**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 develop and implement a comprehensive person-centered care plan (CP) for one (1) of 18 residents (Resident #75) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 09/25/24, at 10:20 AM, the surveyor observed Resident #75 in their room seated in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at three (3) lpm which reflected on the O2 regulator. On 09/26/24 at 10:19 AM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: The resident's admission Record (an admission summary) revealed that Resident #75 was admitted with diagnoses that included but were not limited to Respiratory failure unspecified by Hypoxia (lack of oxygen). The Quarterly Minimum Data Set (Q/MDS), dated [DATE], indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status score of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the Q/MDS under Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 05/15/24 for O2 at 2 lpm continuously via NC to maintain O2 saturation above 92% every shift. Further review of the September 2024 OSR revealed a PO for Restorative Nursing Program (RNP) dated 07/04/24 to perform passive range of motion (PROM) exercise to both lower extremities (BLE) as tolerated. The above PO for O2 administration was transcribed to the September 2024 electronic Medication Administration Record and was signed by the nurses which indicated that the O2 was administered to the resident every shift. A review of Resident #75's comprehensive person-centered CP did not reflect the resident's use of continuous O2 and for the RNP exercises. On 10/01/24 at 09:40 AM, the surveyor interviewed the Director of Rehabilitation/Occupational Therapy (DOR/OT), who confirmed that the resident had a PO for PROM exercise to BLE. On 10/01/24 at 09:57 AM, the surveyor team met with the Licensed Nursing Home Administrator and the Director of Nursing to discuss the above concern. There was no further information provided. A review of the facility policy titled Care Plans, Comprehensive, Person-Centered with a revision date of 1/2024 reflected under: Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation, k. Reflect treatment goals, timetables, and objectives in measurable outcomes; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. NJAC 8:39-11.2(e) thru (i); 27.1(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 administer oxygen therapy according to the physician's order for 2 of 2 residents (Resident #30 and #75) reviewed for Oxygen use. This deficient practice was evidenced by the following: 1. On 09/25/24 at 11:35 AM and on 09/26/24 at 11:30 AM, the surveyor observed on both days that Resident #30 was lying in bed, wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at two (2) liters per minute (lpm) on the regulator. On 09/25/24 at 12:01 PM, the surveyor reviewed Resident #30's electronic medical record, which revealed the following information: The resident's admission Record (an admission summary) (AR) documented that Resident #30 was admitted with diagnoses that included but were not limited to unspecified Dementia (impairment of memory). The Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care dated 06/25/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15, which indicated that the resident had severely impaired cognition. Further review of the A/MDS Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 Order Summary Report (OSR) revealed an active Physician Order (PO) with an order date of 09/03/24 for oxygen at three (3) lpm continuously via NC to maintain O2 saturation above 92% every shift. The above PO for O2 was transcribed to the September 2024 electronic Treatment Administration Record (eTAR) and was signed by nurses indicating O2 was administered to Resident #30 every shift. On 09/26/24 at 12:17 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) checked and confirmed that the O2 was set at 2 lpm from the concentrator regulator. The LPN checked the eTAR and confirmed to the surveyor that the oxygen PO was at 3 lpm via NC. 2. On 09/25/24, at 10:20 AM, the surveyor observed Resident #75 inside their room seated in bed wearing an NC connected to an O2 concentrator at three (3) lpm set on the regulator. On 09/26/24 at 12:25 PM, the surveyor observed Resident #75 seated in a wheelchair inside the dining room having their lunch. The surveyor observed Resident #75 receiving O2 via NC at one (1) lpm connected to a portable O2 tank. The LPN confirmed to the surveyor that the resident was receiving 1 lpm of oxygen via NC. On 09/26/24 at 10:19 AM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: The resident's AR documented that Resident #75 was admitted with diagnoses that included but were not limited to respiratory failure unspecified by hypoxia (lack of oxygen). The Quarterly Minimum Data Set (Q/MDS), dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which reflected that the resident was cognitively intact. Further review of the Q/MDS Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 OSR revealed an active PO with an order date of 05/15/24 for oxygen at 2 lpm continuously via NC to maintain O2 saturation above 92% every shift. The above PO for O2 was transcribed to the September 2024 electronic Medication Administration Record (eMAR) and was signed by nurses as administered every shift. On 10/01/24 at 09:57 AM, the survey team met with the Licensed Nursing Home Administrator, and Director of Nursing. There were no further information provided. The facility policy titled Oxygen Administration with a revision date of 1/2024 under Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. NJAC 8:39-25.2(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 4 (four) residents (Resident #61) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 09/30/24 at 8:45 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN#1) in the room of Resident #61. The surveyor observed LPN #1 checking the resident's identification bracelet and informed Resident #61 that she would be administering the resident's medications. On 09/30/24 at 8:50 AM, the surveyor observed LPN #1 preparing to administer six (6) medications to Resident #61 which included the following, Norvasc 2.5 mg tablet (medication for lowering blood pressure), Baclofen 10 mg tablet (medication for muscle spasms),Buspar 5 mg (medication for anxiety), Cranberry 450 mg (medication to prevent UTI), Eliquis 5 mg (medication for thinning blood and Flomax 0.4 mg capsule (medication for enlarged prostate). The surveyor observed LPN #1 crushed the Norvasc, Baclofen, Buspar, Cranberry and Eliquis and then adding the crush contents into a medication cup and mixed the contents with apple sauce. The surveyor further observed LPN #1 who opened the Flomax capsule and emptying the contents of the capsule into the apple sauce that contained all the other crushed medications. The surveyor observed LPN#1 administered the medications to Resident #61. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to Hypertension (elevated blood pressure), Benign Prostatic Hyperplasia (Prostate enlargement), and Anxiety Disorder (a mental health disorder characterized by feeling worried, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 7/23/24, reflected that the resident's cognitive skills for daily decision-making score was 13 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the September 2024 Order Summary Report (OSR) revealed a PO dated 10/18/23, for Flomax Capsule 0.4 mg (Tamsulosin HCL) give 1 capsule by mouth two times a day for benign prostatic hyperplasia. Administer 30 minutes after meal. Do Not Crush, open or chew. Swallow capsules whole with water. A review of the September 2024 electronic Medication Administration Record (eMAR) revealed an order dated 10/18/23, for Flomax Capsule 0.4 mg (Tamsulosin HCL) give 1 capsule by mouth two times a day for benign prostatic hyperplasia. Administer 3 minutes after meal. Do Not Crush, open or chew. Swallow capsule whole with water. On 9/30/24 at 11:45 AM, the surveyor in the presence of LPN #1 reviewed Resident #61's physician's orders. After reviewing the resident's PO for Flomax, the surveyor interviewed LPN #1, who acknowledged that the resident's Flomax should have not been opened and that she should have administered the medication whole with water. On 9/30/24 at 1:30 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Administering Medication dated 6/19/23, which was provided by the DON included the following: Medications must be administered in accordance with the orders, including the required time frames. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: On 10/1/24 at 10:15 AM, the surveyor inspected the first-floor medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened vial of Lantus insulin with an opened date of 8/24/24 and was expired. At that time, the surveyor interviewed LPN#1 who acknowledged that Lantus Insulin vial which was opened on 8/24/24 and was expired. She stated to the surveyor that Lantus insulin once opened had a 28-day expiration date. On 10/1/24 at 10:25 AM, the surveyor inspected the 1st floor medication cart #1 in the presence of LPN#2. The surveyor observed an unopened bottle of Xalatan eye drops (medication for pressure in the eye) that was not dated and was stored in the medication cart and an opened vial of Lantus insulin that contained no opened date. At that time, the surveyor interviewed LPN#2 who acknowledged that the opened bottle of Xalatan eye drops should have been stored in the medication refrigerator. LPN #2 also acknowledged that once the Lantus insulin was removed from the refrigerator, it should have been dated. On 10/1/24 at 11:45 AM, the surveyor inspected the 2nd floor medication cart #2 in the presence of LPN#3. The surveyor observed an opened bottle of Timolol eye drops (medication for pressure in the eye) that was dated 8/24/24 and was expired. At that time, the surveyor interviewed LPN#3 who stated that the Timolol eye drops were expired and that it should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Lantus insulin vial once opened has an expiration date of 28-days. 2. Unopened Xalatan eye drops once opened should be stored in the refrigerator 3. Timolol eye drops once opened has an expiration date of 28-days. On 10/1/24 at 1:30PM, the surveyor discussed the above concerns to the Licensed Nursing Home Administrator and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy titled Storage of Medications dated 1/31/24 and provided by the DON included the following: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 5. Medications requiring refrigeration must be stored in a refrigerator in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. NJAC: 8:39-29.4 (a) (h) (d)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and correct diet consistency was followed for 3 of 5 residents (Resident #8, #19, and #51) reviewed for dietary preferences. This deficient practice was evidenced as follows: 1. On 9/26/24 at 08:35 AM, the surveyor observed Resident #8 in their room, awake in bed. During the interview, Resident #8 stated their meal trays are usually missing items and/or have incorrect items. Resident #8's breakfast tray arrived during the interview. Resident #8's breakfast ticket stated the resident was on a regular diet with a ground consistency (ground consistency are food that should be soft, moist, and cohesive in texture. Meats should be finely chopped, and vegetables should mash easily with a fork.) The surveyor observed Resident #8's tray were missing a 4 ounce (oz) pureed fruit cup and a 4 oz apple/cran-orange juice as indicated in their meal ticket. The surveyor further observed a piece of coffee cake in a ground consistency. As indicated in the meal ticket, the coffee cake should be served in a pureed consistency (pureed consistency is all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). The certified nursing assistant #1 (CNA #1), called the kitchen to request for the missing items on the resident's tray and clarified what was the consistency of the coffee cake the resident should receive. A review of the admission Record (an admission summary) (AR) reflected that the resident was admitted with diagnoses that included but were not limited to; Dysphagia, need for assistance with personal care and muscle weakness. A review of the Quarterly Minimum Data Set (MDS), a tool used to facilitate the management of care, dated 9/10/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that Resident #8 was cognitively intact. A review of the September 2024 Physician's Orders (PO) included a PO dated 7/1/24 for a Regular diet, ground texture, thin liquid. A review of Resident #8's Nutrition progress note form dated 9/26/24 at 8:30 AM, reflected that the Registered Dietitian (RD) documented Food preferences: no new preferences at this time. Specific food preferences were not indicated within the assessment. 2. On 9/26/24 at 8:55 AM, the surveyor observed Resident #19 who was in their bed and awake. The resident stated their meal trays are frequently missing some items that they had specifically requested. The surveyor observed, Resident #19's breakfast tray, the breakfast ticket stated the resident is on a Regular diet, regular texture, and thin liquids. The surveyor observed Resident #19's tray was missing a 4 oz cranberry juice. Resident #19 stated they were supposed to receive cranberry juice with each meal. On 9/26/24 at 12:55 PM, the surveyor observed Resident #19's lunch meal tray that didn't have the 4oz cranberry juice was missing. A review of the AR reflected Resident #19 was admitted to the facility with diagnoses that included but were not limited to; Multiple Sclerosis, Vitamin B deficiency and Tinea Unguium. A review of the Quarterly MDS, a tool used to facilitate the management of care, dated 8/27/24, indicated that the resident had a BIMS score of 15 out of 15, which reflected that the resident was cognitively intact. A review of the September 2024 PO included a PO dated 6/1/24 for a Regular diet, regular texture, thin liquid. A review of Resident #19's Nutrition progress note dated 7/5/24 at 8:30 AM, reflected that the Registered Dietitian (RD) documented The resident would also like ginger ale and cranberry juice each meal, reported to FSD (food service director). A review of Resident #19's nutrition care plan dated 7/15/24, under interventions and tasks stated, Provide me with my food/beverage preferences. 3. On 9/26/24 at 9:03 AM, the surveyor observed Resident #51 awake in their bed. Resident #51 stated, they had to call the kitchen almost every meal for the missing items in their meal tray. The surveyor observed the breakfast served to the resident on the same day. The meal ticket stated the resident was on a consistent carbohydrate (CCD), no added salt (NAS) diet, Regular texture, thin Liquids consistency. The surveyor observed Resident #51's tray was missing a 4-ounce (oz) prune juice. A review of the AR indicated that Resident #51 was admitted to the facility with diagnoses that included but were not limited to; Heart Failure, Muscle Weakness and Tinea Unguium. A review of the Annual MDS, a tool used to facilitate the management of care, dated 9/3/24, revealed that the resident's BIMS was not completed due to the resident's interview was not able to be conducted at that time. A review of the September 2024 PO included a PO dated 4/2/24 for a CCD/NAS diet, regular texture, thin liquid. A review of Resident #51's Nutrition Progress note dated 8/7/24, reflected that the Registered Dietitian (RD) documented noted order for prune juice in the morning for prevention of constipation. A review of Resident #51's nutrition care plan dated 7/5/24, under interventions and tasks stated, Provide and serve diet as ordered. On 9/27/24 at 9:46 AM, the surveyor interviewed the Food Services Director (FSD) who stated, they were not aware of the missing items on the resident's trays and weekly tray audits were completed by the FSD together with the RD. The FSD also stated Resident #8 was served the correct consistency coffee cake, but unable to provide information as to why the tray ticket stated pureed. On 9/30/24 at 12:41 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Tray identification/Accuracy policy with a revision date of 4/24/24. Under the policy interpretation and implementation, it states, 1. To assist in setting up and serving the correct food trays/diets to residents, the food Service Department shall use appropriate identification (e.g., color coded or computer-generated diet cards) to identify the various diets. 2. The Food Services manager or supervisor shall check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the Nurse Supervisor shall notify the Dietary Department immediately by phone so that the appropriate food tray can be served. On 9/30/24 at 1:16 PM, the surveyor interviewed the FSD, who stated the kitchen staff placed pitchers of juice on the tray carts that goes to the nursing units to be served. The FSD further stated that the nursing staff on the units were supposed to pour the juices into the cups and pass them out to the residents. On 9/30/24 at 1:33 PM, the survey team met with the LNHA and Director of Nursing to discuss the above concerns. The LNHA stated the missing tray items were not acceptable. There were no further information provided. NJAC - 17.4(a)1, (e)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner that would prevent food borne illnesses. This deficient practice was observed and evidenced by the following: On 9/25/24 at 09:41 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. The juice dispensing machine was observed with 3 of 6 juice plastic tubes that lead from the juice concentrate to the juice dispenser, with a sticky substance covering the tubes. The FSD stated the tubing should always be clean and free of any debris. 2. In walk-in refrigerator #1, the surveyor observed the fans, fan grates and panels with a dark colored dust like debris. 3. In the walk-in freezer, the surveyor observed large ice and frost build up on the fans, walls, and ceiling. The FSD could provide an information why the frost build up occurred. On 9/26/24 the Licensed Nursing Home Administrator (LNHA) provided the surveyor with two undated facility policies, titled, Dietary Cleaning and Food Storage The dietary cleaning policy stated under the procedure section, I. The dietary manager will develop a cleaning schedule that includes the frequency of which equipment, and areas will be cleaned. A. The cleaning schedule will be posted weekly. B. The cleaning schedule includes tasks assigned to specific positions within the dietary department. C. Dietary staff will initial next to the assigned task once it is completed. The dietary manager monitors the cleaning schedule to ensure compliance. The LNHA also provided a blank copy of the weekly deep cleaning list which included the tasks of cleaning the freezers and refrigeration. The FSD and LHNA unable to provide the most recent copy of the weekly deep cleaning list. On 9/30/24 at 1:33 PM, the survey team met with the LNHA and Director of Nursing to discuss the above concerns. There were no further information provided. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure a physician's order was followed and perform hand hygiene appropriately during a wound treatment observation for 1 (one) of 1 (one) resident, (Resident #31) reviewed for pressure ulcer. The deficient practice was evidenced by the following: On 7/24/23 at 11:06 AM, the surveyor observed Resident #31 lying in a low to the ground bed. The surveyor observed a wound vacuum machine on the bedside table and there was a tubing that was connected to Resident #31. The surveyor reviewed Resident #31's electronic medical record which revealed the following: The admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident #31's Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/13/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that Resident #31 had mildly impaired cognition. Review of Section M Skin Conditions reflected that Resident #31 had one Stage 4 (four) pressure ulcer. The Order Summary Report dated 7/27/23 included the following orders: Under Pharmacy Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) External Ointment 250 unit/gm (gram) (Collagenase) apply to L (left) gluteal fold topically every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care-cleanse with Dakin's (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach) 0.25 % (1/2 strength) solution, apply skin prep to periwound, then apply santyl to wound bed, then proceed with wound vac application. Start date 7/13/23. Under Other After applying treatment with santyl, place the wound vac drape to periwound skin, then place VAC foam cut to size of wound bed taking care not to apply to intact skin, then apply negative pressure therapy to wound at 125 mmHg every day shift every Tue, Thu, Sat. Start date 7/13/23. Wound vac to L gluteal fold at 125 mmHg (millimeters of mercury) every shift. Start date 7/12/23. On 7/27/23 at 9:31 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) perform Resident #31's wound treatment. The LPN/UM performed handwashing (HW) and scrubbed both hands for 20 seconds under the stream of running water. She donned (put on) gloves and wiped the bedside table with a disinfectant wipe. She doffed (to remove) the gloves, unlocked the treatment cart then donned a clean pair of gloves. She did not perform hand hygiene (HH) with the alcohol based hand rub (ABHR) that was on top of the treatment cart. She placed a blue barrier on the bedside table. She doffed her gloves performed HH with ABHR and donned a clean pair of gloves. LPN/UM then placed a package that contained a cotton tipped swab and 4x4 gauze on the bedside table. She doffed her gloves, performed HH with ABHR and then checked the order in the electronic medical record. Then the LPN/UM donned a clean pair of gloves and placed a medicine cup which she had placed santyl ointment in, a container of sodium chloride and several skin prep packages on the bedside table. She removed her gloves and put on a surgical mask. LPN/UM performed HW which included 10 seconds outside the flow of water and 10 seconds under the flow of water. LPN/UM donned a pair of clean gloves disconnected tubing to the wound vac. LPN/UM doffed her gloves. She performed HW which included 10 seconds outside the flow of water and 10 seconds under the flow of water. LPN/UM donned a clean pair of gloves and took a 4x4 gauze that she wet with sodium chloride and wiped Resident #31's skin that was around the opening and discarded the 4x4 gauze. LPN/UM then took another 4x4 gauze that she wet with sodium chloride and wiped inside the opening on Resident #31's left gluteal fold. LPN/UM doffed her gloves. She performed HW which included 10 seconds outside the flow of water and 10 seconds under the flow of water. LPN/UM donned a clean pair of gloves. She then opened the package that contained the wound vac dressings and placed it on the bedside table. LPN/UM doffed her gloves and donned a clean pair of gloves. LPN/UM then wiped Resident #31's skin around the opening with the skin prep wipes. LPN/UM doffed her gloves and donned a clean pair of gloves. around area. LPN/UM placed wound vac occlusive tapes on the area around the opening. She doffed her gloves. LPN/UM took a pair of scissors out of her pocket and donned a clean pair of gloves on wiped the scissors with a disinfectant wipe. LPN/UM doffed her gloves. LPN/UM performed HW for 15 seconds under the flow of water. She donned a clean pair of gloves. LPN/UM then applied santyl ointment with a cotton tipped applicator. LPN/UM cut a piece of the wound vac foam and when she went to apply the foam into the opening, Resident #31 started moving. LPN/UM talked to Resident #31 and Resident #31 agreed to let LPN/UM finish the treatment. LPN/UM discarded the piece of foam that she had cut. LPN/UM doffed her gloves and performed HW for 13 seconds and stated that she was going to have to rush this [wound treatment]. LPN/UM donned a clean pair of gloves and cut a piece of foam. She then placed the foam in the opening and placed the remaining wound vac dressings and attached the tubing to the wound vac machine. LPN/UM doffed her gloves. LPN/UM performed HW for 10 seconds. After the LPN/UM finished the wound treatment and cleaned the bedside table, the surveyor interviewed LPN/UM regarding the process of HW. LPN/UM stated that she would wet her hands first, apply soap and create friction. The surveyor then asked if the process should be outside the flow of water. LPN/UM stated that she tried to make lather with the soap and water. On 7/27/23 at 10:44 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for HW. The DON stated that the process for HW was to turn on the water, wet hands, get soap, create friction for The surveyor asked if the process of creating the friction under the flow of water was correct. The DON stated that under the flow of water was not correct. On 7/27/23 at 11:26 AM, the surveyor reviewed the physician's order for Resident #31's wound treatment in the electronic medical record. The order included that the wound should be cleansed with Dakin's solution prior to the application of Santyl ointment. On 7/27/23 at 11:27 AM, the surveyor interviewed the LPN/UM who confirmed that she did not cleanse Resident #31's wound with Dakin's solution. She added that if the inside of a wound was bright red then Dakin's solution should not be used and that Santyl ointment was enough. She then stated that Resident #31's wound was bright red now. The surveyor then asked LPN/UM should follow a physician's order as it was written. LPN/UM stated that she would follow an order as written. She added that the order she looked at did not contain Dakin's solution. On 7/27/23 at 01:22 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and Regional DON (RDON), the concern of inappropriate HW and not following a physician's order during Resident #31's wound treatment observation. The DON stated that the orders should have been clarified and put in both of the orders. On 7/28/23 at 8:19 AM, in the presence of the survey team, DON and Chief Nursing Officer, the LNHA stated that the LPN/UM called the physician after the treatment and obtained another order. The surveyor then asked what should have been done if the nurse observed the wound and the treatment needed to be changed. The DON stated that the LPN/UM observed the wound and did not use the Dakin's solution and then called the physician to get the order changed. The surveyor then asked what the LPN/UM should have done when she observed the wound. The DON stated that the LPN/UM made a nursing judgement when she held the Dakin's solution and that she got the order changed based on her clinical assessment of wound. On 7/28/23 at 8:40 AM, the LNHA stated that LPN/UM was inserviced on HW. On 7/28/23 at 02:04 PM, during exit conference, the LNHA confirmed that there was no additional information. A review of the facility provided policy titled Handwashing Policy dated 11/2022 included the following: Washing Hands 1. Wet hands with water and apply cleaning product to hands. 2. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 15 seconds (or longer), covering all surfaces of hands and fingers. 3. Rinse hands thoroughly under running water. Hold hands lower than wrists A review of the facility provided policy titled, Wound Care dated 11/2022 included the following: Preparation 1. Verify that there is a physicians' order for this procedure. N.J.A.C. 8:39-27.1 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00164623 Based on interviews, record review, and review of facility provided documents, it was determined that the facility failed to ensure that two (2) Licensed Practical Nurses (LPN #1 and #2) and one (1) Registered Nurse (RN) had Medication Pass Observation (MPO) competencies to provide nursing care for residents' needs. The deficient practice was evidenced by the following: A review of the facility provided Medication Error Incident Report ([NAME]) for 5/27/23 date of error showed that it was the RN who had a medication error of Klonopin (anti-anxiety medication) for Resident #390 and was given a written warning. In addition, the 5/29/23 and 5/30/23 dates of error in the [NAME] showed that it was LPN#1 who had a medication error of Klonopin for Resident #390 and was given a written warning. Further review of the 5/27/23, 5/29/23, and 5/30/23 dates of medication errors, included in the [NAME] revealed that on the explanation/reason medication error was made by the RN and LPN#1: Resident was previously receiving 0.25 mg (milligrams) tabs (tablets; 4 (four tabs) to equal 1 (one) mg) and new bingo card (Klonopin tabs have plastic bubbles for every day of the month. From the foil sealed to the back of the card, pills can be pushed through and taken) was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming correct dose. The [NAME] for medication error dated 5/27/23, 5/29/23, and 5/30/23 action taken for both the RN and LPN#1 included written up and educated. A review of the provided copy of the typewritten Summary of Investigation for the date of the incident: 5/27/23, 5/29/23, and 5/30/23 showed follow up actions: Incident reports were completed for both separate incidents by each nurse for medication error reports and that the nurses were also educated about the five rights of medication pass and disciplinary action was taken due to the severity of the error and its potential consequences. Further review of the medical records and other facility provided documents revealed that no MPO competency was done to both LPN#1 and the RN before the incident of significant medication error and immediately after the incident was reported and investigated. On 7/26/23 at 01:28 PM, the surveyor in the presence of the survey team interviewed the Director of Nursing (DON) about the 5/27/23, 5/29/23, and 5/30/23 [NAME]. The DON stated that it was the Consultant Pharmacist's (CP) responsibility to do MPO to all nurses. The DON was not sure how often MPO should be done to all nurses. She further stated that she did not ask nor call the CP to do MPO after the significant medication error incident happened. The DON confirmed that there was no follow up MPO competencies were done to both the RN and LPN#1 after the incident of significant medication error. On 7/28/23 at 8:18 AM, the DON provided a typewritten copy of Resident #390's Medication Errors summary that included that LPN#2 was the nurse who did the transcription error on 3/24/23 of the resident for the order of Klonopin wherein LPN#2 wrote for the medication to be dispensed as 1 (one) mg TID (3x/day) instead of 0.5 mg TID. Included as an attachment in Resident#390's Medication Errors summary was the [NAME] for the date of error 3/24/23 with a date of error discovery of 7/27/23 (after the surveyor's inquiry). On 7/27/23 at 8:52 AM, the surveyor reviewed the provided binder of Medication Pass Observation documents and revealed that LPN#1 and #2, and the RN did not have MPO competencies done at the facility prior to a significant medication error that happened on 5/27/23, 5/29/23, and 5/30/23 and immediately after the investigation reports were completed. On 7/28/23 at 11:59 AM, the survey team met with the Regional Chief Nurse Officer, DON, Licensed Nursing Home Administrator (LNHA), and were made aware of the above findings. The LNHA stated that the RN did not have a performance evaluation because the RN was hired on March 2023 and was not due. The LNHA further stated that LPN#1 was an agency nurse, and LPN#2 was hired on 10/31/22 and the performance evaluation was not due to complete. On that same date and time, the LNHA acknowledged and confirmed that there were no MPO competencies for 3 (three) nurses (LPN#1 and #2, and the RN) before the significant medication error and after the incident was investigated. The LNHA further stated according to the facility's protocol, MPO competency should be done upon hire and as needed or periodically. The LNHA acknowledged that the MPO competencies of the RN and LPN#2 and #2 should have been done. A review of the facility's provided Medication Pass Observation form that was provided by the LNHA with a Form 109 B revised date of 6/17 included a medication administration errors list #7 Correct drug, correct amount, correct dosage form administered and #9 Medication Administration: a. Medication checked against MAR (Medication Administration Record) before administering. NJAC 8:39-27.1(a)

2. On 7/20/23 at 10:34 AM, the surveyor observed Resident #78 seated up on the bed awake, alert, and responded appropriately to the surveyor. The surveyor also observed the Certified Nursing Assistant (CNA) assisted the resident with breakfast. The surveyor reviewed Resident #78's medical record. The AR reflected that the resident was admitted to the facility that included diagnosis which included but was not limited to type two diabetes mellitus with hyperglycemia (abnormal blood glucose level), hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), Alzheimer's Disease, essential hypertension (elevated blood pressure), unspecified dementia, and anxiety disorder. A review of Resident #78's PO presented an order initiated on 5/05/23 for Alendronate Sodium Oral Tablet 70 mg, 1 (one) tab by mouth weekly for osteoporosis (A condition in which bones become weak and brittle). The med was changed on 7/12/23 to Alendronate Sodium Oral Tablet 70 mg, 1 (one) tab by mouth one time a day every Sunday for osteoporosis - give with 8 (eight) ounces of plain water, at least half hour before all other food, beverage, or med; do not lie down for half hour. Review of the eMAR documented the med Alendronate Sodium Oral Tablet 70 mg, 1 (one) tab by mouth weekly for osteoporosis initiated on 5/05/23 and the order was changed on 7/12/23; revealed the following: The month of May 2023, 23 out of 27 days the nurses signed for the med indicating it was administered. The month of June 2023, 29 out of 30 days the nurses signed for the med indicating it was administered. The month of July 2023, 11 out of 12 days the nurses signed for the med indicating it was administered. A review of the CP Monthly Report revealed that the CP visited and documented comments monthly, with the last documented visit and comment on 7/05/23. A review of the recommendations for Resident #78 dated 6/8/23 did not document recommendations related to the med Alendronate Sodium. On 7/26/23 at 10:39 AM, the surveyor interviewed the CP who stated that he reviews all resident's meds once a month. The CP further stated that he reviews a lot of things when he reviews a resident's med, which includes eMAR and PO. The surveyor notified the CP of the above concerns related to the med Alendronate Sodium. During the interview with the CP about the med Alendronate Sodium order and eMAR, the CP stated, It was possible I overlooked it since I did not make any recommendations for the month of June regarding that med. On 7/27/23 at 12:52 PM, the survey team met with the LNHA, DON, and Regional DON regarding CP not having recommendation about the med Alendronate Sodium for the month of June 2023. LNHA stated, the pharmacy consultant should have picked up the error. A review of the facility provided; Pharmacy Consultant Policy and Procedure reviewed 01/2023, included the following: Objectives: 1. To facilitate the administration of med with regard to safety, federal and state requirement and to ensure the accurate acquiring, receiving, dispensing and administration of all drugs and biologicals to meet the need of each resident. 5. to have the drug regimen reviewed by the pharmacist and ensure compliance with the drug regime [regimen] requirements. 6. To have the pharmacist find and identify apparent irregularities or potential drug therapy problems . The attending physicians are not required to agree with the pharmacist's report, nor are they required to provide a rationale for their acceptance or rejection of the report. They must, however, act upon the report. This may be accomplished by indicating acceptance or rejection of the report and signing their name. A review of the facility's document pharmacy agreement [name of pharmacy company] the agreement under Duties of Consultant, subsection iii states, Performing a monthly onsite review of the drug regimen of each patient on the Facility's unit census on date(s) of visit. Reports of any irregularities shall be provided on the nurse in charge and/or the attending physician, and the administrator. NJAC 8:39- 29.1(b), 29.3 (a)(1) Complaint # NJ00164623 Based on observation, interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for two (2) of three (3) residents, (Resident #390 and Resident #78) reviewed for Clonazepam (or Klonopin; antianxiety medication). This deficient practice was evidenced by the following: A review of the manufacturer's specifications for Klonopin included the following: Geriatric Use, Clinical studies of Klonopin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. 1. On 7/25/23 at 10:42 AM, the surveyor reviewed Resident #390's medical record. The admission Record (AR; or face sheet; an admission summary) reflected the resident was admitted with diagnoses which included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), unspecified dementia (loss of cognitive functioning), bipolar disorder (mental illness that causes unusual shifts in mood from extreme high to extreme low), dysphagia (difficulty swallowing), peripheral vascular disease (circulation disorder), major depressive disorder (persistent feeling of sadness and loss of interest) and generalized anxiety disorder. The most recent Comprehensive Minimum Data Set, an assessment tool used to facilitate the management of care, dated 5/04/23, reflected that the resident had a brief interview for mental status (BIMS) score of 6 (six) out of 15, which indicated the resident had a severely impaired cognition. Further review of the MDS section E Behavior indicated the resident was not delusional and section N reflected the resident received Antipsychotic and Antianxiety medication. A review of the Psychiatric Progress Note (PN) dated 3/24/23, revealed recommendations that included but were not limited to a discontinuation of Klonopin PRN (administered as needed) and an increase of the routinely Klonopin from 0.5 milligram (mg) twice daily to Klonopin 0.5 mg every 8 hours for anxiety. The Social Services Note dated 3/28/23 indicated, Klonopin PRN was dc'd [discontinued]. Klonopin was increased to 0.5 mg every 8 hours A review of the Order Audit Report (OAR) revealed the order for Clonazepam Oral Disintegrating Tablet (ODT) 1 (one) mg, give one tablet (tab) three times a day related to (r/t) generalized anxiety disorder was created by the LPN and signed by the physician on 3/24/23. A review of the electronic Medication Administration Record (eMAR) with an order range date of 3/01/23 to 3/31/23 included the following physician orders (PO): -Clonazepam ODT 1 (one) mg, give one tab three times a day r/t generalized anxiety with a start date of 3/24/23 and discontinued on 3/27/23. -Clonazepam ODT 1 (one) mg, give one tab three times a day for give 2 (two) tablets of 0.5 mg = 1 (one) mg r/t generalized anxiety with a start date of 3/27/23. A review of the CP monthly report from 3/2023 through 5/2023, did not identify or inform the prescriber of the irregularity between Psychiatric Nurse Practitioner (PNP) dosing recommendation of Clonazepam 0.5 mg every 8 hours dated 3/24/23, against the executed PO of Clonazepam ODT 1 (one) mg every 8 hours, dated 3/24/23. On 7/26/23 at 10:38 AM, during a telephonic interview with the surveyor, the CP stated he did not make any recommendations regarding the executed PO dose increase for Clonazepam on 3/24/23 or thereafter. On 7/26/23 at 11:39 AM, during a telephonic interview with the surveyor, the Medical Doctor (MD) stated he did not recall if the order changes were communicated to him. The Physician also stated that the Psychiatry had prescribing privileges in the facility. On 7/26/23 at 02:21 PM, during an interview with the surveyor, the PNP explained that after a resident encounter her recommendations were documented into a psychiatric progress note. The PNP stated she made a copy and gave it to the nurse on duty. The PNP informed the surveyor that if the physician disagreed with her recommendation, she documented the information and wrote the reason on her psychiatric progress note. At that time, the surveyor asked the PNP if she was aware that her recommendation on 3/24/23 for Clonazepam 0.5 mg every 8 hours was implemented as 1 (one) mg every 8 hours instead. The PNP stated maybe I was not aware of it. On 7/27/23 at 10:14 AM, the survey team met with the Regional Director of Nursing (RDON), License Nursing Home Administrator (LNHA), and the DON and were made aware of the concern regarding the doubled Clonazepam dose in which the CP did not identify or notify the MD and the facility of the irregularity. At that time, the LNHA stated she had discussed and questioned the CP as to the reason why the irregularity was not identified. On 7/28/23 at 11:40 AM, during a meeting with the survey team, the DON stated that the LPN was written up yesterday (7/27/23), for the medication (med) error [transcription error] of placing an order for the Clonazepam as 1 (one) mg as opposed to the intended 0.5 mg recommended by the PNP on 3/24/23. The DON acknowledged and stated that the CP should have identified the transcription error as well. The DON further stated that the transcription error was identified after the surveyor's inquiry. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/20/23 at 10:34 AM, the surveyor observed Resident #78 seated up on the bed awake, alert, and responded appropriately to the surveyor. The surveyor also observed the Certified Nursing Assistant (CNA) assisted the resident with breakfast. The surveyor reviewed Resident #78's medical record. The AR reflected that the resident was admitted to the facility which included diagnoses that included but were not limited to type 2 diabetes mellitus with hyperglycemia (abnormal blood glucose level), hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), Alzheimer's Disease, essential hypertension (elevated blood pressure), unspecified dementia, and anxiety disorder. A review of Resident #78's PO presented an order initiated on 5/05/23 for Alendronate Sodium (medication use to treat osteoporosis) Oral Tablet 70 mg, 1 (one) tablet by mouth weekly for osteoporosis (A condition in which bones become weak and brittle). The medication order was changed on 7/12/23 to Alendronate Sodium Oral Tablet 70 mg, 1 (one) tablet by mouth one time a day every Sunday for osteoporosis - give with 8 (eight) ounces of plain water, at least half hour before all other food, beverage, or med; do not lie down for half hour. The surveyor reviewed the eMAR for Resident #78 for the med administration of Alendronate Sodium Oral Tablet 70 mg, 1 (one) tablet by mouth weekly for osteoporosis, which revealed the following: For the month of May 2023, the nurses signed 23 out of 27 days that the med was administered. For the month of June 2023, the nurses signed 29 out of 30 days that the med was administered. For the month of July 2023, the nurses signed 11 out of 12 days that the med was administered. On 7/25/23 at 01:05 PM, the surveyor interviewed the DON regarding the above concerns for the Alendronate Sodium medication. The DON stated when the order was entered for Alendronate Sodium 70 mg give 1 (one) tablet by mouth weekly on 5/05/23, it was selected for the nurses to document daily instead of weekly. The CP identified the error in 7/08/23, and the DON initiated an investigation for the med documentation error. The DON further stated that the investigation concluded that the nurses were signing the eMAR daily and not administering the med, as the med was not available to be given every day. On 7/26/23 at 11:59 AM, the surveyor interviewed LPN #2, who was assigned previously to Resident #78 and signed for the Alendronate Sodium medication in the eMAR. LPN #2 stated the Alendronate Sodium was to be given weekly and she observed the med was being signed daily. She stated she did not administer the med and documented a progress note dated 5/13/23 and 5/14/23 that she did not give the med because it was already given for the week. LPN #2 acknowledged that it was expected for the nurses to report a concern about a med order and that it should have been reported for follow up to the supervisor. 3. On 7/26/23 at 01:45 PM, the surveyor reviewed the CDR form for Resident #78 on the Magnolia unit med cart. The surveyor reviewed Resident #78's CDR form for Clonazepam 0.5 mg 1/2 (half) tablet (0.25 mg) by mouth every 12 hours as needed for Anxiety for 14 days, which revealed two entries on 7/16/23 at 11:20 AM. Indicating Resident #78 received Clonazepam 0.5 mg. The surveyor reviewed the PO for Resident #78 which revealed an order initiated on 6/09/23 for Clonazepam give 0.5 tablet by mouth every 12 hours as needed for anxiety for 30 days - 0.5 tablet = 0.25 mg, which was discontinued on 7/09/23. Further review of the PO revealed an order initiated on 7/14/23 for Clonazepam 0.5 mg 1 (one) tablet every 8 (eight) hours as needed for anxiety/agitation for 30 days. Further review of resident's CDR revealed the following: On 7/20, 7/21, 7/22, and 7/25 entries documented a single Clonazepam 0.5 mg 1/2 (half) tablet (0.25 mg) was signed out for each of these days. The surveyor reviewed July eMAR, which indicated on 7/20, 7/21,7/22, and 7/25 med Clonazepam 0.5 mg 1 (one) tablet was administered. On 7/26/23 at 02:00 PM, the surveyor interviewed LPN #3, who was the assigned nurse for Resident #78 and confirmed the count of the Clonazepam in the med cart. The surveyor reviewed with LPN #3 the CDR for the Clonazepam. LPN#3 stated that the nurses who were administering the med should have reviewed the directions of the med prior to administering the med. She further stated that when the new bingo card with the correct dose was received that the discontinued med should have been remove from the med cart. On 7/26/23 at 02:10 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) about the process for when a med order was changed. UM/LPN stated when a doctor changed the order that they will fax the new order to the pharmacy. When a new order is received from the pharmacy, the discontinued order will be remove from active med stock. The med nurse will give her the unit manager the discontinued med and that med will be destroyed in the presence of two nurses. On 7/27/23 at 12:52 PM, the surveyor informed the LNHA, DON, and RDON about the above concerns with the Alendronate Sodium med and the Clonazepam med for Resident #78. The DON acknowledged there was a med error, in which an investigation was completed. 4. The surveyor reviewed the hybrid (electronic and paper) medical records for Resident #47, which revealed the following: The resident's AR listed diagnoses that included but were not limited to, unspecified dementia, major depressive disorder, and anxiety disorder. A review of the July 2023 OSR and the July 2023 eMAR indicated that Resident #47 had a PO, dated 6/30/23 for Clonazepam 0.5 mg, give 1 (one) tablet by mouth two times a day for anxiety, which was discontinued on 7/11/23. A PO, dated 7/11/23, was started for Clonazepam 1 (one) mg, give 1 tablet by mouth three times a day for anxiety. On 7/26/23 at 02:09 PM, the surveyor interviewed the UM/LPN about the CDR. The UM/LPN stated upon completion of a CDR, it would be removed from the binder in the med cart, and that it would be given to the DON. The surveyor asked the UM/LPN what the expectations were for when a nurse wasted a controlled med. UM/LPN stated two nurses were to waste (destroy) a controlled med, to witness and co-sign the disposal of the med. The surveyor requested from the UM/LPN the Clonazepam drug records for Resident #47. On 7/27/23 at 10:01 AM, the surveyor interviewed the DON about CDR keeping. The DON stated she kept all original CDR forms for record keeping. The surveyor requested from the DON the Clonazepam 0.5 mg, CDR forms for Resident #47. On 7/28/23 at 10:10 AM, the DON provided the surveyor the Clonazepam 0.5 mg July 2023 CDR forms for Resident #47. A review of the July 2023 CDR forms for Clonazepam 0.5 mg revealed the following: For the entry dated and timed, 7/13 9 PM, LPN #4 signed out for Clonazepam 0.5 mg, 1 (one) tablet. The physician's order was for Clonazepam 1 (one) mg to be administered and LPN #2 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/13/23 at 9 PM. For the entries dated and timed, 7/14 9 AM, 2 PM and 9 PM, LPN #1 signed out Clonazepam 0.5 mg 1 (one) tablet at each of those times. The physician's order was for Clonazepam 1 (one) mg to be administered. LPN #1 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/14/23 at 9 AM, 2 PM, and 9 PM. For the entries dated and timed, 7/15 9 AM and 2 PM, LPN #1 signed out Clonazepam 0.5 mg, 1 (one) tablet. The physician's order was for Clonazepam 1 (one) mg to be administered. LPN #1 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/15/23 at 9 am and PM. For 7/17/23, there were no entries on the controlled drug records documenting Clonazepam being signed out for the 2 PM and 9 PM dose. LPN/UM signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/17/23 at 2 PM and Registered Nurse (RN) #1 signed that Clonazepam 1 (one) mg was administered on 7/17/23 at 9 PM. For the entry dated and timed 7/18 9 AM, LPN #1 signed out two Clonazepam 0.5 tablets. LPN #1 did not sign eMAR for 7/18/23 at 9 AM, the eMAR was signed by LPN #5. LPN #1 worked on 7/19/23. There were no other entries on the CDR forms for the 7/18/23 9 AM, 2 PM, and 9 PM dose to document Clonazepam being signed out for administration to the resident. LPN #5 signed the eMAR on 7/18/23 for 9 AM and 2 PM that Clonazepam 1 (one) mg was administered to the resident. LPN #6 signed the eMAR for 7/18/23 at 9 PM that the med was administered. For the entries dated and timed 7/19 2 PM, LPN #1 signed out two Clonazepam 0.5 mg tablets. On the eMAR, LPN #1 signed, the chart code 5 for the Clonazepam 1 (one) mg to be administered on 7/19/23 at 2 PM. The chart code 5 indicated Hold/See Progress Notes. A review of the Administration note, LPN #1 documented awaiting order from pharmacy. There was no documentation to account if the two Clonazepam 0.5 mg tablets signed out by LPN #1 were wasted or administered to the resident. A review of the July 2023 CDR for Clonazepam 1 (one) mg which was currently in use for Resident #47 revealed the following: For the entry dated and timed 7/22 9 PM, LPN #6 signed their name and wrote wasted to indicate the Clonazepam 1 (one) mg tablet signed out was destroyed. There was no co-signature by another nurse on the entry to document that the wasting of the med was witnessed. On 7/28/23 at 10:25 AM, the surveyor informed the DON and LNHA of the above concerns. The DON stated it was expected for the nurses to follow the PO and if the dose of a med was not available the physician should be called, and the order clarified. The DON further stated it was expected for the nurses to have a second nurse to witness and co-sign on the controlled drug record when a controlled med was wasted (destroyed). The LNHA acknowledged the nurses were expected to follow the PO and administer med accurately. The DON and LNHA stated they would follow up and provide further information. On 7/28/23 at 11:59 AM, the survey team met with the LNHA, DON, and Regional Chief Nursing Officer. The DON confirmed the nurses could only provide the resident with Clonazepam from the resident's med supply in the med cart, that would require the nurses to sign and document on the CDR form. The DON stated there was no alternate access for the Clonazepam med and that there was no back up controlled med stock in the facility. The LNHA provided the surveyor with the controlled substances policy. A review of the facility provided policy; Accepting Delivery of Medications reviewed/revised 01/2023, included the following: Policy Statement 2. Any errors noted in receiving meds shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation 2. Before signing to accept the delivery, the Nurse must reconcile the meds in the package with the delivery ticket/order receipt. 3. If an error is identified when receiving meds from the pharmacy, the Nurse verifying the order shall: b. Return incorrect meds (e.g. wrong strength, form etc.) to the dispensing pharmacy and reorder the correct med. A review of the facility provided policy; Discarding and Destroying Medications reviewed/revised 1/2023 included the following: Policy Interpretation and Implementation 8. Any controlled substance that is considered hazardous waste will be managed in accordance with federal, state and local hazardous waste regulations as well as the Controlled Substance Act and DEA regulations. 10. The med disposition record will contain the following information: a. The resident's name b. Date med disposed e. quantity disposed f. method of disposition h. signature of witnesses A review of the facility provided policy; Controlled Substances dated 11/2022 included the following: Policy Interpretation and Implementation 9. The Director of Nursing services shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. A review of the facility's policy titled, Controlled substances, dated 12/2018, under policy statement read: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The policy did not further address documentation by nurses at the time of medication being signed out and administered. The policy also did not address the procedure by nurses for destroying and documenting the wasting of a controlled medication. A review of the facility's policy titled Administering Medications, dated 11/2022, under Policy Statement read, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, it read: 3. Medications must be administered in accordance with the orders .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . On 7/28/23 at 01:11 PM, the facility had no further information to provide. NAACP 8:39-11.2 (b), 29.2 (d), 29.4(G)(I)(Mk), 29.7(ac) Complaint # NJ00164623 Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure a) medication was accurately received, administered, and reconciled against the physician order prior to administration which contributed to a repeated administration of an incorrect dose to and proper disposal of Clonazepam (Klonopin; a hazardous, controlled substance/narcotic medication (med) to prevent and treat anxiety disorder), for Resident #390, b) accurate signing for a medication in the electronic medication administration record (eMAR), accurate accounting, dispensing, and administration of a controlled substance med, and med was administered according to physician orders and acceptable standards of practice, for Resident #78 and #47. This deficient practice was identified for three (3) of (3) residents (Resident #390, Resident #78, and Resident #47) reviewed for Clonazepam. 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. Reference DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and Health (NIOSH) list of Antineoplastic and Other Hazardous Drugs in Healthcare settings, 2016. Table 3 Table 3 primarily meet the NIOSH criteria for reproductive hazards. They represent a potential occupational hazard to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breast feeding, as they may be present in breast milk. Unopened, intact tablets and capsules may not pose the same degree of occupational risk as injectable drugs that usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers. The manufacturer's safe-handling guidance (MSHG) is typically in Section 16 of the DPI. See Table 5 for safe handling recommendations . Table 3 list included but were not limited to the following: Clonazepam, Increased risk of congenital abnormalities when taken in first trimester; FDA Pregnancy Category D 1. On 7/25/23 at 10:42 AM, the surveyor reviewed Resident #390's medical record. The admission Record (AR; or face sheet; an admission summary) reflected the resident was admitted with diagnoses which included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), unspecified dementia (loss of cognitive functioning), bipolar disorder (mental illness that causes unusual shifts in mood from extreme high to extreme low), dysphagia (difficulty swallowing), peripheral vascular disease (circulation disorder), major depressive disorder (persistent feeling of sadness and loss of interest) and generalized anxiety disorder. The most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 5/04/23, reflected that the resident had a brief interview for mental status (BIMS) score of 6 out of 15, which indicated the resident had a severely impaired cognition. Further review of the MDS section E Behavior indicated the resident was not delusional and section N Medications reflected the resident received antipsychotic and antianxiety medications. The resident's personalized care plan revised on 8/03/22, under the section Intervention/ Tasks, included review medications (meds) and record possible causes of cognitive deficit: new meds or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. A review of the Order Summary Report (OSR) dated 5/01/23 to 5/31/23, included an order for Clonazepam with a start date of 5/16/23, and reflected the following: Clonazepam ODT 1 (one) mg (milligram), Controlled Drug, give 1 tablet by mouth three times a day related to generalized anxiety disorder. A review of the Controlled Drug Record (CDR; a narcotic log/form used to inventory and document each dose of med administered or disposed) with a pharmacy provider label for Clonazepam ODT 0.25 mg, give 4 (four) tablets by mouth three times a day was signed received on 5/18/23, for 90 doses. Further review of the CDR revealed that the med was signed removed from inventory for administration by the nurses from 5/19/23 to 5/27/23 at 2:00 PM. A review of the electronic Medical Record (eMR) did not reflect a physician's order to correspond with the CDR for Clonazepam ODT 0.25 mg that was signed received on 5/18/23, signed removed for administration for 90 doses. A review of the Medication Error Incident Report ([NAME]) dated 5/29/23, revealed under Explanation/ Reason medication error was made reflected Resident was previously receiving 0.25 mg tabs [tablets] (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming the right dose. A review of the [NAME] dated 5/30/23, revealed under Explanation/ Reason med error was made reflected Resident was previously receiving 0.25 mg tabs [tablets] (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming the right dose. Further review of the eMAR for Resident #390 reflected the following: -On 5/04/23 at 2:00 PM, the eMAR was signed absent from home without meds. -On 5/11/23 at 2:00 PM, the eMAR was signed absent from home without meds. -On 5/28/23 at 6:00 AM, the eMAR was signed refused. A review of the CDR for Resident #390 revealed the following: On 5/04/23 at 02:00 PM, one tablet of Clonazepam 1 (one) mg was removed from inventory for administration. No documentation of disposal was annotated on the CDR. On 5/11/23 at 02:00 PM, one tablet of Clonazepam 1 (one) mg was removed from inventory for administration. No documentation of disposal was annotated on the CDR. -On 5/28/23 at 6:00 AM, four tablets of Clonazepam 1 (one) mg were removed from inventory for administration. No documentation of disposal was annotated on the CDR. On 7/26/23 at 9:48 AM, during a telephonic interview with the surveyor, the provider pharmacist stated the physician or nurse enters the order into the eMR, electronically signs off and is transcribed into their system. On 7/27/23 at 10:14 AM, the survey team met with the Regional Director of Nursing (RDON), License Nursing Home Administrator (LNHA), and the Director of Nursing (DON) and were made aware of the above findings. At that time, the LNHA stated that she spoke with the provider pharmacy when the medication error occurred. The LNHA was concerned why the physician's order (PO) on the eMR did not match the med received. She was informed by the pharmacy that they are unable to see what is on the eMR. At that time, the LNHA informed the surveyor that in the event of a discrepancy between a PO and a med received, the nurses would call the pharmacy to rectify the discrepancy and get the correct order for the resident. On 7/27/23 at 12:52 PM, during a meeting with the survey team, the RDON, and LNHA, the DON acknowledged the PO should be followed. At that time, the RDON stated following a PO was based on accepted standard of professional practice to avoid negative outcomes for the resident. At that time, the LNHA informed the surveyor that in the event of a discrepancy between a PO and a med received the nurses would call the pharmacy to rectify the discrepancy and get the correct order for the resident. At that time, the DON acknowledged the med received from the pharmacy should have been reconciled for accuracy against the PO. On that same date and time, during a meeting with the survey team, RDON, and LNHA, the DON informed the surveyor that she was aware the med was refused on 5/28/23 at 6:00 AM. The DON stated it did not cross her mind to in-service (provide education) regarding proper disposal of Clonazepam.

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by following the pharmacy consultant recommendations for 1 (one) of 6 (six) residents reviewed for unnecessary medications (Resident #31). The deficient practice was evidenced by the following: On 7/24/23 at 11:06 AM, the surveyor observed Resident #31 lying in a low to the ground bed. The surveyor reviewed Resident #31's electronic medical record which revealed the following. A review of Resident #31'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 Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident #31's Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/13/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that Resident #31 had mildly impaired cognition. The electronic Medication Administration Record (eMAR) included the following order: Flomax Capsule 0.4 MG (milligram) (Tamsulosin HCL) (used to treat [redacted] who have symptoms of an enlarged prostate gland, which is also known as benign enlargement of the prostate) give one capsule by mouth one time a day for benign prostatic hyperplasia (BPH), with a start date of 3/10/2023. Further review of Resident #31's AR did not reveal a diagnosis of BPH. On 7/25/23 at 11:57 AM, the surveyor requested the Licensed Nursing Home Administrator (LNHA) to provide the pharmacy consultant recommendations. On 7/26/23 at 9:53 AM, the LNHA provided the surveyor a three page Comments Report. A review of the facility provided Pharmacy Consultant Comments Report included the following: 3/10/23 Please clarify the indication for Flomax. 3/10/23 Flomax is not indicated for use in [redacted]. If continuing therapy, please document the clinical rationale. On 7/26/23 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the reason Resident #31 was taking the medication Tamsulosin. The LPN stated that she thought it was because the Resident #31 was incontinent and had bladder spasms. The surveyor then asked the LPN who would follow up on the pharmacy consultant recommendations. The LPN stated that the Unit Manager or Director of Nursing (DON) took care of the pharmacy consultant recommendations. The surveyor then asked the LPN to view Resident #31's Tamsulosin order in the eMAR and if the indication that was listed for BPH was appropriate. The LPN stated that it was not appropriate and that she would check with the doctor. On 7/26/23 at 10:49 AM, the surveyor interviewed the DON regarding the process for the pharmacy consultant. The DON stated that the pharmacy consultant came to the facility at the beginning of the month for a few days few days and performed an eMAR audit. She added that the pharmacy consultant would send a report in a few days by email. She then stated that she typically had been the person to process the recommendations. She added that there were separate forms for the physician and nursing staff. On 7/26/23 at 12:01 PM, the surveyor interviewed the DON regarding Resident #31 and the pharmacy consultant recommendations. The DON stated that the resident was in the hospital and that when Resident #31 came back to the facility on 3/09/23, the pharmacy consultant had done a review of all the orders. She added that all new admissions and readmissions received the review and they give us instructions and they were kept in a binder. The surveyor requested to view the documentation that the DON had followed up on the pharmacy consultant recommendations. On 7/26/23 at 12:57 PM, the DON provided documentation that indicated it was an Electronic Pharmacist Information Consultant with recommendations from the pharmacy consultant which included the same recommendations that the Comments Report had. Handwritten on the document was Resident was on all medications previously and Not accepted was checked off as the response to the recommendations. The surveyor then reviewed Resident #31's February and March 2023 eMAR which did not include an order for Flomax. Resident #31 was not previously on Flomax prior to the hospitalization. A review of Resident #31's hospital records after visit summary dated 3/01/2023-3/09/2023 in the electronic medical record included the following: Under What's Next Follow up with [name redacted] MD in 3 (three) weeks. Handwritten under was Urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system). Under Start taking these medications Tamsulosin 0.4 mg Take one capsule (0.4 mg total) by mouth daily for 30 days. Commonly known as: Flomax. Start taking on : March 10, 2023. Review of other medications listed under the Start taking these medications and Continue taking these medications revealed that some of the medications did not have a specific timeframe to take the medication. On 7/27/23 at 10:50 AM, the surveyor interviewed the DON regarding Resident #31's after visit summary. The DON stated that the admitting nurse would review the after visit summary and place the orders in the eMAR. She added that she was the person to audit the orders to make sure they are in but that she did not always get to it. She then added that the Unit Manager could also check. The surveyor then asked the DON if the after visit summary indicated that a medication should be for a certain amount of days is that what the order in the eMAR should indicate. The DON stated that whatever the prescribed amount of days would be that if that was what the doctor agreed with. The surveyor then asked the DON to view Resident #31's pharmacy consultant recommendation which had written please clarify the indication for Flomax. The DON stated that she thought that she had checked the medications and that Resident #31 was previously on them. She added that she did not recall if the indication was checked at that time. The surveyor then asked the DON if Resident #31 had the urology consult after readmission to the facility that was indicated on the after visit summary. The DON stated that she was not sure and that she would look. On 7/27/23 at 12:02 PM, the DON stated that Resident #31 had an appointment for a urology consult scheduled on 3/24/23 but that Resident #31 had pulled out the catheter and the Unit Manager canceled the appointment. The DON provided the surveyor an additional Electronic Pharmacist Information Consultant paper that included under the Physician Recommendation Flomax is not indicated for use in [redacted]. If continuing therapy, please document the clinical rationale. The response Accepted was checked. Comment or reason for not accepting: handwritten was urinary retention. The document was not signed by the physician or dated. On 7/27/23 at 12:18 PM, the surveyor interviewed the DON regarding Resident #31's after visit summary that indicated to start the Tamsulosin and administer it for 30 days. The DON stated that Resident #31 came back to the facility from the hospital and that the hospital puts all meds for 30 days and that most of time the medications are not just for 30 days. She added that they put the medications in the eMAR indefinitely and that the physician will come in and determine how long the resident should be on them. The surveyor then asked the DON if the physician had documented the clinical rationale in Resident #31's medical record according to the pharmacy consultant recommendation. The DON stated that she would check. On 7/27/23 at 12:53 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and Regional DON the concern that the facility did not ensure that the pharmacy recommendations for Resident #31 Tamsulosin order were followed up appropriately which included a clinical rationale for the medication and the appropriate indication listed in the order for the medication and that the resident did not receive the medication longer than necessary by not having the resident follow-up with a urology consult. On 7/28/23 at 12:18 PM, in the presence of the survey team, the LNHA, Chief Nursing Officer, the surveyor asked the DON if there was documentation of the clinical rationale by the physician addressing the pharmacy consultant recommendation. The DON stated that she forgot to check. The surveyor asked if there should have been documentation. The DON stated that there should have been documentation. The surveyor then asked if the medication order should have been clarified since the indication was not appropriate. The LNHA stated yes. On 7/28/23 at 02:04 PM, during exit conference, the LNHA confirmed that there was no additional information. A review of the facility provided policy titled, Pharmacy Consultant Policy & Procedure with a reviewed date of 01/2023 included the following: Under Procedure: 5. The pharmacist will document and review a resident that has several or many medication changes, to ensure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the need of each resident. 6. The pharmacist will report any irregularities to the attending physician and the DON, and these reports must be acted upon . 8. The pharmacist will provide the DON with Pharmacy recommendation reports on an on-going basis each month. The DON will act upon these recommendations by bringing them to the attention of the attending physician and ensuring any changes are implemented in a timely manner. 9. The pharmacy consultant will report any medications that do not have corresponding diagnoses to support the use of such medications. The attending physicians are not required to agree with the pharmacist's report, nor are they required to provide a rationale for their acceptance or rejection of the report. They must, however, act upon the report. This may be accomplished by indicating acceptance or rejection of the report and signing their name. N.J.A.C. 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ 160489 Based on interviews, medical record review, and review of other pertinent facility documents on 5/3/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 2 of 4 residents (Resident #1 and Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: Review of a facility policy titled Charting and Documentation, dated 1/2022, reflected Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .1. Documentation in the medical record may be electronic, manual or a combination .2 .c. Treatments or services performed .3. Documentation in the medical record will be objective .complete, and accurate .5. a. The date and time the procedure/treatment was provided .e. Whether the resident refused the procedure/treatment . 1. According to the facility admission Record (AR), Resident #1 was admitted on [DATE], with diagnoses that included but were not limited to: Need for Assistance with Personal Care, Difficulty Walking, and Muscle Weakness. The Minimum Data Set (MDS), an assessment tool, dated 4/25/23, revealed a Brief Interview of Mental Status (BIMS) of 13 which indicated the resident's cognition was intact and the resident needed assistance with activities of daily living (ADLs) including toileting. A Care Plan (CP), initiated on 11/1/22 included that the Resident had a self-care performance deficit and was incontinent of bladder. Interventions included but were not limited to: the resident needed assistance from staff for toileting. Review of Resident #1's DSR (ADL Record) and the progress notes (PN) for the month of 3/2023 and 4/2023, lack any documentation to indicate that the care for toileting was provided and/or the resident refused care on the following dates and shifts; 7:00 am-3:00 pm shift on 3/2/23, 3/4/23, 3/6/23, 3/8/23 to 3/12/23, 3/14/23, 3/19/23, 3/21/23, 3/25/23, 4/10/23, 4/11/23, 4/13/23, 4/21/23, 4/24/23, 4/25/23, and 4/27/23 to 4/29/23. 3:00 pm-11:00 pm shift on 3/2/23 to 3/14/23, 3/16/23, 3/18/23 to 3/21/23, 3/23/23 to 3/28/23, 3/30/23, 4/1/23, 4/3/23 to 4/7/23, 4/10/23 to 4/22/23, and 4/24/23 to 4/30/23. 11:00 pm-7:00 am shift on 3/1/23, 3/2/23, 3/5/23, 3/6/23, 3/8/23 to 3/20/23, 3/22/23, 3/27/23, 3/30/23, 4/6/23, 4/8/23, 4/10/23, 4/13/23, 4/14/23, 4/23/23, 4/24/23, and 4/27/23. 2. According to the facility AR, Resident #2 was admitted on [DATE], with diagnosis that included but was not limited to: Difficulty Walking and Muscle Weakness. The MDS, dated [DATE], revealed a BIMS of 13 which indicated the resident's cognition was intact and the resident needed extensive assistance with ADLs. The CP, dated 9/23/22, included that Resident #2 was incontinent of bladder and bowel. Interventions included but were not limited to: the resident needed assistance from staff for toileting. Review of Resident #2's DSR and PN for the month of 9/2022, lacked documentation that the care was provided and/or the resident refused care for toileting on the following dates and shifts; 7:00 am-3:00 pm shift on 9/12/22, 9/17/22, 9/26/22, and 9/28/22. 3:00 pm-11:00 pm shift on 9/12/22 to 9/14/22, 9/17/22, 9/18/22, 9/21/22, 9/24/22, 9/27/22. 11:00 pm-7:00 am shift on 9/12/22 to 9/15/22, 9/18/22, 9/25/22, and 9/26/22. During an interview with the surveyor on 5/3/23 at 10:46 am and 1:28 pm, Certified Nursing Assistant (CNA #1), who took care of Resident #1 during 7:00 am to 3:00 pm shift, stated that CNAs are responsible for documenting the ADL care provided into the Point of Care (is a mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation). CNA #1 further stated that he would document even if the care was not provided due to refusal. He explained that the documentation must be completed in the residents DSR by the end of each shift to show that the care was provided to the residents. CNA #1 could not explain why there were blanks in the sampled resident's DSR but stated that it should have been completed. During an interview with the surveyor on 5/3/23 at 10:57 am, Licensed Practical Nurse (LPN #1) stated that the CNA's were expected to document ADL care provided to the resident by the end of the shift in the DSR. She explained that Nurses and the Unit Managers (UM) were to check the documentation to ensure that the DSR is completed at the end of the shift. LPN #1 could not explain why there were blanks in the resident's DSR but stated that they should have been completed to show that the care was/was not provided from the CNAs. During a post survey telephone interview with the surveyor on 5/5/23 at 1:32 pm, Unit Manager LPN #2 (UM/LPN #2) stated she made sure that the ADLs were provided to all residents. She also stated that CNAs were expected to document in the DSR at the end of their shift what kind of care was provided to the residents. The UM/LPN #2 revealed that she was not familiar with the software and was unable to check if the CNAs were completing their documentation in the Point of Care/DSR. During a post survey telephone interview with the surveyor on 5/5/23 at 1:45 pm, the Director of Nursing (DON) stated that the CNAs were expected to document the care provided to the residents in the DSR at the end of the shift. She further stated that she was not aware that the CNAs documentations were not completed regularly, and that the UM/LPN #2 was not familiar with the software. The DON further stated that the there was an appointed Charge Aide (CA), who was responsible of overseeing the DSR to ensure that the DSR were completed, however, the CA was on leave for personal reason. The DON stated that the nurses and UM were to check and make sure that the DSR are completed. Review of the job description titled Certified Nursing Assistant, dated 9/1/19, indicated .Document in the nursing assistant notes the care and treatment provided to the resident and the resident's response or lack of response to care provided .Complete documentation accurately, timely and following facility policies and procedures . NJAC 8:39-35.2(d)(9)