to administer the resident's meds, turned and stepped into the threshold of the Resident's door. The surveyor stopped the med pass observation. At 9:20 AM, the surveyor and LPN #2 reviewed the bottle of Cosopt at the med cart. LPN #2 confirmed with the surveyor that the bottle of Cosopt did not have a label from the pharmacy that indicated the name of the resident or the med. LPN #2 informed the surveyor that he had labeled the date 02/07/24, when it arrived from the pharmacy. At that time, the surveyor asked LPN #2 if the med should be labeled with the resident's name and the name of the med since Cosopt PF was not the same as Cosopt. At that time, LPN #2 stated he would not administer the med to the resident and would call the pharmacy to confirm if the med was correct and inquire about receiving the eye drop for the resident. The surveyor reviewed the medical record for Unsampled Resident #354. A review of the Resident's admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hemorrhage of the right orbit (bleed around the right eye orbit), cognitive communication deficits and type 2 diabetes mellitus (disease of inadequate control of blood levels of glucose). Resident's most recent admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, dated 02/11/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that Resident's cognition was moderately impaired. A review of the resident Order Summary Report (OSR) that were active as of 02/16/24, indicated the resident had an allergy to Penicillin (a med used to manage and treat a wide range of infections) only. A review of LPN #2's most recent competency for Medication Pass dated 02/02/24, conducted by the ADON reflected that LPN #2 had passed the facility's competency assessment without a concern. At 10:26 AM, the surveyor called the Consultant Pharmacist (CP) for the facility and left a message. On 02/16/24 at 10:28 AM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) the surveyor discussed the concerns regarding the med administration observation concerns. At 10:29 AM, in the presence of the surveyor and the LNHA, the DON stated that the expectation and the policy were that the nurses read, and checked the eMAR and the label to ensure the meds administered were correct before administration. The DON also stated that the policy required all meds were labeled. The medication bottle itself should have had an identifier to ensure the right med was administered to the correct resident. At that time, the DON stated she would investigate as to why the resident's Cosopt was not labeled and the reason why the Cosopt the active inventory for the resident instead of the physician order of Cosopt PF. On 02/20/24 at 8:57 AM, during a meeting with the surveyors, the LNHA, the DON stated that Unsampled Resident #354 came from the hospital with an order for Cosopt and that the Cosopt PF was a transcription error made by the nurse and when a nurse is unsure a clarification call to the prescriber was expected from the transcribing nurse. The DON stated at that time, the facility did not have a process to check all orders entered within the 24-hour period and that they were considering adding a second check. At that time, the DON addressed the concern regarding the missing label for the Cosopt eye drop for Unsampled Resident #354. The DON stated the med came from the hospital, and upon receiving a med from the hospital the facility's nurses were expected to ensure a label with the resident's name was on the bottle. The DON also stated that the bottle had a label when received from the hospital but was unsure when the label had fallen off or was ripped off. At that time, the DON addressed the concern regarding Resident 22's Vitamin D3 and stated that LPN #2 was nervous and admitted ly picked up the wrong dose for administration during the med pass observation. The DON stated the correct dose was available in the med cart. At that time the DON confirmed that both nurses did not follow the expectation or the policy for med pass administration. A review of the facility provided policy; Administering Med dated/revised in April 2019, under Policy Interpretation and Implementation, included the following: 4. Meds are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the med checks the label THREE (3) times to verify the right resident, right med, right dosage, right time and write method (route) of administration before giving the med. A review of the facility provided policy; Med Orders dated/revised in November 2014, under Recording Orders included: 1. Med Orders - When recording orders for meds specify the type, route, dosage, frequency, strength, and the reason for administration. A review of the facility policy provided; Accepting Delivery of Meds dated/revised in February 2021, under Policy heading included: 2. Any errors noted in receiving med shall be brought to the attention of the pharmacist and director of nursing services. The Policy and Interpretation and Implementation included: 2. Before signing to accept the delivery, the nurse must reconcile the med in the package with the delivery ticket or order receipt. A review of the facility policy provided; Labeling of Med Containers dated/revised in April 2019 reflected under Policy Statement, that all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. The Policy Interpretation and Implementation included the following: 3. Labels for individual resident meds include all necessary information such as: a) The resident's name. d) The name, strength, and quantity of the drug. f) The date that the medication was dispensed. NJAC 8:39-11.2 (b), 29.2 (d), 29.4(a)

Based on the interview and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation for six (6) of six (6) fall incidents of Resident #80 reviewed for fall investigations. This deficient practice was evidenced by the following: On 02/14/24 at 10:54 AM, the surveyor observed Resident #80, awake, and laying on a low bed with two floormats in use. On 02/15/24 at 8:18 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for the resident's fall investigations for the last six months. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #80 as follows: According to the admission Record (admission summary), Resident #80 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), encephalopathy (a broad term for any brain disease that alters brain function or structure), major depressive disorder, mood disorder due to known physiological condition, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance. The resident's comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 01/05/24 revealed in Section C Cognitive Status C1000 that the cognitive skills for daily decision-making showed that the resident's cognition was severely impaired. A review of the provided last six months' incidents and accidents (Risk Management) reports by the LNHA showed the following: 1. 8/20/23 Fall=Licensed Practical Nurse #1 (LPN#1), the person preparing the report was notified by the housekeeping staff that the resident was laying on the floor. The resident was not able to describe the incident. The fall incident had no injury and there was no witness found. There were no statements from other staff and the facility did not identify the name of the housekeeping staff. 2. 10/18/23 Fall=LPN#2, the person preparing the report documented that the resident was found laying on the resident's bedroom floor, no injury was noted, and no witness was found. The resident was not able to describe the incident. There were no statements from other staff for the unwitnessed fall. 3. 10/28/23 Fall=LPN#1, the person preparing the report was notified by the housekeeping staff that the resident was on the floor. The resident was not able to describe the incident. The fall incident had a minor injury (redness to left knee) and there was no witness found. There were no statements from other staff and the facility did not identify the name of the housekeeping staff. 4. 11/09/23 Fall=LPN#3, the person preparing the report was called into the resident's room by a staff member and noted resident was laying on the mattress on the right side of the bed. The resident was not able to describe the incident. The fall incident had no injury and there was no witness found. There were no statements from other staff and the facility did not identify the name of the staff member. 5. 12/18/23 at 4:00 PM Fall=LPN#1, the person preparing the report was alerted by staff that the resident was laying on the floor mat on the left side of the bed. The resident was not able to describe the incident. The fall incident had no injury and there was no witness found. There were no statements from other staff and the facility did not identify the name of the staff who alerted LPN#1. 6. 12/18/23 at 8:30 PM Fall=LPN#4, the person preparing the report walked by the resident's room and observed resident was laying on the floor mat on the left side of the bed. The resident was not able to describe the incident. The fall incident had no injury and there was no witness found. There were no statements from other staff for an unwitnessed incident. Further review of the facility's provided investigations of Resident #80 did not include statements from staff for all six unwitnessed fall incidents. A review of the Progress Notes (PN) revealed that there was no documentation of the housekeeping staff's name from the 8/20/23 and 10/28/23 fall incidents. The 11/09/23 and 12/18/23 at 4:03 PM PN did not identify the names of staff who reported the fall incidents to LPN#1 (12/18/23 at 3:555 PM fall incident and LPN#3 (11/09/23 fall incident). In addition, there was no documentation that the other staff provided statements for the six fall incidents that were unwitnessed. On 02/15/24 at 10:00 AM, the surveyor asked the Director of Nursing (DON) for complete investigations, specifically statements from staff, and she stated that she would get back to the surveyor. On 02/15/24 at 12:47 PM, the surveyors met with LPN#1 for an interview regarding the resident's fall incidents. LPN#1 informed the surveyors that he used to be the 3rd floor Unit Manager (UM) and currently working as a 3-11 shift staff nurse. He stated that he works 7-3 shifts at times. He further stated that the facility's fall investigation process is that a nurse, assess the resident, prepare the incident report, and notify the family and physician of the incident. He also included that the IDCP (interdisciplinary team) meets afterward to discuss the fall incident and put interventions into place to prevent further falls, that eventually documented in the resident's care plan. On that same date and time, LPN#1 was able to remember the 10/28/23 fall incident when the housekeeping staff informed him that the resident was on the floor. LPN#1 was unable to remember the name of the housekeeping staff. He stated that statements from the staff including the housekeeping staff should had been gathered but LPN#1 was unable to remember if that happened. He acknowledged that as part of the facility's practice if the incident was unwitnessed and the resident was unable to describe the incident, staff statements must be provided. He confirmed that Resident #80 was cognitively impaired. On 02/15/24 at 01:02 PM, the surveyor asked again the DON in the presence of LPN#1, LNHA, and Chief Nursing Officer (CNO) about the statements from the resident's investigations. The facility management stated that they will get back to the surveyor about the statements. On 02/15/24 at 01:16 PM, the DON stated that there were no statements for all the unwitnessed fall investigations of Resident #80. The DON informed the surveyor that the concern about missing statements from residents' investigations was identified as a concern back in November 2023 and was placed into QAPI (quality assurance and performance improvement) in the November 2023 meeting. The surveyor then asked, if the problem was identified back in November 2023, why statements were not obtained up to this time to complete the investigations, why the problem persists in the 12/18/23 fall incidents (at 3:55 PM and 8:00 PM), and the DON did not respond. Furthermore, the DON acknowledged that for all unwitnessed incidents and residents unable to describe what had happened, staff statements should be gathered to consider the investigation as complete as per facility practice. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns and findings. A review of the provided facility's Accidents and Incidents-Investigating and Reporting Policy with a revised date of July 2017 that was provided by the LNHA included that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on facility premises shall be investigated and reported to the Administrator. Policy interpretation and implementation included on the Report of Incident/Accident form the name(s) of witnesses and their accounts of the accident or incident, any corrective action taken, follow-up information, and other pertinent data as necessary or required. Incident/accident reports will be reviewed by the Safety Committee for trends related to accidents or safety hazards in the facility and to analyze any individual resident vulnerabilities. On 02/26/24 at 12:04 PM, the survey team met with the LNHA and DON. The LNHA and the DON confirmed that there was no additional information and that there were no statements from staff for all unwitnessed fall investigations. NJAC 8:39-27.1(a)(b)

Based on observation, interview, and record review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness as evidenced by the following: On 02/14/24 at 9:55, in the presence of the Food Service Manager (FSM) the surveyor observed the following: 1. In the freezer, the surveyor observed a pack of opened manufactured Cheese Omelet a bag of crunchy fish fillets, and a bag of tot potatoes. All were unlabeled and not dated with expiration or open dates. The FSM manager was unable to say when the package was received, opened, or the expiration date. 2. The Manual counter attached can opener and holder and blade unit was unclean with wipeable by the FSM with sticky brown substance and crumbs. The FSM acknowledged that it needed to be cleaned. On 02/15/24 at 11:34 AM, the surveyor interviewed the FSM. who stated, Having a dirty can opener can cause cross contamination of products being opened and can attract unwanted pests. It is cleaned daily but needs to be scrubbed prior to putting in the dishwasher. He further stated, Food labeling is essential for movement of product and knowledge for the whole staff on when things will expire. It also prevents food born illnesses from expired or freezer burned food. At 02/23/23 at 10:23 AM, the surveyor discussed the kitchen concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). A review of the facility's Cooks Job Description, Duties, and Responsibilities that was provided by the FSM included: #3 All food is correctly labeled and dated. A review of the facility's Food Receiving and Storage Policy dated 2001 and revised 10/2017 that was provided by the FSM included: Foods shall be received and stored in a manner that complies with safe food handling practices, #1) Food Services or other staff, will maintain clean food storage areas at all times, and #8) All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by date). On 02/26/23 at 12:33 PM, the survey team met for an Exit conference with LNHA and the DON, and there were no additional information provided by the facility management. NJAC 8:39-17.2(g)

REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices for performing hand hygiene to decrease the possibility of spreading infection. This deficient practice was observed during dining observation with four (4) of four (4) facility staff in one (1) of three (3) dining areas, in accordance with the facility's practice, policies, and Centers for Disease Control and Prevention (CDC) guidelines for infection control. This deficient practice was evidenced by the following: According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on January 30, 2020, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. On 02/21/24 at 8:07 AM, the surveyor observed the 1st-floor dining area with 25 residents seated for breakfast being served with steam table food assisted by multiple staff wearing gloves while serving food. The Licensed Nursing Home Administrator (LNHA) informed the surveyor that once a month residents were being served with steam table food for breakfast and today was that day. There were no hand wipes, handwashing stations, or alcohol-based hand rub (ABHR) inside the dining area. Inside the dining area, the surveyor observed the Infection Preventionist Nurse (IPN) with one glove in use while providing coffee to residents and providing sugar. The surveyor asked the Director of Nursing (DON) if it was appropriate for all staff in the dining area to wear gloves while serving food to the residents, the DON stated that she thought it was ok but she would ask the IPN anyway. The surveyor observed the DON asked the IPN about the gloves and the IPN went to the surveyor. At that time, the surveyor asked the IPN if it was appropriate for all staff in the dining area to serve food with the use of gloves and the IPN stated yes. The surveyor and the IPN observed that Activity Staff #1 (AS#1) was wearing gloves while serving food, removed gloves, and threw the used gloves into the covered garbage receptacle near the breakfast tray area where the steam table was located. Afterward, AS#1 went to the table with the box of gloves and took a pair of new gloves about to wear when the surveyor asked the IPN if that was appropriate for AS#1 to wear a new pair of gloves without performing hand hygiene. The IPN instructed AS#1 to wash hands after the surveyor's inquiry. Then, the surveyor observed AS#2, Social Service (SS), and External Marketing Director (EMD) inside the 1st-floor dining area serving plated breakfast, coffee, and other drinks to different residents from one table to another wearing same gloves without performing hand hygiene. Later on, the EMD removed the gloves, threw the used gloves in a garbage receptacle without performing hand hygiene, and got out of the dining area. Upon exiting the dining area, the IPN instructed the EMD to wash hands. The EMD did not perform hand hygiene, went to another room across the dining area where the copying machine was located, the EMD took a piece of cardboard broke it into two pieces folded it, went back to the dining area, and placed the 1st piece of cardboard to the foot part of one table with residents and placed the other one of cardboard paper to another table, she went outside the dining room and went across the room to wash her hands for 14 seconds then she went back to get soap and wash again hands for 11 seconds took a paper to dry hands. Afterward, the surveyor interviewed the EMD. The EMD stated that it was okay to wear gloves when serving plated food, coffee, and other breakfast food. The surveyor then asked the EMD if wearing the same gloves to multiple residents and directly touching the resident with the same gloves was appropriate without performing hand hygiene, and the EMD did not respond. The EMD had no answer when asked if the residents in the 1st-floor dining area were on isolation or infection control precautions that she had to wear gloves while serving food. On 02/21/24 at 8:25 AM, the surveyor interviewed Resident #88 seated at a table of other two residents in the 1st-floor dining area while having breakfast. The resident was happy with the breakfast meal and was not bothered that the staff were serving food with gloves in use. The resident acknowledged that four staff (SS, AS#1 and #2, and EMD) who were serving breakfast were with gloves. On 02/21/24 at 9:17 AM, the surveyor in the presence of another surveyor interviewed the IPN. The IPN informed the surveyors that it was a mistake that we were wearing gloves in the dining area. The IPN further stated that when the surveyor notified the IPN of the concern about wearing gloves in the dining area the IPN stated that she looked around and realized that everyone in the dining area serving breakfast had gloves on and it should not be. She further acknowledged that at the time the surveyor was watching the breakfast, there were no hand wipes at that time because they used it before breakfast. The IPN also stated that there were no hand hygiene sanitation areas inside the dining area and had to go to the back to wash their hands. This time the surveyor notified the IPN of the above findings and concerns. On 02/23/24 at 10:42 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns and findings. A review of the facility's Handwashing/Hand Hygiene policy with a revised date of October 2023 that was provided by the LNHA included that single-use disposable gloves should be used: when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. The use of gloves does not replace hand washing/hand hygiene. The indications for hand hygiene is indicated immediately after touching a resident, after touching a resident, and immediately after glove removal. Washing hands includes rubbing hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. On 02/26/24 at 12:04 PM, the survey team met with the LNHA and DON. There was no additional information provided by the facility management. NJAC 8:39-19.4(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ152823 Based on observation, interviews, record review, and facility policy review, the facility failed to provide patient care in a manner that prevented cross-contamination for one (Resident (R)11) of 26 sampled residents. Findings include: Review of the Face Sheet (facility provided) revealed R11 was admitted to the facility on [DATE] with diagnosis that included dementia, left sided weakness, and overactive bladder. Review of R11's electronic medical record (EMR) revealed no evidence of a urinary tract infection (UTI). Observation during incontinent care for R11 on 08/07/23 at 9:41 AM with Certified Nursing Assistant (CNA)1 and Licensed Practical Nurse/Unit Manager (LPN/UM)1, who was assisting to hold and turn R11, entered the room, washed their hands, and donned gloves. CNA1 gathered all her supplies, including new incontinent brief, water and soap in a pink basin, towels, washcloths, and trash bags. CNA1 then adjusted R11's bed, removed R11's linen from over R11, and placed two trash bags at the bottom of the bed. CNA1 removed R11's incontinent brief, turned to the nightstand, and removed a washcloth from the basin. CNA1 then washed R11's genital area by separating the area and washing downwards, as she changed the direction of the washcloth. Then CNA1 with the same washcloth, washed each side of the genital area, and then washed the main area, with changing the direction of the washcloth. However, after finishing washing R11, CNA1 placed the used washcloth in one of the trash bags at the end of the bed. CNA1 did not change her gloves, nor did she wash her hands before picking up another washcloth to rinse R11. After rinsing R11, CNA1 then picked up a towel and pat dried R11's perineal area, all with the same gloves. CNA1 did not remove gloves nor wash her hands prior to assisting in rolling R11 over to R11's left side with the assistance of LPN/UM1. During this turning of R11, CNA1 was observed touching R11's legs and linen. R11 was observed to have had a small bowel movement (BM) when she was turned over. CNA1 obtained another washcloth out of the basin and washed R11's rectal area. However, after finishing, CNA1 did not change her gloves, nor did she wash her hands. CNA1 placed the used washcloth in the garbage bag at the foot of the bed. With the same gloves, CNA1 placed a new incontinent brief on R11. CNA1 then rolled R11 back over onto R11's back, adjusting R11's brief and linen, while LPN/UM1 went to get the medication nurse so that medication could be applied to R11. After applying R11's medication, CNA1 and LPN/UM1 moved R11 up in the bed. CNA1 was observed adjusting her linen, and legs, all with the same gloves. After adjusting R11 and R11's linen, CNA1 removed her gloves and went to the bathroom to wash her hands. Interview with on 08/07/23 at 10:00 AM with LPN/UM1, he confirmed that staff should have changed gloves often. Said that anytime you go from dirty area to clean area, gloves should be changed. During an interview on 08/07/23 at 10:30 AM, the Director of Nurses (DON) said she expected staff to change their gloves when going from dirty to clean, and after removing gloves, she expected that staff wash their hands prior to donning new gloves. Review of facility [name of facility] Attendance Record: Glove use policy and procedure (P&P), dated 03/29/22, revealed, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practices for preventing healthcare-associated infections; hand hygiene must be followed after glove removal each and every time; you cannot go from room to room with one pair of gloves; gloves must be removed after each resident encounter; you cannot stack gloves one on top of the other in lieu of handwashing; and if you encounter a situation where glove is required outside of a residents rooms, it must be followed with hand hygiene. During review of the in-service revealed that CNA1 attended this in-service. Review of facility [name of facility] Attendance Record: Handwashing-infection control, dated 08/03/22, revealed, that CNA1 attended this in-service. No evidence of an agenda. Review of facility policy titled Personal Protective Equipment (PPE)-Gloves, revised 07/09, revealed, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. The use of gloves will vary according to the procedures involved. The use of disposable gloves is indicated .when handling soiled linen or items that may be contaminated . wash your hands after removing gloves. NJAC: 8:39- 19.1 (a)

Based on observation, interview, and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) an assessment tool for 1 of 23 residents reviewed for MDS accuracy (Resident #28). This deficient practice was evidenced by the following: The surveyor observed Resident #28 in bed with eyes open on 11/10/21 at 11:15 AM. On 11/12/21 at 11:19 AM, the surveyor completed a review of the electronic medical record. The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, primary hypertension, osteoarthritis, and chronic kidney disease. The 9/5/2021 Annual MDS indicated that the resident had moderate cognitive impairment. According to the September 2021 Clinical Physician Orders, Resident #28 had physician orders to discontinue hospice service and treatment on 9/19/21. The surveyor reviewed the MDS assessments for Resident #28. There was no evidence that a SCSA was completed. A SCSA is required when a resident receiving hospice services discontinues those services. On 11/17/21 at 12:35 PM, the surveyor interviewed the MDS coordinator. The surveyor asked what type of assessment she would expect to see for a resident who was discharged from hospice. The MDS coordinator stated that she would expect to see a SCSA MDS. On 11/17/21 at 1:41 PM, the surveyor discussed the above findings with the Administrator and the Director of Nursing (DON). The DON stated that she would have expected that a SCSA MDS would be completed. A review of the facility's policy titled, Resident Assessments with a revision date of April 2021 indicated that a SCSA is required within 14 days when a resident discontinues hospice services. N.J.A.C 8:39-11.2(i)

Based on observation, interview, and record review it was determined that the facility failed to implement a comprehensive care plan for Resident #28, 1 of 23 residents reviewed. This deficient practice was evidenced by the following: On 11/10/21 at 11:15 AM, the surveyor observed Resident #28 in bed with eyes open. A nasal cannula was observed in the resident's nose. The oxygen concentrator was set to two liters of oxygen per minute. On 11/12/21 at 11:19 AM, the surveyor reviewed the medical record for Resident #28: The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to primary hypertension. The 9/5/2021Annual MDS indicated that the resident had moderate cognitive impairment and was currently using oxygen therapy. According to the November 2021 Clinical Physician Orders, Resident #28 had physician orders for two liters of oxygen via nasal cannula. On 11/12/2021 at 12:07 PM, the Director of Nursing (DON) provided the surveyor with Resident #28's care plan. A review of the care plan failed to reveal a comprehensive care plan for the resident's respiratory status. On 11/12/21 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that he would expect to see a respiratory care plan for a resident who is receiving oxygen therapy. On 11/12/21 at 12:27 PM, the surveyor interviewed the LPN Unit Manager (LPN/UM). The LPN/UM stated that I think you're right, I don't even see it regarding the respiratory care plan. The LPN/UM stated that Resident #28 should have a respiratory care plan. On 11/17/21 at 1:41 PM, the surveyor presented the above information to the Administrator and DON. The DON stated that she would expect to see a respiratory care plan for a resident receiving oxygen therapy. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered with a revision date of April 2021 indicated that the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. N.J.A.C. 8:39-11.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/10/21 at 11:19 AM, the surveyor observed Resident #61 in bed, unable to be interviewed, the resident was lying on a pressure relieving mattress, and bed noted to be in a low position. The surveyor reviewed the medical records for Resident #61 that revealed the following: According to the admission Record, Resident #61 was admitted to the facility with a fracture of the neck of the right femur and pressure ulcers. The November 2021 Clinical Physician Orders sheet revealed that Resident #61 had active physician orders to provide treatments to the right and left buttock, right and left heels, right and left malleolus, left foot bunion, and feet. The November 2021 ETAR indicated that the treatments to areas mentioned above were scheduled for the evening shift. In addition, the Quarterly Minimum Data Set an assessment tool dated 10/13/21, indicated that the resident had one stage three pressure ulcer. The most recent Weekly Wound assessment dated [DATE] indicated that the left medial bunion had reopened and a treatment for skin prep to the area and cover with a boarder foam was started. The care plans were reviewed and the care plan titled Actual skin impairment indicated that the right and left buttock wounds, left malleolus, left bunion were discontinued. However, there were no other actual skin impairments listed including the stage three pressure ulcer that was indicated on the 10/13/21 Quarterly MDS. ulcer The last update on the care plan was dated 7/16/21. 3. On 11/10/21 at 11:27 AM, the surveyor observed Resident #96 in bed, with eyes closed. The resident was lying on a pressure relieving mattress. The surveyor reviewed the medical records for Resident #96 that revealed the following: According to the admission Record, Resident #96 was readmitted to the facility with the diagnosis of fracture of the superior rim of the right pubis (pelvis fracture). The Fall Incident Description dated 10/9/21 revealed the resident was found on the floor in the resident's room next to the resident's bed. The resident was crying and stated I was trying to walk to the bathroom. The resident stated that he/she hit his/her head and complained of pain in the right hip. The resident was sent to the emergency room for evaluation. The resident was admitted to the hospital with a pelvic fracture. The November 2021 Electronic Medication Administration Record showed the resident had requested pain medication nine times from November 2nd through November 15th. The resident had a care plan related to fall risks secondary to decreased muscle coordination, taking antihypertensive medication, taking diuretic medication and having impaired vision. However, it was observed that the care plan had not been reviewed and updated to include the resident fell on [DATE]. On 11/17/21 at 12:40 PM, the surveyor interviewed MDS Coordinator who stated that the care plans are reviewed and revised at care plan meetings. She stated the Unit Managers are on top of it. At 12:59 PM, the surveyor interviewed the LPN/UM who stated that the residents care plans are updated by the UM or if she is not in the facility the supervisor would do it. The LPN/UM was not aware that the care plans that were not updated. On 11/17/21 at 1:41 PM, the surveyors discussed the above care plan concerns with the Administrator and DON. They both agreed that the care plans should have been updated. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised in April 2021 revealed the following under Policy Interpretation and Implementation #13, #14-(a,b,c,d); #13 Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. #14(a,b,c,d) The interdisciplinary team must review the care plan: a. when there has been a significant change in condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. NJAC 8:39-11.2 ,2, (i) Based on observation, interview, and record review, it was determined that the facility failed to update and/or revise care plans for 3 of 23 residents reviewed, Resident # 9, Resident # 61, and Resident # 96. The deficient practice was evidenced by the following: 1. The surveyor reviewed an investigation for a fall Resident #9 had. The fall was on 2/10/21. The resident did not sustain any injuries. The investigation determined that the resident fell out of bed while reaching for their cell phone that had fallen on the floor. The investigation of the fall indicated that the Interdisciplinary Team agreed to add the following interventions to the care plan to prevent future falls; a longer phone charger cord and a side rail pouch for the resident to keep their cell phone. The surveyor asked the Director of Nursing (DON) for all of the active care plans for the resident. The DON confirmed that all of the care plans she provided were all of the resident's active care plans. There was no information, update, or revision related to the 2/10/21 fall on the care plan with the focus I have had an actual fall with no injury r/t poor balance and hemiplegia. There was a secondary care plan to address falls. There was no information, update, or revision related to the fall on that secondary care plan with the focus I am at risk for falls secondary to impaired mobility, S/P CVA, left sided weakness, diagnosis of Diabetes Mellitus, amputated toes, impaired vision. On 11/17/21 at 12:59 PM, the surveyor spoke to the Licensed Practical Nurse/ Unit Manager (LPN/UM) and asked about the care plan for falls not being updated after the 2/10/21 fall the resident had. The LPN/UM said the care plan should have been updated after that fall and she didn't know why it had not been updated/revised after the 2/10/21 fall. The LPN/UM confirmed that she would have been responsible for updating the care plan.

Based on observation, interview and record review it was determined the facility failed to ensure a resident received the necessary supervision for smoking and storage of smoking materials. The deficient practice was identified for 1 resident (Resident #42) of 2 reviewed for smoking and is evidenced by the following: The surveyor interviewed Resident #42 on 11/10/21 at 10:27 AM. The resident stated they independently smoked and held their own cigarettes and lighter. The resident further stated they were able to go outside at any time unsupervised to smoke. The resident stated their smoking materials were kept in their pocket when not in use. The surveyor observed the resident smoking unsupervised on 11/10/21 at 11:04 AM and on 11/15/21 at 11:07 AM. A review of the medical record revealed the following information: The 9/25/21 quarterly Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits as evidenced by a Brief Interview for Mental Status score of 15 of a possible 15. The resident's needs with Activities of Daily Living (ADLs) varied from supervision to limited assistance of one caregiver. The resident had no functional limitation in range of motion of the upper or lower extremities. The Registered Nurse Unit Manager (RNUM) provided the surveyor with the two most recent quarterly Smoking Assessments completed on 6/22/21 and 9/25/21. The assessments indicated the resident required supervision when smoking and required the facility to store the cigarettes and lighter. The resident's care plan addressing smoking, initiated 6/25/21, indicated the resident was an independent smoker and smoking materials were to be kept in the medication cart. The facility's Resident Smoking Policy, revised 2018, indicated an independent smoker may smoke safely without supervision, however, lighting equipment such as safety lighters and matches must be kept at the front desk of the facility. The surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #42 on 11/15/21 at 9:48 AM. He stated Resident #42 was assessed to be independent with smoking and was able to hold cigarettes and lighters or matches in their room. The surveyor interviewed the RNUM on 11/15/21 at 9:59 AM. She stated presently all smokers on the unit were independent and holding their own smoking materials. The surveyor interviewed the Receptionist on 11/15/21 at 12:04 PM. The Receptionist stated she gives smokers a walkie talkie and a lighter before they leave through the front entrance. She signs them out in a book kept behind the desk. The surveyor discussed the concerns regarding storage of cigarettes and lighting supplies with the Administrator, Director of Nursing, and the Infection Preventionist on 11/16/21 at 1:15 PM. The surveyor discussed the concerns regarding storage of cigarettes and lighting supplies with the Administrator, Director of Nursing, and the Infection Preventionist on 11/16/21 at 1:15 PM. The Administrator provided the surveyor with further information on 11/17/21 at 9:03 AM as follows: A revised Resident Smoking Policy dated 11/16/21 requiring independent smokers to keep all smoking materials in a locked drawer in the residents room. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to restrain employee hair in the kitchen. This deficient practice was evidenced by the following: On 11/10/21 at 9:37 AM, in the presence of the Director of Nutritional Services (DNS), the surveyor observed the following: In the food preparation area, the surveyor observed the DNS without a hair net over his hair. The surveyor also observed a Food Service Worker in the food preparation area with a hair net on her head yet, her bangs were not fully restrained inside the hair net. The DNS agreed that the hair nets should have been worn appropriately according to facility's policy. The surveyor reviewed the facility's policy titled, Food Preparation and Service dated April 2021. The policy indicated that food and nutrition services staff wear hair restraints so that hair does not contact the food. On 11/10/21 at 12:48 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for: a.) hand hygiene during food and dish handling and b.) failure to properly don (put on) surgical and respirator masks. The deficient practices were evidenced by the following: 1. On 11/10/21 at 9:37 AM, the surveyor observed the Director of Nutritional Services (DNS) in the food preparation area of the kitchen with his respirator mask covering his mouth and not covering his nose. The DNS stated that he had just arrived for work and should have worn his mask appropriately. 2. In the food preparation area, the surveyor observed Food Service Worker (FSW) #1 with gloved hands adjust her hair net on her head, remove her gloves and immediately don a new pair of gloves with no hand hygiene performed. 3. At 9:47 AM, in the dish washing area of the kitchen, the surveyor observed FSW # 2 on the clean side of the dish machine with a surgical mask covering his mouth and not covering his nose. The DNS instructed the FSW #2 to fix his mask. The surveyor observed the FSW #2, with gloved hands, adjust his mask and without any glove changing or hand hygiene, the FSW #2 proceeded to handle the clean dishes. The DNS instructed the FSW #2 to remove his gloves and to perform hand hygiene prior to donning a new pair of gloves. 4. In the dish washing area of the kitchen, the surveyor observed a FSW # handling soiled dishware with gloved hands. With his soiled gloved hands, the FSW # 3 touched the dish machine power switch to turn it off. The surveyor observed the FSW # 2, who was on the clean side of the dish machine with gloved hands, touch the same power switch to turn it back on and then the FSW # 2 proceeded to handle clean dishes. 5. At 11:00 AM, on the third floor in the dayroom, the surveyor observed an Activities Aid (AA) # 1 and an AA #2 both wearing respirator masks. The surveyor observed that both of the AA #1 and AA #2 respirator masks' elastic bands were cut and tied in knots, with the elastic bands secured behind the ears of AA #1 and AA #2. 6. The surveyor also observed an AA #3 wearing a surgical mask which was covering a respirator mask. The surveyor observed the respirator masks' elastic bands were tucked under the surgical mask and not secured on the AA #3's head and neck. At 11:17 AM, the surveyor interviewed the Licensed Practical Nurse, Unit Manager (LPN, UM) who stated that the masks should be worn correctly as instructed during fit testing. The LPN, UM stated that she is responsible for surveillance of proper donning and doffing of personal protective equipment that is used by the staff on her floor. At 11:30 AM the surveyor interviewed the Activities Director (AD) who stated that the masks should be worn properly as instructed during fit testing. The AD stated that elastic band straps of the respirator should be worn on the crown of the head and the neck. The surveyor reviewed the facility's policy titled, Handwashing/Hand Hygiene dated 3/31/21. The policy indicated that hand hygiene is to be performed before applying new gloves and hand hygiene is to be performed after removing gloves. The surveyor reviewed the facility's policy titled, Personal Protective Equipment-Using Face Masks dated 10/31/21. The policy indicated that face masks are to be placed over the nose and mouth and depending on the mask, secure elastic bands at middle of the head and neck. The surveyor reviewed the facility's policy titled, Outbreak Plan dated 10/11/21. The policy indicated that the outbreak recommendations are to implement universal transmission-based precautions and wear recommended personal protective equipment including NIOSH approved N95 or higher level respirator masks for the care of all residents. At 11/10/21, the surveyor discussed the above concerns with the Administrator and Director of Nursing. No additional information was provided On 11/16/21 at 12:38 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that all the facility staff are fit tested for respirator use and since the facility is in outbreak mode, the respirators should be worn properly in the resident areas. The IP also stated that the kitchen staff are allowed to wear surgical masks and that the surgical masks should also be worn properly covering the nose and mouth. The IP also stated that the kitchen staff hands should be washed properly between doffing and donning a new pair of gloves. N.J.A.C. 8:39-19.4(a)

Based on interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for 1 of 23 residents (Resident #70) which occurred over a three month period and failed to document in the Electronic Treatment Administration Record (ETAR) for 2 of 23 residents (Resident #88 and #61) reviewed. 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 casefinding, 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 casefinding; 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. The surveyor reviewed the medical records for Resident #70 that revealed the following: According to the November 2021 Clinical Physicians Order sheet Resident #70 had an order dated 2/25/2020 for Midodrine HCl 10 mg two times daily with parameters to hold the medication when the systolic blood pressure (SBP) is above 120. The August 2021, September 2021, and October 2021 ETAR revealed there were several dates that the nurse gave the Midodrine HCl 10 MG medication when the resident's SBP was above 120. Midodrine HCl 10 MG was given when the SBP was above 120 by the 11-7 nurse on 8/7/21, 8/28/21, 9/4/21, 9/12/21, 9/21/21, 10/9/21, 10/24/21, 10/26/21, 10/27/21, and 10/28/21 and was given when the SBP was above 120 by the 3-11 nurse on 8/6/21, 8/7/21, 8/11/21, 8/22/21, 9/9/21, 9/10/21, 9/20/21, 9/25/21, 10/4/21, 10/21/21, 10/28/21. The surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on 11/17/21 at 1:25 PM. The LPN/UM stated that it is a medication error to give medications outside of ordered parameters. A review of the facility's policy Administering Medication with a revision date of April 2021 indicated under Policy Interpretation and Implementation #3, Medications must be administered in accordance with the orders. 2. The surveyor reviewed the medical records for Resident #88 that revealed the following: According to the Clinical Physician Orders sheet, Resident #88 had physician orders for the application of multipodus boots (a medical brace that addresses foot and ankle alignment and keeps pressure off the heels), and treatments to both feet and coccyx areas, and respiratory monitoring every shift. The November 2021 Electronic Treatment Administration Record (ETAR) revealed the nurse did not document that the treatment was done, that multi podus boots were applied and did not document respiratory assessment on the following dates: 1. DermaFungal ointment 2% to be applied to both feet twice a day was not signed by the 3-11 nurse on 11/5/21, 11/13/21, and 11/15/21. 2. Zinc Oxide ointment 20% to be applied to the coccyx area twice a day was not signed by the 3-11 nurse on 11/5/21 and 11/15/21. 3. Multipodus boots to be applied to both feet when in bed every shift was not signed by the 3-11 nurse on 11/5/21, and not signed for by the 11-7 nurse on 11/4/21-11/6/21, and not signed for by the 7-3 nurse on 11/15/21. 4. Respiratory Monitoring every shift was not signed for by the 3-11 nurse on 11/4/21-11/6/21 and 11/15/21, and not signed for by the 11-7 nurse on 11/4/21-11/6/21 and on 11/15/21. 3. The surveyor reviewed the medical records for Resident #61 that revealed the following: According to the Clinical Physician Orders sheet, Resident #61 had physician orders for biweekly showers, skin prep to be applied to the left and right malleolus (the bony protuberance on either side of the ankle), left bunion area, right and left heel every evening, weekly skin assessments on 3-11, Zinc Oxide ointment 20% to be applied to the left and right buttock area twice a day, Ammonium Lactate cream 12% to be applied to feet every shift, heel pads while in bed every shift, and respiratory monitoring. According to the November 2021 ETAR there were dates that the nurse did not document that the treatment orders were done and listed as follows: 1. Biweekly shower schedule every Wednesday and Saturday on the evening shift not signed for by the 3-11 nurse on 11/3/21 and 11/6/21. 2. Skin prep to the left malleolus, left Bunion, right heel and right malleolus not signed for by the 3-11 nurse on 11/3/21 and 11/10/21. 3. Skin prep to the left heel every evening shift not signed for by the 3-11 nurse on 11/3/21, 11/4/21, 11/6/21 and 11/10/21. 4. Weekly skin assessment every Wednesday on 3-11 shift not signed for by the nurse on 11/3/21 and 11/10/21. 5. Zinc Oxide ointment 20% to the left and right buttock areas not signed for by the 3-11 nurse on 11/3/21, 11/4/21, 11/6/21. 6. Ammonium Lactate cream 12% to be applied to the feet and inbetween the toes every shift not signed for by the 3-11 nurse on 11/3/21, 11/4/21, 11/6/21, and 11/10/21. 7. Heel pads when in bed every shift not signed for by the 3-11 nurse on 11/3/21, 11/4/21, 11/6/21, and 11/14/21. 8. Knee brace to the right leg when out of bed and off when in bed every shift not signed for by the 3-11 nurse on 11/3/21, 11/4/21, 11/6/21, and 11/14/21. 9. Respiratory monitoring not signed for by the 3-11 nurse on 11/1/21, 11/3/21, 11/4/21, 11/6/21, and 11/14/21. On 11/16/21 at 1:12 PM, the surveyors discussed the above concerns with the Administrator and DON. A review of the facility's policy Administering Medication with a revision date of April 2021 indicated under Policy Interpretation and Implementation #12, Topical medications used in treatments must be recorded on the resident's treatment record (TAR). NJAC 8:39-27.1(a)

Based on interview, and record review, it was determined that the facility failed to respond to the consultant pharmacist recommendations for 1 of 21 residents (Resident #70) reviewed. This deficient practice continued over four months and was evidenced by the following: According to the November 2021 Clinical Physicians Order sheet Resident #70 had an order dated 2/25/2020 for Midodrine HCl 10 mg two times daily with parameters to hold the medication when the systolic blood pressure (SBP) is above 120. The surveyor reviewed the August 2021, September 2021, and October 2021 Electronic Medication Administration Record that revealed the nurses administered the Midodrine HCl 10 mg to Resident #70 when the SBP was above 120 on 21 occasions. The surveyor reviewed the Consultant Pharmacist Medication Regimen Review report for June 2021, July 2021, August 2021, and September 2021. The Consultant Pharmacist had submitted to the facility the report that identified for Resident #70 the medication Midodrine had not been held as per hold parameters in June, July, August, and September. On 11/17/21 at 1:25 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that she did not see the Consultant Pharmacist recommendations but that it is her and administration's responsibility to review them. On 11/17/21 at 1:41 PM, the surveyor discussed the above information with the Administrator and Director of Nursing. On 11/18/21 at 10:56 AM, the surveyor interviewed the Consultant Pharmacist. The Consultant Pharmacist stated that he believes that there is an issue with education for the nurses on the floor. On 11/18/21 at 11:03 AM, the surveyor discussed the above information with the Administrator and Director of Nursing (DON). N.J.A.C. 8:39-29.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 5 medication carts and 1 of 2 emergency boxes that were inspected. The expired medication in the emergency boxes continued for four months and was evidenced by the following: On [DATE] at 11:11 AM, the surveyor inspected the 2nd floor South-side medication cart in the presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an opened bottle of Blood Glucose control solution with an opened date of [DATE] that was expired (90-day expiration date). The surveyor interviewed LPN #1 who stated that the opened bottle of Blood Glucose control solution was expired and should have been removed from the medication cart. On [DATE] at 11:30 AM, the surveyor inspected the 3rd floor emergency box in the presence of the Unit Manager (UM). The surveyor observed on the emergency kit contents page had an expiration date of [DATE]. A review of the contents inside the emergency kit revealed the following: 1. Two (2) vials of Atropine 0.4mg/ml injection had an expiration date of [DATE] 2. One (1) vial of Dexamethasone 10mg/ml injection had an expiration date of [DATE] 3. Two (2) vials of Epinephrine 1:1000 injection had an expiration date of [DATE] 4. Two (2) pens of EpiPen 0.3mg injection had an expiration date of [DATE] 5. Two (2) vials of Heparin 5000 units/ml injection had an expiration date of [DATE] 6. One (1) vial of Phenytoin 100mg/2ml injection have an expiration date of [DATE] At that time, the surveyor interviewed the UM who stated that the Emergency Kit was expired and should have been returned to the pharmacy. On [DATE] at 1:00 PM, the surveyor met with the Administrator and the Director of Nursing (DON) and no further information was provided by the facility. A review of the facility's policy for Storage of Medication which was undated and was provided by the DON indicated the following: Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. NJAC: 8:39-29.4 (a) (h) (d)